Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep95: The case for independent practice, with Paul Merrick, M.D., and Dan Greenleaf of Duly Health and Care
Transcript
- Yeah, we save the average American family of four somewhere between seven and $14,000 of health care costs you Austin, welcome to off the chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the Assistant Editor of medical economics, and I'd like to thank you for joining us today. In today's episode medical economics, senior editor Richard Pearson spoke with Dr Paul Merrick, chief physician, executive and chairman of Dooley health and care, and Dan Greenleaf, the organization's CEO based in Chicago. Dooley is the largest independent multi specialty physician group in the Midwest and one of the strongest voices for the future of independent medicine. The trio talked about dooley's new study on health care costs in the Chicago area, which found that independent practices deliver high quality care at a fraction of what large hospital systems charge. Dr Merrick and Dan Greenleaf explain what's behind those price differences, how Dooley works to preserve physician autonomy while partnering with private equity, and why they believe independent practice is key to improving access and affordability. They also share how Dooley is addressing burnout through culture and technology, which AI tools have made a difference, and how independent groups can stay competitive as consolidation continues across healthcare. Dan Greenleaf, Dr Merrick, thank you both so much for joining us, and now let's get into the episode. Thank you for joining us today. Dooley healthcare identifies itself as the largest independent multi specialty physician practice in the Midwest, and upon hearing about I would say the country, that's entirely possible. Yeah. And what I wanted to ask very specifically was, you know, with more than 1000 physicians and other clinicians with 140 locations, at first glance, patients and other doctors might even look at that and say, well, they call themselves a physician's practice, but really, that's just another health system. How do you differentiate yourself? Yeah, I think it's both the operating model, the governance and the ownership piece, all three. So when we went through a capitalization event in 2017 with our private equity partner, Aries. We had had the discipline and foresight to have a retained earnings model. And so if you think of Shark Tank, an investable business is one that's growing, that has earnings. And so we've had earnings over a 25 year period. And so because we entered into that relationship as a coveted healthcare asset, if you will, we were able to negotiate a governance, ownership and operating structure that still affords physicians the privilege and responsibility of leadership in the business partnership. And so we have 11 person Executive Business board with five physicians that serve on that board. So physicians, our private equity partners and our business partners together make strategic decisions that are in the best interest for growth patient and patient care from an operating model. A lot of places call themselves Doctor directed medicines, but physicians hire their their partners, they select they manage the physician performance. They divide the physician compensation pool, and they define the clinical care model and clinical policies. And so that operating model supported by elite business functions, with it revenue, cycle management, procurement, compliance, legal infrastructure and strategic growth plan, it's a marriage made in heaven. What physicians in the independent models traditionally lack is the ability to scale and partner with elite business healthcare executives. And that's probably the number one thing that private equity helps bring to our practice is the recruitment and retention of elite healthcare business executives, smaller, independent practices, candidly, they can't afford to have the level of business talent that we are privileged to work with, and that partnership of focus on patient care plus elite business performance is what allows growth and sustainability. Yeah, the only, only thing I would add to that is we've got six, Paul mentioned, 600 physician shareholders. We have a ramping period in order so you've. Basically have two years to make that qualification of the shareholder and our our physicians own somewhere between 35 and 40% of the company and Paul this board thing is amazing that we have five physicians on our board. I mean, I don't know another I know there's no hospitals with five, with five at 11 board members that are physicians. I know for a fact there are no insurance companies that have that that structure either. I'd also point out that, you know, one of the things that makes Dooley really unique is its affordability. Paul touched on this earlier. You know, we're, in many instances, we're a ninth of the cost of the health system. So an MRI that's done by dually is approximately $500 if it's done at Northwestern it's $4,500 if we if we look at things like knee replacements, it's $8,500 versus $65,000 I had a friend at two knee replacements, same doctor, different site of service. One was $65,000 maybe other one was $8,500 and then, and then the the third one is, you know, there's many, but you know, colonoscopy somewhere, we're somewhere between 400 if it's done in office, to $1,400 if it's done in ASC, the hospital systems are typically 10 to $15,000 and so and and, you know, if you, if you think about like, what's the driver of of wage I would say, I would say wage compression, but lack of wage increases is, is largely health care, and it's this arbitrage that's occurring, like the arbitrage I'm sharing with you, the 45 that that invariably, the self insured employers like ourselves pay for. The other thing is, is quality of care. Paul's got some more data later on. We'll talk to you about that. But it's incredible. What we're what we've are your lights going out because you haven't moved. But it's really remarkable, like you know the Avalara data, we're 25% less expensive than the health systems. We have 15% fewer hospital admissions. We have 13% fewer ED visits. We have 5% better follow up on a patient 14 days after his or her discharge, and, and, and that's Medicare fee for service. This isn't even like, you think about like a value based care program. So our, our, you know, our, our ability to drive quality is is, I would say is, is is second to none. The other aspect I would also share with you is just access. Our access times are two days. On average, the access to get care from us is 20 days less than the hospital systems in Chicago. So we're at two days. Hospital systems are eight to 60 days. There is a hospital system in Chicago that if you get a cancer diagnosis, it's 60 days before you get a follow up appointment. And so, I mean, we just, you know, and then the other one is just consumer experience. Our consumer experience, our net promoter. Scores are 74 hospital systems are 30 to 50. We just looked up Northwestern it's negative 16. And the reason I bring this up is that the consumer experience for our patients is in the kind of the range of think Starbucks, think Amazon, anything above 70 is considered world class and and we're at 74 so we, you know, there's a lot of things that really differentiate dually, and really makes Dooley, you know, I think a one of a kind company when it comes to affordability, access, consumer experience, and then quality of care. That's a great segue into the main one of the main items we want to talk about today, because recently, Dooley Health and Care worked with avelier health on the study Chicago provider, market trends, key considerations for employers. How did that study come about? You know, it came about, I think in part because we saw AMPA do it. They did a large study that obviously underscored the value of an independent medical practice around the things I just described you previously. And we were like, well, we'd like to do something very similar for Chicago, because I do think, you know, and we didn't want to make it, you know, we, I think we're a little we were a little tired of telling people anecdotally that, you know, yes, the consumer experience is better, yes, the quality is better, yes, the cost is better, right? Yes, the access is better. We wanted to document it. And so. So, so this was, you know, the we just didn't want to be in an argument around, just the, just how differentiated Dooley was and, and wanted to prove our point to, like, this is a best in class care model and, and so that's and that's what we set out to do. We didn't, we honestly didn't know where the data was going to land, and we were really, I don't, I don't think we were surprised, but we're emboldened by it. I will tell you that we're not surprised of just how good our doctors are and how good our clinical teams are, but we were emboldened by it. I don't know what else you'd say about that. Paul, yeah, I mean, there's some false narratives out there about non for profit. We don't like that language. We like tax exempt hospitals. I think there is finally becoming awareness of it doesn't matter what your capital structure is. It matters what are the results that you create, and to the extent that we are viewed as a for profit private equity backed entity, it doesn't matter what your behind the scenes capital structure it is. It matters is what are the results and outcomes and the value you create for patients in the system? And I think one of the things that we've done really well in the last couple of years with Danny is we've taken the time and effort to document the good work that we're doing so that it's not a false narrative that is based on a capital structure. What people should care about is, what are the results that you create, and to the sense that we can create exceptionally high quality health care that patients clearly appreciate based on our net promoter scores and the system really needs. The reason that some people don't get health care in the United States is there's so much waste in certain areas to the extent that we can create a much more efficient Medicare and commercial model in an ambulatory setting that creates an opportunity that some of the underserved may be, may get care, but with a highly inefficient system that can only has been created over the last 20 years by large hospital system consolidation and the payers, insurance companies, we should call them, because they're technically not the payers. Dan always like to say, who actually pays the bills in health care. It's self insured employers, which we are and many, many companies are. We responsible for our own healthcare costs? It's the government. The government only doesn't know how to really deliver healthcare that great. They just pay for it. And to the extent that they don't pay for the right things, they don't get the right outcomes and the right models. And with the push towards transparency and pricing, which is how we learn some of this data, which is it is evolving, and the extent that patients are aware that commonly, they pay their bills. And when I was a young doctor, I didn't cannily worry about whether I did my surgeries at a hospital setting or in an ambulatory setting, because really what I wanted was a safe, efficient, accessible operating room. And as we learn more over time, is actually it's our duty to be a good steward of the healthcare dollar and not waste resources for ambulatory procedures in an inpatient setting, and so physicians commonly will just take the path of least resistance and do something that seems familiar and similar to them, until we educate. Physicians need to be educated. Employers need to be educated. Policy makers needed to be educated to what is the best clinical care model, and it's clearly Independent Medical Group Practice. And you know what I was going to say, another great segue. You did touch on some of those findings and results in our conversation already, but to dive into the details on the study, can you provide an overview of the findings. Yeah, we save the average American family of four somewhere between four, seven and $14,000 of healthcare costs, and so to the extent that they don't waste those healthcare dollar resources, the middle income families, and we are going to do that ourselves, as we take our $84 million of health care benefit costs down that allows us to pay our medical assistance, our nurses, our radiology techs, we instead of spending money on. Of healthcare benefits in an inefficient way that allows businesses, including ourselves, to reallocate those financial resources in the form of compensation to the middle class. So just some numbers for you. You know, Medicare beneficiaries treated by physicians at duly posted total Medicare there were $7,800 low on average, and those treated by Hospital affiliated physicians, $7,800 the difference range from, you know, $6,100 or 70% lower for gastroenterology, to 19,500 or 32% lower in oncology. The other thing I would like to point out is hospitals are heavily utilized for routine services, and so nationally, colonoscopies are at around 41% mammograms are 50% in Chicago, that number is, is is 62% for colonoscopies in 78% for mammograms. So Haas Chicagoland is a cautionary tale about hospital consolidation, because there's just way they're way over utilized, even on compared to a national basis. The other thing we also like to note that greater savings also occurred with coordinated care. So we have an example of of where both primary and specialty gastroenterology care for dually saw an additional 36% another additional 36% savings, or over $17,000 per patient. So interesting enough. It wasn't just, you know, people think like, oh, like, fee for service bad, right? And actually, fee for service that is done by independent medical groups actually proves that thesis completely wrong. Actually, when, when, when we you know this is, this is fee for service, fee for service that we're showing these savings on and and then when we double down with a physician, a specialist associated with with specialty care, we're we're seeing an exponential decrease in cost. And then I mentioned to you this, this earlier Medicare beneficiaries under dooley's care had 15% fewer hospital stays, 12% fewer ER visits, and I mentioned earlier 5% more timely follow up care. So timely follow up care is within, within 14 days. And you know what's what's so remarkable, this is how we practice medicine. Richard, this wasn't like, you know, having to get CMS to come down from on high and say, this is the way you will do VBC, this is how this company cares for senior patients, just out of its kind of natural state, which is, you know, we talked about independent This is why independent medical groups that don't have conflicting interest with hospital systems are so much better for the patient. We didn't include the Avalara study. We worked with Wakeley to look at the largest commercial PPO payer in Illinois. We serve 180,000 ungated lives, PPO commercial lives, and we save that 180,000 patients, $240 million million dollars of health care costs in one year, 2024 and so how does that happen? It's the five rights. It's the right treatment by the right person, the right time, the right way, at the right place. And so if you and to Dan's point, it doesn't matter the reimbursement methodology, whether it's through a fee for service undated PPO chassis or a full risk Medicare contract, if you adhere to the five rights, then you create that quality, access and affordability across any pair product. Shaky, Keith, this is all well and good, but what if someone is looking for more clinical information? Oh, then they want to check out our sister site, patientcareonline.com, the leading clinical resource for primary care physicians. Again, that's patientcare online.com and again. Just a great segue to another, you know, another thing I wanted to ask about, because talking about those findings, specifically, your study included an examination of primary care. And we talk about primary care at large as sort of a, you know, very foundational to the American health care system. Can you talk a little bit about what. Found with primary care. So I think our primary care doctors have a wonderful job in the sense that it's it's fully integrated care. So because we have such deep relationships and partnerships, we have that I'll call it system wide access. It's generally under two days. And so as a primary care doctor by having a full depth and breadth of specialty partners when the care needs to transition from wellness and primary care activities to specialty care input, we do that in a very integrated way, which actually translates to the results, such as the the GI results, and we documented that over about five or different service lines, combination of primary care plus specialty care translates into those outcomes, the affordability and access. And so our goal with primary care is to have a nice panel of patients. We generally bring in younger doctors with more senior doctors for mentorship. They learn sort of the ropes, if you will. And then they're given the tools, the clinical staffing tools. Dan referenced the ambient listening tool. And you know, how do we what are the big things that physicians struggle with? Is scheduling, inbox, management and documentation and coding, and as we roll out resources for our primary care doctors to have those tools, they can focus on that deep partnership, trusted advisor relationship, with their patients. And I think that translates into the results. You know, everybody talks about taking the friction out for patients and clinicians. I think those are some of the ways that we've done that historically. I think our belief is, you know, AI is a sort of a buzz word. What are the very well defined, succinct, practical applications? It's in documentation, coding, pre authorization. We've run a pilot on that so patients get care better, faster, sooner. Scheduling is going to be a game changer in terms of, how do you identify a patient and get them to their doctor, not necessarily to the whole system? I sat on Kaiser's Leadership Summit in a number of years, and there was a time when they're like, we're just going to get patients in, we're going to create vanilla schedules. And what they found was, when they uncoupled the patient from their provider, cost went up, quality went down, and engagement of both physicians and patients went down, and so we are increasingly using technology to create a deeper train tracks between not just our broader patient community and our company, but their specific physician provider. So just a couple thoughts. What we do know is independent, team based practices, patients get better coordinated, higher quality care at lower cost. I mean, that's one thing we know unequivocally with our prior and I mentioned just early. The study also demonstrated patients who sought out primary and specialty care under the same roof saw greater cost savings. So independent medical groups in team environments got better coordination, higher quality, right, and lower costs. And then we, and then when we and it was a compounding effect when we added a specialist, which was, I think, a bit of surprise for all of us because, you know, we're kind of trained to think special any specialty care is, is considered, you know, expensive, and it actually improved outcomes in conjunction with the primary care coordination, still being relatively new to medical economics. Frankly, I was really surprised to learn about levels of burnout among physicians and other clinicians in US healthcare internally. Do you have any formal evidence or informal anecdotes about your peer physicians? How do they feel on the job are do you have high levels of burnout within the practice? So burnout really comes from non clinical based activities and responsibilities and not working to the top level of your license, to the extent that you can help with those, those non clinical activities of documentation, coding, pre authorization, you know, prescription refills and things that, that helps a lot. But in addition to that, we had two young women physicians who who wanted to tackle the burnout topic head on, and they started a joy in medicine practice and and they've developed coaching tools. And then we asked them to not just survey them before and after the coaching exercise. Is sort of teach them how to how to navigate through the complexities of being a healthcare provider, but then we encourage them to be very, very specific. And what are the reasons that our clinicians are feeling that that non clinical distraction, we'll call it, and so they directly challenge the inbox management, the documentation and the interaction with their clinical staff and team building, and as they've done those things, the data is remarkable. Once you teach physicians how to navigate through the complexity of their day, they begin to remember the reason that they went into the field to begin with. And so I you, you can't get great outcomes without engaging physicians in a very constructive way. If you're your emotional meter is running low, you're not going to be the best version of yourself. And so we, we want to be attentive to that. We take physician engagement surveys. We have regular communication with our physicians. We've taught them how to do all kinds of different things, even outside medicine, you come out of medicine and the first time you're kind of getting a paycheck, we've done financial classes with them, and then we survey and we do six or eight, what we call physician communication education forums every year, and we base the topics on what people say they need help with you. Hey there. Keith Reynolds here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at kreynos, at mjh, lifesciences.com, with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute. Under the current administration of President Donald Trump, they have begun the initiative to make America healthy again. And how do you foresee or describe independent, independent physician practices playing a role in the MaHA movement? You know, I'll start. I think we're already doing it. I mean, we've got, you know, we've got physicians who are, are teaching patients how to cook healthy meals. You know, we've got a we've got a program by Doctor Dugan and and, and I also think that, you know, we've been extremely proactive in terms of of screenings and outreach, as I mentioned around the mammograms, around colonoscopies, around diabetic screening, around wellness visits, we are very proactive in terms of of reaching out to the patient, reminding him or her that these are things that are going to be good for you. I, you know, you look at Paul, will tell you like, DuPage County is one of the healthiest counties in the whole country. DuPage County where the company was built, and I would argue vehemently, a big part of that is because of a Dooley presidency here. There's just, there is a correlation. So we've got a great example. We've got a best in class use case right here. Where we are. We are on the, you know, the upper, upper ends of the national average in terms of healthy, healthy people. If that's the right description, yeah, it's been for more than a decade, one of the healthiest counties in the country. We take care of half the county. It's not a coincidence, you know, we talk about, how do you make America healthy again? There has to be aligned incentives and independent medical group practices are aligned in incentives to decrease the necessity of hospitalizations, and so to get a hospital system to invest in wellness, and, you know, candidly, decrease admissions, it's actually sort of a. Conflict and interest and and whereas physicians, we create a partnership with the patient to help them lead the healthiest, best version of their lives. And so the the culinary medicine program is going to be published in the Journal of Science, with six months patients had a two inches decrease in waist circumference, improved hemoglobin a 1c was blood sugar management, improved blood pressure. They got better by and again, we talked what is Doctor directed medicine. One of our long standing physicians, Dave Dungan, had a passion for food is medicine, and chose to take the self directed initiative to teach a number of his patients, literally in a kitchen, how to cook better, and created these results that are published. We have a partnership Dan's going to chuckle with a very reputable company called fullscripts, about 70% of Americans take some supplements because our diets are less than perfect. You go to some of the large chain places only, they're only about 30% accurate in terms of the dosing. Fullscripts has a 90% accuracy. They deliver medicines to people's homes. And so we've physicians aren't typically trained in supplement use. We're trained to write prescriptions and do surgeries. And so we've invested in educating and teaching our physicians how to help people eat better, exercise better, have a better spiritual life, and when necessary, supplement those activities with the right type of non prescription resources. There are, you know, among our readership, among our audience, there's going to be some doctors out there who are in much smaller practices, and who may read about dually health and care and say, Oh, I can't match their scale. I can't match their funding. We don't have the same amount of staff, whether it be with this study or just about business conditions in general. What would you like to say to them, or what would you like them to know, especially if they're really struggling to remain in independent practice? I think the independent practice requires devout attention to detail. There's no margin for error. And I do think that if they can find a ways to align with their colleagues and share resources to invest in technology and exceptional business management that affords the best opportunity to preserve what your readers, everybody will say they prefer a doctor directed medicine, independent medical group practice that is uniformly the case, and the reason they acquiesce to a hospital employment model is they're unable to manage that. And so we talk about autonomy if, if it's about clinical autonomy, and they're willing to agree to a partnership model, you have to, you have to agree. You can't get everything your own way all the time, but if you agree to align with like minded physicians, invest in resources, people and technology that affords you the best opportunity to remain independent and working together and showing and document the value proposition The Independent Medical Group Practice, I think, is An imperative to the system broadly, and to those who want to preserve that model. I think the other thing Richard say, if you, if there's people in Chicago, I mean, we're on the m&h Trail, we're hiring doctors, we're hiring a PPS, we're we're putting in new medical office buildings. We're expanding our ambulatory surgery footprint, I would strongly recommend looking for companies like us where they can continue to practice as independent physicians. You know, quote, unquote, independent, independent in the sense that they're going to get autonomy to to care for the patient the way they see fit in the best way that that can be done, but also someone who can lighten their load, like we we are my job, I tell people at the end of the day is to lighten the load for the patient and lighten the load for the physician on the patient side. How do we provide better access for them? How do we make it that experience? You know, some things that they'll that you know, you'd want for your mother, your father, your sister, your brother, your parents. And then on the physician side is like, you know, allowing them to practice on the upper end of their license, because you're, again, I look at a physician, vocationally driven, you know, where it's it. It was a soulful choice at the age of 18. And I said, there's only three groups who make those soulful choices at 18, military, clergy and physicians and and clinicians. And so, you know, making sure that you know whatever they do, that they're, they're, they're being part of a group who supports that and and looks for organizations like us because, you know, we're in the business of caring for patients. We do it better than anybody else in Chicago by a factor of 10, it seems. And, and looking for groups like us and joining a network or or medical group who can do these things that make your job less fun, practicing in a community versus a tiny little practice creates accountability and better results. Can it be and so to the extent that physicians can find people as committed as they are to clinical excellence access should try to figure out a way to align. And again, I agree. We have, we'll have four, five independent practices this calendar year in the Chicagoland area join our practice, and they see that as value creation, because we take away some of that, the complexity, the medical, healthcare, practice management component, and create access to patients, technology and a community of partnership that helps them be the best version of themselves. You Richard payer chin reporting for medical economics. My guests today have been Dr Paul Merrick and ceo dan Greenleaf of Dooley healthcare in Chicago. It's been a great conversation, and thank you so much for joining us. Thank you, Richard. Once again, that was medical economics senior editor Richard Pearson speaking with Dr Paul Merrick, chief physician, executive and Chairman, as well as Dan Greenleaf, CEO, both of Dooley health and care. My name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with healthcare experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart, wherever you get your podcasts. Also, if you'd like the best stories that medical economics and physicians practice published delivered straight to your delivered straight to your email six days of the week. Subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business in medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Luttrell. Medical economics physicians practice and patient Caroline are all members of the MGH Life Sciences family. Thank you. Applause.