Specialty Clinics: Integral to the Value-Based Care Ecosystem

Certain specialties, such as primary care, are generally better positioned to shift to value-based care. Specialists, particularly cardiologists, encounter challenges when transitioning from fee-for-service to fee-for-value. To succeed in this shift, they must rethink their approach to patient care. In this episode of Value-Based Care Insights, Dan Marino sits down with Dr. Sameer Sheth, a board-certified cardiologist who helps specialists transition to value-based care by focusing on a patient-centric approach to medicine. Gain insight into the healthcare provider ecosystem and how data and tools, patient engagement, and communication all support the shift from volume-based to value-based care.

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value-based care insights. I'm your host, Daniel Marino. As we've discussed on the program many times, shifting into value-based care is easier for some specialties more challenging than others. Some of the primary care areas have found it quite, I don't want to say easy, but the transition from fee for service to fee for value and value-based performance around the activities of primary care. It's been a smoother transition. For some specialties, they found it a little bit difficult. We worked with a number of specialty groups in either forming integrated networks, or maybe even a part of a larger ACO, and the common question that often comes up is for specialists and for specialties. What do we track? How do we transition into value based care? How do we make it something viable for our specialty providers. So we can continue that transition into value-based care. And it's no secret that it's going to happen in 2030, as Medicare has said, as CMS has said, you know, their goal is to move really as much as the healthcare community into value-based care. They want to get out of the or out of the framework of managing really patients Medicare patients in a in a fee for service structure, they want to move folks to value-based care under these commercial plans. So the transition for not only primary care, but particularly specialists, is really going to be important.

Well, I have a wonderful guest here today, that's going to help us talk through the transition for cardiology, for cardiovascular medicine from fee for service into fee for value. Dr. Sameer Sheth is joining us today, and he is a board-certified cardiologist practicing at a large health system. He's done a lot of work with not only in cardiovascular services, but with some other specialties helping specialist transition into value-based care. Looking forward to the discussion, Dr. Sheth, thank you for joining the program.

Sameer Sheth:

Thank you so much, Dan, for that warm introduction. It's pleasure to be here on on value-based insights. And I'm excited to discuss our topic today and share some insights with your listeners.

 

Daniel Marino:

Well, thank you. I appreciate that. Let's talk about cardiology and cardiovascular services again. As I said in my opening comments, for some specialties, it's been a little bit challenging to make that transition for fee, for service, to fee, for value. What have you seen within cardiology, within cardiovascular services? Has that transition been difficult? Are you seeing a little bit more momentum? What are you sort of seeing as you work with different providers around the country?

 

Sameer Sheth:

Yeah, historically, as you mentioned, cardiology has been really entrenched in fee for service. And really, what it means is, if you look at cardiology as a specialty. It's a wide range of subspecialties, and each focus on different aspects of heart health from general cardiology to structural health, to heart failure and transplants. And with modern technology, we've had so many advancements in the field of interventional cardiology or electrophysiology. And patients require more and more coordination between the cardiologists themselves. Yet our per our current payment models incentivize volume, they incentivize procedures, and they really don't really incentivize the quality of care for these patients. And so if we look at transitioning from a fee for service world where you're incentivized to do these things to a value-based world where requires a multi-faceted approach. It's a tough transition. And I think more and more realizing that it needs to happen. And really, to do this, you need a few things. You need to emphasize prevention. You need to emphasize coordination data. Utilization becomes a key aspect. How do you use the data that's available to identify patients, patient engagement becomes more important. And then, really, the last form is the innovative payment models that that we can get into and talk about, and the technology that can help that. So I think, really focusing on value over volume requires many steps along the way.

 

Daniel Marino:

Yeah, I agree with you. Good, good. Those are good points. And I, it's really a paradigm shift. But I think the interesting thing about cardiovascular medicine and cardiology, and you mentioned this one, there's numerous subspecialties. Second, is for cardiology, because it's internal medicine based, there's a lot of patients who see their cardiologists as their primary care physician. So when you look at the contracting opportunities there is attribution of lives to cardiologists that are different than other specialties. I think that provides an opportunity for cardiologists. I think it also provides a little bit of a challenge as well, too, because, although you may be focusing on the cardiology based chronic diseases. You may be missing some of the other ones. That and the coordination around that, I think, becomes really key. But other specialties are transactional, based right? Some of the interventional cardiologists. So in your experience, one of the things that you mentioned was alignment right? How do you align all of the sub specialty, cardiology or cardiovascular providers into an integrated network in such a way that they're working towards the same common goal?

 

Sameer Sheth:

That's a great question. And it's much easier in health systems that have all of the specialties in. In my experience as a general cardiologist, having the general cardiologist as a central point and responsible for that patient makes the most sense. They are doing the early diagnostic work, the medical management of these patients, and then referring to their colleagues who are helping with the procedural parts of the care. And so in independent practices where they may be more general cardiologists refer to colleagues that are at different practices, we still need to assign that attribution, and I think it starts with that general cardiologist.

 

Daniel Marino:

Yeah, really, just almost managing the case amongst your colleagues, right? And I, and I think similar to a PCP structure where you have that general colleague general cardiologist, being the quarterback of the of the care.

 

Sameer Sheth:

And I think you mentioned something very important for certain conditions, and as patients get sicker and chronic disease management becomes a big part of Medicare patients' lives. PCPs look to cardiologists for management of congestive heart failure for coronary artery disease. It's a team-based approach because these patients benefit from having their cardiologist intimately involved in their care. And we can't forget that comorbidities with cardiac disease are always existent diabetes, hypertension. And so, having that communication between the cardiologist who may act as that quote unquote PCP. And then their primary care provider, their internal medicine doctor, who is also addressing some of their needs. I think that's a big part of value-based care that we have not seen in the past, because everyone's really been in their silos, in the fee for service world, but that intimate communication is very important.

 

Daniel Marino:

So cardiology and cardiovascular services as a specialty is one of the areas that has been near and dear to my heart over the years. I had an opportunity early in my career, to manage a cardiovascular practice. And really enjoyed it really became engaged with the different subspecialties of cardiology and cardiovascular services. And there's been a lot of changes over the years. There's been a lot of changes from a focus, you know, 10-15 years ago a more interventional type work to less on interventions more on on therapies. In your opinion, you know. How does that come into play? I mean on the surface, you would think that it does help to reduce costs. You would help think that it does help to improve patient outcomes. But frankly, it's a mindset right? I mean that in and of itself depicts the transition from fee for service to fee for value. How is that received by a cardiology group, an integrated cardiology group that's really looking to kind of move or use that as a basis to move into value-based care?

 

Sameer Sheth:

That's a that's a great point. And I think you said it really. Well, it's a willingness to adopt that mindset a patient centered approach and shifting the mentality from volume to outcomes. And but it requires a lot of tools. And so what I say is, you know, a group that's looking to do this, you really need population health tools, you need data analytics, you need a a team based care approach because you can't do everything yourself. Cardiologists are very busy. They're seeing a lot of patients. There's a lot of wait times, but we want to move the care ahead. So I think the focus needs to be on a few things. One is data. Data analytics can really enhance the care provided to patients. So getting real time updates getting real time data from pharmacies. This allows us to treat the patient with the best medical therapies. As you mentioned, we're learning more and more through randomized clinical trials that medical management is the 1st step. Look at a condition like heart failure. Less than 10% of patients are on optimal doses of goal directed medical therapy. And we know that these medications can reduce the risk of hospitalization 40 to 50%, they improve mortality. So how do we leverage the data, knowing that, half of our patients are not on this one medication. Let's create a population health program where our nurses, our nurse practitioners, our pharmacists, can help get these patients on the right doses through trication.

 

Daniel Marino:

Right. Well, then. That's a great point. The data has to drive that because it drives it not only as an understanding of where you're providing the optimal level of care, but also what are the outcomes associated with it? And you know it was. It was interesting. I had the opportunity to work with a an academic cardiovascular, a very well world renowned cardiovascular program in the Northeast as part of an academic medical center. And I'll tell you many of the cardiologists, many of the faculty within cardiovascular services saw themselves as scientists versus even providers. And they love the data! The thing that I noticed was as they started to think about moving into more performance based care felt like they were looking at the wrong level of data. Right? They were looking at maybe more of the research data, but not the data that you just described.

 

Sameer Sheth:

Yeah, you said it exactly. Exactly right. Cardiologist love data. We've been using randomized control trials to show evidence for drugs and therapies. As you mentioned, these trials are very scientific, and look at the outcomes they look at clinical outcomes. But they don't really look at implementation. And so driving evidence based guidelines and reducing clinical variation are critical drivers of VBC and cardiology. We really need to standardize guideline-based therapy, and that requires implementation and workflow management. And so I see it as a need for cardiologists and cardiology practices to really understand, how can we in our existing workflows. Add these levers? How can we make sure that we prescribe the right medication? But how can we make sure the patient picks up that medication. How can we address side effects? How can we follow up in a timely manner? And you can't do everything alone, as I like to say so. There are huge opportunities to build those workflows around the cardiologist.

 

Daniel Marino:

So if you're just tuning in today, I am here talking to Dr. Sameer Sheth, and we're having a fascinating discussion around cardiovascular services and transitioning cardiology, cardiovascular services from fee for service to fee for value. Sameer, the data obviously is really important. But what you do with the data really becomes key. Let's talk a little bit about the governance structure. You know, a lot of cardiology groups obviously, have, you know, a lead physician there, and they, you know, they work with their providers, and so on, and so forth. How does governance? How does the you know the working with the different cardiology, physicians and providers, and so forth. How does that need to be different in a fee for service or fee for value world? How do we create that collective alignment, any thoughts?

 

Sameer Sheth:

I think, having a champion who believes in this is very important. And then having that champion who's willing to implement new programs that may be uncomfortable at first, but allow buy-in from the rest of the group. So for an example, if you look at ambulatory surgical centers, they're a growing field in cardiology, where diagnostics procedures can be performed as an outpatient. It creates better efficiencies lower wait times increase access to care, and they can be they can reduce cost by almost 30 to 40%. But that requires buy in from a champion and the group right? It takes capital. It takes time. You have to do a lot of legislative and processes to get that approved but it helps the group and the patients. And it's a large undertaking. But that's an example. Other things are creating a simple program like having urgent care in your cardiology office, having time to take patients who could otherwise go to the emergency room but bring them in for Iv treatments and therapies to get rid of excess fluid things like that. So there are new programs and having that champion who's willing to try these new programs that are outside the normal protocols and cardiology is a good start.

 

Daniel Marino:

Yeah, I agree with you really think you need to have that that physician champion, right? You have to have somebody in the group that's driving the change that's creating the vision of where the organization needs to go from a value-based perspective. And that could be that champion to activate the vision. And your example of moving from a queue to more of the ambulatory arena for cardiovascular services is spot on. We're seeing more and more of that with a lot of the transitions of care and payers are responding. Payers are asking for that. Many organizations in the contracting that we're doing for organization. They don't want to pay for some of these services that are being done in the Ecu arena. They want to do it in ambulatory. So which kind of leads us to my next question is, is, I was hearing you talk. you know, if we're if we want to build a contract right, get a deal at the end of the day. That's where the rubber hits the road right? You can do all of these great things, and we talk about this time and time again on the program. You could do all these great things around creating measures and aligning your group and being clinically integrated. But at the end of the day, if you don't have a value-based contract or some type of alignment with your payer partner, you know you, you're not going to create the right level of momentum that you that you need to.

 

Daniel Marino:

What are some of the important elements that cardiology, groups or cardiovascular groups should consider as they start to engage in value based contracts?

 

Sameer Sheth:

Yeah, as you start thinking about value based contracts, I think the one thing that cardiology groups need to get comfortable with is being responsible for the patient, not just their cardiology needs. And I think that starts as you mentioned, around attribution. Once you're responsible for that patient. That patient is attributed to you. You have to go beyond their needs for their cardiac episode. It may involve coordination to get them to see their nephrologist. It may require coordinating for them to pick up their medications. And so, as we think about attribution, there's different ways cardiologists should start thinking about it. 1st and is around diagnosis. Am I responsible for congestive heart failure patients? The second is, am I responsible for this patient that has multiple cardiac conditions that sees me more than they see their primary care doctor? Kind of what we call a plurality of claims, kind of, they're seeing this specific provider more than others, they should be responsible for the patient. Then, lastly, I think of cardiologists as kind of network attribution, where your network of cardiology or group or your health system, should be responsible for all the patients that they see. It's almost like an ACO an ACO model where the you know, a primary care organization is responsible or a group of patients. And this could be a multi-specialty group. This could be cardiologist. And I really think once you're attributed that patient. Then you create the programs around that group of patients to keep them healthy.

 

Daniel Marino:

Yeah, I agree with you. And as you're talking about this, you know, the an interesting thought came to mind for a cardiology group that has many of the subspecialties, and really moves towards clinical integration or clinically integrated within the group. You really have 2 contracting opportunities. You can contract direct with a payer around that attribution model right? The attributed lives to the general cardiologist. And probably can even, you know, second to that is come up with some episode based pricing models, right? That could be managed by the general cardiologist and then incorporated with a lot of the sub specialty. So I think that's an important contracting mechanism or an approach. But the second one is to be able to position yourself or position the Cardiology group as a preferred provider partner to ACOs, especially these primary, care-based ACOs. Not that you want to transition the attributed lives from primary care to cardiology, but the sub specialists working closely with the primary care groups, I mean, you want to talk about a way to bend the cost curve. That's it.

 

Sameer Sheth:

You nailed it on the head, I think, working closely with primary care. In my, in my view, is going to be the future of cardiology care because, there is an opportunity to show how cardiology care can improve outcomes. And then with that improve rewards for the cardiology group. So I think there's actually. And you mentioned, there's actually states that are far ahead on this. If you look at Maryland, they have a Maryland episode, quality improvement program. They call the equip program for cardiac episodes, such as heart failure, PCI, cabbage surgery. They have these bundles that look at cost and quality over 60 to 90 days. And that cardiologist can earn upside or earn shared savings from these episodes, and then with primary care it's a similar structure. If you can show value for episodes or through cardiac care, the primary care can subcapitate or give you some part of their shared savings because you also made an impact on that patient's life. So I think there's contracting opportunities with primary care with payers. And it's really new, but I think there's going to be a big uptick in the future with this model.

 

Daniel Marino:

Yeah, I agree with you. I'm a big proponent of episode-based pricing models. I think they really create some strong incentives. I think it really does align the providers. And if you do this well, you you're delivering really good care to those particular patients who are who are within that, that that episode of care, so to speak. But to your point earlier, you're only going to be successful. If you have the data right? You need to have the data to manage it. You need to understand what's occurring and identify some challenges that are potentially, negatively influencing patients who are considered in that episode. Without the data you're really limited.

 

Sameer Sheth:

And I think you're right. There's 2 kind of pieces of data that I see. One is the early real time data around where are your patients? Are they headed to the emergency room? Are they being discharged from the hospital? Because you need to attack the needs of the patient at the at as soon as you can, because that's really going to drive the downstream costs. And then, secondly, what we've been lacking for so many years is data around how am I performing? Am I doing the right things to be able to partake in the shared savings? I don't know where I where I am right now, and I think we've become more sophisticated. And payers have also to allow physicians to see how they're doing so that they can make adjustments quarterly or halfway through the year to say, Hey, I'm not doing so great on this metric. How can we improve as an organization? So data on both sides is very important to drive this behavioral change.

 

Daniel Marino:

So if any of our listeners that, you know, are either part of a cardiology or cardiovascular group, or maybe are part of a multi specialty group that has cardiology. If they're if they're really focusing on moving, wanting to move fast into value-based care. In your opinion, where do they need to start, or where should the predominant focus be?

 

Sameer Sheth:

Yeah, you said a cardiologist are busy enough and need to focus on the patient centered care and focus on prevention and focus on chronic disease. But they need to stay informed about the advancements in policies, in medical technology and really building those strong relationships. And it's really hard to do alone. So my opinion is that to really move into value-based care there are so many partners out there that can help with aspects of that transition. Whether it's contracting, whether it's the technology piece, whether it's helping you form a team-based approach. And I think navigating all those layers is hard enough alone, but with a partner it can be accomplished. So really, starting to shift and see how your practice can do that, it's exciting. Yeah.

 

Daniel Marino:

I think it's essential. And you know, we we've talked about a couple of things, I think, when we work with organizations that are considering either ramping up their work and value, based care, or maybe just starting to dip their toe in the water related to it. It comes down to 4 things. And you mentioned this. You need to have the strategy and the vision where you want to go with moving into value-based care. You need to invest in the infrastructure right? Because this is a different mindset moving from fee for service to fever value. Data is absolutely key right. And you would. You mentioned that, I think, if there was 1 point of our conversation that has really resonated with me, it's the fact that you need to have the data and re look at the right things in order to move that value based bar if you will. And then the last is, you need to create some contracting and alignment of incentives around that. So I agree with you. I know Sameer in in a lot of work that you do. Not only is seeing patients as a as a cardiologist, but you also do a lot of work with your own company. What are some of the things that that you can offer to different groups, or what are some of the things that you know you've brought to your colleagues who have been interested in in moving forward with value based care.

 

Sameer Sheth:

Yeah. And thanks for mentioning that, I think I saw it based on our discussion. We covered all the all the points that I saw the challenges it for cardiology practices. And so I wanted to create a solution. That's a 1 stop solution where they can get the data and analytics. They can get the contracting support. They can get the team to help them transition. And so we created Chamber cardio to do that and I'd encourage listeners to visit www.chambercardio.com if they're interested. We have a blog that really talks about a wide range of topics and value-based care. The upsides, the challenges. It can help cardiologists navigate these challenges themselves or contact us or contact me to help have some support. It's a great resource for anyone looking to implement or improve value-based care in their practice. So I really think this is the future for cardiology. And I really want thank you, Dan, for having me on the show. It's been a wonderful experience.

 

Daniel Marino:

Well, Sameer, this is great, and you obviously have a tremendous amount of knowledge. And I really appreciate you taking the time to share this with our listeners. Again, you know, if there is additional information that you need please look up Sameer's website. And Sameer, you want to share maybe your contact information real quick.

 

Sameer Sheth: Yeah, I'm happy to have anyone contact to me. My email is sameer.sheth@chambercardio.com. And or you can just find me on LinkedIn.

 

Daniel Marino: Yep, alright. Appreciate it, Sameer. Thank you again for joining the program. Really appreciate it. And again, keep driving forward with value-based care. It's something that we all believe in, and I'm a hundred percent behind you on this would love to have you back to hear the successes. I want to thank our listeners today for tuning in 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