NEJM Catalyst Q&A: Value-based care

Speaker 1: Thanks, LeMar. We are here today for a discussion about value-based care implementation for the different key stakeholders, patients, providers and payers. With our special guest, Dr. Wyatt Decker, who is executive vice president and chief physician value-based care and innovation for UnitedHealth Group. Speaker 2: Ed, it's great to be here with you. Looking forward to the conversation. Speaker 1: I am as well. So to start with, in this role, which is very encompassing, how do you view value-based care from the standpoint of implementation? Yeah, Speaker 2: It's such a key question, right? So we've been talking about value-based care literally for decades, yet it still feels like when you look at US healthcare, we're kind of nibbling around the edges. And for us at Optum in particular, we have about 4 million lives in fully accountable care models, which is one version of value-based care. So two quick level setting comments. One is, as you know well Ed and many of our listeners do, whether you're in the US or abroad, the term value-based care can mean a lot of different things. And so I really think of it as aligning payment models with the clinical models. So there's two substantial buckets that have to get sort of figured out how are we going to pay for high quality accessible care that focuses on what most people want, which is I would like a healthcare team that is worried about keeping me healthy and well, but I also want a healthcare team that has my back if I get sick. So when I think about value-based care, I think about how do we create the financial incentives and the clinical models that do what most consumers want their healthcare to do. And so that's key. And as we'll get into, that's a big lift. How do we align the financial incentives away from fee for service, which historically rewards volume into a system that's more nuanced and rewards providers in particular for keeping people healthy. And well, Speaker 1: Our listeners today include many people with health systems, many people with payers, insurers, regulators. Why has it been so hard for these types of organizations and the overall healthcare delivery ecosystem to make headway with value-based care, do you think? Speaker 2: Yeah, and it is hard, right? So it's scary if those of you who are on this platform with us today, if you run a healthcare system that has been designed to be paid for the volume of care that you give, and you still focus on high quality compassionate care because that differentiates you, but still you're paid for how many hospital beds or DRGs have moved through your health system? And that's actually okay. But we wonder, a lot of us in this space, how can we also have a system that brings all the providers and teams around the providers together to help keep people out of hospitals if they don't need to be there or getting upstream, if you will, of serious chronic diseases. And that's hard. Think about the clinical models that one needs to do. Historically in the US system, we haven't really done much. Speaker 2: Again, we've dabbled, but we haven't done much to help be for service. Primary care physicians in particular, focus on keeping people healthy and well. Yes, there's modest reimbursements for some annual wellness visits or testing your cholesterol, but it's very minimal and it doesn't create an ecosystem. It doesn't fund creating an ecosystem building around patient or a panel of patients. Focus on keeping them healthy and well. And when you begin to move to different models, think about accountable care organizations that can have upside or upside, downside rewards for keeping people healthier and getting better outcomes, then you begin to get there. And where, from my perspective, where it gets truly transformative is when we get into fully accountable care models. But again, when you think about care delivery organizations, they have to be pretty mature and pretty sophisticated to be able to say, okay, we're going to take a monthly payment and take full upside downside risk for all healthcare expenditures of this individual and or this population. Last thing I'll say is I think we're increasingly recognizing a certain amount of scale helps get there and partnerships can help organizations who have thought about this are interested but have struggled. We, but also others are increasingly offering models where we don't need to become you. We can partner with you to help you figure out both the financial models and the clinical models, which are different in value-based care. Speaker 1: There's a lot there and I want to unpack it beginning with thinking about value-based care implementation for the different key stakeholders. And the title of this event is patients, providers, and payers. Can you address those key stakeholders? Speaker 2: Yeah. Well, as you and I were chatting a few weeks back, and I'm super excited about the way you've teed up this conversation for this whole conference because each of these groups, I believe, sees healthcare from a different lens. And again, you can parse it even further, seniors, commercial, et cetera, et cetera, rural, urban. But just in big broad buckets, what do most people want out of their healthcare system? And this is not a news newsflash, just go to your own kitchen table and talk to your family members and friends and loved ones and ask what they wish the healthcare system offered most people as we touched, but they wish that the US healthcare environment did more to offer them a team of healthcare experts, but focused on a primary care provider, a primary care physician or advanced practitioner who has their back, who's thinking about them, how many people have to themselves initiate? Speaker 2: Is it time for a screening exam? Should I have a mammogram? Should I get checked, screened for colon cancer instead of a system which do exist? And many people have experienced this as well, that reaches out to them and says that think it's time for you to get screened. How can we help you schedule it? That's a simple example. It gets much more integrated when you think about many Americans have chronic diseases. And so if you're a prediabetic, diabetic, hypertension, hypercholesterolemia, how can the system help keep you healthy and well? How can the healthcare come into your home and get you started on a program that avoids that 9 1 1 call, six months, 12 months, 18 months later? That's a patient perspective. But the other side is if I do get sick, I want to know that you're not saying I need to worry about cost cutting. Speaker 2: You're saying I want to get you the best healthcare as quickly as possible. And so that's the other side of this. And that's where even though we need to focus on affordability in US healthcare, we need to do that by driving out waste and offering excellent care, not by limiting care. So this is a critical point, again, of what people want and before we leave the patient, also add it that there's some interesting consumer work coming out now in the healthcare literature around consumer perceptions of the term value-based care. They like the features that you and I just talked about. Really when you say value-based care to a person on the street, it kind of means cheap care. That's where their head goes when they hear that term. So I think you're going to see a movement, which I'm all for. So let's sort of rebrand this. Speaker 2: Let's repackage it a little bit into things like patient-centered care, which is what people want. When you talk about providers, especially primary care providers, burnout is rampant. And most providers went to medical school or advanced nursing school so that they could do a great job taking care of patients and being told that you have 15 minutes per patients, 25 patients to see you get somebody who showed up for a quick recheck, but actually they've gained 10 pounds of edema because they are swelling from their heart failure. Now you've got a 45 or a 60 minute visit that throws the provider's day off completely, and now they're frustrated and many providers are spending additional two to three hours a day on administrative tasks like documenting in DHR. Some go home and do it from home, but they're exhausted and frustrated. So from a provider perspective, putting a team around that primary care provider is a game changer. Speaker 2: And when it's done well, there are still administrative hassles. I guess there always will be, but when we can minimize them, when we can offload them to maybe slightly team members that that's part of their job and get everyone practicing to the top of their game, that is a burnout fixer. So we've seen this. And then lastly, if you're a payer, whether you're a large employer, whether you're the government, you are frustrated with how expensive healthcare is, yet, how fragmented and variable the results are, which is the US healthcare system. And so you want to see understandably good access, great care for those you're responsible for at both a inflationary rate that's manageable, but also just a total cost that's manageable. So we've seen, this is something we're directly going after at Optum and UnitedHealth Group, and again, many others are too, as we advance value-based care. Speaker 1: That's a really interesting tie that you just made between value-based care and clinician burnout, very compelling value-based care is also discussed as a potential means of addressing social needs and social determinants of health. Can you talk about that? Speaker 2: Sure. So what's really exciting when you go to fully accountable care models is you don't need to generate ACPT code or billing code for every interaction. You don't have to do that. You're looking creatively, you can unleash innovation because you're looking across the spectrum at all the factors that are going to influence the outcome of a panel or a population's health outcomes. And you're asking yourself, okay, I do have a limited budget here, but where can I place my services and interventions where they're going to have the most impact? And I'm sure pretty much everyone listening today has seen the pie charts showing impact on a population health outcome. And the physicians and the medical system is typically estimated in that 10 to 15% impact range regardless of country of origin. So I would say, okay, we know that as a swath you're going to see a much bigger pie chart or pie chunk of that pie from social determinants. Speaker 2: And then what are the social determinants that you as a value-based provider can intervene on? And sometimes they're pretty straightforward, food insecurity, housing insecurity, transportation security. If a person cannot get to their clinic, you're interested in solving that for them, even funding it for them, because you know that if you can get them to the clinic or alternatively send a team into their home, you are going to get a better health outcome. So you get a happier patient. You also get a person. You also get a lower total cost of care, which is what we're after, high quality care with lower total spends. Speaker 1: I've been really interested in Optum's house calls program, which seems to accomplish a lot of great outcomes all at once. Could you please talk about how that ties in with social determinants of health and is it a value-based program? Speaker 2: Yeah, that's a great question Ed, and appreciate it because it sometimes gets misunderstood. We do over 2 million house calls, visits with advanced practitioners, physician assistant, or a nurse practitioner. They schedule a visit into an individual's home and they go over a variety of preventative and early diagnostic factors to identify any gaps in care. And what's interesting is sometimes those gaps are things that map towards risk adjustment factors. Many times they're not so 60% ish of the activities that nursing professional does in that home have nothing to do with risk coding. And they have everything to do with getting a better health outcome. So lemme give you a couple of examples. Think about if they're in someone's home and they notice obstacles that might cause a fall throw rugs for the seniors can be a risk, especially if they're thick or they tend to move around on the floor. Speaker 2:So simple things like that. But let's go a little bit deeper. What about depression or mental illness? Right? So you might notice subtle clues of mental illness and now you're able to refer that individual in as appropriate either to primary care or behavioral healthcare resources. And then let's go back to the social determinants. You might notice that the house is a little disheveled and they might inquire about their ability to get nutritious food and ask permission to look in the fridge or the cabinets and determine that this person really is struggling with food insecurity but might not be forthright about it. Maybe they're uncomfortable talking about it. And so as they identify these kinds of factors, then we can arrange community resources to help with that. There's a whole host of factors that we identify in a house call visit, some social determinants, some early intervention for healthcare. We've actually seen published a study with a group out of Yale Medical Center looking at the impact of house calls and seeing as you really would common sense would say, if we're doing our job, there will be fewer ER visits and hospitalizations downstream. And we've seen that and published that in peer reviewed literature. Speaker 1: So final question for our listeners seeking to implement value-based care in their own organizations, they're probably thinking it's difficult. We've tried this. Speaker 2: That's right. Speaker 1: Based on your experience, what are the keys to actually getting it done? Speaker 2: Yeah, Ed. So it's a journey. First, you got to be ready for a transformative journey. Second is cultural. It's super important to have these conversations with frontline staff, with physicians, tell 'em where you're going. And in my experience, these are actually super exciting conversations. So as leader of Optum Health, when I would go talk to an independent group of primary care physicians or multi-specialty physicians, most of 'em are super anxious in a good way. They're leaning in, they're like, how do we get there? But it's a cultural change and you have to talk about that. And then you need to begin to actually put the clinical model in place alongside working with payers for the financial model. And that's where bringing in someone with expertise in this space, if it's new to your organization, is highly, highly valuable. Speaker 1: Well, thank you Wyatt for sharing your insights. It's been a really interesting conversation. Speaker 2: Well, Ed, thank you. Enjoyed the conversation as hopefully you and the audience can tell I'm very passionate about this topic. I believe the future of the US healthcare system needs to evolve rapidly towards value-based care. And I think we need to think about how we're talking about it to broader audiences. Maybe it's patient-centered care, which resonates with what people are looking for. But thank you. It's been great to be here with you. Speaker 1: Well, thanks again, Wyatt. And I'd now like to welcome Dr. Thomas Lee, who is editor in chief of NEJM, catalyst Innovations and Care Delivery.