Having equal access to quality health care across the United States shouldn't be a privilege, but a reality. Yet, seniors battling multiple chronic conditions often face disparities. The challenges are significant, from struggling to reach appointments to affording basic needs. Enter Accountable Care Organizations (ACOs). Are they the answer to improving coordinated care and reducing costs for seniors? In this episode of Health Care Rounds, Bill Lane joins John to explore how Accountable Care Organizations (ACOs) are transforming health care delivery, particularly for seniors.
ABOUT HEALTH CARE ROUNDS
Health Care Rounds is a weekly podcast developed for health care leaders who are at the forefront of health care delivery and payment reform. Join Darwin Research Group founder and CEO John Marchica as he discusses the latest advancements in healthcare business news and policy developments.
ABOUT BILL LANE
Bill is ilumed’s Executive Vice President of Network Development, leading the ACO REACH’s contracted provider and beneficiary growth over 200% from 2022 to 2024. Prior to ilumed, he spent over 15 years with Humana and held leadership roles in hospital/hospital system contracting, alternative payment model creation and deployment, including the nationwide lead for Humana’s adoption of CMS’ Primary Care First model. Before Humana, Bill was with the national PPO, MultiPlan for over ten years, where he held progressively responsible network leadership roles in the southeast.
Bill and his wife of 32 years, Kathy, live in south Florida, where he enjoys golf most of the time and looks forward to welcoming his three grown children home as much as possible.
ABOUT JOHN MARCHICA, HOST OF HEALTH CARE ROUNDS
John Marchica is a veteran health care strategist and CEO of Darwin Research Group, a strategic consulting and market intelligence firm focused on hospitals, health systems, physician groups, and the evolving health care ecosystem. John has a degree in economics from Knox College, an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Health care Executives and is pursuing certification as a Fellow.
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Welcome to Health Care Rounds.
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I'm John Marchica, your host today, and
I'm really excited.
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I'm going to be speaking with Bill Lane,
Executive Vice President of Network
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Development at Ilamed.
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So Bill has spent, he's spent over 15
years with Humana and has had many
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leadership roles regarding hospital system
contracting, alternative payment models.
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I mean, actually was part of Humana's
adoption of
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CMS' first, or primary care first model.
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So we're going to get into more of his
background here, but today the focus is on
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value -based care, accountable care
organizations, and why we need to pay
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attention to these things.
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And what sort of what the state of the
union is today.
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So Bill, thank you so much for taking time
to talk.
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I really appreciate it.
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My pleasure.
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So we were talking for just a minute
before we started recording and I...
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And I said, you know, I really feel like,
you know, where we are today, it's almost
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like population health, this term that
everybody throws around population health,
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pop elf, are you in pop health?
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Yeah, I'm in pop.
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But it means different things to different
people.
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And it's almost like it's taken on this,
this, era of almost like it doesn't mean
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anything.
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So that's kind of how I feel about value
-based care.
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Like a lot of people have a sense of what
it's about, but.
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maybe definitionally, they're not quite
there on really what we're talking about.
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And so maybe a good place to start from
your perspective, if we were to roll back
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the clock to like the, you know, late
eighties, nineties and managed care
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revolution, right?
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Talk to me about where we were at that
point in time.
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And then when we started to see the sort
of
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idea of value -based care take shape?
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Hmm.
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Well, that's a, it's a big question.
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That's a big question.
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well, understand, you know, I'm, I'm, I'm
not that old, but old enough to remember,
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back in the day when, you know, your
parents were guiding you through your life
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and you know, you want to get a good job
with insurance, right?
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Right.
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Make sure that insurance.
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And I'm talking as far back to the early
eighties, you know, when I was graduating
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high school and going into college and,
you know, back when you had employer
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sponsored healthcare, it was an indemnity
plan and health health plans were known,
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you know, the Cadillacs, right?
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Blue Cross, Blue Shield, indemnity, go to
any doctor you want.
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And the physician, the provider is
indemnified for that covered service.
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And then you have, you know, usual and
customary and all these terminologies.
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It's whether people are aware, or have an
understanding of what those terms were.
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There was little attention paid to, my
God, HMOs, you know, that was a dirty
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word, dirty, dirty acronym, right?
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Yeah.
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Well, I mean, just to interrupt briefly
the, the, the insurance that you're
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talking about, the indemnity insurance,
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If we have anybody like under 40, I'm not
that old either, Bill, you and I are about
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the same age.
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So let's just say we're both we're both
young.
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But anybody under 3035, they might not
even know what that is.
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I mean, that's like, the way I describe it
is it's it's almost like your car
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insurance.
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And of course, you pay a premium.
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Your car insurance isn't paid for by your
employer, the indemnity insurance very
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often was right, or at least most of it
was paid for.
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And then all of the machinations and the
agreements and everything was kind of
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happening in the background.
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And maybe you would get a bill, right?
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This is what this is what was not covered.
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And now you've got to write a check for
your whatever part of the doctors,
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whatever the difference was, but it
operated very much so like car insurance.
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And then into the dirty word, as you said,
HMO, what was different about that?
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Yeah.
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So population health value based care,
alternative payment models.
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weren't even a gleam in people's eyes back
in the, to any great extent, right?
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In the eighties.
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And it was largely driven not by Medicare,
but by private health insurance, you know,
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starting with the HMO Act in 74, you know,
Kaiser Permanente latched onto that and
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their staff model.
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I'm gonna throw some, probably add fuel to
the fire of confusion.
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That's okay.
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The acronyms, right?
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That's fine.
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But then you had...
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an initiative where how can we best
control care, managed care?
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How do you manage the care?
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Hopefully not to the detriment of the
wellness of those patients being treated,
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but for the cost of care.
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It was really largely a cost model.
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We're going back to the 70s, early 80s,
the introduction as a diversion from
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health maintenance organizations where you
had the pre -authorizations, the referrals
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and so forth.
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PPO's preferred provider networks,
basically HMO Lite.
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You didn't need a referral.
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They were broader networks and they did
cost more money in terms of premium, but
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that seemed to be the solution.
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And I'm talking from the lens of, from the
health carrier.
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So PPO's, those preferred provider
networks proliferated largely.
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And that became kind of the currency of
value -based care.
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not really value -based care, but in terms
of managed care.
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So it wasn't really until the 90s that it
became a little more better understood of,
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I have a PPO.
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I can only see these doctors on this
printed directory.
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Otherwise I'm out of network and I'll have
to pay the freight like an indemnity plan.
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And that didn't go sober because then they
have out of network claims and so forth.
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Urgent and emergent care was cared for as
a network and so forth.
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But the advent of what we now know as
value -based care, really its origins hark
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back to those times where you had either a
gated network, in other words, the
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referral required or a PPO, still the
conundrum of making care effective and
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cost effective, most importantly, that
became the onus of a lot of private
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insurance companies.
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So think of Blue Cross Blue Shield, Aetna.
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Humana, where I came from and so forth and
some of the smaller players.
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Again, from our perspective, what we
hopefully wouldn't talk about is
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alternative payment models or value -based
care and the Medicare space.
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It wasn't until the passage of the
Affordable Care Act, back in the early
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aughts where you had CMS by, by that
legislation creating the centers of
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Medicare and Medicaid.
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innovation.
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Okay.
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And that was the advent of accountable
care organizations going back to 2012, the
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pioneer model was the first dip of the toe
into the value -based care arena or
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alternative payment models, which CMS
launched the pioneer model.
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And then from there expanded that reach to
what we now know as MSSP, Medicare Shared
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Savings Program.
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the hundreds of ACOs out there that are
participating in that program, and
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there've been iterations above and beyond
that.
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Okay, not answering the question, right?
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That's right.
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That's right.
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So, but before you answer the question, I
just want to put some context.
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I've talked about this before, probably,
and in healthcare rounds, but just to put
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it in context of my role in all of this.
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So when I started in graduate school, the
first time around, I was at Chicago,
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And I got a I got an inch I got lucky
actually, through a contact, I got an
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internship.
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My my internship was for the American
Association of Preferred Provider
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Organizations.
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sure.
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And they were doing an employer survey.
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And so my internship was to conduct a
survey is probably a couple 100 people
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somewhere in my mementos box, I still have
a copy of the results of this.
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Because it was one of my first projects
that I worked on.
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So I had that familiarity pretty early on
I started working on that project back in,
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gosh, 1988.
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And then I was the managed care analyst at
Abbott.
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So I had exposure at that time to the
dirty words, the HMOs, right, the dirty
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acronyms.
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Although I don't think that we really
approached it that way.
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But it was kind of like in the early 90s,
it was this new customer class, you know,
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that you really had to work with.
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And but the thing that I would say is, at
that time, the managed care, at least the
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perception was that it was all that you
could get to where you wanted to go by
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cutting, by denying claims, or cutting
costs.
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And there really wasn't at least, again,
this is retrospectively looking back.
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a lot of talk about the AAA, which didn't
come about until what, one or something
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like that.
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Yeah.
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And then the final piece of the puzzle,
then I'll turn it back to you.
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When I went back to school, the second
time around, at Dartmouth, in our doctoral
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seminars, we were talking about these
value based care models.
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I mean, that was among other things, but
that was part of it.
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And, you know, Elliot Fisher from
Dartmouth was one of the people who
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And actually, you can see him on
healthcare rounds.
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And I think an episode we did a few years
ago, but Elliott Fisher being kind of that
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ACO, I don't know, father of the ACOs,
sometimes he gets credit in that area.
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But we were looking at these models back
in 06, 07, you know, kind of like, as just
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different, different ways to pay for
different models for paying for healthcare
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and delivering healthcare.
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So fast forward now back to you, Bill and
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the Affordable Care Act and all these
different models.
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And then back to the original question,
which was around, you know, how value
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-based care evolved from this concept of
managed care and why they're different.
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Yeah, it's really, it's almost stupefying
in terms of the amount of information out
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there.
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It's overwhelming to most people, even
myself included at times as to where do I
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start?
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And when I hear population health, value
-based contracting, value -based care,
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accountable care, they're used to a degree
interchangeably because there's a lot of
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common threats.
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starting with population health.
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So let's talk pop health and what do we
mean by population health and improving
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the health, well -being, quality of care,
reducing social inequities in healthcare
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delivery for an entire population.
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So that's the, from my eyes, right or
wrong, the overarching concept of
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population health.
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Sure, we want people to be healthy.
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We want people to...
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live longer and high quality of life,
quality of life, not just prolonging life
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for the sake of prolonging life, but
improving the population, regardless of
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race, creed, rural, urban, suburban, et
cetera.
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that's our main focus.
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And from my perspective as being part of
an accountable care organization and we'll
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talk great segue.
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What's a kind of care.
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Okay.
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Well,
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It's really drilling down.
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It's more of a vehicle to achieve
population health.
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So in a accountable care organization, we
can talk about what does accountable care
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mean?
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And I believe most physicians bristle,
rightly so, accountable care.
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I'm accountable.
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I'm a physician.
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I'm the primary care physician for this
patient or this patient panel, whether
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it's 500 or 5 ,000, I'm accountable.
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How dare you say I'm going to be in an
accountable care organization.
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My goodness.
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And I take I get that.
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I'm not a clinician.
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I took biology and I think I skated by
with a C plus.
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And that's the extent of my life sciences
training.
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But, you know, I've been in this business
for 30 years.
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I grew up.
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My mother was actually an office manager
for a pulmonologist.
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I can recall doing my homework in the
chart room.
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before PHI requirements.
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And I sat there on the charts doing my
math workbook in fifth grade.
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But the point is I'm very much attuned to
physicians' perspective.
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We're not suggesting anything that is not
accurate, that physicians, of course, are
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accountable.
219
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They're doing a great job.
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How can we improve the delivery of care
without impairing their, not getting in
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their way?
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00:13:52,686 --> 00:13:58,646
but empowering them with the tools to do
even a greater job at the top of their
223
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license.
224
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Accountable care is a vehicle to
accomplish that.
225
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So what do we mean by accountable care?
226
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Really, it's these two facets to it.
227
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There's the cost equation and there's the
outcomes equation.
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00:14:14,466 --> 00:14:16,566
And hopefully they intersect, right?
229
00:14:16,566 --> 00:14:21,710
So if you're doing a good job in terms of
care management, seeing your patient,
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00:14:21,710 --> 00:14:26,810
keeping them out of the hospital for
unnecessary admissions, keeping them post
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00:14:26,810 --> 00:14:32,370
-discharge, going back to the hospital for
another 30 -day readmission, keeping
232
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control of their polychronic condition.
233
00:14:34,620 --> 00:14:41,090
And most seniors have more than one
condition, whether it's diabetes, COPD,
234
00:14:41,430 --> 00:14:44,050
chronic kidney disease, among other
things.
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00:14:44,050 --> 00:14:49,470
How can we help that, and I'm talking
primary care, specialists are a whole
236
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nother conversation.
237
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But when I'm talking about is where the
rubber hits the road with those primary
238
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care physicians and how can we help
empower them to be not more accountable,
239
00:15:00,190 --> 00:15:07,170
but more effective in the cost and quality
of delivery of health care.
240
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And that's really what accountable care
organizations hope to accomplish.
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And there are many out there that are
doing a phenomenal job improving the care
242
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delivery, helping the physician,
empowering them, especially with the
243
00:15:20,150 --> 00:15:20,942
headwinds.
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00:15:20,942 --> 00:15:26,742
of overhead staffing, EMR systems, people
knocking your door, selling all the
245
00:15:26,742 --> 00:15:28,082
different things that they do.
246
00:15:28,082 --> 00:15:31,142
There's a lot of distractions out there.
247
00:15:31,142 --> 00:15:37,062
So an accountable care organization helps
facilitate that and can help you with that
248
00:15:37,062 --> 00:15:41,582
glide path, that journey with your
patients and not just, again, improving
249
00:15:41,582 --> 00:15:46,522
the bottom line, but also improving the
care and delivery to those aligned
250
00:15:46,522 --> 00:15:48,562
patients that you have.
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00:15:49,222 --> 00:15:50,606
You know, I wanted to make a
252
00:15:50,606 --> 00:15:52,326
a couple of comments.
253
00:15:52,326 --> 00:15:58,666
The first is when you mentioned the
doctors and their initial reaction, we
254
00:15:58,666 --> 00:16:00,826
definitely saw a lot of that initially.
255
00:16:00,826 --> 00:16:08,366
And if you went to, you know, kind of like
2016, 2017, some of the ACO conferences
256
00:16:08,366 --> 00:16:14,166
that were out there, I think by that time,
most of the doctors, at least the ones
257
00:16:14,166 --> 00:16:17,386
that go to those conferences had
completely drank the Kool -Aid.
258
00:16:17,386 --> 00:16:17,986
Yeah, right.
259
00:16:17,986 --> 00:16:20,750
I mean, they were all in on the model.
260
00:16:20,750 --> 00:16:28,130
One of the things though that I think
criticisms, I don't know, maybe that's too
261
00:16:28,130 --> 00:16:33,390
heavy of a word of the ACO model, is that
people say, especially doctors will say
262
00:16:33,390 --> 00:16:36,910
this, hey, my patients are accountable
too.
263
00:16:36,910 --> 00:16:44,878
And when you think about the diabetic
patient that refuses to stay on her diet,
264
00:16:44,878 --> 00:16:49,838
or the smoker that refuses to stop
smoking, or any other whole host of things
265
00:16:49,838 --> 00:16:54,478
that doctors deal with, the primary care
doctors deal with, that they say, you
266
00:16:54,478 --> 00:16:56,738
know, how do we get the patient to be more
accountable?
267
00:16:56,738 --> 00:17:03,138
Because, hey, if I'm accountable for my,
you know, hemoglobin A1c scores through
268
00:17:03,138 --> 00:17:08,398
the ACO, well, my patients, I don't have
control over them, but they need to learn
269
00:17:08,398 --> 00:17:10,178
to be accountable too.
270
00:17:10,178 --> 00:17:12,632
But I don't want, and maybe,
271
00:17:12,814 --> 00:17:14,904
So there's that, there's that component,
right?
272
00:17:14,904 --> 00:17:17,374
I'm sure you've heard that a lot on
patient accountability.
273
00:17:17,374 --> 00:17:18,594
Absolutely.
274
00:17:18,594 --> 00:17:19,594
Right.
275
00:17:19,594 --> 00:17:25,764
And then the other thing is I don't want
to, I don't want to gloss over this.
276
00:17:25,764 --> 00:17:29,244
You said costs and outcomes, and I want
you to talk a little bit more about that.
277
00:17:29,244 --> 00:17:36,814
But for me, you know, when you think about
the triple aim and I've been working on
278
00:17:36,814 --> 00:17:37,486
kind of this,
279
00:17:37,486 --> 00:17:41,746
grumpy piece about why it's not a good
idea to say things like quadruple aim and
280
00:17:41,746 --> 00:17:44,346
quintuple aim and all of these other
sextuple aim.
281
00:17:44,346 --> 00:17:50,066
I'm sure we'll have that by 2025, but the
general concept of you can actually
282
00:17:50,066 --> 00:17:58,366
provide better care for either the same
cost or for lower costs is foreign to a
283
00:17:58,366 --> 00:18:04,666
lot of people because I think that we
equate price with value or I mean, just
284
00:18:04,666 --> 00:18:05,518
think of it, you know, like,
285
00:18:05,518 --> 00:18:08,938
going to buy a Ferrari or you're going to
buy Honda, you know, you're going to buy
286
00:18:08,938 --> 00:18:14,318
an Armani suit or you know, you know, off
the rack at, you know, men's warehouse.
287
00:18:14,318 --> 00:18:16,078
And we use price as a signal.
288
00:18:16,078 --> 00:18:18,818
And we think about those things.
289
00:18:18,818 --> 00:18:21,647
We've applied it to healthcare in some
way.
290
00:18:21,647 --> 00:18:26,258
And the ACO model says, Well, wait a
minute, and this comes back to the, you
291
00:18:26,258 --> 00:18:33,158
know, Don Berwick and the IHI and all
that, hey, we can if we if we do this,
292
00:18:33,158 --> 00:18:34,702
right, we can actually take
293
00:18:34,702 --> 00:18:38,882
better care of populations and save money.
294
00:18:38,882 --> 00:18:43,842
And all the while have people have a
better experience with healthcare.
295
00:18:43,922 --> 00:18:48,022
And I just I don't think that we can
underscore that enough that that's for a
296
00:18:48,022 --> 00:18:49,242
lot of people.
297
00:18:49,242 --> 00:18:54,142
If we were to go back in time, the
mismanaged care days, people would say,
298
00:18:54,142 --> 00:18:56,902
Well, wait a minute, no, you just you pay
more, you get better care.
299
00:18:56,902 --> 00:19:00,992
Or if you want to reduce costs, you just
don't approve things, right?
300
00:19:00,992 --> 00:19:02,862
That old managed care mindset.
301
00:19:02,862 --> 00:19:06,742
But that's not what accountable care or
value -based care models are saying.
302
00:19:06,742 --> 00:19:12,882
It's saying how do we improve care while
not ringing the cash register or
303
00:19:12,882 --> 00:19:14,472
constantly increasing?
304
00:19:14,472 --> 00:19:15,502
How do we make it better?
305
00:19:15,502 --> 00:19:17,522
How do we improve outcomes?
306
00:19:18,502 --> 00:19:24,242
And so the nuts and bolts of the way that
I describe the ACO model, and please tell
307
00:19:24,242 --> 00:19:27,526
me if I'm wrong on this, is if...
308
00:19:28,110 --> 00:19:31,930
you know, see, if we just look at the
Medicare example, but a lot of the
309
00:19:31,930 --> 00:19:34,610
commercial ones try to be similar to this.
310
00:19:34,610 --> 00:19:39,390
And the Medicare example says, Look, we
think it's 2024, we're going to look
311
00:19:39,390 --> 00:19:40,470
forward to 2025.
312
00:19:40,470 --> 00:19:43,270
And we think you're going to spend this
much money.
313
00:19:43,550 --> 00:19:43,660
Right?
314
00:19:43,660 --> 00:19:47,910
Are you going to get reimbursed by this
much money, we're going to project that.
315
00:19:47,910 --> 00:19:50,170
And then 2025 happens.
316
00:19:50,170 --> 00:19:55,490
And then at some point in 2026, we look
back and we say, Well, we had a
317
00:19:55,490 --> 00:19:57,774
projection, we had a budget of what
318
00:19:57,774 --> 00:20:03,994
we think that you would have spent on this
population of people, given how sick these
319
00:20:03,994 --> 00:20:07,554
people have been, all risk adjusted and
all of that.
320
00:20:07,554 --> 00:20:14,754
And if you came in under budget, great,
we're gonna have what's called shared
321
00:20:14,754 --> 00:20:15,954
savings.
322
00:20:16,474 --> 00:20:21,834
And at least in a full risk model or two
sided risk model, if you come in over
323
00:20:21,834 --> 00:20:26,190
budget, if you spent more or were
reimbursed more technically,
324
00:20:26,190 --> 00:20:30,070
you spent more than we said you were going
to spend, then you got to write a check to
325
00:20:30,070 --> 00:20:30,850
the government.
326
00:20:30,850 --> 00:20:34,520
And we're going to split those losses,
right?
327
00:20:34,520 --> 00:20:40,130
So if we said you were going to spend 110
million, and you spend 120, that $10
328
00:20:40,130 --> 00:20:44,930
million is going to have to be paid for
somehow, and half of it's going to come
329
00:20:44,930 --> 00:20:46,090
out of your pocket.
330
00:20:46,090 --> 00:20:46,750
Did I?
331
00:20:46,750 --> 00:20:48,430
Did I say that?
332
00:20:48,430 --> 00:20:49,670
Is that about right, Bill?
333
00:20:49,670 --> 00:20:55,310
Yeah, well, there's a there's a common, a
common theme when we
334
00:20:55,310 --> 00:20:57,930
People talk about a kind of a care
organizations.
335
00:20:57,930 --> 00:21:01,310
It's all about the benchmark.
336
00:21:01,890 --> 00:21:04,930
Yeah, that's what you just said.
337
00:21:04,930 --> 00:21:11,170
And as well for us to give some context, I
represent an ACO REACH model.
338
00:21:11,170 --> 00:21:17,770
So you have the MSSP's A, B, C, D, E
enhanced, next generation is gone, was
339
00:21:17,770 --> 00:21:23,510
superseded to a large extent by direct
contracting the DCE model program, which
340
00:21:23,510 --> 00:21:24,742
has now been
341
00:21:25,294 --> 00:21:27,394
overtaken by ACO Reach.
342
00:21:27,394 --> 00:21:34,294
So I sit squarely within an ACO Reach
global risk model, 100 % part A and part
343
00:21:34,294 --> 00:21:35,494
B, not D.
344
00:21:35,494 --> 00:21:40,134
So for all those original Medicare
beneficiaries that we're responsible for
345
00:21:40,134 --> 00:21:47,094
in 14 states, 74 ,000 and change,
traditional Medicare beneficiaries, we're
346
00:21:47,094 --> 00:21:52,714
responsible for the total cost of care for
Medicare reimbursement.
347
00:21:52,714 --> 00:21:54,382
We've performed the function.
348
00:21:54,382 --> 00:21:55,022
as a payer.
349
00:21:55,022 --> 00:22:00,462
So the ACO REACH is significantly
different than MSSP where CMS continues to
350
00:22:00,462 --> 00:22:01,422
pay the claims.
351
00:22:01,422 --> 00:22:07,182
So the ACO REACH model, we're the
delegated payer for physicians, for
352
00:22:07,182 --> 00:22:09,382
primary care physicians in particular.
353
00:22:09,382 --> 00:22:09,782
Okay.
354
00:22:09,782 --> 00:22:12,442
So with that, we can get creative.
355
00:22:12,442 --> 00:22:18,182
And so how to build that platform to
incentivize the, again, that, that best
356
00:22:18,182 --> 00:22:19,822
practice behavior.
357
00:22:19,822 --> 00:22:22,002
That's one side.
358
00:22:22,002 --> 00:22:24,014
You, you teased out another.
359
00:22:24,014 --> 00:22:25,934
patient behavior.
360
00:22:25,934 --> 00:22:29,674
So how can we make that marriage as happy
as possible?
361
00:22:29,674 --> 00:22:34,804
The PCPs and the patients, those aligned
beneficiaries.
362
00:22:34,804 --> 00:22:38,534
And there's a couple ways that the
traditional Medicare beneficiaries are
363
00:22:38,534 --> 00:22:43,634
aligned to a PCP that we contract with and
we're the claim payer for.
364
00:22:43,634 --> 00:22:48,334
It's either claims -based, CMS tells us
the aligned beneficiaries to that PCP we
365
00:22:48,334 --> 00:22:52,622
have in a contract, or in the instance
where they're seeing that PCP,
366
00:22:52,622 --> 00:22:55,142
they have the ability to voluntarily
align.
367
00:22:55,142 --> 00:22:56,332
And why would they do that?
368
00:22:56,332 --> 00:23:01,302
Because ACA reaches such as my
organization, we offer beneficiary
369
00:23:01,302 --> 00:23:02,462
enhancements.
370
00:23:02,462 --> 00:23:07,002
So there's a couple of things that we
approach, cost sharing, cost share
371
00:23:07,002 --> 00:23:07,682
support.
372
00:23:07,682 --> 00:23:13,222
So instead of you paying the 20 % to see
that PCP for your, whether it's annual
373
00:23:13,222 --> 00:23:16,422
visit, hopefully it's more, I'll get to
that in a moment.
374
00:23:16,422 --> 00:23:17,922
We take that.
375
00:23:17,922 --> 00:23:21,518
In other words, we pay the PCP for that
cost share.
376
00:23:21,518 --> 00:23:24,158
removing a barrier to that care.
377
00:23:24,158 --> 00:23:28,698
So a lot of instances a patient will say,
we have patient outreach, non -clinical
378
00:23:28,698 --> 00:23:32,178
that reaches out to those line
beneficiaries and saying, hey, it's been
379
00:23:32,178 --> 00:23:34,028
two months since you've seen your primary
care.
380
00:23:34,028 --> 00:23:37,858
It's like, well, it's either I eat or I
see the doctor.
381
00:23:37,918 --> 00:23:44,258
Some people are in that scenario for their
socioeconomic situation, they can't afford
382
00:23:44,258 --> 00:23:47,438
that cost share, that 20 % of that part P
cost.
383
00:23:47,718 --> 00:23:50,058
So they go, wait.
384
00:23:50,542 --> 00:23:52,752
It's no cost to you to see your PCP.
385
00:23:52,752 --> 00:23:53,322
What's that?
386
00:23:53,322 --> 00:23:54,662
You need transportation.
387
00:23:54,662 --> 00:23:59,202
Yet another beneficiary enhancement, the
ACO reach affords us to deploy.
388
00:23:59,202 --> 00:24:02,042
We can provide transportation to the PCP.
389
00:24:02,042 --> 00:24:03,742
Again, no cost.
390
00:24:03,742 --> 00:24:08,402
And some other bills and whistles that we
have, you know, chronic care reward
391
00:24:08,402 --> 00:24:09,282
program.
392
00:24:09,282 --> 00:24:14,482
If they adhere to a treatment plan,
there's a gift card that we can put out
393
00:24:14,482 --> 00:24:14,802
there.
394
00:24:14,802 --> 00:24:19,662
So on the patient side, we meet them where
they are as well.
395
00:24:19,662 --> 00:24:25,662
And in terms of the PCP, we provide them
with upfront per beneficiary per month
396
00:24:25,662 --> 00:24:30,702
upfront cash, no cost, no recovery, no
clawback.
397
00:24:30,702 --> 00:24:35,082
That's an investment that the ACO Illumid
does for those PCPs.
398
00:24:35,082 --> 00:24:39,982
So the expectation is that they will see
the patient at least four times once a
399
00:24:39,982 --> 00:24:41,362
quarter, four times a year.
400
00:24:41,362 --> 00:24:43,842
And with that, a lot of magic happens.
401
00:24:43,842 --> 00:24:47,758
You can, you can get ahead of those.
402
00:24:47,758 --> 00:24:52,578
conditions that are either being not
treated or maybe not even diagnosed.
403
00:24:52,578 --> 00:24:58,158
So a lot of people have, when I say
dormant, unidentified conditions that can
404
00:24:58,158 --> 00:25:03,138
be addressed if they're seeing the
physician on a regular basis.
405
00:25:03,658 --> 00:25:05,418
And with that, yeah, go ahead.
406
00:25:05,418 --> 00:25:06,698
Just quick, quick question.
407
00:25:06,698 --> 00:25:10,268
What is your compliance like on that?
408
00:25:10,268 --> 00:25:14,894
If your goal is once a quarter, what's the
reality of?
409
00:25:14,894 --> 00:25:19,674
what you're seeing with patients in this
model, how often that they actually make
410
00:25:19,674 --> 00:25:20,574
it in?
411
00:25:20,574 --> 00:25:25,934
It's probably in the mid to high 50s.
412
00:25:25,934 --> 00:25:31,874
So 50 % of our PCPs and our contractors
seen our patients four times a year.
413
00:25:31,874 --> 00:25:33,614
That's incredible.
414
00:25:33,774 --> 00:25:38,274
That's, I mean, because the way I'm
thinking of it, if you can get somebody in
415
00:25:38,274 --> 00:25:41,702
at least once a year, but if you can beat
that.
416
00:25:41,710 --> 00:25:44,770
and have them coming in two, three, four
times a year.
417
00:25:44,770 --> 00:25:51,530
To your point, you're flagging things
before they become a problem, hopefully.
418
00:25:51,530 --> 00:25:54,690
Or if they have chronic conditions,
they're being better managed because
419
00:25:54,690 --> 00:25:56,850
they're being seen more frequently.
420
00:25:57,090 --> 00:26:02,510
And I would think there's a kind of a
knockoff effect of patients sort of
421
00:26:02,510 --> 00:26:07,822
feeling more accountable in the sense that
just they're engaging more often.
422
00:26:07,822 --> 00:26:09,042
with their doctors.
423
00:26:09,042 --> 00:26:12,322
So maybe they feel like they're more of a
part of their healthcare.
424
00:26:12,322 --> 00:26:13,062
Right.
425
00:26:13,062 --> 00:26:14,212
Does that sound right?
426
00:26:14,212 --> 00:26:15,362
No, 100%.
427
00:26:15,362 --> 00:26:15,622
Yeah.
428
00:26:15,622 --> 00:26:20,162
I'll even go one step further in terms of
outcomes or, you know, let's, where does
429
00:26:20,162 --> 00:26:25,962
the, the, the cost equation intersect with
quality and outcome and whether or not
430
00:26:25,962 --> 00:26:28,082
this is an outcome per se, it is not.
431
00:26:28,082 --> 00:26:32,582
But when I look at the financial
performance, because again, it's a cost
432
00:26:32,582 --> 00:26:34,782
model, but also cost and quality.
433
00:26:34,782 --> 00:26:37,910
So when I look at our top performing
physicians,
434
00:26:38,062 --> 00:26:44,562
And one of our guide posts is seeing the
patient within three days post discharge.
435
00:26:45,002 --> 00:26:48,462
wait, CMS tells us 14 days.
436
00:26:48,622 --> 00:26:50,222
Isn't that good enough?
437
00:26:50,582 --> 00:26:51,582
Quick answer?
438
00:26:51,582 --> 00:26:52,242
No.
439
00:26:52,242 --> 00:26:54,242
No, it's not.
440
00:26:54,242 --> 00:26:55,422
It's not.
441
00:26:55,422 --> 00:26:56,172
So, okay.
442
00:26:56,172 --> 00:27:00,782
Is this some abstract number pulled out of
the air?
443
00:27:01,002 --> 00:27:05,614
understand the leadership here, myself
included, came from immersed in.
444
00:27:05,614 --> 00:27:08,254
managing global risk for Medicare
Advantage.
445
00:27:08,254 --> 00:27:14,694
You had all the levers, you had the gated
network, you had sub caps, you had either
446
00:27:14,694 --> 00:27:17,234
you covered or not covered.
447
00:27:17,234 --> 00:27:17,814
Okay.
448
00:27:17,814 --> 00:27:21,764
So what we have here is traditional
Medicare beneficiaries, no gated network,
449
00:27:21,764 --> 00:27:25,234
no network, even though we say it's a
network, you can go anywhere you want.
450
00:27:25,234 --> 00:27:27,954
So how do we best control the
uncontrollable?
451
00:27:27,954 --> 00:27:31,714
Well, one of the things that we do, as I
talked about, is seeing a patient at least
452
00:27:31,714 --> 00:27:33,074
once a quarter.
453
00:27:33,166 --> 00:27:36,506
And most importantly, if they do find
themselves in the hospital, and I say do
454
00:27:36,506 --> 00:27:38,806
find themselves, that's so glib.
455
00:27:38,806 --> 00:27:41,486
Unfortunately, people do have to go to the
hospital.
456
00:27:41,486 --> 00:27:46,526
Of course, when they get discharged, the
expectation of the PCP with that upfront
457
00:27:46,526 --> 00:27:51,726
cash that we pay them, the expectation,
they're going to do that follow up within
458
00:27:51,726 --> 00:27:54,286
72 hours post discharge.
459
00:27:55,146 --> 00:27:58,026
What's the results?
460
00:27:58,026 --> 00:27:59,986
Let me check here.
461
00:28:00,626 --> 00:28:02,308
About 40%.
462
00:28:03,854 --> 00:28:05,074
Really good.
463
00:28:05,074 --> 00:28:06,614
No, it's not.
464
00:28:06,614 --> 00:28:11,214
But what I will share with you is that the
top for your standards are higher than
465
00:28:11,214 --> 00:28:12,054
mine, Bill.
466
00:28:12,054 --> 00:28:21,254
The top performers who are seeing the
patients 60 % or more within three days of
467
00:28:21,254 --> 00:28:24,998
discharge are killing it on the cost side.
468
00:28:28,142 --> 00:28:35,122
Their benchmark is here, wait here, okay,
and their spend is here on a per
469
00:28:35,122 --> 00:28:37,202
beneficiary per month basis.
470
00:28:37,282 --> 00:28:42,142
So what that means is that they're not
only delivering awesome care and seeing
471
00:28:42,142 --> 00:28:46,962
the patients as much as possible, but
they're beating the pants off their
472
00:28:46,962 --> 00:28:47,906
benchmark.
473
00:28:49,678 --> 00:28:52,358
That's that's that is amazing.
474
00:28:52,878 --> 00:28:57,538
One thing I don't want people to to lose
this part.
475
00:28:57,697 --> 00:29:06,338
So in the traditional MSSP model, and by
the way, Bill listed off a whole bunch of
476
00:29:06,338 --> 00:29:07,338
models.
477
00:29:07,338 --> 00:29:11,698
If there's any demand for somebody to
explain all of these and to do a
478
00:29:11,698 --> 00:29:15,518
supplement on healthcare rounds, I'm happy
to do that.
479
00:29:15,558 --> 00:29:19,138
It might put some people to sleep, which
is why Bill I don't want you to go through
480
00:29:19,138 --> 00:29:19,534
those.
481
00:29:19,534 --> 00:29:20,354
through these now.
482
00:29:20,354 --> 00:29:27,414
But but in the re in the ACA reach model,
you're paid, you're given a global payment
483
00:29:27,414 --> 00:29:31,054
or a per payment per member estimate,
right?
484
00:29:31,054 --> 00:29:32,814
And then you're the payer.
485
00:29:32,814 --> 00:29:36,274
Yeah, so you're actually with every claim.
486
00:29:36,274 --> 00:29:41,994
And so you're really close to knowing
who's above benchmark and who's below
487
00:29:41,994 --> 00:29:46,014
because you're it's like it's all
happening in real time.
488
00:29:46,014 --> 00:29:46,554
Yes.
489
00:29:46,554 --> 00:29:47,894
Yeah.
490
00:29:48,206 --> 00:29:53,126
what we do to give you a little insight
there, well in advance of us signing
491
00:29:53,126 --> 00:29:53,926
someone up.
492
00:29:53,926 --> 00:29:54,866
Yes, indeed.
493
00:29:54,866 --> 00:29:56,966
We are making informed decisions.
494
00:29:56,966 --> 00:30:03,286
We partner with one of the well -known CMS
data aggregators care journey, shameless
495
00:30:03,286 --> 00:30:04,286
plug for them.
496
00:30:04,286 --> 00:30:09,386
So we have ready access to historical
original Medicare claims data.
497
00:30:09,386 --> 00:30:15,366
So within that, it gets very, very
granular in terms of, you know, the NPI,
498
00:30:15,366 --> 00:30:16,808
the practitioner.
499
00:30:16,814 --> 00:30:22,614
how many aligned beneficiaries they have,
where they're spending the money, what are
500
00:30:22,614 --> 00:30:25,714
they spending Medicare's money, I should
say.
501
00:30:25,974 --> 00:30:30,834
How often they see the patient, what's
their average risk score of their aligned
502
00:30:30,834 --> 00:30:34,694
beneficiaries, hierarchical condition
category, HCCs.
503
00:30:34,714 --> 00:30:36,394
So we have line of sight to that.
504
00:30:36,394 --> 00:30:40,984
So we can pretty much project as to if
they were participating in a model today,
505
00:30:40,984 --> 00:30:42,474
how they do.
506
00:30:42,834 --> 00:30:45,070
And there's some folks out there,
507
00:30:45,070 --> 00:30:47,170
They're focused, you know, right or wrong.
508
00:30:47,170 --> 00:30:50,150
That's like I see him once for their in
real wellness visit.
509
00:30:50,150 --> 00:30:50,850
Good to go.
510
00:30:50,850 --> 00:30:51,970
See you later.
511
00:30:52,570 --> 00:30:57,310
That's probably not the practice that we
want to engage with unless they're just
512
00:30:57,310 --> 00:31:00,090
champion at the bit to be schooled up.
513
00:31:00,090 --> 00:31:05,110
But there's not enough time because as you
said, we get a we get a benchmark from CMS
514
00:31:05,110 --> 00:31:10,830
based on the historical, you know, claims
utilization of that physician.
515
00:31:10,830 --> 00:31:13,582
So to ramp them up.
516
00:31:13,582 --> 00:31:18,142
You know, we're not in the training wheels
stage in our model.
517
00:31:18,422 --> 00:31:25,542
Those are some of the tech to off the A,
B, C, D, E enhanced and starting after A
518
00:31:25,542 --> 00:31:29,802
and B, getting to the risk share part with
MS with CMS.
519
00:31:29,802 --> 00:31:33,042
But it's not 100%.
520
00:31:33,042 --> 00:31:37,342
The top run with enhances 75 % upside
only.
521
00:31:37,342 --> 00:31:41,742
But anyway, we could go down that rabbit
hole very, very quickly.
522
00:31:41,742 --> 00:31:43,470
But in our world,
523
00:31:43,470 --> 00:31:50,750
with this particular model, this is a high
risk, high reward.
524
00:31:50,750 --> 00:31:56,070
And for that, we have to be very mindful
as to what partners we select.
525
00:31:56,070 --> 00:31:57,060
So far, so good.
526
00:31:57,060 --> 00:32:02,860
We had a very good year in 22, likely to
be similar for this past year.
527
00:32:02,860 --> 00:32:07,850
Of course, with the CMS models, whether
it's MSSP, AC or REACH or anything else
528
00:32:07,850 --> 00:32:12,062
for that matter, it's always the
reconciliation period occurs.
529
00:32:12,270 --> 00:32:15,690
months after the close of the performance
year.
530
00:32:15,830 --> 00:32:24,610
So we will see how CMS MSSP models did
sometime this coming fall for 2023 last.
531
00:32:24,610 --> 00:32:25,650
For the last one.
532
00:32:25,650 --> 00:32:25,810
Right.
533
00:32:25,810 --> 00:32:26,880
Right.
534
00:32:26,880 --> 00:32:29,924
And, you know, I mean, in my opinion,
535
00:32:31,534 --> 00:32:37,574
One of the problems with the with the ACO
model is the delay, you know, in in when
536
00:32:37,574 --> 00:32:41,394
you actually get punished or rewarded for
your behavior.
537
00:32:41,394 --> 00:32:42,594
Yes.
538
00:32:42,594 --> 00:32:50,414
And to some degree, the actual degree to
which you get penalized or rewarded for
539
00:32:50,414 --> 00:32:56,234
your behavior, you know, if if you've
spent as a physician, as a physician
540
00:32:56,234 --> 00:32:59,618
practice, let's say you're a physician led
ACO.
541
00:32:59,758 --> 00:33:03,718
I think of like Commonwealth here in town,
that's kind of like that about 100
542
00:33:03,718 --> 00:33:04,978
doctors.
543
00:33:06,398 --> 00:33:14,038
You know, if if you invest all this time
and effort, and you get a check back or
544
00:33:14,038 --> 00:33:19,338
your investment or something, for you
know, $800 at the end of the year, it's
545
00:33:19,338 --> 00:33:22,438
kind of like, well, why did I invest all
this time and effort?
546
00:33:22,438 --> 00:33:26,638
You know, but Mike, I had two questions
for you.
547
00:33:26,638 --> 00:33:29,658
One is, in 2024,
548
00:33:30,030 --> 00:33:35,710
Do you find that doctors are self
selecting to be part of things like ACO
549
00:33:35,710 --> 00:33:37,630
reach and part of your organization?
550
00:33:37,630 --> 00:33:43,210
Or are you still getting a whole bunch of,
you know, I guess it's an ACO.
551
00:33:43,210 --> 00:33:44,830
I guess I should be part of it.
552
00:33:44,830 --> 00:33:48,510
Do you find that there's at the like the
ACO model has been around long enough that
553
00:33:48,510 --> 00:33:52,910
you're getting some self selection of, of
better performers or at least people who
554
00:33:52,910 --> 00:33:55,600
have bought into the model?
555
00:33:55,600 --> 00:33:56,930
Well, I'll check my phone.
556
00:33:56,930 --> 00:33:57,170
Nope.
557
00:33:57,170 --> 00:33:58,930
No one's calling me.
558
00:34:01,830 --> 00:34:06,438
Now, when all seriousness, there's a,
there's a, there's a,
559
00:34:08,046 --> 00:34:10,846
Significant market consolidation.
560
00:34:11,126 --> 00:34:14,196
Okay, so there's been about 1200.
561
00:34:14,196 --> 00:34:15,246
Let's start from the top.
562
00:34:15,246 --> 00:34:19,246
There's approximately 1200 ACOs since its
inception 2012.
563
00:34:19,246 --> 00:34:20,966
There are currently around 500.
564
00:34:20,966 --> 00:34:26,266
There are more ACOs that dropped out of
ACOs than there are today.
565
00:34:26,266 --> 00:34:28,086
Still participating.
566
00:34:28,386 --> 00:34:29,406
Okay.
567
00:34:29,846 --> 00:34:33,326
So MSSP, the pretty, the battle lines have
been drawn.
568
00:34:33,326 --> 00:34:35,946
Those that are in those ACOs,
569
00:34:36,622 --> 00:34:40,142
probably going to stay there because
they've been in there multiple years,
570
00:34:40,142 --> 00:34:45,142
assuming of course that their organization
is transparent and giving them the
571
00:34:45,142 --> 00:34:48,521
reporting data and providing them the
support.
572
00:34:48,602 --> 00:34:55,102
If they earn $20 million, I'm sorry, if
they earned a surplus of $20 million, that
573
00:34:55,102 --> 00:34:59,062
will be distributed fairly and equitably
according to the contract.
574
00:34:59,062 --> 00:35:03,022
And for those that don't, we do find some
attrition.
575
00:35:03,022 --> 00:35:05,042
and those people seeking options.
576
00:35:05,042 --> 00:35:05,922
I think that's what you're talking.
577
00:35:05,922 --> 00:35:12,162
My phone is still not ringing by the way,
but you know, those are the folks that are
578
00:35:12,162 --> 00:35:16,042
considering options, you know, Hey, I'm in
this economy organization.
579
00:35:16,042 --> 00:35:20,702
I've heard of you or you know, I've seen
your flyer.
580
00:35:20,702 --> 00:35:24,042
I saw your conference, you know, that's
I'd like to learn more.
581
00:35:24,042 --> 00:35:26,682
And that's kind of where that is coming
from.
582
00:35:26,682 --> 00:35:32,366
A lot of referrals, a lot of folks that
are dissatisfied where they are today.
583
00:35:32,366 --> 00:35:35,546
But to your point, yes, there's what we
call the selection effect.
584
00:35:35,546 --> 00:35:39,786
Those that are successful are eager to
earn more.
585
00:35:39,786 --> 00:35:45,986
And the ACO reach affords them that
vehicle to do that versus the just upside
586
00:35:45,986 --> 00:35:48,606
only, you know, risk reward, right?
587
00:35:48,606 --> 00:35:50,936
This is economics 101.
588
00:35:50,936 --> 00:35:54,236
The more you put at stake, the better the
payout could be.
589
00:35:54,236 --> 00:36:00,066
It's like, I don't want to say the analogy
is Vegas, but if you put the odds, right?
590
00:36:00,066 --> 00:36:00,622
All right.
591
00:36:00,622 --> 00:36:03,902
It kind of plays out that way.
592
00:36:03,902 --> 00:36:06,702
But again, it's not a land grab as it was.
593
00:36:06,702 --> 00:36:11,742
Not that we were involved with a land
grab, but there are a lot of folks out
594
00:36:11,742 --> 00:36:14,566
there that are still engaged with the.
595
00:36:16,174 --> 00:36:22,334
trying to build market share in here too,
but good market share.
596
00:36:22,394 --> 00:36:26,294
Hopefully those folks that do my phone
still not ringing, John.
597
00:36:26,294 --> 00:36:31,774
But anyway, the, the, the point of the
story is, you know, there's a lot of out
598
00:36:31,774 --> 00:36:37,934
there and, yeah, this is selected
selection effect indeed that they, why are
599
00:36:37,934 --> 00:36:38,544
they calling me?
600
00:36:38,544 --> 00:36:43,594
Yeah, they're still not calling it, but
the follow -up question is, and I don't
601
00:36:43,594 --> 00:36:44,686
know, I don't know if you,
602
00:36:44,686 --> 00:36:50,366
I don't know if you track this, but it's
always been my sense that there's a pretty
603
00:36:50,366 --> 00:36:56,786
substantial spillover effect in terms of,
let's use your example.
604
00:36:56,786 --> 00:37:05,026
If of your ACO patients, your Medicare
patients that are in the ACO, that you,
605
00:37:05,026 --> 00:37:07,946
it's sort of a goal to see them once a
quarter.
606
00:37:07,946 --> 00:37:12,306
And then you start seeing the benefits of
seeing patients more regularly.
607
00:37:12,346 --> 00:37:14,350
Wouldn't you take that same,
608
00:37:14,350 --> 00:37:19,510
approach with your entire panel of
patients like, Hey, maybe it's a good idea
609
00:37:19,510 --> 00:37:25,070
that that I go talk to, or that john comes
in for him because he's not of Medicare
610
00:37:25,070 --> 00:37:29,850
age, that john comes in at least a couple
of times a year.
611
00:37:29,850 --> 00:37:33,850
And the same thing for your diabetic
populations, those that aren't part of the
612
00:37:33,850 --> 00:37:35,190
population.
613
00:37:35,190 --> 00:37:42,926
Like, it seems to me that habits developed
or habits encouraged in the ACO model.
614
00:37:42,926 --> 00:37:45,926
spill over into patient care generally.
615
00:37:45,926 --> 00:37:47,626
What is your experience?
616
00:37:47,626 --> 00:37:52,446
That's me as a sort of researcher, but
what's been your experience there?
617
00:37:52,446 --> 00:37:57,406
You teased out something that I was
meaning to talk about in terms of
618
00:37:57,406 --> 00:38:00,246
influencing physician behavior.
619
00:38:00,246 --> 00:38:03,806
And a question came to me about 18 months
ago.
620
00:38:03,806 --> 00:38:07,026
I wish it came to me much earlier.
621
00:38:07,026 --> 00:38:12,558
And that is, what is, okay, okay, doctor
or doctors,
622
00:38:12,558 --> 00:38:17,038
You know, you were a primary care
physician organization like Sleepy Hills
623
00:38:17,038 --> 00:38:19,598
Primary Care and fictitious state.
624
00:38:19,598 --> 00:38:20,618
OK, there's two.
625
00:38:20,618 --> 00:38:23,738
There's a thousand beneficiaries that yay,
we win.
626
00:38:23,738 --> 00:38:27,578
You know, wow, what a great pickup that a
little bit just got another thousand
627
00:38:27,578 --> 00:38:28,938
beneficiaries.
628
00:38:29,958 --> 00:38:37,338
What percentage of this thousand
represents of your total patient panel?
629
00:38:38,178 --> 00:38:40,098
Is it 10 percent?
630
00:38:40,098 --> 00:38:41,798
Is it 20 percent?
631
00:38:42,030 --> 00:38:47,410
If it's underneath 20%, the likelihood of
us, whether it's me, my chief medical
632
00:38:47,410 --> 00:38:52,890
officer, our clinical team, our CEO, a
CFO, a COO influencing their behavior is
633
00:38:52,890 --> 00:38:54,510
going to diminish greatly.
634
00:38:54,510 --> 00:38:56,650
If it gets under 20%.
635
00:38:56,650 --> 00:38:57,890
That makes sense.
636
00:38:57,890 --> 00:38:58,170
Okay.
637
00:38:58,170 --> 00:38:59,190
That makes sense.
638
00:38:59,190 --> 00:39:04,170
And that, that came, came, I came to that
realization like, why aren't they, this
639
00:39:04,170 --> 00:39:04,890
is, this is great.
640
00:39:04,890 --> 00:39:05,880
They're doing so well.
641
00:39:05,880 --> 00:39:07,390
They could do be so much better.
642
00:39:07,390 --> 00:39:10,414
They should cross pollinate this best
practice.
643
00:39:10,414 --> 00:39:14,514
to their entire, and that would make it so
much easier separate apart from EMR
644
00:39:14,514 --> 00:39:20,654
systems and remote patient monitoring and
data analytics and pop health platforms
645
00:39:20,654 --> 00:39:23,034
and all these things that are
distractions.
646
00:39:23,034 --> 00:39:26,054
Quite frankly, it's shovels and picks.
647
00:39:26,054 --> 00:39:27,854
We're talking shovels and picks here.
648
00:39:27,854 --> 00:39:31,274
If you go to one of these managed care
conferences, your head's going to spin.
649
00:39:31,274 --> 00:39:32,674
I love all those vendors.
650
00:39:32,674 --> 00:39:36,214
They have great products, but they're
peripheral.
651
00:39:37,214 --> 00:39:38,566
They're peripheral.
652
00:39:38,670 --> 00:39:42,390
Okay, they're nice compliments to have and
we use many of them.
653
00:39:42,390 --> 00:39:46,650
But at the end of the day, it's
practicing.
654
00:39:47,270 --> 00:39:51,930
Again, I don't mean to say they're not
practicing good medicine, but seeing the
655
00:39:51,930 --> 00:39:56,810
patient, it's like, see the patients, see
the patients and if they find themselves
656
00:39:56,810 --> 00:40:01,390
in hospital, make sure you have an open
slot for them to come in.
657
00:40:01,390 --> 00:40:04,550
Or, you know, it's not just a face to
face.
658
00:40:04,550 --> 00:40:07,758
We do provide support for telemedicine.
659
00:40:07,758 --> 00:40:11,278
as well, but you need to have that patient
engaged.
660
00:40:11,278 --> 00:40:15,300
They took home, they came home with a big
bag of medicine.
661
00:40:16,814 --> 00:40:19,454
10 prescriptions.
662
00:40:19,974 --> 00:40:26,758
How is an 80 year old widow going to
manage through that bag of scripts?
663
00:40:29,646 --> 00:40:30,766
Not very easily.
664
00:40:30,766 --> 00:40:31,946
Not very easily.
665
00:40:31,946 --> 00:40:36,526
The likelihood of her bouncing back to the
hospital because of either adverse adverse
666
00:40:36,526 --> 00:40:40,856
drug reaction or not taking it twice a
daily, whatever the case.
667
00:40:40,856 --> 00:40:43,426
I'm not a pharmacist, but I've seen this
in action.
668
00:40:43,426 --> 00:40:50,466
And for those doctors, the top physician,
top, I mean, top, actually, he's a
669
00:40:50,466 --> 00:40:51,766
phenomenal practitioner.
670
00:40:51,766 --> 00:40:55,826
He spun off from an existing group and he
came to me and said, I like to go out on
671
00:40:55,826 --> 00:40:57,226
my own.
672
00:40:57,346 --> 00:40:59,526
I go, you have our support.
673
00:41:00,366 --> 00:41:05,026
Do you know how many aligned beneficiaries
he had on day one he came on with us?
674
00:41:05,026 --> 00:41:06,406
Zero.
675
00:41:06,726 --> 00:41:09,466
We deployed voluntary alignment forces.
676
00:41:09,466 --> 00:41:12,546
We got them up to 600 within one month.
677
00:41:12,546 --> 00:41:13,786
Wow.
678
00:41:14,386 --> 00:41:16,686
That's, that's really good.
679
00:41:16,686 --> 00:41:17,826
You know what his hit?
680
00:41:17,826 --> 00:41:25,246
He's seen the patients 83 .3 % of the time
within three days discharge.
681
00:41:27,886 --> 00:41:35,426
So he's, he's clearly sees the, not only
the benefit, but the results.
682
00:41:35,426 --> 00:41:39,486
And if he's one of your top performing
people, absolutely.
683
00:41:39,486 --> 00:41:41,926
It's nothing magical here.
684
00:41:41,966 --> 00:41:48,586
And that's what always, it seems to me
like so much of this is common sense, but
685
00:41:48,586 --> 00:41:54,146
you know, I forget the saying, but it's
like that, which you don't measure, you
686
00:41:54,146 --> 00:41:56,626
can't improve or something along those
lines.
687
00:41:56,626 --> 00:41:57,446
And so,
688
00:41:57,742 --> 00:42:01,842
it just simply the fact that you're paying
attention to some of these things that
689
00:42:01,842 --> 00:42:03,602
seem like no brainers.
690
00:42:03,602 --> 00:42:08,442
But for other people, you know, like you
said, if, if, if they've got a small
691
00:42:08,442 --> 00:42:15,552
Medicare population, they're probably not
right for you, but maybe they're just,
692
00:42:15,552 --> 00:42:18,402
they're, they just have a different view
and they're not going to be in, even if
693
00:42:18,402 --> 00:42:21,342
they became part of your group, they're
not going to be influenced by some of the
694
00:42:21,342 --> 00:42:23,182
things that you're looking to accomplish.
695
00:42:23,182 --> 00:42:25,262
Yeah, no, it can get overwhelmed.
696
00:42:25,262 --> 00:42:29,532
It can be and some of the early complaints
were all the reporting right?
697
00:42:29,532 --> 00:42:31,562
Yeah, like we got to put all these systems
in place.
698
00:42:31,562 --> 00:42:32,922
We got to report this to here.
699
00:42:32,922 --> 00:42:35,182
Here you're pulling from this database
here.
700
00:42:35,182 --> 00:42:38,542
We got to report directly and so it kind
of got.
701
00:42:38,902 --> 00:42:43,540
Confusing for a lot of the at least early
on so.
702
00:42:45,358 --> 00:42:50,298
If we had another hour or two, Bill, I'd
really like would really get into it.
703
00:42:50,298 --> 00:42:54,438
But where I want to go from here, because
we don't, we only have a few more minutes.
704
00:42:54,438 --> 00:42:59,898
I want to be respectful of your time and
of the audiences as well.
705
00:42:59,958 --> 00:43:07,258
So where we are just looking to the future
that there's this, I would submit that at
706
00:43:07,258 --> 00:43:14,738
least in concept, the idea of value based
care has been around long enough that,
707
00:43:14,738 --> 00:43:15,654
that,
708
00:43:16,110 --> 00:43:17,010
Pretty much so.
709
00:43:17,010 --> 00:43:21,910
I think most people are on board, most
doctors, whether they're actually engaged
710
00:43:21,910 --> 00:43:26,310
in doing that, but they understand the
concept and they understand we're moving
711
00:43:26,310 --> 00:43:34,230
to this, hopefully this goal of improved
outcomes without raising costs.
712
00:43:34,230 --> 00:43:41,590
Where do you see things headed in terms of
value -based agreements and maybe, maybe
713
00:43:41,590 --> 00:43:42,630
just starting.
714
00:43:42,630 --> 00:43:44,686
Cause as I said, we only have a few
minutes left.
715
00:43:44,686 --> 00:43:49,746
starting like what you think Medicare
might do and then on the commercial side,
716
00:43:49,746 --> 00:43:55,486
how you see what you see for value -based
care models in the next two to three
717
00:43:55,486 --> 00:43:56,646
years.
718
00:43:57,666 --> 00:44:01,426
boy, deep breath.
719
00:44:03,406 --> 00:44:09,216
Well, I hesitate to speak on behalf of
CMS.
720
00:44:09,294 --> 00:44:11,854
This is Bill Lane's perspective.
721
00:44:11,854 --> 00:44:13,414
This is not CMS's.
722
00:44:14,014 --> 00:44:15,024
Or Elements' perspective.
723
00:44:15,024 --> 00:44:16,164
It's just your perspective.
724
00:44:16,164 --> 00:44:17,394
No, absolutely.
725
00:44:17,394 --> 00:44:23,134
And I say that a little tongue in cheek
because we do have a very strong and
726
00:44:23,134 --> 00:44:26,114
productive relationship with the
leadership team, the deputy director of
727
00:44:26,114 --> 00:44:28,074
the CMMI, Liz Fowler.
728
00:44:28,074 --> 00:44:30,694
We have an open channel communication.
729
00:44:30,694 --> 00:44:34,974
Actually, a few weeks ago, it was a
national association of ACOs conference in
730
00:44:34,974 --> 00:44:38,094
the spring in Baltimore.
731
00:44:38,094 --> 00:44:41,054
And the direction is thus, it's not gonna
stop.
732
00:44:41,274 --> 00:44:43,494
I'll make that very clear.
733
00:44:44,274 --> 00:44:50,274
The DIA is cast, ACOs are going to be with
us to give you the distinction.
734
00:44:50,274 --> 00:44:51,314
We're a model.
735
00:44:51,314 --> 00:44:54,854
ACO REACH is a model, demonstration model.
736
00:44:54,854 --> 00:45:00,674
Medicare Shared Savings Program is a
program that is now bolted on the CMS.
737
00:45:01,634 --> 00:45:03,404
That's not going anywhere fast.
738
00:45:03,404 --> 00:45:06,974
So the question comes, okay, where's ACO
gonna go?
739
00:45:07,630 --> 00:45:11,990
likely either dovetail as a program,
unlikely they're going to create a new
740
00:45:11,990 --> 00:45:13,010
model.
741
00:45:13,110 --> 00:45:17,550
They may extend ACR -Reach because it was
a five -year demonstration, direct
742
00:45:17,550 --> 00:45:19,850
contracting, change to ACR -Reach.
743
00:45:19,850 --> 00:45:21,230
Hey, we're a new model.
744
00:45:21,230 --> 00:45:23,050
Give us a couple of extra years.
745
00:45:23,050 --> 00:45:27,370
So that has promise as well.
746
00:45:27,370 --> 00:45:33,390
But at the end of the day, whether it's
ACR -Reach, MSSP, they introduced a few
747
00:45:33,390 --> 00:45:37,230
weeks ago, actually a month or so ago.
748
00:45:37,230 --> 00:45:44,470
the ACL PCP flex model, which is a tack on
to low revenue MSSP.
749
00:45:44,470 --> 00:45:48,490
We're going to really confuse people when
I just talk about low revenue MSSP's, but
750
00:45:48,490 --> 00:45:49,730
that's okay.
751
00:45:49,730 --> 00:45:57,730
It's a smaller subset or small subset of
MSSP's whereby CMS will offer an
752
00:45:57,730 --> 00:46:04,290
additional program that blends it or
incorporates with the MSSP strictly for
753
00:46:04,290 --> 00:46:05,536
PCP's.
754
00:46:05,870 --> 00:46:13,870
for the ACO rather, but the investment
model is a $250 ,000 upfront investment.
755
00:46:13,970 --> 00:46:15,070
It's a low interest.
756
00:46:15,070 --> 00:46:16,890
No, it's a grant, not a low interest loan.
757
00:46:16,890 --> 00:46:17,670
It's a grant.
758
00:46:17,670 --> 00:46:19,130
We can go on about that.
759
00:46:19,130 --> 00:46:25,050
But at the end of the day, these are all
advancements to the ultimate coal of CMS,
760
00:46:25,050 --> 00:46:31,770
which has been stated thousands of times
that CMS wants to have every single
761
00:46:31,770 --> 00:46:34,126
Medicare beneficiary.
762
00:46:34,126 --> 00:46:36,966
aligned to a value -based arrangement.
763
00:46:36,966 --> 00:46:42,466
Here we go again, another value -based
arrangement, whether that's primary care
764
00:46:42,466 --> 00:46:49,836
first, an ACO model, which up to and
including the PCP Flex model, ACO Reach,
765
00:46:49,836 --> 00:46:53,806
which may have another iteration either as
part of MSSP.
766
00:46:54,186 --> 00:46:58,926
So all these things again are advancing
toward the ultimate goal of CMS stated
767
00:46:58,926 --> 00:47:03,796
multiple times to have everyone in an
accountable care.
768
00:47:03,982 --> 00:47:08,382
like model doesn't have to be an ACO by
2030.
769
00:47:08,442 --> 00:47:10,842
So what happened here advantage fall under
that?
770
00:47:10,842 --> 00:47:12,542
Actually, yes, it does.
771
00:47:12,542 --> 00:47:13,072
Yeah.
772
00:47:13,072 --> 00:47:14,042
Yeah.
773
00:47:14,072 --> 00:47:15,462
so let's take a step back.
774
00:47:15,462 --> 00:47:16,442
So what does that mean?
775
00:47:16,442 --> 00:47:23,882
60 million Medicare eligible folks out
there.
776
00:47:23,882 --> 00:47:27,692
Me within a few arms reach of that, as I'm
not sure what I'm going to do.
777
00:47:27,692 --> 00:47:32,422
But the point of the story is half of
them, 52 % actually are in Medicare
778
00:47:32,422 --> 00:47:34,132
Advantage plans.
779
00:47:35,630 --> 00:47:37,300
So what about the other 48 %?
780
00:47:37,300 --> 00:47:38,610
What are we going to do about them?
781
00:47:38,610 --> 00:47:39,540
That's where we're here.
782
00:47:39,540 --> 00:47:40,330
Right.
783
00:47:40,490 --> 00:47:45,020
And from CMS's perspective, they don't
care.
784
00:47:45,020 --> 00:47:47,690
I mean, it's just they want 100 % of
their...
785
00:47:47,690 --> 00:47:52,530
They want all people either being quote
unquote managed through a Medicare
786
00:47:52,530 --> 00:47:59,050
Advantage plan or through any one of these
accountable...
787
00:47:59,050 --> 00:48:02,930
Whether it's a demonstration project or
it's a fully functioning program.
788
00:48:03,374 --> 00:48:04,674
Fully covered.
789
00:48:04,674 --> 00:48:09,414
And the backdrop of that is because, you
know, this is not talking about economics,
790
00:48:09,414 --> 00:48:14,414
but it's been kicked around for some time
in terms of the solvency of the Medicare
791
00:48:14,414 --> 00:48:15,674
Trust Fund.
792
00:48:15,674 --> 00:48:20,694
And that has been projected to be, we're
talking the Part A, that's the
793
00:48:20,694 --> 00:48:26,334
hospitalization P of the benefits that
will be unable to meet its obligations by
794
00:48:26,334 --> 00:48:27,694
2030.
795
00:48:27,714 --> 00:48:29,814
that sounds familiar, 2030.
796
00:48:30,094 --> 00:48:30,794
Hmm.
797
00:48:31,134 --> 00:48:33,574
So that's where that
798
00:48:33,742 --> 00:48:38,002
Intersects and whether it's 20, 20, 30,
you know, 20, 30, and you know, not again,
799
00:48:38,002 --> 00:48:42,702
we could cover so much ground here because
people are living longer.
800
00:48:42,702 --> 00:48:44,792
Are they living better and healthier
lives?
801
00:48:44,792 --> 00:48:46,162
That's up to debate.
802
00:48:46,162 --> 00:48:47,222
Sure.
803
00:48:47,222 --> 00:48:53,282
But in understanding that there are more
people like you and me, unless people age
804
00:48:53,282 --> 00:48:57,462
wise that is then are going into the
payment system.
805
00:48:57,462 --> 00:49:01,822
So think of, you know, social security,
Medicare, these entitlement programs, I
806
00:49:01,822 --> 00:49:02,638
say entitlement.
807
00:49:02,638 --> 00:49:06,767
wincing because entitlement I paid into
it.
808
00:49:06,767 --> 00:49:08,018
Don't I get it back?
809
00:49:08,018 --> 00:49:09,348
Yeah, so right.
810
00:49:09,348 --> 00:49:10,758
I'm kind of with you on that one.
811
00:49:10,758 --> 00:49:12,028
I'm with you on that one.
812
00:49:12,028 --> 00:49:17,218
Well, listen, Bill, we could talk we have
so much more to talk about.
813
00:49:17,218 --> 00:49:18,658
But again, timing.
814
00:49:18,658 --> 00:49:24,558
Maybe we can do another one in in six
months or whatever the case I'd appreciate
815
00:49:24,558 --> 00:49:28,598
that I just do another one kind of kind of
go through how things are progressing with
816
00:49:28,598 --> 00:49:29,238
you.
817
00:49:29,238 --> 00:49:30,098
Yeah.
818
00:49:30,926 --> 00:49:34,486
Lots to talk about with respect to ACOs
and value -based care.
819
00:49:34,486 --> 00:49:40,346
So I'll look forward to part two, and I'm
promising our listeners that we're not
820
00:49:40,346 --> 00:49:45,086
gonna wait two years to make that happen,
that Bill will come on again and we'll
821
00:49:45,086 --> 00:49:46,526
continue to talk about these.
822
00:49:46,526 --> 00:49:47,986
But I mean, this has been great.
823
00:49:47,986 --> 00:49:49,706
Thanks so much, Bill.
824
00:49:49,706 --> 00:49:54,206
I really appreciate starting the
conversation here.
825
00:49:54,286 --> 00:49:55,966
So it's exciting.
826
00:49:55,966 --> 00:49:57,466
It's really exciting.
827
00:49:57,466 --> 00:49:59,630
I'm aware, and a lot of people look at
this with...
828
00:49:59,630 --> 00:50:02,970
a lot of trepidation and worry, where are
we going?
829
00:50:02,970 --> 00:50:04,490
I think it's exciting.
830
00:50:04,490 --> 00:50:09,490
I think that enough people are looking at
it, at healthcare improvement and doing it
831
00:50:09,490 --> 00:50:11,770
right, that these are good times.
832
00:50:11,770 --> 00:50:12,540
So I appreciate it.
833
00:50:12,540 --> 00:50:15,280
I welcome the opportunity to speak again
with you.
834
00:50:15,280 --> 00:50:17,630
You're a great host.
835
00:50:17,870 --> 00:50:18,830
Excellent.
836
00:50:18,830 --> 00:50:19,810
Thanks again.
837
00:50:19,810 --> 00:50:24,238
So everybody that'll do it for another
episode of healthcare rounds.
838
00:50:24,238 --> 00:50:28,178
Our guest today has been Bill Lane
executive vice president of network
839
00:50:28,178 --> 00:50:33,838
development at Illam -Ed as always I'm
your host John Marchica CEO of Darwin
840
00:50:33,838 --> 00:50:39,718
research group now listen You guys hear me
say this and usually it's a recording, but
841
00:50:39,718 --> 00:50:43,758
I'm not like a recording that's going
again and again now I'm actually asking
842
00:50:43,758 --> 00:50:49,178
please Spotify Apple podcast wherever you
get your pot now.
843
00:50:49,178 --> 00:50:52,478
We're up on YouTube wherever you get your
podcasts
844
00:50:52,750 --> 00:50:56,490
If you like what you see and what you
hear, please give us a rating.
845
00:50:56,490 --> 00:50:59,310
If you don't like it, don't bother.
846
00:50:59,690 --> 00:51:04,890
If you don't like it, certainly give us
that rating, but maybe reach out to me and
847
00:51:04,890 --> 00:51:08,110
tell me why and maybe we can make
healthcare rounds better.
848
00:51:08,110 --> 00:51:13,050
So again, thanks to everybody and we'll
see you next next healthcare rounds.
849
00:51:13,050 --> 00:51:14,214
Thank you, John.