Latest / CareTalk: Healthcare. Unfiltered. / The Path to Building Stronger Primary Care w/ Kate Goodrich

Transcript

The Path to Building Stronger Primary Care w/ Kate Goodrich · CareTalk: Healthcare. Unfiltered.

• 0:00
  Primary care is the cornerstone of a healthy healthcare system, yet it faces mounting challenges from workforce shortages to reimbursement struggles.
• 0:08
  What would an advanced primary care model look like and how could it work for patients?
• 0:19
  Hi, everyone.
• 0:20
  I'm David Williams, president of Health Business Group.
• 0:22
  And I'm John Driscoll, chairman of Waystar.
• 0:25
  Today's guest, Dr.
• 0:26
  Kate Goodrich, is chief medical officer of Humana and a strong proponent of primary care.
• 0:32
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• 0:37
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• 0:44
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• 0:46
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• 0:47
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• 1:25
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• 1:27
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• 1:32
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• 1:37
  Dr.
• 1:38
  Goodrich, welcome to Care Talk.
• 1:39
  Thank you for having me.
• 1:41
  You you missed the part where I put John on the toboggan and send him down.
• 1:44
  I was going to say, was, I was going to build on that one.
• 1:48
  Do you got me there yet?
• 1:49
  You there first, but welcome Kate.
• 1:50
  Yeah.
• 1:51
  Well, we're going to talk about primary care, John, not orthopedic care.
• 1:54
  So it depends on where you're tobogganing David.
• 1:56
  Most of us actually look where we're going.
• 1:58
  All right, John, primary care.
• 1:59
  You care about that.
• 2:00
  What do you think?
• 2:01
  I guess Kate, what's exciting about Qmana is you probably made the biggest investment in both building primary care as well as providing the infrastructures of the data so that the docs actually know what they're managing.
• 2:17
  But maybe you could talk a little bit about the advantages of primary care and particularly what Humana is doing to make kind of turn primary care and that integration of data into care into sort of a superpower in the Medicare Advantage program.
• 2:31
  And then obviously talk to us a little bit about the population you serve.
• 2:35
  Be very glad to do both.
• 2:36
  I'll start actually with the population.
• 2:38
  know, at Humana, we've really leaned all in into Medicare Advantage.
• 2:42
  So that is the majority of our business.
• 2:44
  We also, I do want to say, have a growing Medicaid business.
• 2:49
  And of course, we are one of the TRICARE contractors.
• 2:51
  So military is very important.
• 2:54
  So we really focus on the actual government-funded businesses.
• 2:58
  But we have, you know, a little over 5 million Medicare Advantage members.
• 3:03
  And you're right.
• 3:04
  we are all in not just on primary care, but on what I call value-based primary care.
• 3:10
  So really aligning the financial incentives for the clinicians who provide the care with the better health outcomes in a very meaningful and intensive kind of way.
• 3:23
  There's all kinds of evidence that primary care is good and more of it is even better.
• 3:27
  We didn't have to go out and generate that evidence.
• 3:29
  That's out there.
• 3:31
  problem is that our primary care system in this country is broken.
• 3:35
  Less than 5 % of the health care dollar goes towards primary care, which I think is just- Maybe, Kate, sorry to interrupt, but maybe describe what you mean by primary care for those of us who aren't healthcare wonks like David, who use all kinds of phrases that no one can understand.
• 3:51
  If you could just maybe start with how you think about what primary care means and then get into value-based.
• 3:57
  I think it's really, it all falls together.
• 3:58
  Sure, yeah.
• 4:00
  Well, primary care really at its simplest is your family doctor or your family clinician, right?
• 4:06
  That you go to for, you know, vaccinations and preventive care.
• 4:11
  We tend to focus on seniors, and so we think about it as preventive care first and foremost, but also really good management of chronic diseases like high blood pressure, diabetes, asthma.
• 4:25
  Those are all things that primary care doctors do day in and day out.
• 4:30
  Importantly, they also get to know you as a person and incorporate the aspects of your sort of social environment into your medical care.
• 4:41
  Because we know that 80 % of health outcomes are actually influenced by non-medical factors.
• 4:48
  So where you live, what your diet is, do you exercise, those kinds of things.
• 4:53
  So that's basic primary care.
• 4:55
  So why is primary care struggling if it's so important, it sounds good, and why is it only getting a nickel?
• 5:02
  Well, that's because the payment system is fundamentally broken for primary care.
• 5:06
  And this country, I hate to say it, just is not invested in primary care in the way that many other countries do.
• 5:12
  Some states are doing better at that than others, but in general, that is true.
• 5:17
  Primary care is not reimbursed very well.
• 5:20
  So our country values, in a dollar sense, primary care less than it does specialty care.
• 5:30
  There's a long complex history behind that that I won't go into, but at the end of the day, that's really the main problem.
• 5:35
  And so what you see is fewer and fewer medical school graduates and residency graduates going into primary care and more and more specialization in fields that are better reimbursed.
• 5:49
  But the primary care need hasn't gone down.
• 5:52
  Population grows.
• 5:53
  And so we need more primary care.
• 5:56
  And as I said, the evidence shows, especially for seniors, the more primary care you get, the fewer complications you have, the better your health outcomes.
• 6:05
  And so as you see that workforce declining, but the need increasing, what's happening is those who are still in the primary care workforce have way too many patients.
• 6:15
  And so, and because they're reimbursed on a fee for service system, meaning they get paid every time they see a patient by the health insurer, whether it's Medicare or Humana or whoever, They have to see more and more patients in order to make ends meet.
• 6:32
  What does that mean?
• 6:33
  Shorter and shorter appointment times with less time to be able to get to know your patient and meet all of their needs.
• 6:40
  Just so you can contextualize that, Kate, describe how much time the average primary care doctor spends doing the overview of the updates with their with their patients.
• 6:52
  I think what is it like five to seven minutes?
• 6:55
  In some places, it is that short.
• 6:57
  that is not an uncommon scenario.
• 7:00
  Probably what we see mostly is about a 10 minute visit.
• 7:05
  And for an initial visit, when you're first meeting the primary care doctor, they might allow for a little more time, maybe 15, 20, sometimes 30 minutes.
• 7:14
  But in general, they're really short.
• 7:15
  And think about a senior who has multiple chronic conditions, is dealing with functional decline, maybe cognitive decline.
• 7:24
  has a family member with them accompanying them to the appointment.
• 7:28
  They need more time and they don't get that time in our primary care system for the most part.
• 7:35
  David, David, David, you're gonna need a lot of time.
• 7:38
  Well, John was coming up to the five to seven minutes, because actually his doctor only wants to him for half the amount of time as usual.
• 7:44
  doctor doesn't want to see me at all.
• 7:45
  But let's talk about this workforce issue because there's a couple of things that have happened.
• 7:49
  You one is you're saying fewer primary care doctors and then they have David, what do you mean by workforce?
• 7:53
  You guys got to keep I'm going to explain it.
• 7:55
  What does a work?
• 7:55
  Yeah, exactly.
• 7:56
  OK, I'm talking about the people doing the job.
• 7:58
  So what's one of the things that's happened with primary care and this happened with my primary care physician, I know with a lot of others, they went to concierge practice, which meant that rather than having 1500 or 2000 or 3000 patients, they put it down to 300, which meant that all the patients, including me, who didn't go with them, are now dumped on the existing people that are taking regular primary care.
• 8:20
  And you hinted at something before where we said physician, but then you're talking about more broadly providers.
• 8:25
  So I'm talking about when I say workforce, I'm talking about doctors, but I'm also interested in your view on nurse practitioners, physician assistants, any others that may be playing a role.
• 8:35
  Absolutely.
• 8:35
  So we think of primary care physicians as being mostly family practice doctors or internal medicine doctors or pediatricians, obviously, in the case of children.
• 8:45
  Those are primary care doctors.
• 8:47
  Increasingly, we're seeing more and more advanced nurse practitioners.
• 8:51
  So these are nurses who have advanced degrees and have more training and can be more independent in taking care of patients.
• 8:59
  And also physician assistants who also have not less training than physicians, but have regular schooling.
• 9:08
  And then they have really what I think of as on the job training.
• 9:13
  I'm actually a big advocate of expanding the workforce for primary care to advanced nurse practitioners and physician assistants.
• 9:19
  And both in particular, PAs are supervised by physicians and review some of their more complex cases with physicians.
• 9:27
  And there's state licensure requirements and everything.
• 9:30
  But it has been a way to expand the primary care workforce.
• 9:34
  And I used to think a lot about quality when I was back at CMS.
• 9:38
  I worked for Medicare for a long time.
• 9:40
  And we know from our data that nurse practitioners and PAs can provide very, very good quality care, just as good as physicians in many instances.
• 9:51
  A more complex patient might really need a physician to be their primary care practitioner, but many, patients do very well with nurse practitioners and PAs.
• 10:01
  In fact, I've been seeing a nurse practitioner myself for many, many years, and I feel like I've gotten really great care.
• 10:07
  The thing that I remember early on in care was hearing the phrase that your specialist knows nothing and does everything, and your primary care doctor knows everything and does nothing.
• 10:19
  But maybe you could explain why it's so important.
• 10:23
  was thinking about you as a specialist.
• 10:26
  I think I know nothing and do nothing.
• 10:28
  Where does that fit?
• 10:29
  But maybe you could talk a little bit about what the promise of care coordination in primary care really Why that's so important.
• 10:38
  Yeah.
• 10:40
  You know, we talked a little bit.
• 10:41
  I'm going to go back for a second to answer this question about the lack of time and why that is so critical.
• 10:46
  It's not just that you don't get to know your patient.
• 10:48
  If I'm a primary care physician and I have five minutes with the patient, I'm not going to able to address everything and I'm not going to be able to know that patient well.
• 10:56
  And what happens in primary care because of the lack of time is that patients are that normally a primary care physician is trained to work up.
• 11:06
  So certain conditions they may come in with or certain symptoms they come in with.
• 11:11
  We're trained as internists and family practitioners to work up a lot of stuff and handle it ourselves.
• 11:17
  But because of the lack of time, what ends up happening is patients often get referred to specialists.
• 11:23
  And we've seen the increase in specialty referral go up and up and up over the last 10, 15, 20 years because of this problem.
• 11:32
  And I don't want to say anything bad about specialists.
• 11:34
  I love specialists.
• 11:36
  but we're using them more than we need to.
• 11:38
  And unfortunately, there's not always a very good handoff or communication or coordination between the primary care doctor and the specialist.
• 11:47
  And that is really fundamentally because of the lack of time and infrastructure to be able to do that well.
• 11:54
  And we know that there actually is a type of primary care that does exist, actually does in concierge care, but it also does in some other types of advanced primary care practices where The physicians do have more time and they are able to work up things themselves and less reliant on specialty care.
• 12:12
  But when they do need to refer for specialists, they have the infrastructure in place to be able to coordinate that care with those specialists.
• 12:20
  So care coordination is a critical part of it.
• 12:23
  But at the end of the day, it comes down to the same basic problem, which is lack of reimbursement, which leads to higher volumes per clinician.
• 12:33
  and no time to really do all the things that you need to do in a coordinated, seamless fashion.
• 12:39
  So it sounds like, we're not just going to be able to have enough doctors to deal with it.
• 12:43
  We have other parts of the workforce, physician assistants, nurse practitioners.
• 12:49
  There's data, there's care coordination, and there's other other sort of roles like for technology beyond that or other, you know, other approaches.
• 12:59
  I guess reimbursement is one of them.
• 13:00
  But this whole advanced primary care model What does it look like when you put it all together?
• 13:05
  That's a really important point.
• 13:07
  So we actually have a care delivery arm in Humana called Centerwell and these are senior focused primary care clinics.
• 13:15
  It's also a home health and pharmacy, but I'll focus on the primary care for this discussion.
• 13:20
  So in our clinics, and there are others like us out there, I would consider us to be an advanced primary care, know, care delivery model where the payment, the way that clinicians get paid is very, very different.
• 13:36
  Clinicians are paid usually a salary with significant bonuses for providing high quality care as measured by a number of very standard metrics.
• 13:47
  And so what it does is what I said early on, it aligns the payment with really doing the right thing.
• 13:54
  Now, this type of advanced primary care requires really transformation of how that care gets delivered.
• 14:02
  And that requires upfront resources, upfront payments to be able to invest in technology, to be able to invest in the data so that the clinicians have right at their fingertips all the information they need about the patient in front of them, but also about their population of patients and how they're doing taking care of all of their diabetics, how they're doing at keeping people out of the hospital and out of the emergency room.
• 14:31
  it's really important to have those data.
• 14:33
  And we do help, we provide those data to our advanced primary care clinicians, both in our contracted network clinicians, our physicians on the human side, but also in our central well clinics.
• 14:46
  So I'm really glad you brought that up because both of those things I think are absolutely foundational to advanced primary care, to be able to actually know how you're doing in taking care of patients and how the patient in front of you is doing.
• 15:00
  from a quality metric or care gap perspective.
• 15:06
  And obviously, Humana has invested a tremendous amount, billions of dollars in actually building primary care capacity uniquely, to serve other groups as well.
• 15:15
  And you've spent probably hundreds of millions of dollars in terms of data and infrastructure.
• 15:20
  You've made those investments.
• 15:22
  You're caring for millions of seniors.
• 15:24
  What's the impact?
• 15:25
  How do you measure success or the gaps in your plan?
• 15:30
  to close the gaps in care?
• 15:32
  Yeah, so I'm so glad you asked that question.
• 15:35
  One of the fun things I get to do with Humana is I lead our research group.
• 15:38
  And we've done a number of studies to look at exactly what you're asking.
• 15:43
  So we started off by looking at the impact on outcomes like hospitalizations, readmissions, ER visits, cancer screening, et cetera, et cetera.
• 15:54
  For our members who see value-based care or advanced primary care providers, So those who were paid in this way that aligns the incentives with better outcomes compared to traditional Medicare, right?
• 16:08
  And what we saw is that in Medicare Advantage, most of those outcomes actually are better, just Medicare Advantage overall, even for our members.
• 16:16
  How do you measure when you think about outcomes again, how would you, from a patient facing perspective, how do you describe that?
• 16:23
  So there are standardized national metrics around, for example, diabetes control, whether or not that are under control.
• 16:30
  So if they're hemoglobin A1C, which is a lab test that tells you how good your diabetes is doing or how badly it's doing.
• 16:36
  Blood pressure control, cancer screening, vaccinations, patient experience.
• 16:42
  then, you know, we really try to keep people out of the hospital, right?
• 16:46
  Getting admitted to the hospital can often be avoidable.
• 16:49
  So we actually measure hospitalizations and ER visits that are avoidable.
• 16:53
  So it's those types of metrics that are frankly really meaningful to patients and to doctors.
• 16:59
  So we look at, we know they're better in MA overall compared to traditional Medicare.
• 17:04
  We took that one step further.
• 17:06
  Within MA, we looked at outcomes for patients who see physicians that we pay under fee for service compared to physicians that we pay under value-based care, so paying for better outcomes.
• 17:18
  And we saw that all those same metrics are better in value-based care.
• 17:23
  And then finally, we took it one last step and we published this recently in Health Affairs where we looked at those same outcome metrics for our members who go to these really advanced senior focused primary care clinics like Centerwell, you may have heard of Oak Street or Chin Med, they're also similar types of clinics compared to other value-based care clinicians and fee-for-service clinicians and found actually, again, even better outcomes just in that subset of senior focused primary care clinics.
• 17:54
  And interestingly, the outcomes were the patient population that was most impacted by being able to see those senior focused primary care clinicians, again, very advanced primary care, were those who were black and low income.
• 18:10
  So actually it seems to have a disproportionately positive impact on some of our most historically disadvantaged members.
• 18:18
  So Kate, mentioned a couple of names even of others that are taking this kind of advanced primary care approach.
• 18:24
  talked about concierge as another approach, which is obviously you know, basically putting more dollars against something.
• 18:30
  So that's not something that's gonna work for everybody.
• 18:33
  What else is out there?
• 18:34
  I hear about direct primary care.
• 18:36
  Is that something different than advanced primary care?
• 18:38
  And how might it fit into the overall equation?
• 18:42
  So I think when you say direct primary care, I think about that as the original sort of model that was proposed during the first Trump administration that was really trying to get to having Medicare pay for this advanced primary care, often concierge type care.
• 19:01
  And I do want to say there actually are similarities in the way care is delivered between concierge care and advanced primary care.
• 19:10
  I'm not familiar with direct primary care being something different from that, but really honestly, the secret ingredient beyond the financial structure for both of those is having more time with patients.
• 19:22
  In our clinics, We have 30 to 40 minutes per patient, right?
• 19:26
  And so if direct primary care is kind of the same thing, I think the model is probably very similar to what I've already talked about.
• 19:36
  So, the Medicare managed care has come under a lot of pressure and criticism.
• 19:45
  It comes at that sort of, there's an overlay of criticism about managed care, which obviously this horrible assassination of Brian Thompson has sort of crystallized and managed care, Medicare managed care in itself has had sort of a mixed reputation over the years.
• 20:05
  What's the state of Medicare managed care right now?
• 20:08
  And obviously the feds believe that they've been overpaying for subsidizing, if you will, the growth of it.
• 20:15
  We don't have to get into V 28 and all the different reimbursement pieces, but certainly there's There's economic pressure as the federal government comes under just budgetary pressure for Medicare and Medicaid.
• 20:26
  There's Medicare and managed care comes in and out of favor.
• 20:30
  What's the state of Medicare managed care right now?
• 20:33
  And if you were to argue the pro case for what you're doing, which I hopefully you'd be able to do as the expert, what would that be?
• 20:42
  Approximately 52 % of seniors right now are choosing Medicare Advantage.
• 20:48
  And probably the reasons for that is that they actually pay less out of pocket and they have benefits that they don't have in traditional Medicare like vision and dental and hearing benefits.
• 21:03
  So it is certainly growing in popularity for that reason, right?
• 21:08
  And we, as I mentioned before, I think one of the biggest benefits of Medicare Advantage is the flexibility to actually innovate in how you pay clinicians so that they can actually deliver care in different ways that are better for seniors.
• 21:22
  I think that's a major advantage.
• 21:24
  have 70 % of our Medicare members are seeing a value-based care or advanced primary care position.
• 21:31
  And we think that is all to the good.
• 21:34
  I think what CMS and others are worried about is are we paying too much for it, right?
• 21:38
  And I do think that we are able to actually hold down costs within Medicare Advantage through these value-based care arrangements so we have less acute care through the very unpopular prior authorization process.
• 21:52
  And if you want to get into that, we can do that.
• 21:55
  Although I think that is really intended to reduce the amount of services that just aren't don't have evidence behind them and aren't really needed.
• 22:05
  We should not be denying services that are needed.
• 22:07
  I want to say that very clearly.
• 22:08
  We should be really focused on the things that really don't have much value, and that is where we try to focus.
• 22:15
  So I do think that the agency, and potentially eventually Congress, are going to need to look at the various policies that are going to look at the various policies associated with MA to learn from, you know, what what we've been doing over the last several years and how we can make some of these policies better, whether it's through what CMS did with V28 and risk adjustment.
• 22:36
  I think actually what they were trying to do was really the right thing.
• 22:39
  They were trying to make sure that we are really being incentivized to take care of sicker patients and be more accurate in how we understand the illnesses of our patients and submit that to CMS.
• 22:54
  I think that that was actually a rationalization of the risk adjustment model.
• 22:58
  I'm sure there's more of that to come.
• 23:00
  I think there's improvements that could be made in the quality program, for example.
• 23:04
  So I'm certain that there's gonna be changes that come to Medicare Advantage to really to try to continue to strengthen the program.
• 23:11
  And I think that's welcome.
• 23:12
  I think that we wanna be at the table to talk through some of those and offer ideas.
• 23:17
  But I do think that that makes sense, especially given just the ongoing skyrocketing cost of care in this country.
• 23:24
  Kate, for the last question, I want to ask you a little bit about what it's like to be a primary care physician.
• 23:29
  From what I can see, people aren't that happy.
• 23:32
  You see even primary care physicians unionizing, for example, which is something I wouldn't have imagined a few years ago.
• 23:39
  What's it like?
• 23:41
  is there hope for people that actually want to practice primary care, that it could be rewarding and not something that you feel you need to run and jump to collective bargaining for?
• 23:52
  People go into primary care because they want a career that allows them to really get to know their patients.
• 24:00
  They don't just want to go in and like do a surgery and leave.
• 24:03
  Not that there's anything wrong with that, but that's not the kind of person that is attracted to primary care.
• 24:09
  They want to really get to know their patients.
• 24:11
  They like the challenge of the complexity of medical care that is in front of them and being able to, you know, rise to that challenge and really help their patients and keep them out of the hospital.
• 24:22
  They go into primary care for all the right reasons, but their day-to-day is really tough.
• 24:27
  Often they'll see 30 patients a day, again, five to 10 minutes each, and then they've got to do all the documentation.
• 24:33
  And documentation is important.
• 24:35
  There's a lot of reasons for good documentation.
• 24:37
  What ends up happening is they can't get it done at work, so they go home and get it done at home, usually after they've put their kids to bed, and they spend two to four hours on the computer documenting their notes for every patient they saw that day.
• 24:48
  And then they go back the next morning and they do it again.
• 24:51
  And through all of this, they're not really able to do the stop and think part of the job to really work up a patient in a meaningful way that they really want to.
• 25:01
  That's not a never, but it is a big complaint that I hear from primary care doctors.
• 25:06
  Is there hope?
• 25:07
  There is definitely hope.
• 25:08
  We have models of care now that are expanding, that are demonstrating value to the patients in terms of the quality measures and outcomes I mentioned.
• 25:18
  And I didn't talk about the physician or clinician experience But that's really important.
• 25:22
  It is a much more satisfying way to provide primary care.
• 25:26
  Most of our physicians have come from the fee for service world and they come to CenterWell because they want to do things differently.
• 25:33
  They want more time with their patients.
• 25:35
  Sure, there's still frustrations day to day, but we're doing things like pilot.
• 25:39
  We're using actually an AI tool to be able to allow the documentation to happen through ambient AI, artificial intelligence.
• 25:47
  that is already showing that it's reducing that pajama time at home that we talk about.
• 25:52
  So I do think there's hope, but I think these models need to be supported and need to spread.
• 25:58
  And then my hope is that over time, if primary care payment changes the way it needs to, that we see more and more people coming into primary care.
• 26:06
  Well, that's it for another episode of Care Talk.
• 26:09
  Our guest today has been Dr.
• 26:10
  Kate Goodrich, Chief Medical Officer of Humana.
• 26:13
  We've been talking about primary care and especially for seniors.
• 26:17
  I'm David Williams, President of Health Business Group.