LUMINA Podcasts

One of the critical bellwethers of a healthcare organization's success in strategic planning is how well the health system leaders work with their boards. In this episode of Value-Based Care Insights, we sit down with Ivan Mitchell and Ann Scott Blouin to identify 2024 healthcare trends, their impact on provider organizations, and how executive leaders can engage with their board of directors. Gain insights on the top trends that are the greatest hurdles for healthcare providers and the importance of collaborative leadership.

• Achieving short-term goals while maintaining a focus on long-term objectives requires healthcare provider organizations to actively engage and collaborate with health system leaders and boards.
• Challenges in Medicare Advantage, such as misalignment and administrative issues, may pose a threat to provider organizations.
• Improving financial performance requires hospitals to align incentives, engage physicians in decision-making, and leverage tools such as telehealth to address labor shortages and ensure equitable access to care.

LISTEN TO THE EPISODE:

Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. In today's episode, we're going to spend some time talking about some of the challenges that we see as we enter into 2024, I had an opportunity to write an article kind of highlighting. Some of what I see is, is these key trends as moving in 2024. I've done this for the last, probably 7, 8 years. And I often do it by reflecting on what we've seen in in 2023 or the years prior. And then how health systems, how healthcare leaders either reacting to it or what they may face as we enter into this New year. But as I was writing this this year's article, and reflecting on some of the work and the conversations that I've had with healthcare leaders, one of the things that really, that that dawned on me that was an important element was really around effective governance. In 2023 we had an opportunity to do quite a few strategic planning sessions or engagements, and had done a number of board retreats and it and kind of a critical element, as I reflect back on successes of organizations as they've navigated through the challenges of 2023 is how well health system leaders had worked with their boards and effective governance being really a critical component in allowing these organizations to realize some of the opportunities, but also manage through some of the challenges. My article focuses on 8 key trends that we see facing healthcare providers, but it also identifies some insights that healthcare leaders, as well as healthcare boards should consider as they work together to plan some of these exec some of these initiatives.  

Well, I'm really excited today to have as my guest a prominent CEO Ivan Mitchell. He is Chief Executive Officer of Great Plains Health in North Platte, Nebraska, and I'm also joined today by Ann Blouin, a prominent board member, former healthcare executive nursing leader, and a longtime mentor of me. Very excited to have both you, Ann, Ivan, with us today on the program. Welcome. 

Ann Blouin:

Thank you. 

Ivan Mitchell: 

Good to be here.

Daniel J. Marino:

So I think maybe we can. We can start with you as you reflect back on 2023.Talk a little bit about what you see are some of the things that have been really important to you and to your team. And have you worked with your board to kind of navigate through some of the challengeswithin your market. You know, you're in the rural health space. There'sbeen obviously some challenges that you've had, but some opportunities that you've been able to achieve. Talk a little bit about that working relationship with your board.

Ivan Mitchell:

Well, we'revery lucky. Here is an independent nonprofit organization that's locally owned and operated.We just haveWe got great board engagements.as you've said, we've had some real challenging times in healthcare recently. And soI think that from the management perspective, We've tried to do our best to help our board understand kind of what's going on. You know, sharing that in in 2022over 50% of hospitals lost money and just kind of some of the challenges that we have with theworkforce. Medicare advantage some of the pay or mix changes and transitions. And so I think it's important for leadership teams to keep their boardup to date on what's going on in the industry. There were monthly flash reports that shared how hospital financials were doing and just making sure that that's out in front of your board, so that they canif you make a recommendation toward them that they have a good understanding of what'sout there, and what the situations are that we're dealing with right now per second. 

Daniel J. Marino:

Yeah, no, I absolutely agree. I keep in the board engage and using them as a as a resource is key, and you've been on both sides of the fence, you you've been a a healthcare leader for a number of years. And now you're on, you know, at least 5 provider boards.What do you see askind of the success, Ormaybe the role of the board member in supporting the healthcare leaders. As we're navigating through these challenges.

Ann Blouin:

I think that's a great question, Dan, and I think Ivan sort of laid out the importance of board engagement. One of the biggest challenges I'm seeing in boards is being able to balance the focus on the short-term challenges, which are many, as you've pointed out in your article.And the longer term strategic planning, where does the organization want to go? It's tough to do strategic planning, Covid sort of put us all kind of gave us all a little slap across the face, and said, Holy cow! You know things are very different now.But the Board's role from a governance perspective is to help support management that do management but support management in their activities in the short-term challenges. Understand themWell, 140pose appropriate questions, but never take the board's eye off the long-term strategic planning. 

Daniel J. Marino:

Right,Sothey're really incorporating them as a is almost a unified front right in the strategic planningprocess. So I want to, I want to focus our discussion today on what I see are 3 really key trends that we're going to have to work through in in 2024. I think the first one is really around Medicare advantage, we saw in in 2023 the biggest increase in Medicare advantage covered lives the biggest growth across the country, I think, you know, heading into 2024. about close to, you know, 55, maybe close to 60% of Medicare eligible patients are eligible. Beneficiaries are involved in some Medicare advantage plan.The second topic that I'd like to talk a little bit about is going to be around medical group financial performance and the impact on hospitals and health systems. And third is the transition and the growingfocus on in in home care if you will.

But before we get to that, let's touch on Medicare advantage. Ivan, you know, within the rural community no secret. There's been a lot of challenges with Medicare advantage. Lot of articles A lot of research has been done. That kind of speaks to, you know, some of the quality opportunities that have come out of Medicare advantage contracts, but a lot of the a lot of the challenges that that's occurring. And for the most part those challenges have really been as a result of misalignment with the plans and creating a bit of a financial challenge for many of the hospitals. Where do you see Medicare advantage going in particularly rural healthcare as we move into 2024? 

Ivan Mitchell:

Great question. I think you've seen a lot of therenowned healthcare system start to make a change, and you see, Mayo Clinic withdraw from Medicare advantage contracts using scripts healthcare. So you know, all medicare advantage.And I think that's going to be a trend that you're going to see rural healthcare was kind of slow to adopt medicare advantage and good for them theyshould have beenyou know. Here we did end up adding tocontracts. And we we're in network with 2 Medicare advantage plans, and we will be looking at options to exit the markets by the end of this year, if we possibly can. So that's I think we're getting out of it.

Daniel J. Marino:

Yeah. And there's a lot that are no, no doubt about that. Has the challenge been, from your perspective,has it been the reimbursement? I mean most of it is that medicare rates, anyways. Or has it been the administrative challenge? Has it been the lack of pre certifications? Do you feel like it's been more of an administrative burden on your physicians and your providers.Where can you, you know, maybe draw the biggest challenge from some of these medicare advantage contracts.

Ivan Mitchell:

Yeah, I think you'reaccurate. We administrate improvement. We have the Medicare advantage. Contracts will say we will pay you medicare rates. The data at our facility is the link with stay for Medicare advantage. Patient is 2 days longer than a traditional Medicare patient.So if you go from an average length to stay from 4 days to 6 days. Medicare pays what's called a Drg. A diagnosis related group.I just increased my cost by 50%, and I decreased my capacity and access.Along with that, you know, you lose money on Medicare patients, anyway, 80 to 85% of the costs. So what you've done is you've taken a kind of a safety net program, and you've added all of the bad behaviors of the insurance company into a program that doesn't meet your costs. And so it is. It has been a drain on us and, as you said, the incentives are aligned and we've seenvery poor behavior from the insurance industry, and I don't. I don't see that changing.  

Daniel J. Marino:

Yeah, no, I agree with you. I think we'regonna continue to see more and morehealth systems back out ofofmedicare advantage contracts. And it'sit'sgonna be interesting to watch, too, because Cms sees Medicare advantage as a big initiative. They want to get out of the thethe position or out of the thethe place of managing a lot of the Medicare beneficiaries. And from a board perspective, though I think it it, I don't know what are what are your thoughts. It seems to me. It kind of puts the board atthe difficult position because they have relationships with the community. You want to take care of these Medicare patients. But yetyou've got this fiduciary responsibility to the hospital. 

Ann Blouin:

Yeah, I think there are 3 areas from a governance or a board perspective that the board needs to be thoughtful around. One is from a patient serving the community. There are a large number of people that when they sign up for Medicare advantage they either just pay attention to the TV ads, or they look at the price, and they look at everything being included. You know, it sounds so good from a cost perspective and out-of-pocket cost. And so people don't realize when they sign up for medicare advantage exactly what they're getting and what they would not be getting compared to traditional medicare fee for service. And it's a complex thing that that, frankly, is not very well understood and explained to the to the average person in the community. So that's one area is the disappointment and confusion that people have.  

The second area is from a legislative standpoint. State and local government officials, I think, can be called upon to Ivan's point to try to leverage, to understand fairness and equity in payment structures. Because the problem is that if you're losing money on every single Medicare advantage you can see why Mayo and others, want to, you know, get out of it. So leveraging relationships with local legislators, I think, is one strategy the Board can adapt.  

And then, thirdly. I think that a careful understanding of what will happen with people who are in Medicare advantage plans from the Board's perspective. What happens to those community members? Do they are they able to get back into a Medicare plan. How do they do that? It's not. It's not something that's easy to do. So there's some mechanical pieces that I think obviously the health system gets stuck with frankly, the denials of claims are very significant, and to Ivan's point consumes a lot of administrative time.  

Daniel J. Marino:

A lot of administrative time, and, like, you know, as you both mentioned, you don't make a high margin Medicare patients, anyways, in some cases it's even a loss. So when you have the merge administrative burdens that it even makes it a little bit more challenging.  

If you're just tuning in, I am Daniel Marino, you're listening to value based care insights. I am here today talking with Ivan Mitchell, CEO of Great Plains Health, and Ann Blouin, board member of many health of many boards provided boards. We are talking about the importance of effective governance, and navigating some of the headwinds or the challenges that we see in in 2024. It kind of building on Medicare advantage, and the challenges with or the implications to the financial performance of hospitals and health systems.  

Another trend that we're going to see in 2024 is the continued obviously employment of physicians by hospitals, maybe even by private equity and the competition with private equity. But hospitals, they're going to continue to look at the financial performance of their employee medical group. Many hospitals in 2022, 2023, focused on tightening their belt right reducing some of their cost structure, trying to right size the ship, so to speak. There certainly was a focus in 2023 about improving that financial performance. And we feel it's going to continue as we move into this new year, Ivan, when you think about where your group is, and maybe other rural healthcare providers as your employing physicians that are part of your community. Where do you think the biggest opportunity is, is it in maybe the compensation structure? Is it in renegotiating? Some of your professional payer contracts? Is it maybe creating access and efficiencies for your physicians and any anything that you can draw on.

Ivan Mitchell:

Yeah, this is challenging topic. I think that we talked about how Medicare advantage had misaligned incentives. And so I think the key with your physicians is, you need to make sure that your incentives are aligned. I think, ensuring that I know that the position has kind of a panel. a seat at the table, but you know, if the hospital does well, they do well and have some performance based incentives hooked into that. And I've noticed every time we've done that here with our physicians, you know, we'll typically bring them on a guarantee for so many years. And after that practice is built up. When we do a production quality incentive. Every time we move someone into a position to where our incentives are aligned, that that behavior follows. And so I think that's always the best opportunity, I think, of the medical group side. You know, we have a real labor issue, and you know we II don't know the country that you look at how many people try to get into medical school. They can't get into medical school, and the amount of under supply that we have with physicians. I shared that I worked at healthcare.  

Rob Allen was the regional VP of the time. He's currently the CEO of the Company, and I was listening to a to a podcast he was on. And he said that they're in Idaho, Utah, Nevada, and Colorado, Montana. You said, if in around healthcare hires, every single medical graduate from those 4 States or 5 States. it will not replace the supply of those positions that will be retiring. And you know, in around healthcare. They're in Colorado. You have UC health, you have banner. You have all these other organizations that are there. So I think the financial performance of simple, simple economics supply and demand. We're going to see some additional foreign trained doctors that we need to recruit hopefully. That will increase. But it is very frustrating. You have your best paying jobs in your country. We are feeling and scenario that we have in place, and I think the financial performance is going to continue to deteriorate. 

Daniel J. Marino:

Yeah, great point. And I'vespoke many times about the lack of supply. Absolutely. It's contributed to access challenges that we'vehad, you know. I'm sure, in your organization as well. But I'd love your point on aligning incentives, and I'm a firm believer of that right. Have physicians at the table partner with the physicians, create a structure that aligns the incentives. Ann, when you, when you think about it from a from a board perspective. Talk a little bit about that alignment. How could the board support? That Is it around, maybe supporting, creating that stronger alignment with the medical staff. Is it making sure that that physician leadersare integrated in in some form or fashion within the board structure. Any thoughts come to mind?

Ann Blouin:

Yeah, 3 areas one is, I totally agree with Ivan and you, Dan, on the alignment. And I think transparency in that alignment so that they understand exactly how they're being paid, what they're being compensated for, what the productivity standards are. I think that's critical, so that there isn't a feeling of secret secrecy, there is a feeling of trust. 

Secondly, is, I do believe, physicians should be on boards. I think that having a physician, one or 2 physician representatives on a board depending upon the size of the board. who are well respected in the community. I think that is a critical aspect of that alignment and trust and developing respect. 

And then the third area is, the board can help by asking questions around. How can we reduce the hassle for physicians, administrative hassle the managed care documentation hassle that physicians experience. Obviously lots of health systems have begun to use more effectively advanced practice providers, physician assistants and nurse practitioners to expand. The physicians reach and effectiveness and have those advanced practice providers see lower acuity patients, so the physician can concentrate his or her efforts on higher acuity activities. That makes a lot of sense. I think use of telehealth is a is a question the Board should be raising in areas, as Ivan points out, like psychiatry. Where there are, there is a critical nationwide shortage of psychiatrists, and has been for a long time. So I think, not only looking at the supply side, but looking at the demand side. What can we do? As people are aging as the baby boomers are getting older and older and need more physician services. What can we do to assist with that demand? In addition to continuing the recruitment and retention activities on the supply side.  

Daniel J. Marino:

Yeah, I agree with you. I think you know, as we pointed out. The supply of physicians of providers in general. I think we're a long way from increasing that supply in order to meet the demand. So the only way that we're really going to be able to do that is is, we have to incorporate innovation. We have to incorporate technologies. Frankly, we have to change the care model right? That is, allowing us to think a little bit more innovative on how we can deliver the right level of care to patients.  

Which kind of brings us to my third topic. Then in in 2023, of course, artificial intelligence, the increase in technology it has, it's created, you know, different types of care models expanded the care models, incorporated technology into the care models. We saw reasonable growth of home based care. That would allow us to kind of manage through some of these challenges. I I believe, as we look into 2024, and certainly related to the aging baby boomers and some of the requirements that they want in their own care and the delivery of that. I think we're going to see things like, you know, sniffs it at the home hospital at the home different types of models that will incorporate different care delivery systems if you will, different technologies and so forth. Ivan is as as a hospital health system leader. Where are you in in in that level of thinking? Is that part of your strategic planning process? Is it? Is it something that you're kind of, you know, taking a wait and see based on the needs of your community. What are your thoughts there? 

Ivan Mitchell:

Yeah, I think you'regoing to see.And moving healthcare to home base care. And II think you've already seen that just from the inpatient to outpatient transition, you know, surgeries where people used to stay a week and go home same day, and really taking care of by their families. So I think you've already seen kind of a transition going that direction.We at Great plains health we had until this year we have home health and hospice. As well as home medical equipment under our umbrella. We still have home medical equipment. We ended up partnering with a company, another nonprofit called better health.They run nursing homes, and we actually transfer our home health and most hospice services over to them.Over the last 10 years we had lost about $300,000 a year in front of the Hospice. You know, it's a small team, 16 peopleyou have one biller. When that biller turns over it'sit's a totally different billing model. And it's very unique. 

Daniel J. Marino:

So home health Hospice care. I mean, that'sit's very specialized, if you will. So yeah, that makes sense. But I but I also feel like it has to be integrated.Right has to be almosta transparent component of your care model.Soyou're not necessarily seeing the challenges with readmissions, andyou know, over utilization of the emergency room, there's a smooth transition from a queue to the post, acute and to the home environment.

Ivan Mitchell:

Yeah, I agree. You know, we were pretty selective with our partner.I've seen places sell toventure capital. The united healthcare. Some of these other areas, and it kind of seems like their model wastaking a loss on home to get them on Medicare advantage plans or or things.So anything you'regoing to see it. We have seen a lot of health systems do the hospital at home model.You know. And I think you'regoing toprobably see some success there. Most of the hospital at home programs have not been extremely successful. They've been very low census. Andyou know, Haven't really done well at this point. But for us it'son our strategic plan. I think, that for organization our size. Our goal is to once we see best practices that are out there to partner and implement those as quick as we can.So that's kind of wherewe've gone. We think we found a a good partner for help, home, health, and hospital services. Well, and we'll keep our eyes open for the for the next transition best practices that are out there. 

Daniel J. Marino:

So, Ann, as you know, as as a nurse and as a former nursing leader. You know any any quick thoughts on home based care. You see, this is a good thing?

Ann Blouin:

Yeah, yes, I do. And I just was at. I'm on the I Chi Board Institute for Healthcare Improvement Board and went to an innovative session on hospital at home that was conducted by Kaiser Permanente, and Mayo, and it was fascinating. I don't think there's going to be a large super large volume of patients that will qualify for hospital at home. They are selective clinically, certain types of patients are better served, but they may be served in a sniff versus at home and during Covid, one of the boards I sit on, which is a skilled nursing facility Company and assisted living, actually took highly acute hospital patients to decant the emergency departments and the and the critical care units, and became much more acutely focused in the skilled nursing area, upskill and train. So I think there is something here. Cms is pushing us toward this as an industry, because they want to reduce costs. They have a you know they have an interesting perspective there, and their measurements are beginning to look at continuum based measures as opposed. You know, population-based as opposed to all acute care core measures. 

The last thing I'll say about that is that the board needs to understand may need an investment because hospital at home doesn't come without expenses associated with those support services. Whether that's supply chain, human resources. When you're in the hospital, you can reach around and grab another physician or nurse and get some things done very different. If you're in a home environment.  

Daniel J. Marino:

Sure, absolutely. Well, Ivan, Ann, this has been a great discussion, you know never long enough. II we certainly can talkfor quite some time around a number of these issues.And butI think one of the key things is, as you both brought out. The importance of having the healthcare leaders working with their boards and the board supporting the healthcare organizations is just is just critical.It'sgoing to be an interesting 2024. I'm looking forward to see how things move forward and where our industry goes. I want to wish you both a very happy and prosperous 2024. Thanks again for coming on the program. 

Ann Blouin:

Thank you.

Daniel J. Marino:

And for our listeners. I want to wish you all a healthy and prosperous 2024. And until our next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

With post-acute care, providers face various challenges, ranging from reimbursement struggles to meeting the evolving demands of an aging population. Hal Katz, a partner with Husch Blackwell, lends his expertise to shed light on how post-acute providers can navigate these challenges and advance into value-based care (VBC). Gain insights on transforming post-acute care models, establishing integrated networks and how providers can flourish in the VBC ecosystem.

• As providers transition into value-based care, a primary obstacle is to organize post-acute care providers into collaborative networks that prioritize cooperation and integration.
• Post-acute providers, as they move towards value-based care, must navigate diverse obstacles such as funding, payer reimbursement, employment considerations, and effective patient care management.
• Under private equity, a successful integrated network requires payer contract alignment and firm partnerships with health plans and acute care providers.

LISTEN TO THE EPISODE:

Transcript:

Daniel J. Marino: 

Welcome to Value-Based care insights. I'm your host, Daniel Marino. In today's episode I want to spend some time talking about value-based care, as it relates to the post-acute environment, post-acute providers, definitely have been challenged over the last number of years. And I think most of the challenge really comes in in the level of reimbursement. Most acute providers are have contracts with either Medicare or Medicaid. Few of the commercials but they're really challenged. All of them, I think, are under some level of financial pressures. And yet they're such a critical part of the value based care, ecosystem. Especially as we start to see. A number of retiring baby boomers who are who have some level of post-acute needs. And out of that. We're seeing some real changes to the care models. So, for instance, many of the baby boomers really want this at home care. So we're starting to see some of these resources shift to more of a sniff at the At home model, if you will, or a hospital at home or home health, you know, really picking up steam, but all of which has a significant value proposition to it and supports value based care. But the question really comes down to how you structure these arrangements in such a way that it allows the post-acute providers to maybe share in some internal resources to leverage that level of expertise, and just to create more of an integrated model and delivery of care. 

Well, I'm really excited today to have a guest with us. He's been on the program before. A great guy. I've worked with him very closely on a few different client engagements. Hell, cats. Hal is a partner with Husch Blackwell. He leads the healthcare practice, and works with number of organizations around the country very knowledgeable in in this as well as other aspects of Provider Integration Network. So Hal, welcome to the program. 

Hal Katz:

Dan, always great to be with. You, always love the chance to be on your show.and of course, to work with you out in the industry. Thank you. Thank you. Thank you. 

Daniel J. Marino: 

Well, thanks, Hal, for that. I appreciate it. So in in, in working with some of the post, acute providers, you know, and especially as they're giving consideration to moving into value-based care. What are some of the challenges that you're seeing?

Hal Katz:

You set it up nicely, Dan. the points that you laid out are definitely some of the same things that I'm seeing in terms of challenges, be it funding and reimbursement, staffing challenges, complexity of the industry, how that's changingas well as the conditions that patients are experiencing. And then, lastly. patients are becoming very picky. What? Where they want their service, how they want their service. Sothe it'sa very competitivemarket lots of pressures within the space from payers, health systems and the consumer individual consumer. 

Daniel J. Marino:

Yeah. And it's such a critical component of really the care model. Right? So especially when you seepatients who have some level of an acute care visit right? And they're getting discharged. Many of them are being discharged to some level of a post. Acute facility, whether it's skilled nursing, or a senior level facility, or even a rehab facility, so that integration becomes so critical, and I see such a divergence, if you willon the different care models. Right? So there, there's that lack of true, integrated clinical care thatthat's occurring between the post-acute environmentand the hospitals. Are, are you seeing as these networks are starting to be formed? Or maybe this is the reason why these networks are being starting to be formed, to create a little bit more integration, a little more synergy between the post and queue providers and the queue care providers.

Hal Katz:

Dan, I am, for all the reasons we've just laid out.These providers are having to identify the other types ofcare support needed to get the patient what the patient needsto ensure that there are these smooth transitions of care from a more acute facility to the post-acute setting. They can't do it on their own. Historically, that'swhat's happened. They've just tried to go out and hire people to provide those services in house and they've looked across the healthcare space, and they've seen this network model. They've seen how ancillary providers it be therapistsand other social services have been pulled in through independent contractor types of arrangements, to help manage the needs of the patient and to meet the quality standards that are that are expected for the patient outcomes. And that model has been successful. So now we see the post-acute space experimenting with networks clinically integrated networks.I would say. We'reon the earlier stages of that model. But we are quickly seeing markets across the country have more and more activity using that CIN approach.

Daniel J. Marino:

So when and I am a I'm a huge proponent. As I've talked about in this program time and time again huge proponent of integrated provider networks and clinically integrated models. II just think, in my experience I've seen so much value coming out of that when you have the providers come together to really begin to efficiently manage patients. It reduces the cost of care, produces some incredible, incredible outcomes.  

When we look at forming these clinically integrated networks in the post-acute space where are they starting. Is it home health providers coming together to form a home health cin? Is it the skilled nursing facilities coming together to form a cin. Or maybe it's a number of the post-acute providers coming together to find a to almost produce a very longitudinal based cin. Where are you seeing the starting point? 

Hal Katz:

Dan,It's really market specific, I mean you,you know that so well on health care. You see, in one market you've seen one market. It depends on the sophistication of the players in that market, the degree in which they? They have a managed care market, be it Medicare managed care, Medicare advantage specifically. The acopenetration, be it Medicare or otherwise. And what types of value-based arrangements the hospitals are entering into in that market.So it really depends. We can see situations where the hospital, the health system is actually the convener for a cin to aestablished, fairly sophisticated post-acute care provider leading the way to bring in other post-acute care providers to create the network and identify what other supporting providers should be included as participating providers in the network. 

Daniel J. Marino:

Yeah. Well, you, I mean, you clearly have to have one anchor organization right? That that has the vision and is driving a lot of it. And as you mentioned, I mean, I think you know hospitals are in a unique position to possibly do that. Are you seeing private equity getting involved as the catalyst to creating these networks?Or is it really more of the post to queue providers? Or, you know, maybe the hospitals kind of leading the way?

Hal Katz:

I do have at least one example of private equity helping facilitate a lead agency created network. So the agency, I mean in in this particular situation, there's a lot of alignment with the players. Particularly the a health plan who'svery interested. A national health plan that sees the value of a clinically integrated network focused on thissector and then the post-acute care provider having a private equity investor that wants to fund the creating the creation of the network. And in this situationthere's only a fewpost acute care providers that will also be an owner of the cin. But there is that opportunity to invest. There's really 2 opportunities. They caninvest and participate as a provider, or just participate as a provider.

Daniel J. Marino:

And that's an interesting, interesting model. Because, you know, as you know, it's expensive to create this right? I mean, you've got to build the infrastructure and the infrastructure supports a network and supports the performance. Many post-acuteproviders theydon't have the funds who invested. They don't have the reserve. Soyou know, in my mind, having some level of private equity does come with some opportunities. But I think it also comes with some challenges, and that's where I guess the legal component comes into place as you're starting to structure it.

Hal Katz:

For sure.for sure, negotiating those transaction documents. Governance reserve powers becomes the main focus. When structuring that relationship with the investorrelated for this particular scenario on the capitalconsideration, it helps. When you have a an eager health plan. You know. Often they willbe willing to put up some capital. They will also be willing to pay a per member per month reimbursement rate, so that there is some real revenue that starts to flow immediately into the cin, based on the number of attributed lives in a particular market, so that that helpskind of spread both the risk and the negotiating leverage with the private equity investor. It's not all on them.The cin is also bringing a payer to the table for day, one which you know frankly, is not all always, or even often, the case. Usually you have to build it and hope that they will come in the cin world. But in this particular case, and I think there are other opportunities across the country. You have health plans that are so,They see such value in this sector that they're willing to help facilitate the development of the cin on day one. 

Daniel J. Marino:

If you're just tuning in, I'm Daniel Moreno. You're listening to value-based care insights. I'm here with Hal Katz partner with huschBlackwell. And we are talking about post-acute strategies to advance into value-based care. And I'mgoing to build on that Hal because I think it's an interesting point that you just brought up. One of the big challenges the cin have is to create some type of a tangiblecontractual arrangement with a payer, right? So you can start to get some level of dollars and some revenue flowing into the to the cin. I think you'rethe structure of aligning with the payersbecomereally important. But I think it's also a challenge, right? Soas it's sort of the chicken and the egg. Right? Do you build the entity first and create the infrastructure before you have the contract? Or do you create some level of contract that allows you to invest in the infrastructure. Where are you seeing that really come into play?

Hal Katz:

Again, It's market by market. If there is a market where there is a good relationship or an existing relationship with an acute care provider, you know, call it a larger, acute care provider and a health system or not a health system, but a health plan. Starting those conversations. Is there an interest? If we built this, would you, be interested in a relationship? What would that look like? So you have some sense of whether they'regoing to contract with you if you build it.

Daniel J. Marino:

Yeah, yeah, absolutely. Absolutely. And then II can't help but think, you know. So II feel like that's a great approach, becauseit aligns the interests of the health planand then aligns the interests of the post-acute providers, assuming that it's structured right. But I can't help but think that the hospitals would be a little nervous in that regard? Right? Because all of a sudden they're managing that. Sohow does how do you manage that hospital relationship? Do you create? Then, a separate, almost third contractual relationship with the hospital based on alignment, with maybe theirrisk-based contracts or some of their performance based contracts? Or do you almost create a single contracting mechanism across all of the lives? 

Hal Katz:

Great question, Dan, in the in the few situations that I've been involved in the acute care network has leaned on the health plans, contracts withthe Hospitals. At least in these markets. There, there has been confidence in the care that has been provided and the willingness to coordinate without a more formal or structured arrangement. The cin is impacted based on the performance of the hospital. If hospital costsare higher than what they should have been. they can be impacted. So you know, there, there is some risk there. But so far I have not been  I have not seen those arrangements include a direct contractual relationship between the network and the hospital system.  

Daniel J. Marino:

And there's so much opportunity there for the hospital side, because one of the things that we often see isfrom the hospital perspective. Their readmission rates, visits to the er, you know. Some of that comes as a result of a lack ofclinical efficiencies that occur within the post-acute arena.So by having them collaborate, there is a direct opportunity there. But I guess it really comes down to how you how you create that alignment and who the partners are. 

Hal Katz:

And Dan, if I could just add, I mean there is, you know, almost an equal financial slash, economic opportunity for acute care providers to align witha health system. If that health system hasit's own aco, its ownvalue-based care model that's large enough to support this kind of effort. It can have the same kind of financial benefits as what we're talking about with a payer.

Daniel J. Marino:

Yeah, II agree with you. I agree with you. The post acute environment is heavily regulated, are thereyou know you. And of course, when you build a cin. There are also some regulatory impacts, right related to Ftc requirements and legal aspect around clinical integration and so forth. Do those change? Or are there other things that need to be specifically focused on in the post-acute environment? Given all the regulatory regulations and the regulatory requirements? Or is it pretty much aligned with the general thinking of clinical integration?

Hal Katz:

Great question, Dan. It'spretty much in line with the traditional issues that we face when creating a clinically integrated network. For any other provider type physicians and across the board, and II do want to emphasizethat point, especially when it comes to the antitrust considerations and remind people that getting together solely for the purpose of getting better reimbursement rates is seen by the Federal Trade commission as anti-competitive. SoI'm even in the early exploratory stage of this kind ofbusiness relationship arrangement we strongly advise the parties to avoidusing that kind of description. For this effort, providers can definitely or competitors can definitely get together to explore how to create a business that is going to improve care, improve access, improve competition, respond to market demands, market pressures.But we don't want to in incorrectly frame it as a way ofincreasing reimbursement rates from payers. 

Daniel J. Marino:

Great point. Great point, Hal. Because I think a lot of folks don't take that into consideration, and at the end of the day. The reason why organizations need to do this is they really do need to emphasize, to increase the emphasis on their value. Based performance. Right? So that's managing cost of care, managing quality, managing efficiencies, managingutilization and so forth. I couldn't agree more so in in, in thinking through that, you know, I think, that the key documents, the key legal aspects, is really thinking through. You know. What's the bylaws of the organization, how you'regoing to structure it. And then I would assume, you know, the participation agreements become really critical, right? Defining sort of the rules of the road? 

Hal Katz:

Exactly, exactly, you know, from the participating provider agreement, as you know, to policies and procedures that are put in place to ensure quality measures are obtained, achieved, and how corrective action is implemented. 

Daniel J. Marino:

Yeah. So when so, I recently had a conversation with ahome health organization, they were interested in in sort of forming their home health. CIN. Their challenge was really getting the groups together right. Cause they saw that there were different levels of quality andperformance. And plus, you know, it was predominantly in the home health world. 90% of the reimbursement comes from Medicare. Now some of that is changing as ma is occurring, but commercials haven't historically played a large role.What are you seeing? As as some of the other big challenges with moving this forward, as you're as you're starting to have initial discussions with either home health or skilled nursing or other post-acute providers as they start to think about pulling this together?

Hal Katz:

There has to be a need, of course, in a need, an opportunity. So again, back to the market specifics. The providers have to feel the pressure that that we've described as being the motivation for coming together to create a more competitive product. If we don't have that then it's then it's tough to motivate to create this kind of arrangement. But I would say most providers are at least aware of this trend that's happening, even if it's not in their backyard. They know that this is happening across the country. In in traditional Medicare, medicare advantage moving to commercial.

Daniel J. Marino:

Yeah, moving to risk based contracts. I mean all of those, all of those areas. And I, and I think I mean you're spot on. You have to define the need, and they have to define the value proposition. Right? I mean, sort of as we kind of say, define. Why do you wanna do this as it takes work and takes resources.

Hal Katz:

To your, to your point, Dan, just toto emphasize that it takes a lot of work socan't just be an exercise. If if people don't really believe in in the value, the benefits that will come fromthis hard work. 

Daniel J. Marino:

Yeah, no, that's that'sabsolutely true. Well, if any of our listeners today, any of our providers in particular areinterested in in moving forward with this, and you know what's the one piece of advice maybe you could share with some of our listeners. Where would they start?

Hal Katz:

Great question, Dan. Well, besides hiring someone like you or me, they've got to do their research. So you know one. They have to understand their own organization. How are they doing? What's happening in their market?There, there are great publications out there that have been created by trade associations and advisors like the both of us, that that talk about these issues in more detail, that is the homework, and then, in all seriousness, fi! Finding the right advisorto at least guide them on the options and helping them determine if this makes sense for them. And if sohow to get there.

Daniel J. Marino:

Yeah, no, III agree with you. And I think doing the research and really getting the groups together to almost create the vision. I know a lot of times when I when folks come to me and they say, Well, we want to start as clinically integrated network. I often say, Okay, have you done any type of visioning, you know discussions with some of your partners to sort of find why you want to do it. I mean, that's the first thing. And if you don't have that commitment, there's no sense spending the money on anything or going any further. 

Well, this is great. I really II appreciate the time. Great discussion. I know it's a it's an area that is of real importance to many of our listeners. I, if any of our listeners or folks you know, who may be listening in now or down the road. They want to get a hold of you, Can you share your email address, or maybe direct them to your to your website or anything in that regard.  

Hal Katz:

Absolutely. easily found on LinkedIn how cats with Husch, Blackwell.Of course. Huschblackwell.com is our website. You can also find me there. My email address is Hal.Katz@Huschblackwell.com. My phone numbers (512) 703-5715. And I'd love totalk with anybody who's interested in learning more about this type of business arrangement. 

Daniel J. Marino:

Well, Hal, it's great. And I would definitely encourage our listeners to reach out. You know Hal has. He's got a great approach with working with providers and any type of these value-based contracting, and certainly setting up the entities. Hal, thanks again for joining today. I love having you on the program. Just you bring a wealth of knowledge andgreat conversation. Really appreciate it.

Hal Katz:

Dan, always great to be with you thanks for including me today.

Daniel J. Marino:

And I want to thank everyone today. You, our listeners for tuning in really appreciate it. And until our next insight, I am Daniel Marino, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

As 2023 draws to a close, we’d like to revisit episodes that explored relevant issues we’ve seen throughout the past year. Host Daniel J. Marino revisits these profound discussions and how they impact the future trajectory of health systems, hospitals and the provider community. Featuring esteemed guests in their respective fields, Dan and his guests look back on important elements impacting strategic growth of hospitals, financial performance of medical groups and successes in risk-based contracting.

• Nillie Djassemi, CFO of Houston Physician Hospital, provides insights on how leaders can navigate hospital financial pressures by emphasizing operational efficiency, physician partnerships, employee engagement and strategic management of supply cost and payer contracts.
• Healthcare consultant and industry thought-leader Jeff Peters discusses the evolving landscape of medical groups, valuing the importance of organizational culture, physician empowerment and expanding access in response to improving medical group performance.
• Managed care expert Cliff Frank reflects on the recent shift to risk-based contracts, emphasizing the challenge of managing contracted population risk, the growing demand for health equity, and key takeaways to succeed within Medicare Advantage.

LISTEN TO THE EPISODE:

Transcript:

Daniel J. Marino: 

Welcome to value based care insights I'm your host Daniel Moreno. Every year at this time we take a look back at the most popular episodes as identified by you our listeners, or maybe those episodes that addressed the relevant issues that we saw in this past year.Well we have three episodes that we want to highlight this year and we're gonna play snippets of those episodes during today's program.

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In 2023 hospitals continued to be under financial pressures and some of those pressures resulted with reimbursements some were some challenges with supply costs and wage inflation as well as just some of the strategic positioning. Well one of the programs that we had I really enjoyed the conversation it was with the CFO of Houston physician hospital Nellie Djassemi. Nellie discussed not only those challenges with reimbursement and supply cost, but also discussed what their organization is doing with improving the culture and really engaging their employees which really made a difference in 2022 and in 2023. let's give it a listen. 

So newly given those above challenges that I mentioned and some of the things that are identified in the and all National Hospital last report what are you seeing as some of the major issues affecting Houston physicians hospital financial performance? 

Nillie Djassemi:

I think the two major drivers for this hospital is the reimbursement pressures from the payers.We are in the last like 18 to 24 months we've had to go into renegotiations with the with the few payers and it's we got beat up and we got we got knockout actually on one of them you just got knocked out. And the other one is supplycosts which is not I meanwe're seeing that everywhere every hospital dealing with that and so we're doing some things that are help helping us offset those increases in supply cost that we can talk about later.  

Daniel J. Marino: 

Well in in as you know you know revenue is one side of the equation but your expenses and how you structure those are the other and if your expenses are going up you know you can't just automatically increase your revenues your revenues are fixed and tied into the to the payers.

Nillie Djassemi:

That's correct.yes and so we we'vedefinitely started increasing the revenue and and not through rate but through volume and the volume growth is is helping us help offset the rate impact 

Daniel J. Marino:

Have you focused more on surgeries or is there an ambulatory component either through the ASC or maybe through some of your therapies that are figuring into your volume expansion?

Nillie Djassemi:

Yeahsowe'vedefinitely brought in different types of surgeons.Sowe'veopened up a that opened up but we'vedefinitely expanded our robotics services through the GYN and general surgeries.And so we bought a davinci last year and oh great yeah so just because you know I mean that that'sdefinitely it's for GYN and general surgeons that'sdefinitely something they want and we haven't really focused on that those service lines before so we invested in one.Again that was in play probably three years ago when we made that decision and it just took a long time to get that here because of all the supply chain issues.So we actually weren't able to launch it till mid last year and it was supposed to be launched much sooner than that.So those were things that we had already we knew that we had to prior to the reimbursement pressures coming down the pipeline. 

Daniel J. Marino:

Right so you needed to do something in terms of volume yeah you know I guess the supply chain challenges that you had a couple years ago essentially worked in your favor right because now you're able to get that and add additional surgeries based on some of the robotics to to support it.Which you know I think that'sthat's certainly key. How about some of the turnover and and the staffing challenges?Are you seeing a lot of turnover is it stabilizing are you are you know particularly in the nursing arena are are you able to recruit or or are you still see the same challenge in your organization? 

Nillie Djassemi:

It's the it's I can't say it's a huge issue our turnover rates are are much lower than what I see around the market but it's still a problem.Right because every time someone leaves the cost of bringing them back it's still much more plus the training cost and everything right. I wanna say our people areare our nurses and our non clinical staff are happier here.Our turnover rate is is lower but yeah we still have the challenges of course we do because the nurses and especially on you know on our on the inpatient and the surgery world the history our nurses are right yes they definitely they all talk they know the market.So yes we've had a deal with increases and looking at the market rate we're doing market analysis every six months now we used to never have to do that right so HR has processes that where they actually have to look at market rates market now every six months that's just didn't I mean Dan you know that's crazy yeah but you have to because we don't want to be caught off guard if you know if our CST's are coming to us and like hey someone down the streets paying me X dollar more an hour we don't want to be caught off guard. We wanna be able to have that knowledge in our back pocket to be able to give them nowthat'sactually not true or yes that's this is what we can do.And it it's very difficult it's very very difficult.But we that's the process that we put in place to help for us to be knowledgeable

Daniel J. Marino:

Well you have to be right I mean getting that insight that's the only way to be competitive.And to be yeah totally transparent to our our listeners I've had the the wonderful opportunity to work with Houston physician hospitals for a number of years and nearly a year your leadership team has built a great culture out there. I felt time and time again and I spoke about this with many folks across the country you have to be competitive on rates, but in order to really manage a lot of the turnover challenges, the financial challenges related to our workforce, you have to create a strong culture. You have to create the culture that makes people wanna work there.And as you've said and I agree with you I think people are happy working in in your organization and we see that a lot of times with smaller community hospitals are we specialty hospitals.

Nillie Djassemi:

Right.yeah we definitely I think I've told you this damn before I came to HPH.youknow II came from a more corporate healthcare background and so that employee engagement here is something I've never experienced anywhere else.And I'm not just saying that because I've worked here.But we put in a lot of effort to have that high employee engagement and it'sit's it takes resources and it takes a lot of time.But it does pay off because our turnover rates were so much lower. We still have todeal with itthe pressure, the externally pressures of inflation with saleryrates.I really think that is a huge piece of the puzzle, that we put so much in employee engagement. When I first started here our CEO, I would be like wait,we're spending how much T-shirts? you know.We give out you know we're known for our T-shirts here.

Daniel J. Marino:

It's a little things, they make a difference.

Nillie Djassemi:

It really is. we every month we every in my department we spent one there's one thing we focus on every month and in the department ,and for example last month we focused on integrity.And each person had a banner and it was what does give me what your integrity motto is for you for you as a as a person. And so everyone and again and that it wasn't all across the hospital but for all my departments they did their individual ones but across the hospital what we did was every department made their own banner and then we were able to hang it up and in our cafeteria area and everyone could see what everyone's motto was in terms of integrity that's one of our mission statements that we believe in. And soit's just we really do focus on that and this month we have something else that doing but yeah.

Daniel J. Marino:

And the culture piece is, I mean it'shuge.

Nillie Djassemi:

Yeah.

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Daniel J. Marino:

In 2023 medical groups were also impacted quite a bit and as we reflect back on what it transpired with a lot of our medical groups many continued to look to their hospital partners for employment others decided to align with these four profit organizations like optimum continued to employ many of the independent medical groups and providers in 2023 as well as many groups decided to align with private equity. Well in this episode I was joined by Jeff Peters. Jeff is a national expert on the physician provider space, Medical Group strategy, and we discussed three areas that really impacted medical groups this past year. Access being one of them, physician well-being, and different areas that are affecting strategic growth. Let's listen in. 

So just when you reflect back on where some of these independent medical groups are these different hospitals and through your career close to 40 some years you've been doing this you've worked with over 500 organizations across the country. How have you seen these challenges evolve over the years?  

Jeff Peters:

Yeahso I really thought about the fact that when I first created and employed physician group at Ingles hospital, which is now part of the University of Chicago health system.And the financials are coming out to the board you know the board is just overwhelmingly perplexed as to how we could possibly run physician practices that are losing $30,000 per physician, per primary care.And now when you see the losses over $100,000I'm sort of thinking what were they worried about?that was great. I mean really?you're beating me up over this?you have data on ownpractices and you know it's very clear what the problem is.There's more demand for physicians and advanced providers than there are supply.So you have to pay more to attract and retain physicians. And you also have to pay more for their support staff.

Daniel J. Marino:

Yeah, for their support staff.yeahyeah I believe I I think the you know when when I as well as with you I I talked to many leaders all the time across the country access is the number one issue that they struggle with.Wage inflation, if it's not number one it's a close #2 and retaining the staff is really key.And as well as then physician well-being.So solet's talk a little bit about access though you know if you've got limited number of providersyou've got more demand than you do with supply, what are you seeing on some of these strategies how are organizations how how are they dealing with some of this?

Jeff Peters:

Well I think the first thing is that you've got to assemble teams to manage a group of patients.It's not only physicians,it's advanced practice providers,and in in more quaternary tertiary practices nurses.And you need to allow the advanced practice provider to see the patients that they're qualified to see, and you need to reserve the physician's time for the more complex patients.So the idea that we're always going to see a physician, it's just not going to happen. I mean recently I had a annual skin exam, I called my dermatologist, I was scheduled with an advanced practice provider. I thought she did a fabulous job.yeah she was thorough and personable and identified things.So we've gotta be creative in terms of our workforce and we've gotta save physicians time. When I go to my ENT with a sinus infection,there's a medical assistant who'sassisting him with the scope and just getting everything ready.And he has a scribe.He's dictating as he's seeing me what's going on and he's able to really make efficient use of his time so we've gotta be creative with their time.

Daniel J. Marino:

And really innovative right? these what you just described on these innovative care models around team based care, around helping the physicians succeed, and innovation in the care models, I fully agree with you,that's how we'regonna help to kind of work through some of these access challenges. I think without doing that the traditional model is not sustainable.

Jeff Peters:

No.And physicians like the team model a lot of the work that the team is doing is work that physicians don't like to do.The charting and the things like this, I mean you hear physicians complaining about the fact at the end of the day they're spending one or two hours on the EMR. getting caught up with their documentation to save them an hour or two a day.Phenomenal. And the other thing is just handling the telephone and the patient calls that come in, and the emails that go to the physician. We'vegot to be creative and identifying what work can we take away from the physicians that gives our patients the care that they need and deserve, yet doesn't burden our high costproviders.

Daniel J. Marino:

I absolutely agree. Ithink is worth thinking about the future strategy of medical groups whether you're independent or employed.These innovations that you spoke about this way of ofof kind of making the physicians more efficient spot on. Iabsolutely see that as a necessity of performance.But let's talk a little bit about growth though.You know obviously everybody's concerned about growth, and especially if your expenses are increasing, you can't necessarily cut services you cut can't cut staff. I think we'reprobably as lean as we've ever been you have to focus on increasing the patient volume.You have to focus on increasing revenue.In your opinion where what where are some of those key growth initiatives that help to kind of drivethe financial performance? 

Jeff Peters:

Yeah and I think there's been models in the market for a very long time multispecialty groups are very profitable.And they tend to attract and retain providers.And single specialty groups like urology where you're able to get all the urologists in a market to come together so that they not only share practice overhead, but then it supports pathology, it supports imaging and treatment for it makes sense. So what the growth has to focus on is getting a large enough group of providers that drives ancillary revenue.You're not going to make your money on the profitability of a physician practice.Where you'regoing to make your money particularly for academic medical centers or hospital practices in establishing integrated ambulatory campuses.Where there's urgent aid to take care of the patients that don't have a primary care or don't want to wait at primary care, surrounded by specialists, so the urgent aid for the patient that doesn't have a physician can refer that patient to the primary care so there's an ongoing relationship.As that primary care picks up a heart murmur there's a cardiologist in the building that they can refer them to and there's a spectrum of diagnostics and treatment what we're seeing is in the University of Chicago has been masterful of this creating these integrated campuses with urgent aid, primary care, secondary care.

Daniel J. Marino:

Right so it's all sort of integrated and it's right there for the patient and for the physicians so you can actually have create more of a a longitudinal care model getting the results that you need.

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Daniel J. Marino:

In 2023 our industry saw a continued influence in Medicare Advantage. Medicare Advantage continued to grow and as all of us know if you're continuing to look at a lot of the news and the direction Medicare Advantage, into 2024 is going to be one of those topics that we're going to see continued growth, as well as Medicare Advantage though risk based arrangements also impacted our physicians our medical groups our hospitals our health systems and so forth. In June of last year I was joined by my colleague, Cliff Frank, and we had a great discussion on the rapidly changing Medicare Advantage products as well as some of the risk based arrangements. Cliff always provides great insights along with a little bit of entertaining conversation. Let's listen into this episode.  

So Cliff how this makes sense of this. What are you seeing in terms of some of these changes there's been a lot going on just in in the last month and a half or so. 

Cliff Frank:

Well CMS has been taking a lot of heat from Congress and from industry observers, that they kind of gave away the store for the last 10 years.SoI'mbasically uncapped risk adjustment.Now they signaled with some of the ACO products, a willingness to change that and that they capped the risk score gain the get in in MSSPACO is at 3% over multiple years whereasit's uncapped in Medicare Advantage, until 2024.With the new with the new ratesthey're signaling that that game is going to end.In several ways.First they're making it harder to actually get risk adjustment. a lot of that they went from I CD9 to ice I should be 10 or 10-1, I forget which but anyway,they're they killed a lot of diagnosis that adjust they were like 2000 diagnosed there's a lot particularly in diabetes those are gone.They don't they don'tget you more risk.Then the second thing they did was they said oh we'regonna really start auditing a lot more closely, and it's not and the risk boards have to come in through claims not through some magical home visit that that the plan has orchestrated.So they're really kind of making all that much more difficult. At the same time CMS is signal of a rapidly growing interest in insuring and enticing health plans to tackle health equity.Aad so as if you kind of think of it as a as a kind of a teeter totter as the HealthEquity side goes up the risk score side goes down in terms of dollars so the dollars are still be there but they'll be there for different reasonsin two years.

Daniel J. Marino:

Right so there's really you know two key things that going to see. I think it's thinking about how we're positioning ourselves for risk, within risk, managing risk ,identifying risk within the contracts ,you know that that's a big one.And then the health equity piece and where that comes into play.Let's start with the risk piece because I have a few questions here that I'mkind of working through in my mind. So I you know I'mkind of thinking that there's two pieces to this right? You know we spent a lot of time as providers talking about the fact that we need to capture HCC's. And that HCC's are supporting the RAF scores.And the RAF scores give us a better idea on the sickness, if you will, of our population of which then dollars are tied to that.You know and andand a lot of providers we spent a lot of time educating theirtheirtheir physicians and monitoring it and and almost going back and recalculating that.Was that in particular was it wrong? I mean did we overstated? 

Cliff Frank:

Oh not at all, that's all good stuff for lots of different reasons.The first is that providers like to compare themselves against each other. So if my remember per month spend is 20% higher than you, of course the first thing I'm you know I'mI'mgoing to whine about it well my patients are sick population sicker.Right so so the RAF scores actually level that debate which then moves us to the next level. which is what are you doing that I'm not doing what are you not doing that I'm doing let's have a conversation about clinical path use utilization pattern.So you can't have that without some sort of severity adjustment risk adjustment population standardization.So regardless of what else happens inside CMS in the deal between the payer and the provider it's really useful information. Then further to have some indicator as to what's changing in your in in particular patient, the risk for just jumped 30%.Well there's an indicator for some case management intervention some care support, so further love and attention from the doctor, it could be you know referral to a specialist, could be any number of things. But it's an early indicator it can be an early indicator of a problem that's coming hard and fast at the member and atat the at the provider network. right so all those things still have plenty of value regardless of what else happens. And then the third is remember risk scores can go down.So she isn't saying oh will insulate you from the down as much as we catch you on the up. So you know if if you if you fall asleep on risk scores and suddenly you drop two or three points guess what you're and you've got a percent of premium deal up your revenue just went down. 

Daniel J. Marino:

Yeah, you just went down. So the performance model still has to be there right it still has to be there. You still have to manage that population around cost of care around utilization yeah and then you have to accurately identify the risk. I think the key to it though is that if the risk is going up if the postal care is going up, and and even you know based on overutilization as you mentioned some interventions around Karen here management has to come into play, and you have to show that you're taking some responsibility to manage that. I think as we start to think about it the model has to be clean, but we also have toprepare or some type of audit or some type of realization that this may be questioned right.So we've we'vegotta get back to the data, the model, and the clinical performance to be able to show that hey what we're doing is is actually the right thing to be done.

Cliff Frank:

I think all that is true.There are plenty of places for CMS to come looking.And and I mean it starts with RPM, CCM, telehealth, I mean lots of new areas that are have been exposed already to some pretty significant fraud.Sothey're looking, and then you have their relationship with the plans which now cut through to the provider.Because it's the provider providing the claims information so they'regoing towant to see the documentation that supports that. So if you're just submittingdiagnosis with no documentation good luck.

Daniel J. Marino:

I'm going to thank all of our listeners for tuning in without your support your interest your feedback our program our episodes would never be as successful as it is.For anyone wanting to share their opinions or their comments or even suggestions for additional topics please feel free to reach out,I'd love to hear from you.My e-mail is d.marino@luminahp.com. As we close 2023we're looking into 2024 with some wonderful topics and some real fascinating guests.We're looking forward to bringing that to you in the new year.Until then, I want to wish all of you a very happy holiday season and a very healthy and prosperous 2024 and as always until the next insight I am Daniel Marino bringing you 30 minutes of value to your day, take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

Amidst uncertainties surrounding financial returns and the pace of value-based care, providers and executives harbor reservations regarding the privatization of risk. This episode unravels the intricacies of transitioning from fee-for-service to value-based care, shedding light on the challenges and opportunities that accompany this transformation. In this episode of Value-Based Care Insights, Dan sits down with Dr. Will Faber to explore the effects of value-based care on physicians, dissect payer pressures, and uncover why value-based care presents a golden chance for providers to enhance the quality of patient care.

• Physicians navigating the transition to value-based care face hurdles such as increased workload, concerns with well-being and equitable compensation.
• The changing dynamics of payer systems pose both challenges and opportunities for physicians as they adapt to change. This includes a shift towards concentrating on high-risk populations and embracing contemporary primary care practices.
• The emergence of nontraditional providers compels physicians to take charge, embrace risk, and pool resources to enhance both financial outcomes and patient care.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I am your host, Daniel Marino. As we've talked about value-based care numerous times on the show, there's continues to be a lot of discussion around the pace of transformation from fee for service into value based care. There was an interesting article that came out, Oh, I want to say, maybe it was in the summer from HFMA, and many of the the CFOs that were interviewed actually were pushing back on value based care. And We're concerned about that pace and the investments that were required, and not really seeing the returns. Yet when you look across the industry, there's still tremendous amount of momentum that is occurring and moving us to value based care, shifting us to accepting more risk, based contracts, and beginning to identify or help or holding, having provider organization held accountable to the care that they're delivering to their patients.  

It's fascinating right now the environment that we're in. And as we think about moving into 2024, I can't help but think that this, this transformation challenge, and really the pace of which is something that we're gonna continue to discuss and work through as we move into 2024. And as we focus on that, there's tremendous impact on the physicians, physicians and providers in general are the ones that are really stuck in the middle of this fee for service value based care conundrum, if you will. 

Well, I am really excited today to have a guest joining me somebody that I have personally and professionally worked with over the last 15 years. Dr. Will Faber will welcome to the program. 

Dr. Will Faber:

Thanks so much, Dan. Great to be here with you.

Daniel J. Marino: 

Well, I'mreal excited to have you join a program today and talk about this discussion. This is obviously a topic that is near and dear to your heart. You've worked with numerous organizations across the country in your career, helping them to shift into, to value based care. What are you seeing as some of these challenges related to to the pace? right the pace of moving from fee for service into fee for value.

Dr. Will Faber

Well, we're constantly having to adapt, and we're having to adapt as providers. and I will be sharing today my point of view.My point of view is that as value-based care is growing, and I'm going to make a case where it may be growing more than we think it is, or we often recognize that it is. I'm in it for the physicians, and I'm in it for the patients. I'm in it for the providers of the health care. I myself am a primary care doctor, practiced for many years in lots of settings, and I care about population health. I love getting better quality results and outcomes for patients at a lower cost by cutting out waste and unnecessary utilization. And as the shift occurs, it seems like the insurance companies are making as much, if not more, money than they ever did. And executives of large organizations are still making astronomical fees, but primary care, primary care, doctor income relative to inflation and relative to the incomesof other specialists, have not gone up very much. And yet value based care brings with it a lot of things that primary care doctors need to do. And they need to document. Sothere's a lot more work without a lot more money.

Daniel J. Marino:

Yeah, I absolutely agree, especially on the compensation piece. So let's talk a little bit further about that.When you're working with the physicians and your physician colleagues, whether it be primary care or specialists, there's in my mind, there's 3 things thatI think they're struggling with one is the well-being physician, well-being, or the burnout factor.I think the second is the challenges they have with understanding how their care model has to change. And then, third, as you talked about is compensation.Are you seeing those as the main 3 challenges that are really affecting your provider colleagues. 

Dr. Will Faber:

Yeah, I think that's a really nice summary of whatchallenges us, as we know, during the pandemichundreds of thousands of nurses walked off the job, and a lot of doctors have sought early retirement.It's just too much. They're burning out in droves. This is a huge conversation. We've got some thoughts I'd like to share about how to preserve the provider or providers so that they don't have to burn out.The elements of their compensation is changing, and that calls for a change in their care model of the microsystem that they work in, the operational workflows. So be happy to touch on all 3 of those. 

Daniel J. Marino:

Do you think, as these care models as physicians are being forced to change their care models? Are they getting the right level of support or help fromtheir health systems if they're employed, or maybe from the community or from other partners. If they're independent?

Dr. Will Faber:

it depends on the health system.You mentioned independent doctors, and they really struggle. Because if you're an employee physician, you'repart of a of a network that's got resources. I worry about the independent doctors. And of courseI've been associated with you and starting a lot of clinically integrated networks that allow independent doctors to participate in these, and we have to find better ways to support the doctors and support them in a different kind of care model. I can talk about those specific supports If you want here any place along the conversation. 

Daniel J. Marino:

Yeah, no, I agree. I thinkthat's part of what I'mseeing as a challenge more so for the Independence, right? Soyou know, we were on a we were on a conversation recently where we had one of the physician colleagues, that of a CIN that you know both of us had had worked at for a number of years, and he is an independent physician in a in a rural community.And he is really struggling with making that level of investment in order to support what frankly needs to occur. To be successful in these in these contracts right to really drive a lot of value. And those investments are aroundanalytics. They're around care management. It's around care model redesign. It's around all of that. So you know. Again, I mean, What are you seeing? What do you think? How? How is this alignment between either the health systems the CIN, how can it better support physicians in an independent environment?

Dr. Will Faber:

Well, I give you a literal anecdote from 2 months ago. I'm serving right now as an interim executive in a clinically integrated network, and I went out to speak to one of the independent doctors. Matter of fact, I met with all the independent doctors I could get to at least the primary care ones. And he said, Will.I have had to hire 2 part time people just to help me do all the paperwork or computer captured metric, and HCC Coding work just to get that check at the end of the year that shows that I did well in these shared savings contracts that we get through the CIN. And of course I told him, it's my goal that we at the network levelprovide as much of that as possible so you don't have to hire staff in your small business, which just hurts your margin. 

Daniel J. Marino:

And I'll tell you. Well, that's not an unusual commentfrom many independent physician or practices, you know. They feel like they have to add staff.They have to add the infrastructure. And maybe it's because these CINs, these health systems, either don't have the financial means to invest or they don't have the right structure to invest.

Dr. Will Faber:

well, and let's be clear about it. Doctors want to practice medicine. They wanna interact with the patient. They wanna make clinical decisions, and so much of what payers require is proof that you did something. That is a clerical task. It's something doctors should do as little as possible of. And one of my principles is, make it easy for the doctor or the provider to do the right thing. I've talked to doctors who view value based care, unfortunately, and as more check boxes in their day, more in basket tasks. And we need to offload those tasks toother people working at the top of their license. It's not top of license work for a doctor, and certainly in some cases not even for an RN. You can have clerical people do some of this stuff that the provider that the payers are requiring.They they've been burned by people who are fraudulent before saying they were doing things they weren't doingand not ticking the boxes. But that's all infrastructure that needs to support providers so they can actually take care of patients. 

Daniel J. Marino:

Yeah, no, you're absolutely right.Let's shift the conversation a little bit on the pressures or what's occurring in the payer environments. You know, there'sbeen obviously a huge shiftto Medicare advantage.There's CMS has made it very clear that by 2030 they wanna get out of the management of ofMedicare beneficiaries, and either have all these beneficiaries pushed into Medicare advantage or the ACOs.Yet it's created real strains on the physicians to understand how they need to succeed, not to, not to mention all the challenges around the administrative tasks which have really considered seem to continue to increase, which has really been a challenge to delivering care. What are you seeing right now? And with working with your colleagues? What are they saying about the increases in Medicare advantage, and so forth? 

Dr. Will Faber:

Well, many of the doctors that I work with hate Medicare advantage, and they want to not take it. But of course they can't not take it because their competitor might take it. And then they're just gonna lose market share. They'regonna lose patients and it's making them angry all around the country.But let's not make any mistake about it. Medicare. Advantage is growing very rapidly in the last 2 to 3 years. Just in 2023. I think most of our listeners will know Medicare advantageEnrollment now has exceeded straight Medicare in the United States, and the trajectories to continue to grow by leaps and bounds over the next few years. I wanna contextualize this with a statement, that politicians are low to raise taxes and they're low to cut benefits, they wanna get reelected. So the government has not done a very good job keeping Medicare solvent. And of courseit's predicted to become insolvent during this decade. CMS. Has said, the only way we're going to make it is to shift risk off of the government onto individual providers. I call it privatizing riskand to preserve Medicare. They're going to have to do something we're not enjoying taking on the risk. Doctors are very loath to take downside risks and institutions need to step in and help protect the doctors so they can do what they need to do with all the kinds of supportswe're talking about here to continue to float the boat. 

Daniel J. Marino:

If you'rejust turning in, I'm Daniel Marino. You're listening to value based care insights.I'm here today talking to Dr. Will Faber. Will's providing a fantastic perspective on where the physicians are today and the benefits related to value-based care.SoWill just building on what you had mentioned, with the shifting of risk a. As we begin to to think about how the payers are putting a little bit more pressure on the providers as we think about how they're adding additional requirements onto the providers.Where do you feel like there's athere's an opportunity for them to succeed? Is it really being focused on,say that I don't, wanna, you know, just carve out. But you know, is it are, do they need to be more focused on the high risk population? Can they really support all the patients that they need to support under these risk based contracts? Or should there be separate care models or new care models, team-based models, if you will, that help them to succeed? What are you seeing in terms of that, that evolution of the delivery of care under these models?

Dr. Will Faber:

doctors just have to embrace the change that they can't just have the individual pleasant interactions with patients and do it all themselves. Like many of us baby boomer doctors did, we enjoyed sitting down with the patient for a 30 min visit, and sometimes talking about how the grandkids are doing, and so on. Modern primary care is a team sport, for sure. I've often created an analogy with the orthodontist who's got 5 chairs running, and he goes from chair to chair telling his technicians what to do to straighten the teeth of the patients. primary care. Doctors have just got to be the quarterback of the team, and there's so many things that care managers ought to be doing. Clerical people ought to be doing. Coordinators ought to be doing. And I also make a very big point. We've got to tame the electronic health record instead of serving it. It should be serving us. We need to automate all kinds of processes like with Cpt. 2. Coding to capture things that the payers are gonna require to prove that we did something. And of course we're trying to get patients to do things they don't wanna do like get a colonoscopy. We need to let other people go chasing after the patient, chasing after the metric chasing after the data so that we can have meaningful motivational interfaces with our patients.  

Daniel J. Marino:

Yeah, II agree, and you know that infrastructure support in my mind is absolutely critical. As we've talked about you and I. And then, obviously on the program numerous times.We can't ask physicians to do more work. We actually have to reduce the amount of work that they're doing and give them the tools to perform smarter and not harder. And that's really where the infrastructure support comes in.

Dr. Will Faber:

That's a great pivot into talking about physician compensation plans which you and I have helped many an organization to design. I think there's some shortsightedness in rewarding doctors just for our views generated.That makes it sound like they are the only generator of net value. It's really a team of game here. And so just cranking more patients throughwithout a thought of what the mix of those patients are whether or not it's meaningful work for a doctor to be doing, whether or not somebody else should be taking that off your shoulders, and a way to compensate the overall team for performance is probably a preferable direction to go as we evolve our compensation models.

Daniel J. Marino:

Talk a little bit about that, you know, when you've when you're working with organizations and particularly primary care, with new compensation models.What are you seeing? How are you seeing these models evolve? I think you know. for some of the most of the organizations. They're still on a revenue Rv. Based model right of compensation. I think they've started to incorporate some other elements. But it's predominant. RVUs.What are you seeing in terms of the right level of incentive alignment? If you will, betweenfairly rewarding the physiciansrelated their compensation and alignment with any of the risk based contracts? 

Dr. Will Faber:

Well, most organizations of certainly those who employ doctors are dialing in more and more quality dollars, and not just a straight RVU model. Most of them sequester or withhold a certain amount of money that you earn back through your quality performance. But the quality performance is definitely a team game, and I think the degree to which youreward through the compensation plan quality or efficiency related work is related to the penetration of value based contracts in your portfolio. If you've only got 5 to 10% of your income coming through value based care, Well, then, you'd have a relatively low part sequester in the Comp plan for the doctors. But if you're 50 or 60%. Well, then, you should have a much larger amount.

But going back to my basic premise here. All the doctors are doing with that sequestered 20%, let's say, of their income is earning back money to just become whole. What they would have gotten for service. In the first place. 

Daniel J. Marino:

right? They're not making any more yet. They're in in some cases actually working harder, creating a lot more investment just to make the same amount of money they made before.

Dr. Will Faber:

right, and of course it brings up a chronic complaint I've had, and that's the way the value of a primary care doctor is accounted for in a lot of systems. Never talk about the contribution factor to the organization, which is why you have primary care doctors to create access points to feed the whole network.That just isn't accounted for, and it frankly, is a bone of contention with me, and it always has been. But I think it should be because the net benefit of the physicians, particularly primary care to the entire enterpriseis much greater than what seems to get passed on. If you just look at what they generate in terms of the poultry sums that we get for our E and M work. 

Daniel J. Marino:

Yeah, yeah, Iabsolutely agree. So I want to get your thoughts on one other area here, Will. We have seena lot of these what I call the non traditional provider organizations. And in some cases these big for-profit entities coming in and buying these primary care groups. And I'm and I'm referring to sort of the Oak Street health. Who was bought by CVS. Obviously Walgreens and Bootspaid a tremendous amount of money for some medical group and city. Md. How are you seeing this affecting the physicians?

Dr. Will Faber:

Well, I was really hopeful.I've known some of the people that started these amazing organizations like VillageMD, ChenMed, Oak Street and they were disruptors in the model of Clayton Christensen's disruptive innovation model and I thought great. Now physicians are taking control again, and they are leaning into risk, which is a big point I want to make on this broadcast. Doctors have traditionally run away from risk.Well, that actually gives power to the payers. Payers take the risk, and if you're not willing as a provider to take the risk, you're going to get left with some unsavory things. So these doctors went out and said, Okay, we'll take the risk.We'll take on Medicare patients. Specifically, we'll take the high acuity ones. We think we can manage them better and really create a value proposition, and I was so proud of them. It's been discouraging for me to see that asthey've created this better kind of care where less of the money goes to the big payer.One by one I see them being bought out by other organizations. And let's not kid ourselves. Venture capital is really leaning into physician aggregation. And soI don't blame a doctor or group of doctors who created a wonderful a disruptor for them, saying, Okay, well, I guess I get to be a billionaire now. But I would like to see doctors continue to band together, Take on risk, cut out the middleman frankly disintermediate mediation of the insurance company, and stayed true to that, so you could pass the savings on to the patients and the doctors.Andphysician aggregation is the way to go we've seen with United and Optum exactly collecting more and more doctors. They saw this end game 10 years ago.  

Daniel J. Marino:

Yeah. Oh, no, that's true. that's true. Well, it's gonna be fascinating to see where where this goes. You know as more of these entities start to you know, either buy out these practices or just offer tremendous amount of investment dollars to these physician practices can be really interesting to see where it goes. 

Last question that I have. And it's a little off topic. But it's related. You know, we're we. We've spent time talking about the value to the physicians and what the challenges are. What about the patient? Give me your thoughts for the next couple, you know. Maybe the next 30 s or so. Do you feel like patients are benefiting from our transformation into value based care? 

Dr. Will Faber:

In some cases they do, and others not very much. One of the thing that strikes me is in the world of preventive care which I care so much about. We're often trying to get patients to do that which they don't want to do. They don’t wanna have a healthy lifestyle. They don't wanna get their vaccinations. They don't want to take the medications that we control their blood pressure and their lipids, and so on. And so it's a slog for us. If the patients would go along with that, they would definitely benefit in their health. But it's really quite a task, which is why you need an army of care, coordinators and care managers and navigators to help these patients do what is gonna be beneficial to them.   

Of course, one of the biggest things that helps in value based care is great access. Great access is wonderful, for patients. Wouldn’t it be wonderful if all patients could get in with the doctor's office when they really felt they needed it, or could get a hold of somebody on their care team after hours. 365.  

Daniel J. Marino:

yeah, I can't tell you how many people I talked to who have challenged, getting in to see their physicians. And it's not just a couple of weeks out is 3, 4, 5 months out. Well, we'll this is great discussion. I I'm so excited to have you on the show today, and to talk about these topics. You brought up some wonderful points. If any of our colleagues are that are listening today, anybody wannaget in touch with you, you know. Can you share your yourLinkedIn address or your email address? Or how could folks reach out and get in touch with you?

Dr. Will Faber:

Absolutely. I live in service, and I want to help as many providers out there as possible, do the right thing to help patients thrive and do well, and to actually make mebe rewarded better for the work that they do. I will provide all my contact information. I welcome anybody who's listeningto reach out. I'll get back to you as fast as I possibly can. If I can be helpful. 

Daniel J. Marino:

Great, we'll include those in the liner notes and again encourage anybody who's interested just to follow up with Will for future conversations well again. Will, I want to thank you for your time today, and also want to thank our listeners. Really appreciate you tuning in until our next insight. I am Daniel Moreno, bringing you 30 min of value to your day. 

Take care. 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

In recent years, the call for health equity has driven healthcare systems to champion better care and well-being of their patients and the communities they serve. However, this aspiration brings with it a series of social and cultural challenges. Join us in the latest episode of Value-Based Care Insights as we sit down with Vanessa Guzman, CEO of SmartRise Health, a healthcare thought leader on the frontline of change. Vanessa highlights the key priorities and challenges encountered by provider organizations and offers actionable solutions for effective integration of health equity into care delivery models. Gain valuable insights on leadership requirements, data collection, and what it takes to bridge the disparities gap and promote health equity.

• The pursuit of health equity requires strong leadership commitment, cultural alignment, and effective data collection.
• Quality care is only possible with equitable access to it.
• Top issues faced by health providers include budget allocation, health equity return-on-investment, and integration of health equity into existing revenue streams.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I am your host, Daniel Moreno. As organizations are advancing into value, based care. Of course, they think about a lot of the issues related to chronic diseases, and how they manage the population and stratifying risk, and so on and so forth. We we've talked about all of those items in depth on our program. But one of the areas that has definitely gained a lot of attention over the last couple of years is how health equities plays into population, health, and the management of patient care related to different types of health equity issues, whether it's lifestyle or social determinant factors, socio economic issues, a whole host of things that are out there. So health, equity definitely is an important factor. And not only is it important to the care that we deliver in our own communities. 

But it's gaining a lot of national attention. Last spring, some of you may know Cms released a lot of their framework for health equity, and then included 5 priorities which I thought were really interesting. They're sort of taking the perspective now of trying to create a little bit of a structure around what health equity is. And those 5 priorities focus on expanding collection data reporting. 2 is access causes of disparity. Priority 3. Is building capacity of healthcare organizations to really focus on reducing healthcare disparities within the community. Within the patients they serve priority. 4 is advancing language, access, health, literacy. Priority. 5 is increasing all forms of accessibility to healthcare. 

So again, I think it's a great framework. It's a great start. I think it touches on a lot of the elements that are important to help us begin to manage a lot of the healthcare challenges related to some of the inequities that we see within our community So, to help us talk through this today, I'm really excited to have a great guest, Vanessa Guzman. She is CEO of Smartrise. She works with organizations all around the country health systems, Acos payers, other partners to identify some key trends, such as health equities and many others, and she's done a lot of work on helping organizations. Think about what the strategies are to begin to kind of. Put some of these things in place and really provide a lot of the change management. Vanessa. Welcome to the program. 

Vanessa Guzman:

Thank you so much, Daniel, for having me. I'm excited to share and exchange some thoughts with you. I think this is a really important topic, and we're often frazzled with where to start so hopefully, we can shed a little bit of light today. 

Daniel J. Marino: 

Well, thank you. I agree. So maybe we could start with what you're seeing with some of the top issues, with some of the healthcare providers around the countries, particularly those that you're starting to work with, who maybe come to you and said, Look, you know, we're interested in advancing some of our health equity initiatives. What do you see? Are some of the top issues that they're struggling with. 

Vanessa Guzman:

yeah, I knowDaniel, I think they're pretty. They're pretty standard across right, even regard it regardless of size and resources.They're key challenges that are coming across the old stakeholders. One, for sure, is the appropriateness of allocating budget and resources. To the topic of health equity especially when there's, you know, already, limited resources, limited reimbursement, and folks are trying to understand. You know, what is the Roi associated with making such investments. So that'sprobably one of the top reasons we see as a barrier to implementing.

Daniel J. Marino:

And that's a big one, I think, particularly in population health.When you're when Cfos are being asked to invest in capabilities, you're investing in things with the idea that you know, hopefully, you'regonna prevent them from occurring. That's hard to be able to wrap anroi around it. I think in health equity is as you mentioned. I think it falls in in the, in the same type of perspective, where it's hard to really invest in it. Hard to get anroi. 

Vanessa Guzman:

Absolutely. So we try our best. Our model really is designed so that it connects with existing revenue streams existing infrastructure. Sothere's the least amount of resistance like, if you connect health equity with quality is probably the best starting point, just because if you participate in any value based contract or MIPS, or any other, any other similar program like shared savings, there's at least the fundamentals to build upon it. I mean, I see health equity as a more tailored, more specific approach to improving quality of care. I think one can't exist without the other. And that's if we bring that mentality forward. I think there's a lot that we can do.  

Daniel J. Marino:

Yeah, that's a that's a good point. How about some of the leadership requirements? What are you seeing in terms of maybe the culture alignment. I can't help but think that that this is really, you know, in some cases could be really a paradigm shift for how leaders think about serving patients within their community and kind of breaking down some of those disparities.

Vanessa Guzman:

Yeah, for sure. I mean, most of the leadership, eitherleadership teams that are being assembled or those existinghave stories right? Like myself. Which is why we're in this business, which is why we wanna see things change over time, and that gives them the motivation and the knowledge of what community should we serve? What type of data do we need? How you know, how can we mobilize our resources to do the right thing while still keeping the lights on? Because that's our main responsibilities. If you oversee any health system or pay your organization. But I thinkbecauseit's everyone's responsibility. Part of leadership's role is also tobuild that culture of equity that you reference by having the tricky dialogues that we need to have around?Why do a a disparities exist? What are the root causes of disparities in our organization and the population we serve without understandingthose gaps is hard to know where to start.  

Daniel J. Marino:

Yeah, yeah, I agree. You know many organizations over the years have invested a lot in, let's say, different levels of accessibility. Right? I think the really brought that to our attention and force organizations to make changes. But if you're if you're really gonna be addressing a lot of the health inequities that are occurring, I really feel like you need to do more right. You need to really expand that accessibility area. What do you see are some of the challenges that that our provider partners are struggling with?

Vanessa Guzman:

Yeah, the probably the probably the number one is around data collection, and when we hear that term being used, we immediately think Hr.Discrete fields right? What we know biometrics. But we're talking about engaging members and patients and their and caregivers and families right? In a dialogue, so that they understand why we're asking some of these questions, how this information is being used.And, more importantly, how is it clinically relevant in meeting their needs. I mean, that's really, ultimately what patients want or seeking and that's, you know that that process of collecting datadoes include it infrastructure, you know, caregiver experience. And asking some of these questions and education forward to the patient. So I think the data piecewhich sheds light right to what is. The problem we're trying to solve isis probably the number one challenge at the moment. 

Daniel J. Marino:

Solet's dive into that a little bit. Because again. I I'm a huge proponent that if you can't get the data, if you can't measure what's occurring, you can't impact the change. When you when you think about the data, where does the data come from? Does it developed in terms of the providers getting it? Is there ways that you can get some of this data from, let's say, the quality of the claims data. Or is this externallyexternal data that we need to bring in?

Vanessa Guzman:

Yeah, I think that's a great question. So if we focus our attention and standards of care that have been developed by some of the measurements towards like the national community of quality. Like Ncqa, for instance. the common denominator is collecting demographics such as race ethnicity, language, sexual orientation, gender identity, disability, or abilities just to start right as to start and then integrating that into existing quality measurements that providers already generally have in their Ehrs. If there's especially if they're already reporting on quality measures and heat as measures. Most organizations start there and then apply some of those demographic variables deep, diving a little bit into like, well, you know, are there differences in how different races engage in flu shot right? Just to make something up, or blood pressure control. 

So the data is, is somewhat there to some extent, because you should be most of providers already reporting it. The demographic piece it will require additional questions, but a lot of the providers already had some of this data as part of registration, for instance. But where we see the biggest gaps is especially in Gen. In sexual orientation, gender identity. And the challenges with asking those questions sometimes become tricky because some patients are not ready to answer. Those questions are not certain why they're being asked the questions and also culturally, they're not ready to engage in that type of conversation. And that becomes, even trickier for providers to feel comfortable asking those questions. A lot of it, because it's a lot of misinformation out there and building trust with patients is key is not just asking the questions.  

Daniel J. Marino:

Well, and it could be a bit of an uncomfortable conversation. Right? 

Vanessa Guzman:

Absolutely.

Daniel J. Marino:

You know, I can't help but think. Let's say, if a patient has challenges with transportation, right? Soyou're asking the question, you clearly want to capture that I think many providers feel like if they get asked that question, they have to do something with it.

Vanessa Guzman:

Right, So the second part is if you know something, do something. And that's where community resources come into play. Right? If we're talking about social determinants of health screening questions like the prepare, for instance, and many providers ask. My suggestion is always start with maybe a couple of those questions. So once where you have an immediate resource, or an immediate support, or a referralor a partnership out there. Don't ask all 10 questions, if you know we're not there yet, but also start with the questions that you know are most relevant to the population.If you have, you know, social workers or other or other form of resources. It's important to recognize what you're able to do and what your capacity is to support some of that work.

Daniel J. Marino:

If you're just tuning in. I am Daniel Marino, and you're listening to value based care insights. I'm talking today with Vanessa Guzman. And we're talking about the issues facing provider organizations as they advance into health, equity, and the delivery of that within their patient care model. 

So when we think about those questions, and that's a great point. Right? So start small, start impactful and then and then kind of build from there. Is, you know, is, is there? Is there training recommended, is there? II would think there's got to be approaches in terms of you know, 2 types of training one. How do you ask the question, gather the information, and then what do you do with it? Right? How do you put it into? How do you put it into the care model? So it becomes relevant to your outcomes or your performance, or, frankly, just helping the patient.  

Vanessa Guzman:

Yeah, absolutely. And that's part of change management. That's the second, probably most common challenge Daniel that we see with integration. And so we certainly recommend training for caregivers, but also training for patients and their families, because, like, I say families, and because it's so important thatthe patients seek resources wherever they feel most comfortable. And sometimes that's their family. Especially when we're talking about people of color. That'sprobably the most predominant resource that they have.But there's also has to be work flows established, so that everyone who's engaging patientsis following the same mantra right? And following the same lighthouse. Because then, with consistency, we have the ability as a system to say, Do we need to modify?Is it having the impact we're intending to have? But still having that personalized touch that each person as as individuals bring to the table, which is beautiful, at which attracts patients generally to payers and health systems.  

Daniel J. Marino:

Yeah. And frankly, that's what I think many physicians appreciate right? You got to incorporate it into their own practice and connecting with the patient. So when you're working with organizations around the countrywho's taking on this responsibility? Kind of a leading the charge within health equity, is it? Is it the medical officers? Is it the chief nursing officers? Who are you seeing really leading the charge? Within the provider organizations.

Vanessa Guzman:

We see a lot of new appointments with health equity officers these days. Which may be new leaders into the industry, who have been proven to be superstars and other areas like quality, like medical officers, or even community health workers right in the community partnership piece.But they all have something in common. Generallythey're people of color. Generally, they're people with lived experiences and diversity, but also they have some sort of connection or social connection to the community. And I think thatit's intended to build trust right across the organization from a person who who's likely have lived through some of the challenges that they're we're trying to solve to for the patient. But the challenge we see there is that these folks are often not given enough resources to do their jobs effectively, because it's not a one person joband so where we come in generally to help iswhat type of roles and responsibilities do we all have the collective, we in the organization, although there's some centralized function, perhaps, that this person plays. 

Daniel J. Marino:

Yeah, that's a that's a great point. We've done a lot of work over the years with community health organizations and really bring in Karen to the community, particularly with social workers. And to your point, social workers have really struggled with the right level of fundingto not only help the patients, you know, when they're in the office, but to kind of address. A lot of those other out issues that, you know frankly, may even have a more significant impact on the overall health of those patients. But it, it does come down to it does come down to the funding. So when you think about that level of investment, if an organization is really thinking about moving forward with putting a lot of these health equity initiatives in place.Where does the where does the investment start? Doesn't start with the data? Does it start with training? Does it start with maybe hiring an individual to kind of lead the charge?

Vanessa Guzman:

Right. It. It all depends on where the core. Competencies of that organization exist right, the path of least resistance. But generally we recommend it look at the area that already generates revenue, like, for instance, quality and many organizations have relationships with payers, for instance. So there could be potential collaborations between the payers and providers to identify well, how can we share resources so that the investment is intelligent and smart, and goes a long way because it's now but a bit more collaborative. But I would think. There's 3 areas that I would recommend. Investing the collective “We.”  

One is in data infrastructure collection engagement, patient engagement. Everything we talked about. 2, I would say investment in leadership, and organizational structure. That means making sure that the workforce is very much representative of the population, that you're serving, that there's accountability structures that you're able to report on. What are the disparities and understand what is the problem you're trying to solve? Right? And then 3, making sure that you have sufficient funding to now close the gaps right. So there is beautiful disparities that are that are not beautiful at all. And we often try to normalize, because, you know, that's just how what makes sense and is comfortable to for most of us. But you know, I think looking at you, just investing dollars in those 3 areas is is really where we all start. You know how we go about. It could be differently through assessments, data, whatnot. But those generally are the are the 3 ones, and where we see gaps is is, is making sure that there's culturally and linguistically appropriate services available as we tailor right our programs to patients. So that I is the big ask for me to all of you listening. But that gets integrated into whatever your plan is. 

Daniel J. Marino:

Yeah. Those 3 points, I think, are absolutely right data leadership. And then, you know, just having that that funding path, I think, is really key. So when you're when you're working with organizations around the country, and we see this all the time in the work that we've done. We've you know, we work with folks in the in more of the rural areas. I have a number of clients in Western Nebraska and done a lot of work in South Dakota as well as then the heavy metropolitan areas, right Chicago, New York, and so forth. I would think, and more than I think II know that the health inequity issues are. Some of them are the same, but some of them are very different between and rural. 

What are you seeing there in terms of those types of disparities? Are? Are there some clear differences, or do you kind of approach it? The same? Because again, we're trying to solve a lot of those same issues across the gamut of health, equity.

Vanessa Guzman:

Yeah great question. When we look at studies across the country, we see that metropolitan urban areas. Have more, have more health, equity gaps or disparitiesin you know, clinical diseases, such as asthma and hypertension and diabetes.Those highly dependent on things like food access or access to healthy food, and stable housing and finances, whereas of those residing in rural less connected communities. We see more challenges with things like behavioral health and substance abuse, alcohol use. And I thinkwhere the gapsreally fall apart is that each of these settings have limitations, right of different things, whereas of like rule settings have challenges, things like transportationin urban areas, you have such a diverse group generally of people of color. That, you know, is not homogeneous, right? So it's not like a one size, fit all approach to the work that we do when it comes to things like food access. Because, culturally, and even linguistically, that changes right. How those conversations, and what diet and exercisemeanstotally different things for these different groups.

Daniel J. Marino:

Great point, I mean, you're you are spot on. So I guess. Really, looking at some of those drivers, those factors that are really important in in your particular market, your particular setting. And you know a. Again, I think, trying to create that path. The plan to really address some of those. But it has to be very different, right? It can't be a one. 

I would also think that there has to be some culture norms that come into place as well right. You know when, when you think about different areas of the country. You know, there's some areas which obviously are much more conservative than other areas. And you know how you communicate and how you train around. That. I would think has to come into play.

Vanessa Guzman:

It's and it's different. You know, we work with in settings where gender affirming, you know, roles and resources can be tricky just because of policy making and regulations that are different, for instance, in those States. And they in those clients they hesitate to use the term health equity, because immediately gets shut down. So we really promote that is, really it's how, how is health equity relevant from a clinical perspective. And if we all look at it without making this political, just making it about the health of the patient. And what does that mean?Then you're strategically positioning your organization for success. Right? That that is, that is the key cause. It's all about the health of the patient, and good quality of care cannot exist without equitable access to care.

Daniel J. Marino:

Yeah, you're absolutely right. And you know, it's if you're doing a good job. I'm trying to incorporate lifestyle information, really understanding what's occurring with not only the patient but within the community raising the overall care of patients within that community. So II agree with you, II think we really need to focus on and removing ourselves from some of the political aspects and breaking down some of those challenges really about what's in the best interest of the patient and really building that into your overall care model. 

Well, this has been. This has been great, fascinating discussion. Obviously, it's an area that I have a lot of interest in if you were to give some advice to our listeners. II know many of our listeners are just starting to get into health equity, start to understand how they can incorporate this into their care model into their focus around value-based care, any pieces of advice that you might be able to share? 

Vanessa Guzman:

Yeah, absolutely. The first, the first part is understanding the communities and populations that you serve, no matter where you're at. You need to understand that so that you can make the most efficient use of your dollars and time. And you can use all the different data types that we discuss today and sources, or, you know, using quality heat as measures as the starting point. The second piece of recommendation is making sure that the leadership is accountable for making the right investments without the necessary budgetary app allocation, whether is of centralized resources like an officer or resources, the closest disparities, you're just talking a good game. But ultimately you're lacking action. Then the third is having dialogues right? We don't have sufficient dialogues with our partners whether there's payers or community providers, and that is so important. So I encourage having those tricky conversations, because without that we're really never going to get to the root of what is most important to us. 

Daniel J. Marino:

Yeah, you're really never going to advance a lot of the health equity initiatives.You'regonna be stuck. Well, Vanessa, I can't thank you enough for joining me today. Great discussion. If any of our listeners have questions or want to follow up with you directly. To share your information?

Vanessa Guzman:

Absolutely. You can visit our website at www.smartrisehealth.com.We're also on LinkedIn. And my email is Vanessa@smartrisehealth.com. SoI wanted to thank you so much, Daniel, for the opportunity to share these insights. And in our websites, you'll find a ton of resources that hopefully help you understand where you can best startbut also resources that can really help advance where you're at today. So I thank you for that.

Daniel J. Marino:

Well, thank you. II really appreciate it. And you know, obviously a very important topic. As we move forward? So thank you again. I also wanna thank our listeners for tuning in today. Certainly do appreciate this. And until our next insight, I am Daniel Marino, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

Electronic health record (EHR) systems can be powerful management tools, but using them improperly can present challenges for physicians and patients. In this episode, we dive into the role of EHR systems in support of value-based care. Our guest, Dr. Kim Furry, a seasoned orthopedic surgeon and an Epic-certified Physician Builder, unveils the intricate challenges physicians encounter while building and augmenting EHR systems. Discover time-saving techniques, the importance of data quality, and enhancements that can improve physician efficiency and patient care.

KEY TAKEAWAYS: 

• Physicians spend a significant amount of time on EHR tasks, like documentation and management of alerts and messages, diverting valuable time from direct patient care.

• The performance outcomes in healthcare heavily depend on the efficiency of the EHR system build and usage.

• Customizing EHR systems to suit individual workflows is central to optimization, however, focusing first on data integrity and quality is imperative.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. As we've discussed before, certainly around position, well-being, and improving position. Well, being one of the areas that it tends to be a big challenge for physicians is the use of their Ehr, and it's not so much I think, using the functionality. The EHR. I think, as many physicians have gone through the implementation over these past, many, many years, they view they they've learned how to use this system. The EHR. And have learned how to, I think, delivered patient care both within and around the EHR. So that's a good thing. However, the EHR has definitely continued to create a lot of challenges for physicians and I think those challenges have come in in in a couple of different areas. I think one is that positions have and continue to spend a lot of time in their EHR documenting activities, working through messages, managing alerts, and so forth, all outside a lot of the direct, patient care, activity that they have either within their clinics or with patients. And that creates a lot of challenges, and frankly, a lot of dissatisfaction for physicians.  

I think the other thing that we see here, too, is because, as we think about value-based contracts, there's a lot of performance outcomes indicators and so forth, that are really dependent on the EHR we extract all of those data points. We extract all of those outcomes from the HER, and we use that to not only track the care that we're doing to patients, but we evaluate the performance of our value-based contracts. So if information is not entered appropriately, then physicians may not necessarily get credit for the good care that they are providing. So I'm really pleased today to have a soon to be strong physician, builder in epic somebody who we worked with for a number of years. Dr. Kim Furry. Dr. Furry, is a board certified orthopedic surgeon. She right now is going through a lot of epic training. She's worked on epic for many years and is becoming an epic builder really to support some of her colleagues. And with the idea that really, we're going to enhance a lot of the functionality of the system. Kim. Welcome to the program. 

Kim Furry:

Thank you, Dan. It's great to be here.

Daniel J. Marino: 

So, Kim, you worked on epic for a while, and you've heard probably a lot of the challenges and the complaints and dissatisfaction from your colleagues. From your perspective. What are some of the leading challenges that you see from physicians that really iskind of standing in the way of them, practicing efficiently, either through epic or another. EHR.

Kim Furry:

I think many of the challenges are basically the time that you spend in any EHR, and it seems like it depends on how you utilize the EHR. But some physicians are spending, you know, concentrating on the EHR. During the current visit as well, and instead of attention to the patient. This is a complaint you get from any patients as well. That the doctors just looking at their computer and typing away and not really paying attention to me. So that's a big challenge, I think. Is that patient interface. And the time is a big one, I think and taking that time upfront. We may talk about this later as well to customize it so that it works for you. The EHR could be a big burden, but it can also be a big time saver if you take the time to customize it. 

Daniel J. Marino:

Yeah, I definitely think that as we as you think about creating efficiencies in the care delivery model, the EHR can certainly help right? So if you could be, if you can connect 

better connect the physician with their with their clinical assistant. Obviously, that helps if there's particular integration that occurs with the specialists that would help. But there's integration that really, that occurs with maybe the lab result right or some other radiology report. I think that would help. But it is really dependent on that integration. And I sort of feel like we're still at the point where that integration is really not efficient. 

Kim Furry:

No, you're right, it's not efficient, and I think it also depends on the system you're in. 

Many people have, you know, it's a contain system like Kaiser, or something like that, where I'm getting my labs in a Kaiser lab. Geyser probably is similar. I don't know exactly. But you're all your specialists are in Kaiser. All of your labs are probably in Kaiser and that's probably more integrated. You know where I am in Colorado. It's a 20 hospital system with a few in Kansas, a few in Newton, the rest in Colorado. But we get our labs at very many different places. And so those getting imported into our HER is not very efficient and they don't communicate so well. The same with reality studies and imaging reports and things like that getting those uploaded into our system so we can look at it directly, is burdensome on the staff. 

Daniel J. Marino:

and not always doesn't always occur rightright? Right well, and I think tying that then in with even the in basket management, also is a big challenge, you know, early on, and probably I want to say, the mid 2000s. And for about 10 years after that we did a tremendous amount of EHR implementations. And we really focused on incorporating physicians. Physician super users to design the system that really works well for the physicians practice style and basically integrates a lot of the efficiency that are important, but I can remember it was probably about 4 or 5 years ago. I was talking to one physician and he brought up an interesting point, he said. You know, Dan in basket management is probably the biggest challenge that I have right now. It probably adds 3 additional hours to my day. And I was like, Wow, I mean, that to me was just was unbelievable. And you know, physicians put in a lot of time anyways. But then adding in 3 more hours to their day, clearly takes away from their personal time right time that they could spend with their family and just real challenge to keep up.

Kim Furry:

That's huge, I've been on epic for 8 years now, and my first start practice in 2000, you know. The MA would come to me at various points in the day with a number of messages, and I would respond to those messages, and then boom! You know that that took minutes at the most. And it was it was done. My part was done occasionally I had a follow up with calling a patient about something but for the most part she'd asked me the question I'd answer. I'd give her an order, or whatever calling this prescription, she would call it in. I wouldn't have to sign off on anything. And that was very efficient, I think you know. And remember that 3 hours that you said on investment management at the end of the day that doesn't include all the other documentation and other work that he had to do. It was administrative or chart review, or notes written for school release, or whatever it is right. Authorizations. 

Daniel J. Marino:

Yeah so when you add in all of that, oh, my goodness, if you have a 6 or 8 h clinic. You'reprobably spending another 4 h at least on top of that.

Kim Furry:

Exactly. So. I think people can build. There's a couple of things I have to say on that one about 3 years ago, probably our system. My healthcare system, the the medical group kind of went through and created a bunch of different rules on what we might want to keep and not. And we deleted like hundreds of thousands, maybe even a million. I can't remember the number, but it's hundreds of thousands of in basket messages that we're sitting in people's in baskets to just get them out there and try to clean it out and start with a cleaner slate right? And then what really needs to go to the physician? What can go to an Ma. Or a nurse to try to create some triaging capabilities there and then, if you take the time again, it's taking the time upfront, which is going to save you a bunch of time on the back side to build quick actions so that, you know when you get an abnormal lab, I'll just give one for me. I would be as I do, some mossy process Karen for Julie, for extra care, and so I would check vitamin d levels, and I had, you know, patient vitamin d level was such and such no change. So I have a quick message. I just have to click one button, and that message would go to MA. So I'm to keep taking the same vitamin d level. If I wanted to go up to 2,5000 one button for each of those it would go to the MA. It would sign a note, and the ma would call in that prescription or calling that recommendation, right? 

Daniel J. Marino:

So it seems like a lot of the efficiencies that you've experienced really comes down to how the system was built?

Kim Furry:

somewhat, how the system was built, and then those quick actions are how I built them. Right? So the system allows thatmy system is built such that I can do that, and you know EHR's are not one. Size fits all. You buy the base. You may buy different modules for the Phoenix, for oncology, for cardiology, whatever it is. But your system has to buy those modules. But when you buy it, it's still kind of like the basic build right? And your own system. Builders will customize that to any, customize it and improve it to improve the efficiencies.

Daniel J. Marino:

Right.Yeah. So you just can't get the module right. I mean you really, from what I hear you say, you really need to take the time to build it correctly. You really need to take the time to figure out how you can create efficiencies in a new care delivery model, integrating with the EHR. Not just by the module and hope. It's a panacea.

Kim Furry:

Absolutely, and it's not just you customizing it for your work flow. Your system has to customize it for your system as well. And I've been on the so epic has. So that that dissolves, or that gives you an idea of who I work with. For my Hr. But epic has these steering committees and steering boards really for the different specialties. So for the last 3 years I've been on the stream board for orthopedics, and that's a group of orthopedic from around the country, and we give epic ideas on what things they should build. And so there are some things that we've all customized in our own institutions, But what we're trying to import upon them is the importance of building some of these things for the system itself, so that when somebody purchases the bones component. Then some of these things are pre-built into that bones component, and the system itself doesn't have to reinvent the wheel right?  

Daniel J. Marino:

Right. Right. Well, if you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today talking with Dr. Kim furry. We are discussing. Both the challenges and some of the opportunities around maximize performance of your HER and Kim so is yourisyou're talking about the build in my mind. I guess it comes down to 2 things, one the system needs to be built appropriately. So it does create efficiency. So you're not actually putting in a lot more time. But you're creating some efficiencies both to improve patient care and obviously to make it easier for the physicians. But I think the second part of the build is around how we're capturing the data I can remember early on when we were doing EHR implementations, you know, for instance, if we were capturing and he will go in a one C result of a patient one, the naming conventions. We're all different. 2. There were probably 2 or 3 different areas where we could put it into the EHR. Has that resolved itself, or is that still an issue? 

Kim Furry:

I think it's still an issue. I think the problem is, we can only find the data that's in this discrete data field. So even if I'm even if I'm writing a note right? Say, I want to do research on total recovery and range emotion, or whatever it is right. Whatever I want to do for total needs. Unless I write my note in what's called note writer, and I put the range motion and note writer. I will never find that range of motion. So if I just have a smart phrase and I dictate the range of motion this visit, or I type it in. I'm not ever going to be able to retrieve that data. Likewise many of the quality metrics that we need, especially from a hospital standpoint. It's largely related to revolves around nurse. It's nursing dependent in there. And so if I say my note something about it coty catheter associated urinary infection. but it's not in a flow sheet somewhere that's never going to be 5. 

Daniel J. Marino:

So even though you may be doing it, even though you may be performing it. You're not capturing it appropriately. So as you start to extract the data, you're not going to know you're not. You're not going to be able to get the results. You're not going to be able to get credit for the work you'redoing 

Kim Furry:

Exactly garbage and garbage out. So if you're not tracking it correctly, and have it mining. The chart notes is super hard mining, the data discrete data fields much easier. But some of that stuff is there either doesn't exist to this week data field, or it's missed, or it's put in incorrectly, or whatever and some data will be missed. 

Daniel J. Marino:

Well, one of the things that I've heard you say, a number of times. You really need to build the system to ensure that you're trusting of the data and many of the physicians 

Struggle with that right? So when you pull reports, they don't believe the reports, and I think some of the reasons why they don't believe the reports is they feel like. Well, it's not a good representation of the care that I'm delivering to the patient. 

Kim Furry:

Right. That's exactly true. And even if you look at surgical time. So you know. Say, acl time is on average 55 min or something like that, right? And we're trying to create my surgical block time. But in reality I put in. I put in a request for an acl plus repair and a level minuscule repair, so that takes my 55 min for each one of those and creates my block for that case. At what 100 1,500 min? 50 min right? Which is really not the case, because that doesn't include everything for each of those cases. And so when they try to tell you that this is your Olympic averaging. We're going to schedule this case for 3 h. You're like. No, it'sit's not a 3 h case, you know. Little example of where the data misinforms downstream effects and then has a big problem there. 

Daniel J. Marino:

So when you're when you're working with physicians, you know, and I know you're just starting to get into this, I give you a lot of credit for now diving into to a lot of the the epic training and becoming an epic builder. I think that's I think that's fantastic for the for you and the organization and your colleagues. In your mind. Where do you see starting, or, let's say, better integrating with the physicians or with the system to enhance some of the bills? 

Kim Furry:

Daniel J. Marino:

so maybe the notifications are certainly one area, right where some improvements. 

Kim Furry:

Notifications, building of order sets can be improved as well. And become more efficient you know, pre checking some of the things and only showing the pre-check, having things so that they're not all fully expanded. So you don't have to scroll scroll scroll, so they're all collapsing. If you want to go into this particular order or this part of a note, you know, like our so notes. For our build, you know, the subjective, objective or always end plan are always collapsed. So when you want to read the subjective, you can just open that up and same for the objective or the assessment plan so less scrolling, less clicking, those types of things. 

Daniel J. Marino:

So when I was working with one of my colleagues not too long ago, and he's in a similar role, kind of an epic position super user. One of the things that he really focused on was reducing the clicks, the unnecessarily non-necessary alerts, and in some cases he actually turned some of the notifications off for the physicians. Is that something that that you see as a benefit that that other folks should look into? Or is it really a case by case situation per physician?

Kim Furry:

No, I think also, some should look at it. I think there are alerts that shouldn't fire. I think one of my phone all just said in order to kind of finish reading a sleep study, or it wasn'tremember what it was, but he had like 30 some clicks to do that. When I mentioned it to 1 one of the builders, I wasn't a builder at that time. And you know they were able to get that way down. So I think less than 10. So you know, what we don't know. We don't know, either. And so people have to bring some of their issues to us, and then we can optimize some of that workflow as well over time. 

Daniel J. Marino:

Yeah. Well, and again, I think to have somebody like you that that is an epic builder that you know begins to get trained. And really, you know, you sort of build those internal capabilities. I think that's all important. Many organizations. And we used to see this all the time when we were going through our EHR implementations. You don't know what you don't know to your point, right? So you don't know what the system can do for you to really enhance your clinical workflow. So a lot of times what physicians do, or what organizations do is they build around what they know, which is either a previous EHR. That wasn't very efficient, or maybe their paper environment. And I, even though many organizations have been on epic, for you know. 10, 20 years. In some cases, I don't think they've really gotten past that. I don't think they've really gotten past the point where that efficiency has really been built into their clinical work workflow, using epic or Cerner, or any of the EHRs as a tool to, to really enhance patient care. 

Kim Furry:

No, I agree completely. I think you can make it. You can make the order says you can make. The Vpa. Is somewhat dynamic, right? So if somebody's allergic to penicillin, and you have this order set and it recognizes patients allergic to penicillin. It's not going to give you the penicillin options. It's going to give you the alternatives and say that there is a penicillin algae, and these are the alternative antibiotics. They're not allergic to penicillin. Then that's not even to show up. They're just going to give be given the option for penicillin,

Daniel J. Marino:

right? So the system, like, you know. If I can try to, then the system becomes intuitive right to what's occurring to with the patient, but also then it's better informing the physician.

Kim Furry:

Correct exactly. but you have to build it such that it does those dynamic the charts and recognizes something. 

Daniel J. Marino:

Yeah, build the algorithms and and all of that. So so far, listeners today, you know, are there in in your experience? Are there a couple of quick wins? Are there a couple of key things that maybe folks should be focusing on that that would really help the physicians? Efficiencies. And and really, maybe the satisfaction with the HER.

Kim Furry:

yeah, I think so. I think taking the time to customize it for yourself. I know it takes time, and nobody wants to do that at the end of a busy clinic. What I would say is, when you first start on an HER.Isa time to start that customization process, because most of the time when you transition to an EHR. Your clinic schedule has been shortened quite a bit to give you time to kind of work through that. That doesn't last for very long, and most people are just trying to find their way through the woods and weeds at that point in time, so they don't take the time, but very as quickly as you can, and even if you haven't done it, starting now take 30 min a week and take your top diagnosis that you think whether it's Chf. Or near arthritis or whatever it is, and create a plan, create a patient information sheet create a physical therapy order for your Pt. Whatever it is. Create a order set that's customized for your totally pre-OP and host out. Most of them come with a pre opt totally, and a post office totally, but you need to customize it for your yourself. You know. Pre-check the buttons that you want. Check to me to put your name into the physician. You need to put your hospital into the location and if you take that half hour once a week for your top 10 diagnoses in the course of 3 months.You're going to have most of it built, and that's going to save you hours literally on the back side.  

Daniel J. Marino:

Yeah, I love that. Yeah, II really do. II think that's great advice. I mean, take, you know. Take a look at your top diagnosis. Codes, take a look at and really focusing even 30 min a day, probably time well spent to invest in in improving a lot of a lot of the activities there and then, what about the data, Kim re real quick? Is there some things that organizations can do to run some reports that validates the data that they're putting into their Hr. Reflective of the care that they're delivering. 

Kim Furry:

I might put that question back on you.

Daniel J. Marino:

Well, I would say yes. To tell you the truth, we negotiate a lot of the value based contracts and work with a lot of the payers in the organization. So I would say, Yes, build, or you know, do your checks and balances to make sure. That you know the data that's being entered is clearly reflective ofof the care that's being delivered. So II couldn't. II definitely think that that's the case.

Kim Furry:

How does that occur that I don't know how that occurs. I don't know how we can validate some of that data without a lot of manual work

Daniel J. Marino:

Well, this has been fantastic, and I know it's a topic that is top of mind with many of our listeners, particularly our physician listeners. If anybody has questions for you any thoughts, anyways, that they can get a hold of you?

Kim Furry:

Yeah, absolutely. Email is probably the best or text. Me call me, either those are fine. My cell number is (970) 903-7540. And my email is, Kimfurry@cetura.org. 

Daniel J. Marino:

Wow! That's great. Well, again, this has been a great discussion. And again, I think congratulations to you, taking the initiative and moving forward with these certifications and becoming a position builder in epic. II think you're going to be great. You clearly have the passion for it. So thanks again for coming on the program. Really appreciate it.

Kim Furry:

Thanks for having me. It's been great.

Daniel J. Marino:

and thank you to all of our listeners for tuning in today. Really appreciate it until the next insight. I am Daniel Marina, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

Today, medical groups are grappling with financial challenges due to the pressures from limited access to providers, private equity, declining reimbursements and rising costs. On this episode of Value-Based Care Insights, Daniel J. Marino sits down with colleague Lucy Zielinski to discuss the opportunities associated with forming strategic partnerships for clinical service lines. Learn about the nuances of service line trends, structural goals and the distinct approaches for primary care and specialist service lines.

KEY TAKEAWAYS: 

• Types of strategic partnership to drive improved financial performance.
• Health systems are managing continued pressure from private equity.
• Consider different types of reimbursement structures based clinical service line performance.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value based care insights I'm your host Daniel Marino as we look around the country and see some of the changes that are happening with medical groups whether you're an employed Medical Group or an independent Medical Group we're seeing a lot of pressure being placed on either health systems or these medical groups related to some of the challenges competition that's coming into their market with private equity or let's say specialty medical groups such as cardiovascular services or gastro or even cancer not being able to sustain their financial performance like they used to and the interesting thing that that we're seeing right now is the pressure that's being placed on these special medical these specialty medical groups are really coming from both sides so the pressures are coming from the payers wanting to obviously lower the reimbursement those pressures are coming from shifts inside of service not so much from shifts in value based care although some areas of cancer and some of the specialty service lines we are seeing a little bit of pressure from value based care from the payers but mostly from fee for service but we're also seeing these pressures what I would call from bottom up which are really the rising costs and some of these specialty care physicians and even primary care for instance aren't able to maintain their incomes like they used to, or their practices are really financially challenged so it's forcing them to look at different alternatives. whether that would be going private equity becoming employed by their hospital or maybe even joining another larger independent Medical Group. 

Well interesting topic one that we've been spending a lot of time talking to hospital leaders around the country and here today to help me with this conversation talk through it a little bit is my colleague Lucy Zielinski. Lucy welcome. 

Lucy Zielinski:

Thank you Dan thanks for having me.So Dan I'm going to flip the tables on you you're the host of the show and I know you've been doing quite a bit of work in this space recently we've had several clients that you've worked with them on some specialty service lines as well as supported many health systems in their strategy to system this you know as you know organizations healthcare organizations these days really want to grow their market share and really improve it quality and and lower costs around value based care So what have been some of the trends that you've been seeing across the country as an as it were as they relate to service lines? 

Daniel J. Marino: 

Yeah it's interesting when you look around the country it's a little different in each of the markets but it's also different by the different clinical specialties so for instance as we know a few years ago when they changed Medicare changed to be in person with cardiovascular services the year that followed was a tremendous amount of movement towards or shift towards employment for cardiology right so even today there is very few independent cardiology or cardiovascular groups are they're really employed now we're seeing that that continued trend occurring on in other specialties. 

So for instance orthopedics if you will they're not so much becoming employed by the hospitals but what we're seeing is private equity coming in and offering these big dollars to take over the groups and it's part of their strategy to shift to say in more of an AC type of a structure or something in that regard also seeing a lot of shifts and changes in gastroenterology and cancer as well and as I said in my opening remarks a lot of it is because of the cost pressures so I I would say that the biggest trend right now is with private equity coming in the market second to that is some of these nontraditional providers like Walgreens on optum has been very aggressive in this space and a few of the other nontraditional providers coming in and employing or purchasing these practices and then third they are looking to either the health systems or other independent groups in their market to merge or to form some type of joint venture. 

Lucy Zielinski:

Mm-hmm and Dan I think many of these health systems are achieving this systemness through strategy driven service lines and what do you what do you think are those goals those top goals for these service line structures?

Daniel J. Marino:

Well yeahyou're right I think that the system is that we're seeing here is taking on a couple of different forms it's not necessarily employing these medical groups it's creating these strategic partnerships.soit's not it's not a single solution like it was a number of years ago when cardiovascular became employed so we're seeing different types of strategic partnerships and that's important to understand within the strategy as leaders are thinking about how to protect the particularly the specialty services within their within their community.So you know I think your question is a good one what at the end of the day what's the goal? well the goal is to make sure that you have a sound relationship between the specialty providers especially if they'reindependent right? these cancer anthology groups for ENT groups or orthopedics. if they're independent you as a hospital leader want to make sure that you have this strong relationship and even for the leaders of these specialty service lines or these independent medical groups you also want to make sure that your financial position is protected.So the goal is to create the relationship but you have to do it in a way that it's a win right focusing on growth focusing on cost management focusing on ensuring that the financial performance and even the well-being of their physicians if you will are really improving and not necessarily creating more pressure on these individuals.

Lucy Zielinski:

YeahDan and I think quality is probably another one just really improving those clinical outcomes as well as that patient experience because as you know when you have a whole bunch of groups doing the same procedures there there's a lot of variationthey're doing it different ways so clinical variation I think is definitely a challenge with multiple groups.I think this is where service lines come into play as well

Daniel J. Marino:

yeah you you're absolutely right and focusing on clinical variation reduction is important certainly when you think about shifting to value based care but also in managing costs.The other thing that I think is a big driver here Lucy is these strategic partnerships that you begin to create helps you solve the access issue and right now there is a significant under supply if you will of physicians of providers by clinical service lines, and there's an over demand by patients right I mean in some cases orthopedics it takes three months to get in to see an orthopedic physician because you know we're working with one cardiovascular group right now and it it's close to 60 days to get for a new patient visit.That's not sustainable.So by creating these strategic partnerships andand allowing the availability of more resources and it's not just human capital resources but it's technical resources you help to create the strategy to improve access. and that has benefits all the way through the health system. 

Lucy Zielinski:

Yeah then and I think another point too is you know the physician burnout right and I think IT service lines really involve physicians so they're more engaged and there's better alignment and they aim at better quality improvement.Because you haveteam working on things now.

Daniel J. Marino:

Yeah you're absolutely right and you know I I can't help but think that the underlying driver for primary care and some of these changes that have occurred in primary care are really is a big result of primary care physician burnout.right you know and it's very tiresome for primary care physicians. so you know when you've got a Walgreens coming to you or you have a CVS coming to you or you have even an option coming to you and saying look we're going to reduce your administrative pressures by 20 percent you know we're going to cut the time that you're spending completing your you know in basket of your EHR we're gonna give you more resources that's very appealing to a physician who historically has been working 10/12/14 hours a day.

Lucy Zielinski:

It sure is it definitely is so the primary care physicians I think you know are really interested in in some of this service line strategy.How do you think it is different for primary care physicians versus specialists?

Daniel J. Marino:

Well I think for primary care as we talked about,I think the drivers of the incentives are a little bit different theythey're focusing on creating a better let's say life environment for themselves.well you know improving their well-being.And then I think for specialists it'sreally aboutmaintaining their financial performance, and maintaining what they built particularly if you have a specialty group like answer who you know has been around for 20-25 yearsthey're independent they may lead the market you know they wanna make sure they can continue continue to grow.So when you think about that the strategic implications and the directions that you go are slightly different for primary care than for specialty care.Soit's important for leaders to really begin to think about what are those drivers that are going to create the right levels of success and you know the question that you had asked that I think is a good one really focusing on onwhat's the goal as we start to advance our clinical service lines.

Lucy Zielinski:

Yeah So what is the goal like what would you say would be the top goal for especially for primary care service lines?

Daniel J. Marino:

Well I I think I think there's a couple of things that are impacting that goal I think you have to look at what the reimbursement is in your market and how proficient value based care is in your market particularly risk based contracts so I had the opportunity not too long ago to talk with a an administrator a physician administrator actually of a large health system that they're taking a very interesting perspective with their primary care. What they're actually doing they've got probably 152 hundred primary care physicians they've actually carved their primary care out of their fully multi specially employed Medical Group and they've created primary care as a special as a separate entity. And they've done that for one main reason it's because these full risk global capitation contracts are really advancing in their market. So they're basically saying to their medical groups to their specialists in two primary care love primary care we're going to give you the ability to manage this we're going to give you the autonomy to really not only treat the patient make sure you're managing quality efficiency and utilization but we're also wanting you to take the lead on working with the specialist and I'll tell you so I sort of asked once I heard the strategy. I thought it was really interesting because obviously for a big health system it impacts referrals right? I mean that's if I was the administrator so I've been thinking about. 

 So I asked the question well you know how are the specialists responding to this and he said great he says it's put sort of the specialist on notice that they have to think about delivering care differently you need to focus on referral management right following up with the PCP's working through clinical pathways and protocols for their specialty to make sure that they are providing efficiencies of care. And to your point earlier cutting down including some of that clinical variation reduction so I think the the primary care strategy in particular it's not a one-size-fits-all. It's really dependent on the market it's really dependent on the reimbursement it's really dependent on whether your primary care physicians are employed or whether they're independent 

Lucy Zielinski:

Yeah and that makes sense Dan you know I think about MSP especially when organizations are in a model where they're they have downside risk it's very critical that they manage that patient population and what better way to do it is through a primary care service line that addresses some of those chronic conditions that are thrown off some of those costs and carry you know putting management services around those.

Daniel J. Marino:

Yeahyou're absolutely you'reabsolutely right and then when you pick a specialty care you know it it needs to be integrated the strategy needs to be integrated but it is a little bit different the strategy for specialty care I guess you know it really depends upon if they're employed specialists or they're independent.If they're independent specialty groupsthere's a there's a lot more vulnerability there to have another organization such as private equity or some of these non traditional providers come into your market and to employ them.Right?so that strategy really has to focus on how we can continue to support growth.How we can continue to create alignment with the health system or other providers in the market so we are protecting the care that we're delivering to patients in that community. That that becomes really critical

Lucy Zielinski:

Dan you and I I've done quite a bit of work with medical groups in the past around strategy and this just seems to me that medical groups should be considering some of these service lines and as really a Medical Group strategy. 

Daniel J. Marino:

Yeah yeah you know and it's interesting over the years and you know we we've been doing this for years I bet you I've been working with shaggy for 20 some plus years at least. There's there historically has not been a lot of focus on on growing this strategy of clinical service lines. And now with the pressures that are being placed on you know either the medical groups or the health systems or even the communities there is a larger focus there. 

If you're just tuning in I'm Daniel Marino and you're listening to value based care insights I'm talking today with Lucy Zielinski and we're having a a fascinating discussion on the on the clinical service lines and their impact on advancing Medical Group strategies. 

So Lucy yeah you're absolutely right I I think as you start to think about what those strategies are for the the specialist for instance focusing that attention on what the goal is how you begin to integrate how you begin to think about the market and protecting the care that's being delivered to patients within that community or within that geographic region I think it's critically important. 

Lucy Zielinski:

yeahyeahyeah I agree and so Dan I have another question for you we've talked about how service lines can provide better outcomes and how about the financial performance?You know we can't letlet that be unseen here it's definitely a critical point for for many health systems as well as service lines.How do how do service lines support maybe your contract negotiations and then performing well how do they perform well in those contracts.

Daniel J. Marino:

Yeah that's a a good question you know the the financial performance of specialty care of these of these specialty groups has changed right it's evolved overtime and the types of contracting and how we're contracting also is continuing to change one of the things that COVID did was it really showed that not all this care needs to be provided in the hospital.That we can really be providing this care in the ambulatory environment in an ASC or even in an office based structure. 

Lucy Zielinski:

Or even or even telehealth Dan

Daniel J. Marino:

Right even yeahyou'reyeahyou'reabsolutely right so these shifts and site of service and being proactive in understanding how we can continue to shift and evolve to from a queue to ambulatory from ambulatory to even office space I would even say from office space even home the home environment right. 

Lucy Zielinski:

Daniel J. Marino:

Yeah that has to be integrated in the strategy and then it has to be negotiated appropriately with the with the payers because at the end of the day the medical groups can't just accept a lower reimbursement for shifts inside of service because you know then you know they're sort of cutting their own throats but if you can negotiate a fair reduction as you go from the shifts in different side to services I've mentioned the medical groups undoubtedly will pick up some financial opportunity because the cost structure is different when you go through each of those areas. But it needs to be done smart right? You you know you you need to really think about both sides of the equation both the reimbursement and the impact to it as well as the cost and the impact to cost. 

Lucy Zielinski:

Mm-hmm and when we talk about these these services that are shifting in inside of service you know I've seen quite a bit around imaging in some of the procedural services.Can you speak to some of the the other procedures may be specialties that we're seeing the greatest shifts? 

Daniel J. Marino:

yeah you know we're we're seeing these in the ambulatory arena ASC's providing a lot more surgical services than they used to.So you know you you in the past we may have single service line on ASC's around orthopedics or in some cases cardiovascular or GI providing endoscopy you know as there are and and their own ambulatory arena.Now what we're starting to see is these multi specialty ASC's really emerging which I think is is great right?Because you're able to do a lot more with less.We're also starting to see like in radiology and that radiology iconology you know you'll have the hematology oncology group coming together and now partnering with radiation oncology right?Historically that's been separate so that that becomes important as you start to think about consolidating these services.We're combining these services that's how much consolidating but combining these services but you've got a contract around it right?And you have to think about what those thatimplicationare both to the competitors that are in the market but also your growth strategy.

Lucy Zielinski:

I and I think I I saw a recent statistic that you know by 2030 that more than 80% of hospital patient department cardiovascular procedures could be allowed in ambulatory surgery centers. That’s a huge shift.

Daniel J. Marino:

Oh yeah it's a huge shift and we're seeing that now so we you know we just got done working on a cardiovascular strategy and a big part of that strategy was how they needed to continue to evolve on the surgical services the procedures from an inpatient Cath lab if you will to more of an outpatient Cath lab or moving you know imaging to more outpatients and as I said I think this trend is going to continue.It'sgoing to continue to more even office based procedures. I had an interesting conversation with one of our clients who's an ENT physician and he's actually going through his surgical all his surgeries right now he's looking at by CPT code and he's actually having conversation with an anesthesiologist to say what can we do in the office based procedure versus ambulatory, because the reimbursement is going to be the same, right?And he actually can build some of the technical component around it and it just improves his overall financial performance and it's much better for the patient. 

Lucy Zielinski:

yeah and it's isn't it fascinating that the physician is involved in looking at this and I I see these physicians being involved in more and more and more in the strategy planning with systemnesswith service lines and so on.So having these dyad structures and triad structures of leadership I think is really key. How haveyou've seen these leadership structures change? I mean obviously we've seen physicians involved right?

Daniel J. Marino:

oh gosh yes and the physician leader has really evolved over the last couple of years.And they're continuing to evolve very quick and in some cases is putting the physician leader in a little bit of a difficult position because they've never had training around that, yet the need for them to really step up to be part of the strategy to think about how they need to advance some of their clinical services in some type of a strategic partnership is absolutely critical.And what helps them with this is to your point is having the strong administrative partner that you can work hand in hand.

Lucy Zielinski:

So Dan what time what advice would you have for these CMO's chief medical officers or administrators?

Daniel J. Marino:

Yeah I you know oftentimes folks will ask me well where do we start and I think the place to start is having the conversation right be proactive don't wait because if you wait there's going to be external pressures that are going to come into your market that are either going to come in and and purchase these independent medical groups or steal some of the employed groups and put them into a larger group.Have the conversations now.

Lucy Zielinski:

And those employees visit or those employed physicians are more likely to leave for better work life balance you got to retail clinic sometimes we've seen that happen quite a bit.

Daniel J. Marino:

Oh yeah you you are absolutely right have the conversation create the strategies the strategy it's not like the the strategic plans need to be a 10 year strategic plan right?it's a one year three-year strategic plan have the conversation.And especially if if you're working with an an independent Medical Group you do not have to talk about merging you can talk about having a strategic partnership a joint venture you know strategic partnerships take a lot of different forms, and I'm I'm happy to share some of those with you, but I think the key to it Lucy because you have to have conversations and you have to have pro you have to be proactive.

Lucy Zielinski:

Yeah Dan it sounds like having conversations with the physicians with the multidisciplinary team is is definitely important to start planning on what where should you start what service lines make the most sense for your organization and then you know how do how to build into some of these value based contracts because there's typically better performance when you're managing the whole service line.

Daniel J. Marino:

Oh you are absolutely right I mean so many components so many implications that you really need to to consider.And it's fascinating to see where these clinical service lines these independent specialty care groups are going to go. Well Lucy I want to thank you for joining me today fascinating discussion I I enjoyed kind of being a little more than the host being the participants today it's it was fun so thanks again for for coming on I really appreciate it.

Lucy Zielinski:

No problem Dan, it was fun to ask you some questions and turn the table.So can you tell us where listeners can go to For more information? 

Daniel J. Marino:

Yeah please if anybody is interested in advancing the Medical Group strategy, I think we talked about this on our last episode with Jeff Peters, please feel free to go to luminahp.com/insights. There is a Medical Group strategy page and just a wealth of information. We have a lot of articles there, webinars, and even some of our podcasts. Or if you're interested in in just finding out a little bit more just having conversation around your clinical service lines and advancing some of the strategies feel free to reach out to me my e-mail is dmarino@luminahp.com. 

Well Lucy, again, I want to thank you for joining me today great discussion I really enjoyed it. And to our listeners I especially want to thank you for listening today. Until our next insight, I am Daniel Marino bringing you 30 minutes of value to your day, take care. 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

The added pressures for medical groups, coupled with the limited resources and high demands, require an intentional, strategic roadmap to success. On this episode of Value-Based Care Insights, we sit down with Jeff Peters to discuss the evolving healthcare landscape and what medical groups should be thinking about to position themselves for the future. Gain valuable insights into innovative strategies for aligning with providers, improving financial performance, and fostering a healthy, physician-driven culture.

KEY TAKEAWAYS: 

• Medical groups must creatively address access challenges since the demand for physicians significantly outpaces the supply.
• Striving to be a high-performing provider network while balancing primary care expansion with specialized care development with a strong focus on patient satisfaction is a critical strategy.
• A robust, healthy organizational culture, where physicians and staff feel valued and appreciated, drives success.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value based care insights. I am your host, Daniel Marino as well. Many of you have known and have listened in over the years. We do a lot of work working with medical groups, and whether they're independent medical groups or their employee medical groups, that's sort of a passion for me. In particular, I started my career managing a multi specialty group practice before I got into advisory services and working with physicians has always been something that has been near and dear to my heart. And certainly II do a lot of research around this, and think about. You know, different strategies to help the financial performance of medical groups. And frankly, I don't think there's enough ideas that that can come out that can support the direction or the insights that can be given to leaders to help them improve their performance. And it's and it's interesting how the industry, how the structure of medical groups have really changed, particularly since Covid over the last, say 3 or 4 years. For instance, one of the reports I look at on a regular basis is the Kaufman Hall physician, flash report. If you've not seen it, II think it's a it's a pretty well done report. It looks at a lot of great trending information and a couple of key things that have really resonated with me over the last couple of years is one from an employed physician group perspective, the medium subsidy per physician Fte has continued to grow. And it's actually about 12% higher than it was 

just over 2 and a half years ago. I mean, that's a major increase.  

The other thing that I find interesting. That that remains a challenge for medical group leaders is not only, you know, some of the things that are driving, that loss are the productivity. The productivity of our physicians is actually higher, and it's continued to grow when you look at the number of Rvs. But yet the net patient revenue per patient has actually decreased. Which means that we're not getting the reimbursement from our payers. No surprise to many folks who are doing the managed care contracting, but one of the other interesting elements of that is the expense per physician. Fte has continued to grow, to increase. So when you look at all of this the financial pressures put on medical groups continues to be a challenge continues to be a real strain for these hospitals, who are employing them, as well as the independent medical groups who are continuing to determine or consider ways of growing.

Well, I'm really excited today to have a great guest, somebody I've worked with for gosh, you know, close to 30 years he's been a great friend and a great mentor to me. Jeff Peters. Jeff is is kind of in the the next phase of of his career. He's going to be working with Lumina and driving a lot of the medical group strategy. Jeff, very excited to have you as part of the program today 

Jeffry Peters:

I am equally excited. Thank you for inviting me.

Daniel J. Marino: 

and a big congrats to you. You've you. You've now moved into this phase where you're semi-retired and doing the type of work that you really love, and from what you've said to me, really being aiming to you know, do the work that you're given back to the industry. So II love it.

Jeffry Peters:

Yeah, thanks. I'm excited.

Daniel J. Marino:

So, Jeff, you know, when you reflect back on where some of these independent medical groups are, these different hospitals? And you know through the through your career, you know, close to 40, some years you've been doing this. You've worked with over 500 organizations across the country. How have you seen these challenges evolve over the years?

Jeffry Peters:

Yeah, so I really thought about the fact that when I first created an employee physician group at Engels Hospital, which is now part of the University of Chicago health system, and the Financials are coming out to the board, and the board is just overwhelmingly perplexed as to how we could possibly run physician practices that are losing $30,000 per physician per primary care. And now, when you see the losses over a hundred $1,000. I'm sort of thinking. What were they worried about? That was great. And I mean, really, you're beating me up on this but we didn't have data on E own practices. And you know, it'svery clear what the problem is. There'smore need demand for physicians and advanced providers than there are supply. So you have to pay more to attract and retain physicians.

Daniel J. Marino:

and you also have to pay more for their support. Staff. Yeah, for their support staff. Yeah, II think the you know, when I refer, and as well as with you, II talked to many leaders all the time across the country. Access is the number one issue that they struggle with wage inflation. If it's not number one, it's a close number 2 and and retaining the staff is really key as well as then. Physician. Well, being so, so, let's talk a little bit about access, though, you know if you've got limited number of providers, you've got more demand than you do with supply. What are you seeing on some of these strategies? How are organizations. How? How are they dealing with some of this? 

Jeffry Peters:

Well, I think the first thing is that you've got to assemble teams to manage a group of patients. It's not only physicians, it's advanced practice providers and in more quaternary tertiary practices, nurses, and you need to allow the advanced practice provider to see the patients that they're qualified to see. And you need to reserve the physician's time for the more complex patience. So the idea that we're always going to see a physician. It's just not going to happen. I mean, recently I had a annual skin exam. I called my dermatologist. I was scheduled with an advance practice provider. I thought she did a fabulous job. She was thorough and personable and identified things.So we've gotta be creative in terms of our workforce, and we've gotta save physicians time when I go to my ent with a sinus infection. There's a medical assistant who'sassisting him with the scope and just getting everything ready, and he has a scribe and he's dictating as he's seeing me what's going on. and he's able to really make efficient use of his time. So we've gotta be creative and really innovative.

Daniel J. Marino:

Right? These in what you just described are these innovative care models around team-based care around helping the physician succeed and innovation in the care models. I fully agree with you. That's how we'regonna help to kind of work through some of these access challenges. I think, without doing that the traditional model is not sustainable.

Jeffry Peters:

No. And physicians like the team model a lot of the work that the team is doing is work that physicians don't like to do the charting and the things like this. I mean, you hear physicians complaining about the fact, at the end of the day they're spending one or 2 h on the Emr. Getting caught up with their documentation to save them an hour or 2 a day phenomenal. And the other thing is just handling the telephone and the patient calls that come in. And the emails that go to the physician. We've got to be creative in identifying What work can we take away from the physicians that gives our patients the care that they need and deserve, yetdoesn't burden our high cost providers.

Daniel J. Marino:

I absolutely agree, II think, is we're thinking about the future strategy of medical groups, whether you're independent or employed these innovations that you spoke about this way of kind, of making the physicians more efficient spot on, II absolutely see that as a necessity of performance. Let's talk a little bit about growth, though. You know a obviously everybody's concerned about growth, and especially if your expenses are increasing, you can't necessarily cut services you cut can't cut staff. I think we'reprobably as lean as we've ever been. You have to focus on increasing the patient volume.You have to focus on increasing revenue. in your opinion. Where? What? Where? Are some of those key growth initiatives that help to kind of drive the financial performance.

Jeffry Peters:

Yeah. And and I think there's been models in the market for a very long time. Multi specialty groups are very profitable and they tend to attract and retain providers and single specialty groups like urology, where you're able to get all the urologists in a market to come together so that they not only share practice overhead, but then it supports pathology. It supports imaging and treatment, for it makes sense. So what the growth has to focus on is getting a large enough group of providers that drives ancillary revenue. You're not going to make your money on the profitability of a physician practice where you'regonna make your money, particularly for academic medical centers or hospital practices in establishing integrated ambulatory campuses where there's urgent aid to take care of the patients that don't have a primary care, or don't want to wait that primary care surrounded by specialists.

So the urgent age for the patient that doesn't have a physician can refer that patient to the primary care. So there's an ongoing relationship as that. Primary care picks up a heart murmur. There's a cardiologist in the building that they can refer them to. And there's a spectrum of diagnostics and treatment. What we're seeing is and the University of Chicago has been masterful at this, creating these integrated campuses with urgent aid, primary care. Secondary care. 

Daniel J. Marino:

soit's all sort of integrated. And it's right there for the patient and for the physicians. So you can actually have create more of a longitudinal care model getting the results that you need.

Jeffry Peters:

And the patients like it, cause they're getting care close to home location. And it's those high margin ancillaries, your infusion centers, your linear accelerator, your Asc that is actually gonna drive the profitability of those campuses. 

Daniel J. Marino:

If you're just tuning in, I am Daniel Moreno, and you're listening to value based care insights. I'm here today with Jeff Petersand we are fascinating discussion on strategies to help medical groups improve their financial performance. So Jeff, kind of building on your commentswhen you think about growth.it is, should the growth be more focused on primary care growth? Should the growth be more focused on specialty care growth? Or is it really an integrated growth strategy where you're thinking about how those2 domains, so to speak, can really complement each other to drive even more value. 

Jeffry Peters:

Yeah, I mean, I think you answered your own question increasingly. I think it's an integrated strategy where it's primary and secondary care. That's how multi specialty groups has succeeded in the market and patients like it because they're going to one organization to get all of their health care needs met.And itit's integrated. There's a level of understanding and comfort. So I think that's what you need to focus on integrated systems.

Daniel J. Marino:

But what about those organizations that have really invested incertain clinical service signs like cardiovascular like, you know, oncology and cancer. you know, orthopedics continues to do well.ent gesture neurology, some of the others.How does that growth strategy fit intothe either the integrated model or ways to really enhance the financial performance of the of the full group and even of the whole organization.

Jeffry Peters:

Yeah, so your primary care platform is going to support specialties, particularly like a comprehensive cardiac program or things like that. And you want your comprehensive specialty programs to really have a depth of specialist in them. You know your general cardiologist? The the rhythm, the electric.

Daniel J. Marino:

But then, probably having the sub specialists, too. Right? Soyou're keeping everybody in that network. III love it. II agree with you. I think the more comprehensive that you can be around that specialty fee. Certainly everything in there. You're really driving the value.

Jeffry Peters:

Yeah, that's where you're driving value in physicians like that because they can give better care to their patient they can stay a generalist or specialist if they want to. But the other thing that a large group does is, it reduces the call burden, and it creates the lifestyle of the physician to be more acceptable, balanced, so it gives a greater level of care to the patient. But at the same time we're establishing mechanisms where we're addressing some of the lifestyle issues which are a detraction for many providers. 

Daniel J. Marino:

Well, II think that's one of the top issues, right? I mean, there's been. You talk to physicians. We were. I was just in a in a in a meeting the other day wherethis integrated medical group was talking about. How they're still managing physician Burnout, the physician well, being challenges for their group. Just post Covid, right? And again, we're a couple of years into it. We're still feeling those effects. Solet's talk a little bit about culture. Right? You. You've touched on this a couple of times. In your opinion. How do we need to evolve the culture of either our medical group leadership or our physicians.

Jeffry Peters:

Daniel J. Marino:

we'd like you to come up with a plan and implement it right? Soit's position led right? It's physician driven. And I think, where we've often. And we saw this a lot of times in Covid. If you're losing a lot of moneyadministrators will typically kind of jump in inside and sort of right size of ship. And I am and what you're saying, and II fully agree. I think wehave to engage our physician leaders and our physician governance body to really turn this around, I think, in order to not only achieve the goals, but to make sure that the culture continues to grow.

Jeffry Peters:

Yeah. And I think the second component is aligning physician compensationwith the organizational incentives paying physicians based upon the profitability of their practice. And if it's a specialty,that's not going to be profitable, you can reward them based upon reducing the loss. But, I was at a very successful oncology practice this week. It dominates oncology in this Mid Western City, and the oncologist is able to decide whether they want to be supported by a nurse, whether they want to be supported by an MA. Whether they want more than one nurse or more than ama, whether they want advanced practice provider, and then their compensation is based upon the profitability of of his individual practice. The revenuethat he generates and his team re generates minus the cost. I was with one system where the board mandated that thelossper physician within this groupbe reduced by $50,000 a physician within the next 2 years. So what they did is, they established an incentive pool, wherepeople were rewarded on their profitability and their productivity, but they shared 50%. Of the reductionof the loss with the providers.And that's great way to share the incentive love that. And the reduction was based upon your percentage of the group's productivity. So if you generated 10% of the revenue, and the incentive pool was a million dollars.

Daniel J. Marino:

You got an extra $100,000, and it just aligns with where we're going with with value based performance. So you, you're clearly working with a lot of organizations around the country on their medical and their medical group strategy. And and they're improving their strategic performance as leaders are thinking about the strategy for their organization. And 

you know, thinking about how they need to improve that that performance deal with the culture deal with access issues. All the top of mind issues that you know that you had brought up. What would be the piece of advice that you'd give to these leaders. Where should they start?

Jeffry Peters:

I think the way you start is by bringing your physicians together and saying. we want to make thisan organization that provides the best care to our patients, and part of the way that we do it is to make our physicians feel valued and appreciated.What are the things that are important to you that we look at changing? And what we wanna do is develop a plan that the physicians help to shape and help to execute it.because what we've gotta do is give the practices back to the physicians, so they feel personally attached to the health of their patients and the health of their practice. Yeah, great point. And I agree, II think, instead of having the administrators to find the plan.

Daniel J. Marino:

including the physician leaders, engaging the physician leaders, having the physician, as you mentioned, sharing inthe performance outcomes right? Cause. Then then there, there's ownership. They're bought into it great points. II couldn't. I couldn't agree with you more. But, Jeff, this has been. This has been great. I'm sure there's a number of our listeners who are physician leaders who are practice leaders. If they have questions, you know if they want to connect with you orfind out a little bit more. can you share your information with them?

Jeffry Peters:

Yeah, I mean, feel free to email me at J. peters@luminahp.com luminus spelled LUMI NAHP. N. You know. Call me.It's fine. (312) 330-6800, Dan. It's always a pleasure.

Daniel J. Marino:

I'll tell you, Jeff, I'mvery excited for this, and I'm particularly excited to leverage a lot of your experiences and insights as we work with organizations around the country on their on their medical group strategy. So thanks again for being here, and a special thanks to all of our listeners, until the next insight. I am Daniel Moreno, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

With the adoption of capitation models and the growing demand for coordinated care, healthcare providers continue to shift away from traditional payment models. On this episode of Value-Based Care Insights, Lynn Carroll, COO of HSBlox, sheds light on this transition. Learn about the evolution from performance-based to risk-based contracts, the value of sub-caps within capitation models, and the pivotal role of care coordination.

KEY TAKEAWAYS: 

• The healthcare landscape continues the shift toward capitation contracts focusing on quality and fixed reimbursement. 
• Effective capitation models depend on seamless collaboration between primary care physicians and specialists. 
• Sub-caps within capitation models, such as primary-care physician caps and bundled payments, can help manage costs and enhance patient care.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. As more health care providers as more hospitals and health systems transition into value-based care, particularly the contracting side ovalue-based care. There's a progression of contracts and organizations go through a progression. Maybe moving into performance-based contracts and then moving into shared savings contracts and then eventually moving into risk-based contracts. On this program. We've talked about risk based contracts a number of times. It's an area that I think is both interesting and challenging for providers, many providers, many hospitals, health systems. As I'm talking with them around the country, they often say, well, II don't know if I'm ready to get into risk yet. And frankly, I don't know even if I can succeed into risk. But as organizations are moving into risk-based contracts, there's a progression into capitation or fully capitated type levels of reimbursement which is structured around a Pmpm. And again, it's a journey as you start to build those capabilities, to drive that success. There are a number of elements that go into it, as you know, as we've discussed changing the care model, putting in place strong care management, looking at the performance analytics to drive a lot of the successes around managing the population in a capitated environment. 

Well, I'm very excited today to have as my guest. Lynn Carroll. Lynn is the COO And head of strategies for HSBlox. HSBlox provides a lot of business support and a payment business or analytics platform. That helps organizations drive success around capitation. And he wrote a really good article that really caught my attention called, why capitation contracts can benefit providers, payers, and patients. We will put a link to that in our notes. Lynn. Welcome to the program.

Lynn Carroll:

Dan. It's great to be here one of my favorite topics. SoI'm looking forward to the conversation. 

Daniel J. Marino: 

Well, Iappreciate it. So, Lynn, let's jump right into this.What are you seeing around the types of concentrated capitation contracts that providers are getting into? Both in terms of the payer structures, and maybe, whatpayers or what providers are struggling with or challenged with, as they enter intosome of these capitation arrangements.

Lynn Carroll:

Sure, Dan, in our business. We have kind of seen, but as you mentioned in the your opening commentsort of a progression from some more traditional pay for performance pay for quality type programs.And certainly we in our business see a lot of Mssp and then, now, we're seeing some more ACO reach types of programs out there. We've also seen programs taking hold in the commercial arena as well. But a lot of the programs kind of fit these characteristics. First of all, they all have some type of a qualitycomponent in the programs.But they are typically defined sets of services for a defined population with some type of a fixed, either per head or percentageof premium type of a model. 

Daniel J. Marino:

Right? So that's kind of like a Pmpn type of a reimbursement structure.

Lynn Carroll:

Sure, sure per head at a fixed sort of a rate or a percentage of the premium for a completely go global type of an approach.Some of the programs will also incorporate on the risk bearer side where there will be some sub caps going on to sort of delegate some portions of the risk downstream. 

Daniel J. Marino:

Solet's dive into that a little bit when you say sub caps. What do you mean?

Lynn Carroll:

So typically might carve out some piece of the pie underneath a global capitation model. So there's a percentage of premium. There might be a Pcp cap underneath it. There might also be some elements of either bundling or episodic types of reimbursement to try and manage the overall cost structures underneath the programs. And then we'll also see and have seen programs. And you probably read about one almost every day where folks are contemplating different types of carveout scenarios which would be either, you know, chronic kidney disease certainly comes to mind Ms. K. And other programs where there's a defined set of services and a need to create some type of a coordination mechanism between more specialty and primary care to address trying to find the right care path sooner in the continuum to make sure that the diagnosis is correct. 

We see that happen also in scenarios where there may be poly chronic parts of the population to make sure that there's alignment between primary care and specialists.

Daniel J. Marino:

Are you seeing that more so in the specialty areas whereparticularly high cost services are occurring?

Lynn Carroll:

Because of COVID-19, there has been a renewed emphasis also on, you know, mental medical and social areas. And sowe've seen some emphasis and some of the behavioral health areas as well. Just to try to bring in different models.

Daniel J. Marino:

That's interesting. Because tie in the behavioral health piece into a capitation type of a structure. I think it's got to be a really biga big challenge. You could see the medical side on that. But the behavioral health piece has got to be really tough for providers to assume level of responsibility. 

Lynn Carroll:

Well, so it's interesting, right? Because if you look at a global reimbursement scenario, one of the first things that you want to be able to do is where are parts of expenditure that could potentially be capitated in a sub model. Right? And so you start to carve out different scenarios. And we've seen things getting folded in under the more global programs. And so when you're talking like, for example, total cost of care, percentage or premium scenarios. You're going to see a different pot pods or pockets underneathThose programs start to get capitated as well so that you can fix the cost that you're at risk for. 

Daniel J. Marino:

We have worked with numerousorganizations and clinical service lines or specialty providers where you know you look at cardiology, or you look at orthopedics. Or you look at neurosciences. The cost of care is different. Right? So you can create some episode based pricing models and then negotiate those structures around that. But I guess I've always kind of struggled with how then you would pull that into some type of a capitationPnpmstructure, right? Because you're not necessarily managing the primary care piece of that. If you're saying orthopod per se, or even maybe a cardiologist, you would. If there'syou know you have some patients who are seeing their cardiologist as more of their primary care. Physician? But pure specialists, I think it becomes difficult. Ho! How are you? How are you seeing those structured? 

Lynn Carroll:

Yeah? So I think what we have typically seen is scenarios to make sure that if there's a global risk component the stratification of the population identifies where there are high touch, high need patients as well as who are sort of low, touch, low need patients and then trying to address where there may be high touch needs you know. What are what is sort of the bucket of services? Are there ways to control the cost of those services. 

And I think, probably, as you've seen pretty closely in your work, that the network driven components start to get narrowed, they start to get narrowed. The question starts to become, what's in it for the patient? And when you start to take a look at reduced choice, there has to be a value proposition from a care, coordination standpoint to make sure that those care transitions across different types of needs medical, behavioral and social are met otherwise, one of the tenants, we typically say, is that for value based contracting the patients, your best partner. II think what we mean by that is that you have to consider the holistic view of what's going to happen underneath global types of programs to see if you can create some kind of synergistic alignment from the care, coordination, patient experience, side of things rather than taking sort of a more traditional approach to say, you know, I'm going to limit utilization or I'm going to attack length of stay. For, you know, inpatient 

Daniel J. Marino:

Right, that'll never work. You'regoing toget. You'regoing to get pushed back. Andis that often said in a lot of the presentations and the models that you know discussions I've had with physicians a big difference between capitation these days and capitations of the nineties. Right? Andcertainly I lived a lot through there as I was managing practices.Quality wasn't a component of capitation. So it seems to me in in the discussion, there's really 3 areas that become really critical as you're starting to think about capitation type ofof models. I think one is understanding the risk of the populationto what's the utilization trends and really making sure that you're managing the the out migration, right? Or maximize your domestic utilization. And thenthird to that is, what are your performance outcomes? Look like of your of your network.

Lynn Carroll:

Yeah, so it's definitely the case. And so, as we've kind of alluded to, and some of the discussion so far. This, you know, concept notion or approach of Pcp, or primary care, and especially alignment, becomes an important part of avoiding sort of the unnecessary spending side of things, trying to see if you can get a hold on duplicative services,and it's easier said than done. Okay, butessentially youhave to look at the network structure who'sparticipating and look at trying to control things so that you can gain market share by, you know, keeping folks in house and sort of reducing that leakagecomponent that then improves a couple of things and improves care coordination for the patient, and it also addresses those quality opportunities that we'resort of talking about and the use of, you know, looking at the referral patterns and high value provision of services is a big component to that. And part of that is sort of stratifying patients to know who are the high need high touch folks. And when we kind of think abouthigh touch, these may be patients that need, you know, as much as a daily interaction gets into sort of a more care, navigation sort of component.

Daniel J. Marino:

All these become the patients who are more complicated patients and patients who absolutely, you know, they need that care. If you're just tuning in. I am Daniel Marino. You're listening to Value-Based Care insights. I'm here today talking to Lynn Carroll. Lynn is the COO of HSBlox. They have a discussion on understanding capitation contracts, and what drives their success. 

Lynn, let me ask a question, though. There was an interesting quote that caught my attention in your article. and it was around incentives and creating the right incentives. And one of the things that I've I've talked about many times on the program, and a lot of the work that I've done in helping organizations kind of advance their clinical integration capabilities, if you will is you need to have the right level of incentives? I wanna I wanna read this, quote real quick and then ask a question around there. But the quote is “these newer competition models are designed to better align incentives between primary care providers and specialists, but if the specialty care under value, base or fixed price type program isn't harmonized or primary care. Providers may fail to meet the cost containment or the program goals in order to reduce unnecessary or duplicative services.” 

An interesting statement. I think nobody would argue with the fact that that alignment has to occur. What have you seen in terms of the solutions around these types of capitation models that does begin to align primary care and specialists. 

Lynn Carroll:

Yeah, so you know, I think a big portion of this sort of gets into the care, coordination, aspect of things.and an emphasis on the care management pieces. So you think about the transitions and care that occur.Primary care can't go it alone right? If you havea quarterback, if you will, in a primary care, physician, and you have a poly chronic individual. Effectively, a significant amount of the care is actually being managed by multiple specialists. Number of those cases which can do a couple of things. One. It can create a poor patient experience. 2. It can also result in unnecessary leakageand sort of the third part of it is that when you look athow theinteractions occur, you can have a lack of visibility between what I would call different pods.

Daniel J. Marino:

Absolutely. And II think that's an interesting point, becausephysicians undoubtedly do a great job of managing patients that are sort of withintheir within their realm, right within their 4 walls, and especially if you've got a complex patient who's seeing multiple different specialists, it's hard to understand which each of the specialists are doing. And how do you coordinate that care longitudinally around that whole care plan for the patient?

Lynn Carroll:

Right,So what we see sometimes happen is in a poly chronic scenario. Let's say, a patient is quote unquote, enrolled into a particular program. And let's sayIt's, you know, either a diabetic program or it's a Copd program or something. Well, sometimes they will be assigned into, you know, a care management path, and in that care management path the care manager or care coordination component may be unaware that they just had an admission last week.And so part of this is sort of understanding how you're going to share data effectively for those and important and sentinel types of events.So if, for example, you have a poly chronic patient, they may be actually enrolled in 3 different, you know. Programsthose programs can't be siloed in nature. And so this and you mentioned that yourself, this longitudinal view of who all is involved in seeing this patient today,and what's going on across the continuum of services they may be procuring, because what we have seen is a need to. If you have a value-based programthat's got a significant cohort to it. You're going to have poly chronic individuals that you need to share information on information sharing piece is really what you'regoing to be talking about in terms of a care team that needs to be informed of what's happening when they're not the ones seeing the patient?

Daniel J. Marino:

Well, so just building on that, I think, you know, that's I think that's really the key point.So if you'regoing to start to align primary care and specialists and even specialists and the sub specialists,an important element of success, at least in my mind is that you need to have the right level of data. You need to be able to share that data with the different providers and with their respective care teams and then have sort of an oversight care management individual.Maybe this is, you know, with input of the primary care physician, to really allow the quarterbacking of that care, right? So maybe in influencing it. So you never gonna tell a provider what they need to do. But you should be able to influence what they provide to that patient. So it does meet the objectives, both for that patient and for the performance outcomes related to that patient in that contract.

Lynn Carroll:

Daniel J. Marino:

Yeah, because leakage,I'll tell you from the analysis that we've done, Leakage is the biggest cost driver.Leakage, and you know, redundancy of care services. But you know, one of the things when we've done some analysis, and I'll be interested in hearing your thoughts on this. We did actually advise providers not to necessarily get involved in competition contracts until their leakages really less than 10%. Because if it's more than that one, you don't have the ability to manage, do to proactively manage the patients appropriately to drive the contract performance. But, second, and probably more important, you're adding an extra layer of costs onto your care model that you're responsible for right? AndI'm not sure you can be successful. Are are you seeing the same thing?

Lynn Carroll:

Yeah. Sosort of along those same lines you have the scenarios where and I think some of the documentation out there will say things likein a hospital system, for example, they may experience as much as you know. 30 or 50% leakage. And you know, a good goal sort of isYou know. Let's try to keep in house you know, or reduce that leakage by anywhere from 10 to 30 of that number type of scenario. Well, you know. What you just said is, let's get it even further down, right in that particular scenario. Andpart of this, too, is looking at. Well, what? What can also help drive that and part of that is again. Well, what's in it for the patient? 

Daniel J. Marino:

Right? Why do they need to do it? What's the right level incentives and also to you know, II want to be sensitive as well tothe market, you know, in a rural communitythey may have 95% of the patients go into one facility. So their leakage is 3 to 5 .In a metropolitan area where you have a little bit more competition, you know maybe 20 is as good as you can get because of the level of competition. But I think to really focus on that, and to havea pretty prescribed approach to how you're managing and steering the patients, particularly those that are high cost. You know you. You need to have that as part of your care model and your care management approach. Otherwise I think you'rereally vulnerable.

Lynn Carroll:

Well, I think that's a good point. I think you know from a pure, patient perspective, too is the benefit design that a patient is under, you know, depending upon what type of a program or what type of coverage they have. Is that benefit design going to be, you know, congruentwith the program design.So one of the things that we have seen, you know, in this, probably, is a little bit more relevant, probably in some of the more commercial side of things. But is, you know, let's say I have a high, deductible program as a plan as a patient. And I have a significant out of pocket cost, and yet from A, you know value-based program scenario. If I'm in a value based cohort. The question for a provider is, well, there's still a large financial collection from the patient. And yet I'm responsible for an outcome that I have a fixed, you know, revenue stream on and from the flip side of that scenario is the patient saying, Well, if you'regoing to reduce my choice or narrow my set of choices, why do I have any out of pocketcosts?

Daniel J. Marino:

Well, like you said, you've got to be able to show to patients, because at the end of the day patients are gonna have decisions. You've got to show the patient what's in it for them? Well, Lynn, this has been. This has been great, and I know you know many providers. Many of our listeners, for that matter, are really given a lot of consideration to moving into capitation arrangements, and I think his folks become more proficient and successful under these risk based contracts moving into global cap is the is the next step.  

You know, if if real quick, if you were able to give, you know, 30 second piece of advice to our listeners who are interested in, and maybe entertaining or or considering, moving into a capitation based model. What would it be? 

Lynn Carroll:

Well, I think, the first thing certainly is, if you're taking risks, know what you're taking risk on, and that that means you. You definitely have to look from a population health perspective to know of the cohort that'syou're suggested to take risk or considering taking risk on. You know what's in there. 

Daniel J. Marino:

Right, understanding it.

Lynn Carroll:

Yep. And sometimes that's a challenge, right? Which is, you know. Say, a proposal comes in, or you're holding up your hand even and saying, I wanna take risk you better know who you're taking it on. So from that perspective, you need to have the data to be able to kind of stratify that population. And again, kind of group it into those buckets of you know who's high touch, high need? Who are, you know, lower need lower touch types of scenarios, so that you can put in the care coordination as well as data sharing pieces that are necessary for success. 

Daniel J. Marino:

Well, I think the data is absolutely key as well as understanding the different aspects of the population. I would also add understanding what's occurring with your participating providers, you know their and so forth. 

A great discussion. Fascinating. I commend you on the work that you're doing, and you know. II think it's I think it's great. I if any of our listeners are interested in getting in touch with you, or learning a little bit more about maybe some of your services, or just sort of connecting with you and your article. How could they get a hold of you? 

Lynn Carroll:

So we always encourage folks to go to our website. HSblox.com. We have a good lot of good content out there. We have a series of 2 min videos where you can learn more about what we do.It's always an important aspect of kind of entertaining dialogue with folks if they can take a quick look at a 2 min video se tends to kind of set up the discussionPretty good. Also, we tend to publish a lot on Linkedin as well about VBC developments and what's happening.

Daniel J. Marino:

Wonderful. Well, thanks again, Lynn. Fascinatingdiscussion. And you know, obviously, we'll keep this going. Because an area. Again, II see this is kind of the future. So thanks again for coming on the program.

Lynn Carroll:

Yeah,it's great to be here, Dan. Thank you so much.

Daniel J. Marino:

I want to thank our listeners for tuning in today to value based care insights until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

In the world of academic service lines, the alignment of physician executives and physician assistants is paramount. On this episode of Value-Based Care Insights, Jason Raidbard, Executive Administrator at the University of Chicago, unveils the challenges and strategies of crafting a dyad partnership of leaders within academic service lines. Gain insights on the importance of a shared patient-centric culture that unites academic, research and clinical operations under one resolute purpose.

KEY TAKEAWAYS: 

• Focusing on a shared culture ensures unified collaboration and a patient-centric focus. 
• Balancing priorities with academic missions and clinical operations help deliver optimal performance. 
• Dealing with academic politics and focusing on mutual respect is critical to achieving goals and building strong partnerships.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. 

On our program. We've talked quite a bit in the past about leadership development, and many of you have listened in know that this is an area I feel really passionate about. I've worked in operations for many, many years and having strong leadership is important. But what's more important is ensuring that you're aligned with a good physician leader.  

So an administrative leader, combined with the physician leader. That dyed structure in my mind, and from what we seen from looking at high performing organizations, is really critical to the success. But I'm really pleased today to have a colleague of mine join our conversation. Jason Raidbard is an executive administrator at the University of Chicago, Department of ophthalmology and Visual Science Department. Jason has had 20 years of healthcare operations, experience, finance, strategy, experience, both on the community hospital or healthcare side. And now, on the academic side. Jason. Welcome to the program. 

Jason Raidbard:

Thank you for having me, Daniel, appreciate it.

Daniel J. Marino: 

So, Jason, when you, when you work in leadership in in operations the community aspect of healthcare working with the hospital or medical group is definitely different than working in an academic operational structure.How's that transition been for you as you'vewent from working at, You know that that community hospital, so to speak, and managing operations now with the University, Chicago?

Jason Raidbard:

Sure. So the transition is different, no matter where you go. So even different community organizations I've worked at have add a little bit of different nuance. I think the different part about the academic institution for me is the tripart Day Mission. You have the focus on education, the focus on research, the focus on the clinical enterprise, the ambulatory operations, and the hospitals. So whereas when you work in the community based settings you're really more focused on just the clinic operations there. There may be some clinical trials here and there if you're on oncology or neurosciences for and on college cancer research. But, generally speaking, that's the big differences. You have one institution that's really focusing on health outcomes as far as the In person visits. 

Daniel J. Marino:

So I think, you know, adding that into the mix for me was a little bit different. And even the economics around that are different. So when you're in a community leadership role, you know, it's all about productivity. It's all about the revenue. It's all about maximizing your collections on the academic side. As you said, it's a 3 part mission right? But the clinical operations are really would drive the revenue. However, you've got to manage your research and your programs. You have to manage education if that's part of the full, the full mission. 

So you know, when you're working through that.  

Have you found that with your community experience, has it really helped you, and kind of driving some of the clinical operations, the clinical revenue activity within the academic setting?

Jason Raidbard:

I think so. I think so. The team that I'm working with right now. I think we recognize both our particular expertise as far as what I had done prior, what they were doing, currently what they had done prior, and what I could bring to the table to help because whenever you go into a situation where you're in a new position, and this is much more of a higher leadership position that I had before you have to learn what's going on. What's the new environment you're in and work? How do things tick? Once you get past that stage? And while you're on that stage. I think it really important you gain trust hopefully. I mean, if you do it right, you gain trust with the folks you're working with whether it's in the university side, or if it's an ambulatory operation side. 

That said, I think there was a way that I could look at maximizing efficiency. Whether it was something as simple as exam room allocation or template optimization. So, looking at physician schedules, what could we do to improve patient access? How are we having an issue with cycle time in the clinic? Is that the issue? Is it an issue with our Emr system? Maybe there's not the right templates. Or is it more of we just need to review the template as a whole, because there's just not enough access, because appointments are too long.  

Daniel J. Marino:

So bring that over to the academic environment, boy. I think that's such a huge value. Add to really drive a lot of the performance. So Ican see how that would really be beneficial for you in your role. Talk a little bit about how you developed your dyad partnerships over the years, you know it. It sounds like to me when you were in the community setting aligning with your medical director is key, and you know that that was a big element of success. Obviously, within your current role. It's going to be equally important. Talk a little bit about what’s what. What that roadmap has looked like for you.

Jason Raidbard:

Sure. And I should preface by saying that in many, if not all, the institutions I've worked at over these 20 years, currently, right now and prior, I feel that when it comes to position leaders that I've worked with, whether it's been a medical director of the facility, or a location, or it's been a chair, or even a chief medical officer of an amateur enterprise.I've worked with some great people I've been fortunate in that way. But I would say that helps so much. 

Daniel J. Marino:

Right? So when you're on the same page, and you and everybody kind of, you know. Both the physician, leader and the administrative leader kind of know their roles and work together. In my experience you get the one plus one equals 3 factor. You're just so much more productive. And it's so much more fun.

Jason Raidbard:

It is, it is. And I think if there is a mutual respect. if there's a shared culture, I think if there is a appreciation for each role and what they do and what they bring to the table. And I think it's important to define the roles, too, because sometimes certain relationships start because one of those positions is vacant, and then the other person is coverings. You have a physician leader doing a little bit more of the business, or maybe you have. You know, the executive administrator or Operations director, or whatever that position is covering a little bit more on the clinical side, or leading out on some of the clinical meetings. I think it's important that there's a distinction, but a mutual respect. But there has to be a shared culture, a shared vision, a shared. What does this look like at first. I mean, looking at you know, what are we trying to do here? What's the end goal, you know? Are we trying to expand to multiple clinic locations in our m market. Are we trying to go beyond that? Are we trying to grow our research portfolio, our development portfolio for fundraising, I mean, depending. You know, where we try about community based setting. 

Or we're talking about a setting in an academic institution. You have to have clear goals. You have to be organized, but you both have to be on the same page. But just, you know, unlike politics, maybe in Washington, DC. Or in Springfield, or wherever you're talking about. There has to be compromise, too, so you cannot go into these meetings or these discussions, or one on ones with your physician leader, expecting you're going to get everything you want just is the same as they won't either. And that's where the prioritization happens. Included in the trust. 

Daniel J. Marino:

The shared culture of the mutual respect. If you don't have that, it's like a house, you have no foundation, and you can't really go anywhere, and it becomes a very uncomfortable relationship, and it usually dissolves in one way, shape, or form, at some point. Well, and you know to your point as you start to align around those common goals as you as you both align around what you want to achieve. The physician leader is critical in driving that communication and the changewith their physicians, and in this case their faculty. Right? So, although you know, I'm sure you have probablya pretty good relationship with the faculty. They report directly up to your chair. So, being able to have that communication mechanism, that mutual respect both with the vice chair, with the chairman, and then with the corresponding faculty, that's how you really drive a lot of improvements. Right? You drive a lot of change. So I think that's critical. 

Talk a little bit about culture, though you brought this up earlier. That is, we talked about in the program here and in our own consulting work. We are very cognizant of the culture and culture has to evolve over time, you know, as they've said time and time again, you can have the best strategy in the world but culture, strategy every day of the week. How have you, or what have you done to help to kind of advance the culture into either, you know, high performing organization, or just making it more exciting for the faculty for your team to achieve some of your goals. 

Jason Raidbard:

Sure, you know II think again, and I may mention this a few times during our conversation today. But you have to have that foundation. First, you have to have not just the mutual respect, but the trust. And okay. So you ask yourself, okay, how do you build that? You're walking into a new situation. Or maybe you're in an existing organization, and you moved into a different position with people you've never worked with and lot of healthcare organizations and universities are large. So it's moving from one place. Another could be like a completely different experience. You have to appreciate and understand what everyone's doing. Now, you in the back of your mind may say, Okay, we're doing a lot of redundant work, or there's some lost efficient. Sure, no one wants a leader to come in and just say everything's wrong. Start over and there may be a ton of things that are right. So I think we have to recognize what's working. Celebrate the wins. If you will focus on the positives, there's nothing worse than walking into work and working with a leader. That is just negative. All the time I've worked in organizations where the person near or at the top is just solely focused on the negatives, and there's no joy, there's no happiness, and I guarantee you in those organizations. Your turnover rate is probably 20,30, 40, you know, in my career I can probably myself on. Generally speaking, my turnovers been under 2 with the folks that I've worked with and I would say about half of that is, people that got promoted either in the organization or outside the organization, and you do that by listening and having the mutual respect. 

I think it's important when you listen to understand the current state of what's going on the relationships beyond what you see. Because when people start to trust you, they tell you all kind of stories of how a physician or a member of the staff, or maybe a member of the organization outside your department, is treating people or not treating them well, you know, whatever it could be good could be bad and I and I think you know, recognizing the wins, listening and then working together on a mutually agreeable plan. Yes, you may be at the top of the department, or one of the top people in the department, or the medical group depending on your setting. 

Daniel J. Marino:

but at the end of the day you have to include others. They may have solutions that can really fix.

Jason Raidbard:

When I was part of a 3 different organizations in a 10 year span. Probably, you know, in the early 20 tens when paper charts were moving to Emr, I mean. That was a very critical time that was shifting the way medicine was documented across the entire country, and I think if you don't listen to the concerns that people have about templates, or how an Emrsworking. I mean, you could a clinic could come to a screeching halt? 

Daniel J. Marino:

Yeah, it could totally implode. If you're just tuning in, I'm Daniel Moreno, and you're listening to value based care insights. I'm here with Jason Raidbard, and we are talking about creating a high performing diet partnership within an academic service line. Fascinating discussion.  

So, Jason, 1 point that I want to touch on and you mentioned this a little bit, and I think it's worth kind of exploring. The economics within a clinical service line obviously are different than slightly different than in a community setting. You know, you've got clinic operations, and you know the department generates a lot of revenue from clinic operations. And then you've got research. And then you've got the educational component, that sort of thing. being within the academic area where you're looking at the department. How are you aligning or working with your partner? Your physician? Chair, if you will. How are you aligning the goals of the hospital and the clinic operation with the goals of the medical school or the academic mission.

Jason Raidbard:

Sure. So I think it's a fine balance. It's a bit more of, I would say, a balancing act or a tightrope, than say when I was just solely focused on clinic operations only, and that has its own web of different goals and politics and issues in and of itself. So I don't mean to disregard it. This is my first real, true endeavor into the tripart mission. So the Balancing act, I mean, I think it's again you're going to need to figure out where you want to allocate your resources. You're you may have goals in your mind but ultimately those goals will turn into a strategy that says we're going to spend X or Y in some certain area, I think in the academic institutions. I think one thing, that no matter what that there needs to be a focus on that, you really don't have in the community. Based settings is your development, your fundraising. That's important. And I think I did not fully realize this until II came to my current institution. The chair that I work with now is excellent. At this aspect of the tripart mission it supports can support clinic operations generally supports research, clinical trials and education creating sound endowment plans creating gift accounts, research accounts that is, external funding, and it can be from grants, from the government, could be from grants, from private institutions, could be from just people that we may have treated in clinic that had a very successful outcome. Of course, in Opy, when you're having vision issues and they get cured. It's an instant gratification of, I can see now 

Daniel J. Marino:

So foundational work it. It may be a bit easier than some of the other chronic illnesses that we see. So I think that's a critical piece to it, too. Now your clinic operations has to provide funding. Of course you have clinical operations and funds. A big part of any type of a department or a section within the academic side.

Jason Raidbard:

It does. So if you're on the academic side, and you're working with your hospital partners or ambulatory partners, you know, when you propose a strategy of adding a new physician or adding a new location. You have to show its value, not just value in the dollars and cents, but downstream revenue opportunities, partnership opportunities. And then how it's going to benefit. The community, you know, one of the things that I brought with, you know, currently was developing a dashboard for certain eye diseases. So we could track clinically healthcare outcomes and prove value beyond even just dollars and cents. Because we all know he just measures is something that insurance companies have. They're important insurance companies, and it's important that a patient have an office visit with any practitioner and have a good health care outcome.  

But balancing the 3, you know you, you really have got to maximize the time your clinicians, your practitioners, your physicians, are working within the clinic, because, unlike in community based settings, there's a set amount of percentage of time that they're dedicated to provide training for the residents training for the medical students. It there is, and that is time that they would normally be in the clinic if they work working in ABC. Health care community clinic down in, you know, Johnstown, or something like that. Now, now they're, you know, 60, 70, 80% of their time as opposed to maybe 99% of their time is in the clinic, the rest of that is supporting other of our tripartite missions. Exactly. But I think if you have, you know, a sound foundation as far as what you're trying to do, and you have defined whether it's performance development plans, a clear understanding of what grants you can get, because it's very easy to develop a budget. And say, we're going to get all this grant money when there's so much competition for public and private are limited. I mean, there's only so much that are out there, and I'll and I'll tell you so. 

Daniel J. Marino:

Years ago I had an opportunity to work as an interim executive director of a clinical service line, large internal medicine group. That was an academic facility down inTexas. And what you described. Was really what I had just thrown into this role, and what I had learned, and I found it fascinating, fascinating to balanceboth the goals and the objective culture and politicsof the hospital and the clinic operationswith the goals, the objectives, the you know, the culture, the politics of the Medical school of the Academic arena, and what I quickly learnedwas my success was really predicated on communicating to those the objectives of both of those areas in a way that you can really bring it together and drive the results. And I think that is so important for the faculty to understand right. And that's where I think the partnership becomesreally valuable. Because if you've got a chair that can that that can communicate that vision, and then you have a strong administrative support person that can activate that combined vision boy. That's I mean, that'swhat'sgoing to drive the success. And it sounds like, that's a lot of the role that you're playing.

Jason Raidbard:

It is, it is. And I think you know, in my role it can be as simple asgoing down to the clinic and trying to help out with maybe a phones not working and trying to escalate something very mundane, very simple, but very important, or it can be, you know, working with your executive director of finance and trying totastefully persuade the reason why we need said position to be open. You know whether we're in a recruitment window, or you know whether you know there's a certain regulatory reason for education program that providethis or it is here. This is actually a positive clinical funding position that will itnear instantaneously be able to fund itself in other programs. And then some because in academic institutions, because your teaching institution, you have toprovide certain services so that your medical students and your residents can train I. And there's a certain number of procedures, and these states they have to see in their rotationsand you may have a sub specialty that is not as profitable, or may work at a loss. You have to figure out how to offset that so that you can still fund the clinic profitably. You can still find the research program, but still provide the education that you need for your students, because those that's the future of medicine, those people that you're training clinic.

Daniel J. Marino:

Good point. If given where the where health care is going and resources continue to bea challenge. Both cap, human capital resources and financial resources. And then, when you think about the pressures to kind of drive that that clinical revenue?You know, it's tough, I mean it is. It's really tough to get everybody aligned. When you think back about your role and think back about, I mean, think about you know where healthcare is going, what's been,You know, the top challenges that that you see, that you know that has been unique for you and your role and for the department and things that you're really trying to work towards.

Jason Raidbard: