Dr. Rajaie Batniji, Co-founder and CEO, Waymark
Dr. Farzad Mostashari, Co-founder and CEO, Aledade
Dr. Ria Paul, Clinical Associate Professor and Executive Medical Director, Value-Based Care Program, Stanford Medicine
Moderator: Chrissy Farr, OMERS Ventures 

Brainstorm Health 2023 - Navigating the Shift to Value-Based Care 

Conferences

Dr. Rajaie Batniji, Waymark
Dr. Farzad Mostashari, Aledade
Dr. Ria Paul, Stanford Medicine
Moderator: Chrissy Farr, OMERS Ventures 

Navigating the Shift to Value-Based Care 

Dr. Rajaie Batniji, Waymark
Dr. Farzad Mostashari, Aledade
Dr. Ria Paul, Stanford Medicine
Moderator: Chrissy Farr, OMERS Ventures

So we've talked a lot about transformations in health care so far today. But there's another vitally important and impactful shift underway that we want to delve into this move from volume to value a system of value based care rather rather than fee for service. It comes down to reward good outcomes instead of paying based on the amount of services provided. These models are meant to drive both patients and providers towards maintaining better health rather than dealing with problems downstream. The hope is to also reduce cost, streamline the process and improve accessibility. Medicare wants every beneficiary to be receiving value based care by 2030. And investors have taken notes according to mckinsey and company private capital inflows to value based care companies quadrupled during the pandemic. So let's talk more about how to make the most of value based care with Dr Raja A N G, co founder and CEO of Way Mark and Dr Farzad Matahari, co founder and Ceo of Alidade and Dr Ria Paul, clinical Associate professor and executive medical director of the Value based Care Program at Stanford Medicine, speaking with Chrissy Fary back on the stage again to lead this conversation. Welcome. Um, so this time I actually do have three doctors. I triple checked. Um, um, so I'm gonna pick on Z over here to kick things off. Um, we are talking today about value based care, which is the topic of discussion that comes up at every single health care conference and rightly it should. Um, but, you know, usually along the lines of it's great. It's, um, where the heck is it? Um So that I wanted you to just catch us up on just, you know, what's the latest, where are we at? What, what are the stats showing? Um And just uh you know, any kind of recent updates from the C MS side that you think we should be aware of. Yeah, so this administration continues the line of previous administrations that say kind of we have to move in this direction of value based care, paying for outcomes, not for volume. I think the difference from the past 10 years is we now have a lot of evidence in terms of what works. And unfortunately, there's a bunch of stuff that didn't work. So what works, what works is giving primary care docs accountability for the total cost of care that works. Um What hasn't worked uh has or has, has had mixed results and, and again, we're still hopeful, we're still looking for models, we're still looking for ways to do it. But what we don't have the evidence for yet is um uh other than for seniors, so commercial is really hard. Uh We heard an talk about that. Uh Medicaid is really hard and I, you know, I have huge respect for the increasing number of groups who are, who are taking that on hospitals is really hard. So, uh you, I, I guess I feel privileged to be doing the easy work here and uh my colleagues on the panel here tackling some of the harder, harder issues. Um Medicaid really hard. You are building a company that's trying to do Medicaid. Um So share with us kind of why you decided to go in that direction, especially having been a collective. You were on the employer side and really made, I would say a bit of a 1 80 shift um into, into this, this Medicaid area with, with way. So um why, why is this need um being so unmet and and why do you think look at first it wasn't really a 1 80? I mean, my clinical work has always been focused on Medicaid, that's where my clinical practice has always been. And my research work had always been on how do we pay for health care and low income settings around the world? And so for me, it was actually a need to say that we had all the creativity and the capital going towards Medicare and employer. And if we were going to do something about health equity, if I wasn't part of the solution then I was part of the problem. And so for me, it was just this mission alignment of, you know, we need to bring some of that same creativity, we need to bring some of that same investment into Medicaid to actually do something about improving outcomes. Um And I think the question is, is it hard? Absolutely. It's hard. It's hard for, for all sorts of reasons. Um You know, there's churn the reimbursement flow. Um probably one of the main reasons that value based care hasn't taken off in Medicaid is that, you know, you actually don't have this arbitrage of, you know, risk adjustment. And so the only way to make a value based model work in Medicaid is to actually improve outcomes and to actually reduce costs. And you know, that's not the same, can't be said for all value based programs. And so that focus is everything for us. And so we have to actually look at far as I talk about evidence, you have to look at the evidence of like, well, what's actually worked and we've seen over and over and study after study in the US and internationally. You know, when you bring care to the community and you've got community health workers, you've got accompaniment for high risk and rising risk patients, you're reducing readmissions by half, you're cutting overall medical costs by a quarter, you're dramatically improving health equity outcomes. And to me, the challenge is everybody says Yeah, but those programs are really hard to pull off, they're hard to implement, like, of course they are and there is no better challenge worth taking on. Yes, go ahead. Um We're not in health care health systems now. Um Well, I was going to direct your question your way. Um So you take care of seniors and um I would say, you know, if we walked down to the streets of, of L A right now, Marina Del Rey and said, you know what's value based care? I don't know that that many people unless you were in this conference would be able to tell you and would know to advocate for it. So how do we actually reach the patients? Do you think that they should know that they're being treated in a value based way or do you think it should just change almost invisibly and suddenly their health care experience is different? Well, I think, you know, first from the health system standpoint, like we are a hospital system and also an Academy Medical Center, which makes it very hard to do value based care. But I think at Stanford, we have taken the bull by the hands. We are, I'm very optimistic about value based care. And though our tripartite mission is to provide innovative care together with education and research, we are focusing on hybrid model where we are providing innovative care but aligning with the value based care principles and as Chrissy alluded to that. What are we doing for the patients? How do the patients know that we are providing value based care? So it's something that happens on the back end, what we are doing with our providers, our providers, we are trying to support them every step of the way in their practice and in their day to day practice because as you know, all primary providers are under the onslaught of various things, right, messages and so forth. So we are supporting them with a care team model where the care managers embedded in the team are reaching out to the high risk patients, the seniors. So then the seniors get a call from the case managers, they feel like they are part of the health system and they are being cared for and that really prevents a lot of er visits and hospitalizations because they don't feel that drop of a hat that they have to go to a hospital or the er and so that is what we are doing and also through COVID, what we saw is like a like a emergence of mental health issues, right? And so we have integrated mental health physicians in our day to day practice to support our primary care provider. Stanford being a very specialist, heavy organization. Many come to Stanford to get specialist care care, has access is impacted and we want to do the value based care model. So what we institute is E consoles where where providers can reach out to specialists just for feedback and particular issues and then get that feedback back. And that is so timely and so convenient. So it kind of encompasses the various strategies of value based care as we practice. And I think the patients slowly begin to feel the benefits. Like one of my patients said, you know, virtual care. I love it now though, he's an elder initially, he didn't like it, but now he says, oh, I love it now. It's so convenient and I think it's cost effective too to the health system. I said you're right, it's cost effective. So I think, I think we are getting there with Valli based care in bits and pieces, small steps. But, but it is a process. I love this patient who wants to save you guys money. That's great. Um OK. So questions from the audience. If anyone has one, you think that's my over there? Hello Ris Bakari. Uh I'm an MD. So uh how sophisticated are we getting in getting providers to accept downside risk as part of BBC contracts versus the kind of current participation awards we kind of handing out today who wants to take this one? So the majority of our lives are now in downside risk contracts and we have downside risk in both um Medicare advantage, but also traditional Medicare and also commercial contracts. Um I personally don't think that it is wise or necessary to put a small practice with like the threat of bankruptcy with a gun to their head to say like, ok, now make good decisions, right? Um I think from an organizational system perspective though, I do think that it's important for organizations taking risk to be facing downside as a uh as a, as a curative to FIFA service incentives. So, Aida, we have 1000 practices last year, 1500 practices this year who work with us, we bear cost risk on the downside, but we don't pass that down to the practices. And we, we take a similar approach at way mark where we take downside risk. My, my view on this is a provider should really take risk on what they control and not things that are necessarily beyond that. And I think in Medicaid care delivery, if you look at the evidence of, you know, what works at actually improving outcomes and recent costs, you know, not very much of that actually takes place within the four walls of a hospital system or a primary care practice. And so, you know, it's actually appropriate for us to take that downside risk for engaging members in the community and doing the things that can actually move the needle but not necessarily, it's not necessarily right for every provider to enter into that risk agreement. I can, I can I jump in on, on the, the the point I raised about uh risk adjustment, go for it. So uh you can't have taking risk without risk adjustment. You need risk adjustment to be able to make sure that we don't get, uh, lemon dropping, you know, whatever skimming the cream, whatever type of things. Um, but it is absolutely true that I think it is done at the, the, the game around discretionary coding really hurt. I think the perceptions around Medicare advantage, risk taking providers because it was just too easy to make money focusing on adding diagnoses. And I'm really glad we started on the traditional Medicare Medicare savings program where that was not an opportunity. And I think it's actually a really important proof point that if the only way to that is proven is not on just risk code, I think that's a, it's really important to like get that point out there. There are a lot of risk taking providers who became specialists in risk adjustment, but that is not the, that is not the, the, the evidence is not entirely rely on for sure on, on, on that group. And there are plenty of groups now who have done it the right way and actually reduced total cost of care. So, on that point, I'm gonna jump in and, um, we are all clearly fans of value based care that's, you know, you're all dedicating your lives to it. Um, and we know, I think we all know the ball case and we're probably all kind of advocates for the most part in this room. Um I'm gonna put you all on the stand and, and give me, give me the opposite, give me the bad case. Um And, uh, you know, we only have a few minutes left but uh, so do it, do it in a way that, that has a little brevity. But um I'm gonna ask you first. Well, the thing is that, uh the, the, the problem with value based care, especially in an A MC like Stanford, where we stand for providing innovative care. That's where it it is at the crossroads, that how we provide innovative care and how we provide value based care. So that's why I mentioned that it always has to be a hybrid model in a, in a, in a academic medical center because will have patients who will come to us for the care that they need and that won't be provided anywhere else. And another thing is that the crossroad is always there. But we see from the specialty perspective, from the specialty side, it is at the crossroads of revenue and utilization. And I hear from every specialty clinical leader at Stanford, why are we doing this? But I think, but at the end of the day, it is the right thing to do and provide physicians are very smart, right, doing the right thing at the right time, right place. And that's that is what we are trying to do with the other part of our tripartite mission is education educating all of our young physicians, medical students, fellow, those residents on the concept of valid this care. We have created a curriculum so that they can incorporate it as they start practicing medicine because without it, there will never be a fire starter. So there's your, there's your bear case for specialist. Why are we doing? Why are we doing this? We're doing fine. Yeah, we're doing fine. Uh My bear case is um, is that if you're uh big, you don't need to actually embrace value care. So the competition and is lacking in health care consolidation has gotten worse. COVID made it worse. And the FIFA service game is the bigger you get, the more power you have in the negotiations. And if you're big enough in the negotiations, then you don't need to take risk any real risk. So you can get some fig leaf value based contract. It can be called an AC, but really it's just another way to pay you more and no one's gonna like, like no one's going to hold you. You're not actually going to be held to account. You're never actually going to be accountable. And I think short of some serious regulatory action in this country, we're going to see entire parts of the US basically handed over to monopolists and, and no, no value based care can succeed where monopoly reigns. I couldn't agree more. I got it. Not just you. Well, well, I, I, I couldn't agree more. Here's, here's the challenge. My bare case for value based care is we've sort of made value based care, the destination when actually it's not a destination, it's, it's the Vietnamese. And so, you know, C MS has a goal of putting 100% in value based care. By 2030 every state Medicaid agency has goals around moving to value in Medicaid. And basically, what that's done is in my mind, created one of the biggest barriers to true care delivery transformation. And that, you know, for, as I called the fig leaf, I often call them value veneers, which is, it technically checks the box of a value based arrangement. You know, there's, there's some shared savings, there's some bonus program, it does nothing to change care delivery and it actually doesn't matter financially for the provider. And so you don't change provider behavior, you don't change care delivery, but you sort of now attributed a member to a value based arrangement. That member can't be part of another one. And so I think making value based care a goal in and of itself is detrimental to the underlying cause of let's improve outcomes and do what's worked. What works, value based care is important because it allows you to do things that aren't paid for under fee for service. And if you're not doing that, it probably doesn't make sense to be in a value based arrangement. Do you think we're going to meet that 2030 goal. No, that's ok. We're gonna make, we're gonna make progress towards it. We're about a third of the, of the primary care doctors in this country are now in, in what I would consider they've actually changed their practice patterns. A third. It's a lot. It'll, it'll, it'll grow, but maybe two thirds. That's ok. And 50% of Medicare beneficiaries are in Medicare advantage. So, um, cool. Yeah, I love the fire we're bringing today. This is like not what I expected to evaluate care panel, but it's great. Keep it going. Um What is the, what do you think is the specialty that will be the first of all in terms of just widespread acceptance and adoption and primary care? Yes, I mean, primary care is the obvious one. But what's next? I'm seeing a fair amount of interest uh in, in among the specialist sub cap or shared risk on oncology. Cardiology are the two that I'm seeing and nephrology are the three that I'm seeing the most where they kind of take accountability for the patient in the same way. No, I I would agree or is coming behind two in a way because so much, so many Medicare beneficiaries need or visits and interventions and so forth. So I would agree with that, the cardiology, nephrology, oncology and or maybe counterintuitively where we're seeing. Actually quite a lot of interest is surprised me. It was not our thesis, but you know, big health systems because for them, especially in Medicaid, where they tend to lose money on each interaction, whatever they can do to keep people out of the hospital, make hospital stays shorter is, you know, hugely creative to their bottom lines. And so we've seen, you know, big health systems be really interested and moving to and again, the value part of it doesn't matter, moving their poor people to. No, no, it's not that it's actually like, what can we do to improve care outside of our four walls? What can we do to actually bring care closer to the community where you can create a new workforce, you can do things that are cost effective that like we can't do in a big hospital system. And they recognize that the wrong point of care for, for a lot of a lot of patients, look, I'd be really happy if the health systems embrace having fewer hospitalizations for their, you know, good case mix patients. I haven't, I don't see the financial incentive for them to do that. And I think people act according to their financial institutions act according to their financial incentives, not people in that, that financial incentive should be universal. Um With that we're out of time and I felt like we had a, an element of debate club on the stage today which I appreciated. Um Thanks for doing the bull case, the back case, everything in between. Um what an incredible group and, um.