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February 25, 2022: Aneesh Chopra, President of CareJourney joins Bill to connect the dots between APIs, open data and payment reform. In order to transform the system we need movement on all three fronts. What progress have we made in 2022 so far? What can we expect in 2023? What do you say to people who are waiting to have a better healthcare experience? Who want their data to move freely across their current health system and then beyond? And how can we move past the current resistance?

Key Points:

00:00:00 - Intro

00:07:00 - A system that costs too much and delivers too little is a quick anecdote about why American healthcare is struggling

00:25:20 - In 2022, the shift will be from a single pipe to the consumer into a bigger pipe to the data lake 

00:36:50 - CMS set the goal that 100% of Medicare and the majority of Medicaid will be value based care models by 2030



Today on This Week Health.

The private sector has the ball and it is the private sector's opportunity in calendar year 2022, to move it down the field with a little bit of a heavier, faster pace than what we've seen over the last call it five years. It is a put up or shut up moment in time on demonstrating that the uniquely American public private model can deliver more with less.

Thanks for joining us on This Week Health Keynote. My name is Bill Russell. I'm a former CIO for a 16 hospital system 📍 and creator of This Week Health, a channel dedicated to keeping health IT staff current and engaged. Special thanks to our Keynote show sponsors Sirius Healthcare, VMware, Transcarent, Press Ganey, Semperis and Veritas for choosing to invest in our mission to develop the next generation of health 📍 leaders.

Today we have Aneesh Chopra with us. Aneesh is an American executive who served as the first CTO of the United States. He was appointed in 2009 by President Barack Obama. And was with Whitehouse through 2021. Chopra previously served as Virginia Secretary of technology under governor Tim Caine. Chopra was a candidate in 2013 for the democratic nomination for Lieutenant Governor of Virginia. He is the author of the innovation state, how new technology can transform government and Co-founder and President of Care Journey. Aneesh, welcome. Welcome back to the show.

Always great to be with you. You're a good friend.

I always look forward to our conversations. They're always informative and fun, and it's just great to catch up with you. You keep a pretty busy schedule. Where I got all that information on you.

I actually don't know.

I got it from Wikipedia. I was going to make a joke that I, hacked your medical record, but that would've been a bad joke to start the show since we're going to talk a lot about data and APIs and those kinds of things, but no, it's straight off your Wikipedia page. Have you ever seen your page?

Yeah, I have. I don't visit it regularly, but you know, certainly after I lost my campaign for Lieutenant governor in 2013, that's why the last time in kind of looking up the profile, but a good.

I'm kind of jealous. I that's like a plateau for me at some point when I get a Wikipedia page, I'll show my parents. I also found out that you were born in Trenton, New Jersey. What was it like growing up in


M y parents were immigrants. And so it was a kind of a blue collar town in that way. There was this bridge slogan called Trenton Makes the World Takes, and it was highlighting a sort of chapter of Trenton's yesteryear where it was a manufacturing hub for the country. And my dad was involved in air conditioning manufacturing, and actually has a few patents under his belt. So it was a heyday for manufacturing, which kind of went into the decline seventies, eighties, nineties, and it's like a shadow of its former self.

We moved to the burbs and I that's one of the challenges in the country when you're in a state of economic decline to kind of make your way out to the burbs. And we found ourselves actually in a prosperous highly educated one of the best school system districts west Windsor Plainsboro high school.

And when you get access to high quality education, your chances in life go through the roof. And so I had great teachers, mentors, guidance counselors and that really gave me the confidence to, move through the economy. And I've been, I've been blessed with wonderful career.

A little bit similar backgrounds, similar timeframe. I grew up in Bethlehem, Pennsylvania when Bethlehem steel was imploding or just fading away to nothing really. But there was no burbs to move to. But what happened in, in the Lehigh valley is education took over. There was I think a good like 10 universities in the Lehigh valley alone. And it was at that time at universities really took off and they became an employment center for the area.

And then it became a distribution center for a lot of the Northeast as well. So all these cities trying to find new identities moving from manufacturing to whatever's next, whatever they can find I guess.

Pittsburg is the best case study. We'll get to that later. Not that it matters, but Pittsburgh transformed from a industrial age, iron steel kind of blue collar if you will. And it's emerged as this computer science centers of excellence. A huge technology base. And it's an amazing story. I'm also a Steeler fan. So I was shedding some tears on Ben's last home game which I thought was just story book in the way it ended. But anyway.

Probably one year too many for Mr Roethlisberger. Although. I know he just, I mean, before the year started all my Steeler fans and I have a lot of them who live around me were saying, they just didn't think he was going to get them to the playoffs. And I guess proved prophetic. I know people are wondering why I didn't talk to you about the white house or all those other things that you've done, because those are all interesting.

And it's really because we've talked about them before on the shows. If people want to hit those, they can hit profile page on this week health and listen to some of those other shows. In fact, we talked about your white house experience and you shared some, some great stories about that. Today we're going to talk about APIs, open data.

We're going to talk about payment reform. We're going to revisit some prior conversations that we have. We're going to check on some progress that's been made over 2022, and we're going to look at what we can expect in 2023. You gave me a title for the show in a subject line in an email, we were trading called connecting the dots.

I think what we're going to do is you're going to, you're going to play the guy, this is what we usually do. You're gonna play the government and I'm going to play the healthcare CIO. And we'll just go back and forth. Where do you want to start?

Let's start with where we are at the macro level for the economy and down, we'll go into priorities. So your listeners understand that we are a uniquely American experiment in how to administer healthcare. We're really public private. Many countries have some degree of public private, mostly public, a little bit of private. We are really purely, I wouldn't call it 50 50, but by and large, you can do the math 50% of the revenue on insurance, a great deal of the delivery systems respond to regulatory pressures.

So we have a unique role in the global marketplace to prove that a healthcare system can be innovative, agile, problem solving, lifesaving, cost-effective. We can do it all. And I'm an optimist. I'm generally bullish on the American experiment but we've got work to do because over the last several years, the expectations from the public sector are slightly deviations from where we are in the private sector.

And so you'll see some of that in the data and interoperability space thematically during our discussion. But the big picture remains that a system that today costs too much and delivers too little is a quick anecdote that every one of your listeners thinking about why we're struggling in American healthcare starts with. And that could either be in the negative sense that we can't get there or in a hopeful sense that we can do better.

And what's the way to get better. We have been basically facing two political camps. One political camp says give up the American experiment. Medicare for all. Let's remove a lot of the private sector, economics in healthcare. My good friends, Don Berwick and Rick Gilfillan wrote pretty provocative article in health affairs parts one and two.

They called it the Medicare advantage money machines. Which is to say the privatization of care delivery in many ways had been hindering our progress. So there's one world view Bill where that private public nature of delivery is sort of yesterday's model. We got to move towards a single payer.

That's one worldview. The other world view is no, we can actually fix this and we can make it work. We will need to put points on the board. If you're on camp public private, we can make this work. We've been spending about a decade now, aspiring to a world where the public private model can do more with less, but we haven't really demonstrated at scale that it can solve our economic pressures, our competitiveness pressures, our equity and access challenges.

So if I say that at the outset what I mean here is that the private sector has the ball and it is the private sector's opportunity in calendar year 2022, to move it down the field with a little bit of a heavier, faster pace. Than what we've seen over the last call it five years. And that's where I would love to spend the bulk of our time today.

Maybe going into what those aspects are, why, but it is a put up or shut up moment in time, in my opinion, on demonstrating that the uniquely American public private model can deliver more with less.

Yeah. I mean, the problems are well-documented and it's an election year, so there'll be documented even further.

📍 📍 We'll get to our show in just a minute. As you've probably heard, we've launched a new show TownHall on our Community channel. This Week Health community. And it airs on Tuesdays and Thursdays. I'll be taking a back seat to some of these people who are on the front lines. TownHall is hosted by an array of talented healthcare leaders who are facing today's challenges head-on. We're going to hear from professionals and their networks on hot button issues, technical deep dives, and the tactical challenges that healthcare faces. We have some great hosts on this. We have Charles Boicey and Angelique Russell, Data Scientist, Craig richard v ille, Lee Milligan, Reid, Stephan, who are all CIOs. We have Jake Lancaster and Brett Oliver who are CMIOs and Matt Sickles, a Cybersecurity first responder. I'd love to have you listen to these episodes. You can subscribe on our Community channel. This Week Health Community, wherever you find and listen to podcasts. Now let's get to the show. 📍 📍

Let me read a little bit of this article. It's about Oschner. So Oschner in new Orleans and it's EVP value based care dr. David Caremoosh have had real success with value-based care and it goes on to note.

Oschner was able to have 30,000 capitated Medicare advantage patients cost a hundred million dollars less than comparable 30,000 traditional Medicare patients, treatment differences for the Medicare advantage population include patient health, risk assessments, in-home visits, outpatient case management, post acute care utilization management, greater use of primary care because Oschner had transitioned so much of his care away from fee for service.

They changed the way they paid doctors. The primary care doctors were no longer paid based on our views, but instead. On performance of their patient panels specialists had a portion of their compensation based on value measures, such as clinical variability in unwarranted care. The result Oschner had its best financial year in 2020, even with decrease in elective, patient volume from the COVID pandemic. When I hear that, what is that an example of? We talk about. So that's an example of public private working.

It is. And in fact while I don't know that particular article, it is exactly what we need to see more of shifting from anecdote to at scale.

So, what are the attributes that you've identified? Number one, you take a physician practice that had largely been born on the fee for service system. You heard about the RVU compensation model and you flip it to one that is incentivized to think about total cost of care, whole person care. So step number one, they've moved the incentive model, the economic model of health care to the future.

In most markets, the volume of lives that will be available for that type of compensation is the minority, the vast minority of the revenue stream. So it's not enough of a signal to change the behavior. What you're hearing in that article is they had, they tip the scales, more revenue was coming through that total cost of care approach than the traditional fee for service.

So they were able to rip the band-aid and go from RVU based to something that looks a little bit more rational, if you're kind of an efficiency afficionado, which is to say let's identify the patients that we need to put into more coordination of care programs, let's maybe see them less on the specialty side care for them more on the preventive services side and all the things that I assume embedded in that article will come forward.

I'm on the team that wants to find those case studies and to celebrate and scale those results. And to me, a lot of this is transparency. Why would it take this author to write this case study? Why can't bill Russell figure out just on his own that there's something happening at Ochsner and we need to study why and then reverse engineer it so that we can learn faster.

We know in healthcare, we have this unfortunate 17 year gap from when there's an approved improvement in certain clinical protocols actually scaling nationwide. And in part that's because we've had such a difficult time tracking and measuring performance because the data sets have all been locked up.

They're largely proprietary. We have to take this author's word for it, that these results demonstrate. That's not an easy thing for us to independently verify. I will go back to say in this case, it is because now the Medicare advantage data is public and we'll get into that. But historically it has not been easy to get this level of transparency to find those a wonderful case studies like that Ochsner news story you


We are going to get into the technology piece of it, but so much of this, I find people oversimplify this challenge and they go, well if we just get the technology, right this all sort of flows together, but it's all of it isn't it? It's the payment models. It's the business model. That's what creates the complexity around it, not just the data and the quality of the data and the movement of the data.

The business model is what drives this and the commentary for me. And I think this is the headline you've heard from many of your guests.

The reason we've limited the returns on investment for interoperability is that the demand for interoperability has been relatively low. And it may seem odd because you and I represent digital health and companies that want to enter into the market in which case the need for data is great.

And so there's a high demand signal from the new sort of entrance, but for the traditional incumbents interoperability has mostly been a compliance to publish the data out as opposed to a demand signal for business reasons to incorporate data in. The demand signal to bring data in, I hope is going to grow faster in 2022.

And that's what we want on the dots connecting a demand signal for inter-op will shift, from compliance out to value based care organizations in and that will hopefully create the virtuous cycle of investments iterations to make sure that the interop works.


one of the things, and I'm not speaking as a CIO now, because I think most CIOs fear what I'm about to say, which is I've always anticipated that eventually we would have a consumer centric demand for the data that doesn't feel to have materialized in my time in healthcare. Would you say that's accurate at this point?

So this

is an area where I have struggled to communicate my views, but also kind of how it relates to public policy. I believe. And I think we are currently in a position where the consumer should have the pipes and the rights to access those pipes and that those should be available and working.

That's where we are today. We've installed pipes across the health plans for the most part, at least the government sponsored plans and most of the provider network. There are now consumer-facing pipes that are available to work, but the last mile demand signal, my mom and dad are not actively looking to access these pipes.

They want to trust others to assist them in making sense of their health information. In that case me. I'm helping them tap their pipes as a son caring for his parents. But I am of the view that there will be consumer services coming, mostly born out of value-based care organizations. I call this the era of health information fiduciaries that will ask the consumer for their trust to organize that information, using the pipes built for them and order to help them navigate. I believe Ochsner in the case example you've referenced, if they could, would build a consumer-facing app to compliment the work you've heard them do. And that article that has been maybe more enterprise level so far that fixing their comp, getting the physicians organized to do the right thing, their next chapter clearly would be, I again, I can't speak for them. I don't know them. They're not a customer care journey. They would presumably offer a service that could help pay or organize all of their data and help them navigate. That's coming. I just think that the demand signal will come from the trusted fiduciary on the patient's behalf before we have individuals doing it on their own. Like my mom and dad.

I love this because we're playing the role so well. Because you are so positive and you are an optimist at heart and I'm playing the CIO who's sort of been dragged through the mud here a little bit going I'm struggling and I've seen some of these companies, I've seen some of these fiduciaries and when I talk to them and I interview them, one of the things they struggle with is a business model. They're like, look, I can connect all this stuff. I can pull all this stuff in for you. But you don't really want to pay for it. The health system does who what's the business model to get somebody to pay for something.

The risk

bearing physician networks, like the Ochsner's that you just outlined when they achieve the savings that they've achieved and natural next step for them, I presume again, I don't have any relationships. I don't know what they're saying, but we're using that as a metaphor for today. I believe that organization, when they get a budget, call it $10,000 a year for Medicare patient. They may invest internally for this sort of consumer data layer, because it will assist them in managing the population in a way that they can't today.

I'll give you a silly example. If you're measuring quality for a population, the way the rules of the road work are the last blood pressure reading of the year is what's used to determine whether that patient is in control or not. What percentage of the time would a Medicare fee for service patient and the year with a physician visit in the proverbial Ochsner network?

If you look at the national data more than a third, might've had their last visit with an out of network specialist or independent doctor. And so one of the challenges for these networks is that they have to go retrieve the chart in order to compute whether or not after the fact the patient was getting high quality and had their blood pressure control in a world where we have the pipes laid and the consumer apps available.

You'll see quality as an example, use cases that will help fuel the demand for these technologies. Independent big tech apps that wish to be fiduciaries, but aren't tied to a value based care budget. We'll have a hard time finding payment. That's what we've seen for the last decade. Is it clinical trial revenue? Is it some consumer investment? Might there be a sponsorship by a plan or a provider for marketing reasons? Those models have really struggled to scale. To me, it's only the value based care investment plan that justifies the consumer-focused offering that we're talking about, especially when they are operating in a large PPO open network environment, unlike a Kaiser.

Can I tell you what excites me the most about this, this API movement, the bulk fire that we're looking at? It is all the work I was asked to do internally. Build out this clinically integrated network where the data flows across and build out all this reporting that we need to measure the effectiveness of the clinically integrated network.

And again, in Southern California and the listeners have heard this a number of times. We had an interesting model. We didn't employ all these physicians. They were all part of a foundation. So they all went out and got their own EHR. And we literally had a spreadsheet of a hundred different EHR.

Now they weren't distinct EHRs, but they were distinct instances. So the data was different. The the connectivity was different and all that other stuff. And so when they came to me and said, as a CIO, all right, we need to build these dashboards. It was as daunting as it can be. You're looking at, okay, I've got to connect to 55 of these EHR across 150 physician practices.

And now I've got to, I've got to bring the data in. I've got to normalize the data in some way and bring it back to meaningful reports that the physicians can act on. That's the part of this, I think, as a CIO, I'm most excited about that, that data layer being set up at this point.

This is why I was very eager to chat with you at the beginning of the year, because if there's anything I would love for today's audience to get, what you've just outlined the pain of yesterday's data normalization dashboarding layer is poised to flip, to turn key, light switch style on or off infrastructure. But it needs your leadership. CIO X. Let me explain. We've spent the first part of this interview talking about the consumer. Is there a demand signal? And we've talked about the fact that the pipes exist.

This is an important clarifying statement, the pipes that were laid to point to consumer apps, were regulated to normalize the data across instances within an EHR and across EHR. It is why Apple health, which requires and validates that your pipe normalized. The lab records to LOINC, normalize the medications list to RX, norm, et cetera.

That the codification is meet the standards or you cannot be approved to feed the apple health app. In many ways, I jokingly refer that apple is sort of is like a real world evidence of government policymaking because on the ground, they will not allow you to connect your health systems pipe to a patient unless it's validated.

What I mean by that, bill is the CIO's who are listening when you interact with the EHRs you're often doing so through their backend databases, which can be competitive and proprietary data model. And so they may speak HL 7 V2. They may even convert the data to FHIR, but at the end of the day, there's a lot of unregulated data formats and structures and quality of the data flowing into a warehouse that needs work to normalize.

But that pipe that went out to Apple health is clean. It's like the crude oil turns into whatever the analogy is the refined oil or whatever that is. And in 2022, thanks to the cures act bi-partisan that single patient pipe to a consumer designated app is now feeding in the same regulated data, feed a population data lake.

So if you wanted to extract every single patient's updated records, every single night, you simply would run it an app, a bulk FHIR app on top of your regulated bulk FHIR server, which the EHR vendors have to supply no later than December of this year and have to price essentially a net neutrality style model where they can't discriminate based on use case to say, well, this is a more valuable use case.

You charge more. This is a more societal good use case. You get to pay less. It's actually normalized to to true costs and it has to be disclosed. So I see in calendar year 2022, the shift from the single pipe to the consumer, into this bigger pipe, to the data lake as the big technology migration. And it's not going to just auto magically happen, CIO, call your EHR vendor and say, when will you ship for me? The technology to test this because it may become the new, what you previously would have in terms of interface engines. It may be your eight data and analytics replacement for an interface engine, which is the foundation of those sorts of dashboards and visualizations.

But you need to ask for it. And if you demand that it works, you need to provide feedback that it doesn't scale. Hitting the production systems, not the call the warehouse systems, all of those operations. We need a growing cadre of CEOs in 2022, testing the regulated big pipes in order to make sure that they work as we enter 2023.

Testing the regulated big pipes. All right. So you lost me a little bit there on, on that phrase itself. What am I testing? The pipe to the data lake essentially?

Lt me describe the regulatory shift. When EHR vendors complied with the patient API requirements, they had a few choices. And I think there's lots of variability in what the what's actually been put in place. Keep your data in your proprietary data model and then at the transaction query convert the data to the regulated FHIR and ship it.. So the backend data lake remains your proprietary data model and it only converts and ships through that transaction. And it's basically a one time use one use case pipe, basically. With this requirement, the move to enable population level sort of a regulated FHIR standards.

It's really hard for the EHR systems to rely on that architecture. Keep the data in a proprietary format and then in mass convert and then deliver. It realistically means that there likely will be, that's why I'm saying, ask your CIO friends to test this. There will likely be a cashed data lake where the data's already been normalized so that it can move through the service the last mile. You follow


Yeah, we've done this with reporting systems for years. We took the transactional data store and we moved it to a secondary data store so that we could run various queries and stuff on it and not bring down the performance of the transactional system.

And what the CIOs need to know is the government didn't dictate this level of technical detail. Can you run a population level query on a transactional system? Does it have to be in an operational data store? That's up to the vendor to decide. And as you would imagine, Bill, if they choose one model, not the other, it's not going to work.

So we need the CIOs to get early testing to demonstrate, Hey, is this thing going to even make it out of the gate? You mentioned in the Ochsner example, what do they say, a hundred thousand MA lives? If they wanted updates on all a hundred thousand lives out of their backend epic system every night, if they have to hit the transactional systems for those differences in patient records, that's going to be a production tax.

We don't want that. So I don't know how it's going to work in reality, but I'm saying to the CIO's ask, test and give feedback if it's not operationally efficient.

Right. That makes perfect sense. It's interesting you talked about Apple, but I'm also thinking about things like Truveta that's out there. And even I would think that this is the kind of model that Truveta would go to its partners and say, this is the way we're going to feed information into the data store.

That's right. And I would say anyone looking to build a platform for care delivery transformation would want to seed that platform with the regulated, normalized feed, as opposed to taking the transactional systems, the backend data warehouses, and trying to create your own separate feed unregulated. Cause then you've got the mess that you described with a hundred instances and everybody's backend is different and you got to normalize it. Did you do it the right way? And you got to double check your math. It's too much of a hassle.

All right. So Aneesh, you're going to, you're going to prop me up here again. I'm going to go curmudgeon on ya. So the, one of the challenges with F IR USCDI, is a very small dataset we were talking about. I know that it.

Includes notes. You're describing the Apple health version, which was like maybe seven or eight FHIR resources, right. That's limited. USCDI is bigger than that, which is to say the version that has to go out by this December with the notes looks a lot more expensive, but keep going with your question, cause I'm going to tell you why I'm excited about 2023.


that's where I'm going, which is to the extent that we can get more of the information normalized out there, as you say, in a turnkey kind of solution. We're going to get closer and closer to what we've been hoping for, which is a system where we don't spend so much time on the plumbing, or we're now actually working on solutions that are going impact costs of care, price, transparency, and all those things.

So here's why another reason why I was eager to come on the show today. So number one, by the end of 2023. So a year in change from today, every EHR vendor has to essentially export the entire call it electronic health record, designated record set. It's the under the term EHI export, which is basically all the other data that's in the backend systems that should belong to the patient.

Because we don't have industry consensus on how to open up the entire Epic data model and the entire Cerner data model and the Meditech data model, ONC said, you can choose your own adventure as to the how. So it's not going to be normalized data Bill. It's going to be accessible data, but not normalized.

The Biden administration put out an executive order in December, which gives me the happy happy's. It says that we're going to look at the American people and their life experiences, and we're going to modernize their interaction with the government and perhaps other parts of the economy, including healthcare.

There's a section in that executive order on customer experience focused on maternity and the Biden administration put out a goal. We're going to assist moms, pregnant moms to organize their genetic testing, images, like the nice ultrasounds as well as their EHR records, whatever the traditional lab results and other variables.

And we're going to work to bring that data in a more structured and organized way available to moms via apps they trust. In my opinion it is an example of the kind of leadership, the public private partnership model of American health care desperately needs. Set a goal. If any of your CIOs are excited about opening up with the use case in mind of moms or moms to be, let's get a coalition of the willing, let's go to the Biden administration and say, we, the coalition of the willing, we want these results in 2022, not 2023. Who's with us at putting together all the data for this life experience. So that kids born before the end of the year, will have all of their records in one digital locker, trusted by their families. We have an opportunity to raise our collective hands. And if any listeners on the show, please email Bill. Reach out to me. I'm eager to get this coalition of good energy to kind of move forward with the EHR vendors with big tech, with app developers, but health systems physicians, pediatricians, OB GYNs. Let's get this coalition moving. It takes an abstract idea that all medical records will be available in digital format upon request nationwide, which may feel daunting to a lot of the vendors into something that is very ambitious, but achievable in the near-term.

So essentially what we're looking at, you said maternity. Are we talking about like every newborn child will have a record starting from birth? Is that what we're looking to populate?

That may be how it scales in the beginning it's let's demonstrate we can actually aggregate that information maybe in a few centers that are willing to voluntarily participate with the Biden administration to bring this vision to life. And then once we demonstrate that it's possible, like anything you can test it, validate that it works.

And then through the levers of government scale. That could mean scaling future versions of meaningful use, whatever we're going to call USCDI plus. And it could mean scaling CMS has investments and reimbursement policies, payment reform to those various centers. So how it scales will take longer than next calendar year, but a few pockets Ochsner ask in the news article that you started the conversation with to say, we can do it here on regulated standardized pipes. Boy, that would be a lot of fun.

Talk to me a little bit about payment reform because another article I read said that fee for service, percentage of fee for service actually increased last year. I think that's probably due to the pandemic and health systems running towards what they know and what drives revenue for them today in the model. That's not necessarily a direction that's going to be helping, I don't think drive down the cost of care and improve health equities and those kinds of things. So I mean, is there payment reform that's required to open up this data liquidity?

It's going

to definitely link to the demand signal. And so now we're getting a little bit of my day job and what, what drives my passion every day of my life now. So CMS launched a really interesting experiment that I want you to pay attention to. It was called the Medicare direct contracting model.

Medicare direct contracting model. CMS basically said, look, it's going to take a while for the entire system to move to value. In fact, CMS set the goal that we'll do that by 2030. A hundred percent of Medicare and the majority of Medicaid in value based care models by 2030. But we're going to create. In the last decade we had training wheels.

So you guys were part of it too. In Southern California, you can become an MSSP ACO one-sided risk. And so as a result of that kind of training wheels model, the demand signal for interrupt was there, but there wasn't a lot of capital to unlock it and to drive it. The CIO is when they sit down with their annual meeting, if that's the thing with their EHR vendor said, okay, where does value based care, demand, signal requirements ranked amongst security, digital transformation, advanced analytics. Like you have to be honest with me, Bill, where would you stack rank that if your EHR vendor says you get one new feature next year, where do you put your pennies? It probably wasn't on the population health.

But see, that's different. Again, we were in California. We had moved to about a hundred thousand managed care lives in Southern California. And so we were moving to this model in a big way. And actually I talked to the CEO of Southern California and he said that was one of the things that saved them through the pandemic. Having that managed care lives was almost a a hedge, if you will, against the loss of fee for service during, during the pandemic,

Let me flip the narrative back to you. The EHR vendors didn't custom build open pipes that were normalized. No. When I described my point of the demand signal, if you're sitting on Epic and Cerner and Meditech side, and they have a, let's just say we have a 500 people in the room representing customer demand. Yeah It's going to be 5% or less. Thank you. And so what I'm saying to you is that demand signal had been faint. With the launch of Medicare direct contracting we have the potential to scale to millions of lives over the next few years. So it started small. We estimate about half a million lives are enrolled in Medicare direct contracting where the entire total cost of care budget is in the hands of that physician group, stable total cost of care upside a hundred percent downside, a hundred percent, by the way, paranthetically this is care, this is my disclosure Care Journey serves about 65% of those lines. Through the various direct contracting networks that are in the market today. So we serve a lot. We serve the plurality of the duck, the networks that are in that market. And that's Clover agile on village MD Humana. You can see the list of all the different publicly available.

53 of them went live in 2021. We expect another, maybe 75 to go live in 2022. The networks are very focused. On interoperability, because when you have a hundred percent downside, you want a much more effective time data platform so that you could understand what's happening with your members and they could intervene more thoughtfully.

So I believe that payment reform option of moving to total cost of care responsibility will grow faster. Over the coming years than any other portion of the. Payment system. And I would keep my eyes on that growth curve, because if that growth curve hits the targets that I expect, the system will hit, we will see a faster turn on the IT side to building out the value based care, the CRM capability, all the things that you need to be effective in that model will be more of the demand signal coming out of the, to the EHR platforms. And the good news is even if they are so busy with compliance on the traditional channel.

Because they've opened up the APIs. This'll be a beautiful use case for those third party apps that are really focused on enablement of value-based care.

You know one of the

things that really has come up over my interviews over the past year has been health systems have put a renewed focus on patient experience. They've always had a focus on patient experience on the campus, inside the building and those kinds of things. They have beautiful buildings.

Wayfinder was a big application.

Right. But now there's the whole digital experience and the experience of the patient. I find that to be, I'm wondering how much of a driver that is. Cause I had to care for my parents as they got older and the experience was, and I'm fairly adept, you're fairly adept, it's still bad. But I mean, are we going to see health systems utilize these tools to drive better exp overall experience around health? Not just healthcare.

So you're

raising the biggest question. I don't know the answer to. If you look at the 53 organizations that went live in the direct contracting program, the vast majority were physician networks, not health systems, which means this is the talent is HCA, right? And I'm not naming them for any making them as a metaphorical name as the nation's largest health hospital chain.

Should they be the most cost effective supplier of hospital services to someone else's direct contracting network or do hospitals wish to manage that full chain? I would say in the Medicare ACO program, it was majority health system led minority physician led, but the physician led had better results than the hospital lab.

Which in part informs why you saw what you saw with Medicare direct contracting, a doubling down of the physician led taking on more cost of care risks. So in my opinion, the majority of hospitals are either going to become ACO or direct contracting entity friendly, and just say, bring your admissions to me.

And I'll make sure that they get a great experience but the whole customer satisfaction question is going to be your responsibility to make that seamless and we'll help you. But the grade is going to be for your networks, customer satisfaction, more so than it will be on the immediacy of my hospital experience as a component. That's the big debate for the industry.

This is a fantastic conversation. I wish we had another hour. But I'm going to hit you up for some advisory stuff here. Who's making the most noise in healthcare right now. Who should we be keeping an eye on?

Look, I think you've kind of heard me say it already. The direct contracting entities and the names because they're the ones that have the highest volume, the Village MDs, Agileons. The physician network value based care platforms. And by the way, I would characterize these as those that are in the enhanced MSSP program.

Like my brothers Farside Mostashari at Alabama. Sean at Privia. Seth at Evelyn. There are enhanced MSSP physician network enablement companies and these new entrant direct contracting entities. These are sort of two kind of halves of the circle here. That's where I see a lot of the innovation. Because they're marrying the economic model with the tech stack for this future delivery center.

I'm excited about that. For society? I've been dreaming of the retailers, right? You open the article with David Carmouche. He's now I think at Walmart, I'm dreaming that the retailers will activate their infrastructure to provide some. Services, even if it's a hybrid digital and in-person experience to expand access and to underserved communities.

The sobering fact Bill is, if you look at the physician clinics in the market today, by and large, they skew a bit closer towards the more economically affluent neighborhoods. And a little bit less so on the economically distressed neighborhoods. It's why, when you look at the methods, we have the Medicare data license at care journey.

When we look at the data of who's enrolled in an ACO, you're more likely to be in an affluent neighborhood. The one group that has the lowest ACO penetration rate are dual eligible patients living in economically distressed zip codes. The exact opposite of what you would want society to be focused on because they need the help the most in care coordination, all the other issues.

So I am most excited about risk bearing physician networks, and there are many hospital owned. But really physician focus. I think your, your predecessors at Providence would be a great example of that. I think UHS, the for-profit hospital chain, they've got very successful network of half a dozen ACS because they've put physician leadership and governance.

So that's where I think the it's not the technology companies that excited. It's the physician networks who need to incorporate that technology. That gives me the most excitement.

It's interesting. We covered the dollar general hiring a chief medical officer. I covered the Walmart Pega's Cheryl .Brilliant sharing their vision. And one of the things she noted was the amount of Walmart stores that are in a underserved medical areas. And that is one of their missions is to bring care into those facilities to serve those. And that's, that's one of the things I like about people were like Dollar General. Why are you covering that? I'm like, they're in those pockets where we don't really have great healthcare.

I pinged him on LinkedIn. The minute he got the appointment as chief medical officer, we had the chance to speak shortly thereafter. They have a lot to work on. So I don't know if they're going to get going like yesterday on this issue, but by good by golly, if we could get that network as an activated front door, whether it be for activating digital services or in-person testing and other things that combined with digital, I think that hybrid bill of digital with some in-person capability will likely be the formula for underserved access. It's what we would call asset light primary care. If it's possible, I feel like that's gotta be part of the


Thank you for coming on the show. Appreciate it.

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