Unlocking the Promise of Value-Based Care for Doctors and Patients with Dr. Will Faber

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'm real 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 incomes of 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. So there'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 that I 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 what challenges us, as we know, during the pandemic hundreds 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 from their 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're part of a of a network that's got resources. I worry about the independent doctors. And of course I'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 think that's part of what I'm seeing as a challenge more so for the Independence, right? So you 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 around analytics. 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 level provide 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 comment from 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 to other 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 doing and 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's been obviously a huge shift to Medicare advantage. There's CMS has made it very clear that by 2030 they wanna get out of the management of of Medicare 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're gonna 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 advantage Enrollment 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 course it'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 risk and 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 supports we're talking about here to continue to float the boat. 

Daniel J. Marino:

If you're just 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. So Will 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 a there'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 through without 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, between fairly rewarding the physicians related 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 you reward 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 enterprise is 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, I absolutely agree. So I want to get your thoughts on one other area here, Will. We have seen a 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 Boots paid 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 as they'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 so I 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. And physician 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 wanna get in touch with you, you know. Can you share your your LinkedIn 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 me be rewarded better for the work that they do. I will provide all my contact information. I welcome anybody who's listening to 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