Name: Brainstorm Health 2024: Technology’s Role in Value-based Care
Uploaded: 2024-05-21
Duration: 18 min 26 s
Description: Dr. Rajaie Batniji, Co-founder and CEO, Waymark, Dr. Sachin Jain, Chief Executive Officer, SCAN Group; SCAN Health Plan, Brent Nicholson, Co-founder and Chief Partner Officer, Carrum Health Moderator: Chrissy Farr, Second Opinion Media

Dr. Rajaie Batniji, Co-founder and CEO, Waymark, Dr. Sachin Jain, Chief Executive Officer, SCAN Group; SCAN Health Plan, Brent Nicholson, Co-founder and Chief Partner Officer, Carrum Health  Moderator: Chrissy Farr, Second Opinion Media

Brainstorm Health 2024: Technology’s Role in Value-based Care

Conferences

Dr. Rajaie Batniji, Waymark, Dr. Sachin Jain, SCAN Group; SCAN Health Plan, Brent Nicholson, Carrum Health, Chrissy Farr, Second Opinion Media

Value based care. So maybe five years ago at a similar conference in another time, we would have been the hot panel, but now it's the A I panels that are the hot panels. So I think I'm going to start with Satin, who's written a lot about this topic of value based care and how much it's real and whether the implementations are actually doing what they say would love to get your sense with where we're at now just on value based care in general. Has it met the promise? I think it's easy to say, no, it has not met the promise. And I think one of the reasons is that I think everybody still has got a split personality about it. Um And when you actually look at what's happening under the hood in most organizations that are so called committed to value based care. Um The commitment is only an inch deep and, you know, a mile wide. Uh And I think a lot of organizations haven't done the hard work to really ask themselves the existential questions about how they're gonna actually evolve to a new business model because they haven't necessarily had to do that. So I think, um, you know, it's largely been an incomplete experiment so far from, from where I sit. I, I wouldn't say that that's uniformly true. I think the future is here in many places where value based care has been implemented at scale. But I would say nationally it's, you know, we're still in the early innings of the value based care story. J do you, do you agree? Do you have a more optimistic view? I mostly actually agree and, and actually, it's a pleasure to agree with that. And you know, I would say that the biggest issue in, you know, way, Mark, we work in Medicaid. The biggest issue we we see in value based care is that there's so much like fake value based care. I wrote a piece on this, um for health affairs called value veneers where I think what we're actually seeing is there are a lot of programs that sort of like check the box on value based care. They, they technically meet the requirements of it so that a health plan and a provider could say yes, you know, C MS, we're doing value based care, but they actually failed to do what value based care was intended to do. And value based care was intended to actually change the nature of care delivery. And so I think my rubric for looking at a value based program is not, you know, is there incentive payment for Xy or Z but has this program changed the nature of care delivery? Um And for us, like that means like, you know, have we created a new health care workforce that can reach patients where they are? Are we able to move responsibility and accountability for care outside of the traditional brick and mortar health care system and directly into the communities that we're serving where those interventions could be most impactful. And so I think unfortunately, so much value based care is kind of operating almost like a loyalty rewards program rather than truly something that can change what's paid for in health care. And that's actually what we have a true shortage of is real value based care. We have an excess of veneers. So one of the things that I think Sarin has also been writing about is just that value based care can focus on a few things like you look at hospitalizations and making sure that people are getting discharged quickly. That can be one way of thinking about value based care. And there are others that we tend to focus on a lot of that based on how the bill works and how we record outcomes Brent for you as you look at what is value based care and what isn't. And through this context of thinking about fake value based care and veneers, what do you think of the true measures or outcomes that we should be looking at so that we don't just get fixated on a few things that may or may not be right for that individual patient. Yeah, sure. I, I think uh what, what we focus on is actually engaging in arrangements with providers that have both upside and downside risk. That's in our version of true value based care. It's engaging with the provider to ensure that they have a shared accountability and actually are invested in the outcomes of the patient. And so, uh you know, what, what we're looking at is uh you know, condition or episodic uh based care in the specialty care area, uh in engaging with providers to have more ownership outside, say the four walls of an operating room uh to extend their accountability to uh not just did we technically perform this procedure correctly, but did it actually get the patient better? Did it actually address what they went into the facility to get the operation for in the first place? And maybe I'll just kind of jump off of that and throw the question out more broadly. But does that kind of work require actually thinking about which physicians are good at what they do and not good at what they do? And I know this is a very uncomfortable topic for a lot of people when we start thinking about how do we rate and rank physicians. But that is essentially part of what you're saying. Right. Absolutely. I mean, we are not believers in the general hospital model that you can have a building that is good at health care across the spectrum. And so when we're looking at, we're zeroing into specific episodic conditions and looking for expertise and top performance down to a very granular level. And you know, we use the power of, you know, massive data sets to help us gain insights into which providers do meet that very high bar of top 10% 10 top 10% performance. Um, and we're looking to engage them in these upside downside risk arrangements, um, so that they can, uh, really do what they do well, and, uh, don't have to be saddled with the administrative burdens of figuring out how do we then figure out how to submit claims and how do we then figure out how to do the authorizations and how do we figure out then handling with the payers to make sure that we get the money in the door. We want to find the best providers, allow them to do what they do well and then make sure that they are rewarded for that. So, so I wanna just say I love this conversation because, um, I think a lot of value based care conversation is actually not about what you're talking about. It's not about getting patients to the best clinicians. It's actually about labor arbitrage is how do we take the work that specialist M DS we're doing to generalist M Ds and then then take work that generalist M DS were doing and take them to nurse practitioners and then take work that nurse practitioners were doing and take them to our ends and take work that RNS were doing and then take them to community health workers and then take the work that community health workers are doing and then give them to people's family members. And I think we have to talk about labor arbitrage and we have to talk about actually what is an excellent health care system actually look like. And I think most of us intuitively get that. You have to actually go to a great clinician who really understands the condition well and knows how to treat it and knows the, you know, boundary conditions of that condition to be able to effectively get the kind of treatment that we need. But that's not the conversation we're having about value based care. For the most part, I totally agree on the labor arbitrage piece. And then, you know, to flip that question, push it further with J how do you see the role of the patient here? Because if they feel like they're just getting pushed into a lower level of care with less of a specialist, wouldn't, wouldn't they? As a patient say, you know, why, why I want to be in the other system? I want to be in the system where I can see the specialist that I want to see. I, I mean, I think to me, we, we center our approach literally around the patient. And so if you think about what's broken in the health care journey, imagine you're you're covered by Medicaid, um which all of our patients are in all the the states that we're in. People have a hard time accessing a physician. They have a hard time navigating the health care system. They need to use social resources that no one has helped them get to. And so to me, the point of value based care is let's actually get the physicians to see them, let's make availability happen. Um Let's wrap those physicians with the expertise that they need to appropriately navigate this member and literally guide them the whole way through their journey. And so to me, it's about complementing the existing system by creating net new resources. I mean, if you look at the data and this is we always start with data, if you look at the data about like what works in health care delivery for a certain population. And I think you need to do this population by population in, in Medicaid, for example, it's like totally clear, right? Like study after study proves that the same models work. The challenge is that those models have been funded either by, you know, a one off grant. Um They've been funded out of like a special budget from a health plan or health system and to actually do these things and do them for a long time so that communities can know that they can rely on these services to exist in the future. You can do them under a value based arrangement so that you can have that kind of permanent source of funding where actually accountability for care can actually move toward these, these new care delivery groups. So just a reminder to the audience that we are taking questions, so I'll slip to all of you next. Um I'm gonna ask you a question about A I because that has been a big topic of this conference. Um We've talked a lot about actually using A I in diagnosis, not just kind of back office, which is where it tends to be more kind of discussed today. Um Sergeant, do you think in a value based world, a true value based world, there is more room for A I in that context because it becomes less about who's going to pay for this. Yeah, the I think yes, a lot of, you know, kind of value based care is in like full delegation of risk to a downstream entity. I think the real challenge of freeing up enough resources to actually invest in A I. Is that how that downstream entity that's taking full risk, actually allocates those dollars to sub entities, how they pay specialists, how they pay primary care doctors, how they pay ancillary care providers. And that is still happening very much in a fee for service way and So then the question becomes like where does the A I get introduced? Does it get introduced at the risk bearing entity level or does it get introduced at the level of, you know, the primary care doctor or the specialists? And is there enough margin in what is actually being delegated, sub capitated to the primary care doctor of the specialist to actually integrate A I in ways that are gonna reduce cost and improve quality of care. And that's, that's a long way of saying, I think we're still figuring it out. Yeah, I would, I would add to that. I mean, I think so much of like the way we talk about A I and health care is about well in the future, you know, humans will be talking to machines, machines will be doing the diagnosis. I I think that's actually totally wrong and you know, our, our approach to A I development is really let's automate the routine tasks so that we can allow our caregivers to spend even more time with patients. Um and second, let's automate the identification of which patients are gonna benefit from certain services so that we can actually spend our time targeting the appropriate patients. And you know, we've been, we've been publishing actually quite, quite a bit on our, on our development in this this realm because I think that is where you have step change, improvement in improving access to care is you're gonna create and enable a net new workforce through A I and actually give them the pattern matching of somebody with years more fair. Yeah, I would offer a slightly alternate perspective uh from scan, which is, you know, our view is that, you know, A I is going to enable humans to become super humans. And so, you know, when you call your health plan member service representative or you're talking to a nurse from, you know, uh a care coordinator department, they're gonna be able to do more and know more about you and, and be able to leverage everything within our system through, you know, advanced decision support to be able to make those interactions more valuable and more meaningful. That's, that's how we're thinking about it. I guess two other um angles, at least from our point of view of Kam is uh agree with Rae what you said about using the power of A I and specifically machine learning to help identify the right patients, get them to the right programs and services at the right time because there's just a sea of information out there. And it can be very hard to understand and navigate for a common patient who just has too many options available to them, too many mouths trying to get their attention. And so being able to do that and say, identifying only a small percentage of the population uh in our instance that we're able to then say we can identi we can correctly identify, say up to 95% of the surgeries that are likely to occur over the coming years. Uh And then uh being able to serve up the appropriate pro program to meet the needs of that patient. And then from the providers point of view, being able to help these providers perform better in value based care arrangements. Um We've seen some tools out there that uh help to uh create these uh personalized care plans that uh you know, harvest all of the information from millions of different patients rather than just a handful of patients that one doctor has seen to be able to do things like optimize variables around, you know, the length of stay the discharge destination, the post operative care protocols so that, you know, they can zero in on a likelihood of readmission and then be able to uh adjust and tailor their follow up and check in protocols uh accordingly to then result in the best outcomes and then perform better under these value based arrangements. I'm gonna flip for a question from the audience who's got a burning question on Vala I RJ does a stats of one inference for the individual. So I love what I'm hearing about, you know, these patient care journeys and how you're really tailoring them. I'd love to know what um what the biggest challenge is to incorporating A I or anything like that into that workflow when well, I I'd say for us. Um you know, one of the considerations is to try and shield the patient from all of the complexities of what we're talking about here up on stage is really to um you know, make it so that the patient doesn't have to uh understand or navigate well, am I in a value based program? Am I not what you know? Uh And so, one of, one of the things that we work on is um ensuring that we are working very tightly with our uh providers on the patient identification um and the and the patient attribution. And so that's one of the things where um we have a, you know, very specific implementation process. We have a very specific pre registration identification process that ensures that uh when the providers that we're working with are seeing a caring patient, they can understand uh that and uh they can uh follow the, you know, the program protocols accordingly. II I think we have a similar challenge for us. The biggest challenge is like, just imagine, right? We, we serve a new market, we're serving 50,000 patients covered by Medicaid there, you know, where do we start? Right? Like how do you know which patients to, to reach out to? And so, you know, our first A I use case was we built this product that, that, that allowed us to bring in all of the historical medical claims, the local zip level social determinants, data information from food banks and housing registries and actually build this composite picture of a patient. And the result of that, which we published earlier this year in nature, the scientific reports was that we had 90% predictive power, positive predictive value in anticipating who's going to use acute care in the coming days and weeks. That means er visits, that means inpatient admissions compared to the next best model that was performing at like 30% right? So that means that now one out of 10 of our outreach is the patients are to a patient that we can't serve versus seven out of 10 if we're using a prior model. And so I think you have to get really efficient at doing that modeling so that you can actually direct your, your resources as effectively as possible. Sergeant. I'm gonna call on you for a last question. We have a few minutes left. Um So one of my, the, you write a lot of pieces, you've written a lot for Forbes. Um And I loved what you said about just the chan problem and having a patient for a single year because obviously, we, we do enrollment annually. How problematic that is. Can you just end us on a note of talking about your idea with a three year? Absolutely. I, you know, so I think one of our biggest challenges in our industry when we actually think about interventions that will actually move health outcomes is that most people are in their health plan for a year. That's the most that we can actually be certain that someone's gonna be in their health plan for a year. So, so, very little right. And the most you can do in a year is maybe you can do an annual wellness visit, maybe you can get them appropriately coded. Um, but as far as actually better managing their chronic disease and then seeing the return for it, it's just not gonna happen. And so, um I believe at least in the Medicare space, we have to get out of single year enrollments, we have to be thinking about 3 to 5 year enrollments, which would then give us the confidence that our investments in year one would have some payback in year 234 and five. I believe that's the foundation of value based care that has been missing in most of the, the so called value based care models because without the reliability that a member is going to be on your books in three or five years, you're unlikely to want to necessarily make the investment in year one to actually, you know, create some health outcome benefit in year, year, year three or year five or you may want to. But it doesn't necessarily pencil from a financial perspective. And I just think um it's these types of structural changes that are gonna actually lead us to true value based care as opposed to the value veneers that uh Rege has written so eloquently about how, how optimistic are you that's gonna happen. So, I think the, the number one objection people have is like, what if somebody finds their way into a plan that, you know, is really bad for them or they're being treated badly by that plan in year one and they really need to get out. Um, you know, I think we have to get comfortable with the trade offs. So, um I think it'll take a while for us to get comfortable with those kinds of trade offs. But I believe that the centers for Medicare and Medicaid Innovation, in addition to all the science projects that they're running right now, should add 11 more science project, which is to really look at what a three or five year enrollment in a plan would do and have it be voluntary. People should wanna enroll and do it. I think people will wanna enroll and do it because it'll be intuitive that a health plan that's, you know, that owns your life for three or five years is going to view your care very differently than a plan that owns it for a single year, time horizon, for risk and a time horizon for, for change. You need to line up. Exactly. Well, you had it here. We love it. Thanks everybody for joining us. Thanks so much.