Josh and Brian are joined by Dr. Asaf Bitton, executive director of Ariadne Labs, and Associate Professor of Medicine and Health Care Policy at Harvard Medical School and the Harvard T.H. Chan School of Public Health. They discuss the need to move to value-based care and change the payment structure. They also reflect on the historical underfunding and undervaluing of primary care.
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Full Episode 132 Josh I.: [00:00:00] I'm Josh Israel. This is the ACO Show, and I'm joined happily by my co-host, Brian Linsky. Hello, Brian. Hey Josh. I'd liked our interview today, Dr. Asof Baton, who is the executive director of Ariadne Labs in Boston and the associate professor of Medicine and health policy at Harvard th Chan School of Public Health and Harvard Medical School. He had a lot of great things to say. ACOs and primary care. Brian C.: Yeah. I feel like he was the perfect guest for the ACO show here at Aledade cuz he both talked about the need for the move to value based care, the need for changing the payment structure, but also the importance, the importance of that primary care and how criminally underfunded and undersupported it is in our system right now. Josh I.: Yeah. Interesting data around how it's the piece of the healthcare system most associated with better health outcomes and longer lives, and yet it is not the piece that is growing fastest. Brian C.: Yeah. [00:01:00] Yeah. He, he just has such a great array of research and, and analysis that he's brought to it. He came to our attention because he spoke, as Josh will explain in the episode at the National Association of ACOs on. Primary care in value-based care arrangements like ACOs. And so we just had that great, very deep look at the American health care system, but also a comparative look at primary care systems across the world to kind of really bring some lessons home on, on how we can improve primary care here in the states. Josh I.: And he had a nice line. I, I don't know if he made this up or have you heard this before? He said he spoke about things moving at the speed of trust. Brian C.: Yeah. Yeah, that was a good one. That was as a, as a writer. I, I caught that one. He's a, it was very very true. I think we've heard in various themes across so many of our interviews. Dr. Bitton: All right, let's get to it. Welcome to the show, Dr. Baton. It's so nice to be here with you. We wanted Josh I.: to start the this, the origins of this show were that you gave a talk at [00:02:00] the National Association of Accountable Care Organizations this year, and we were hearing great things about it, and we wanted to talk to you about it. And the premise of it is how ACOs can realize the full potential of primary care to improve outcomes. Can you give us the origin of how you started thinking about and working on. Dr. Bitton: Sure. Well, I mean the, the quick or the quick backstory is that I'm a practicing primary care doc in an aco, and I've been thinking about and working on practice transformation linked to payment reform for now almost 15 years. I've also worked at this from a leading collaborative level, so leading regional collaboratives on practice transformation. And I'm also a, a senior advisor at cmmi, although I'm not speaking for them here. And so I've, I've seen some of the intersections between the MICROSYSTEM practice change and the Microsystem payment change and the need for their converge. And I think that I, that convergence was really, you know, also driven home for me in the [00:03:00] process I participated in as a member of the National Academies of Sciences, engineering and Medicine report last year on implementing high quality primary care. Brian C.: So yeah, we obviously is very closely involved with the National Association of Accountable Care Organizations and the work there to promote value-based care, particularly from our perspective through empowered Primary. I'd love to, if you could just give us a quick summary of the talk that you gave and kind of the main points that you were making just for those in our audience who weren't able to. Dr. Bitton: Sure, be happy to. The quick summary is that primary care is a really high value item that we don't value enough in the US and that we could value more, both not only on the federal and state and commercial payer level, but also within ACOs. And so what I really presented in the talk is the case for primary care. Associated with higher life expectancy at the regional level as the only part of the healthcare [00:04:00] system that routinely results in better outcomes with equity when you invest in it. And the fact that we all know that it's under a lot of duress and stress. And so what I then talked about was the findings of the National Academies report, which, you know, 400 plus pages boiled down into a couple lines. Basically say what we need to. Is pay for primary care differently to care for people, not for doctors to deliver services. We need to make it accessible for everyone. Train people where, where people live and work design better it, and ensure that this is implemented across the US with scorecards and in particular, and there's an ordering to those recommendations we need to. In both level and form differently for primary care. And that's the the real applicability to ACOs because a lot of even advanced ACOs are still, when they open the hood and look under the engine, are actually unfortunately [00:05:00] paying their practices in an old fee for service way, even while they've taken on global risk. And think that they, they are doing advanced payment models for value. And so changing that form of payment towards prospective capitated, risk adjusted team-based remuneration to deliver the services that we need, both at the community level and at the ACO level to succeed was the, was the real take home point. Josh I.: You mentioned that primary care is the only part of the healthcare system where investments routinely result in longer lives and more. And yet there was some data that you shared showing that what's been growing the most is not primary care, but other providers involved in patients care. Can you, can you speak to that? Dr. Bitton: Yeah. It's a kind of, you know, wouldn't it be nice if trends matched hopes? Right. So the trends are that, that workforce density and, and, and overall numbers in primary care are decreasing [00:06:00] across the. And are consolidating, especially in, you know, coastal and, and, and heavily urban areas while there are increases in specialty density and number and. And associate professions. So the very thing that we need the most right now for our shared goals of outcomes in equity is actually falling by the wayside. Only three quarters of Medicare beneficiaries even have a primary care doctor, let alone team. And so I was highlighting that incongruity and, and really suggesting in a time where 20% of the healthcare workforce has left healthcare because of covid. It's even worse than primary. Which accentuates this kind of critical moment that we're in where we really need to, it's not a nice to have per care is not a charity case. It's not a cute little furry rabbit in the corner that, that we wanna say, oh, you guys are so nice and wonderful to your patients. It's a need to have and it's a need to support within an ACO context with [00:07:00] smarter, more aligned payment. Yeah. Brian C.: One of the really striking data points that was up came up in your presentation was just the flowering of physician relationships that every single patient in Medicare has. It's not, there's this perception that healthcare as a Medicare beneficiary has become more complicated. And that data kinda shows that yes, there are the number of relationships that any beneficiary has with physicians is just growing and it's becoming harder for any one patient to navigate all of their specialists, all of the different types of care that they're receiving. How does the primary care. Role, how do we strengthen that so it helps Medicare beneficiaries start to navigate those different relationships. What are some ways that you've seen that have really started to strengthen that relationship and that coordinator based role of the primary care physician? Dr. Bitton: Well, thank you for bringing that up, that this is, this is work led by Michael Barnett and I was glad to participate in, isn't recently published. And, [00:08:00] and, and it shows that basically between 2000 and 2019, the number of physicians that a PCP needs to coordinate just for her or his panel of Medicare patients almost doubled. And in the 75th percentile of, of of doctors, that number, that, that actual number I is approaching 200 just for Medicare panels. So, you know, you know, let alone all the outpatient insurance types. So the, the bottom line is that, again, as care is more complex, more fragmented, more, In need of that relational coordination. Over time, it's become, it's become harder to do and there are fewer PCPs to do it. So what are the ways to change that? Well, there's, there, there are pipeline issues. You know, we need to train more doctors. We need to lose less doctors, but it's not really even a doctor thing. This is a team thing. We need to create the ecology of a new type of care. That ecosystem is team based. It's not doctor focused. We cannot. [00:09:00] Train our doc, train, get ourselves out of this by increasing training. Only we need to build teams to care for these patients. And the core issue, and this is what the National Academy's report found, and it's unassailable, is that the fund, it's the fundamental issue is payment, the fee for service. Way of structuring payment is not just inadequate. It creates the conditions for and show data, a mathematical impossibility to provide that expansive team-based prospective form of care that's going to produce results. And so we have to not only move away from fee for service, we have to move away for it from it toward an aligned. Prospective, partially capitated form of payment that rewards teams in order to have the teams be capacitated to provide this more expansive relational coordinating care. Josh I.: You think that team-based care can be provided by all manner of primary care [00:10:00] practices, or does it need to be your large, clinically integrated network teams, you know, employed physicians? Do you think doctors who. Solo practices, two or three doctor practices, do you think they are just as able to provide the kind of team-based care you feel is. Dr. Bitton: I do, I, I actually think that in some cases, smaller practices, clearly the data would suggest, can provide better experiential care, sometimes can be better coordinators of care and, and capacitated with the right level of resources for some population registries, for some proactive outreach, for some risk stratified care management. It's been my experience observing practices use differential payment in, in, in the cmmi. Small practices are often able to do just as well or better than large practices. I think. Though that the secular trends that are way bigger than primary care payment would suggest that there will be fewer and fewer small practices. But that doesn't [00:11:00] mean that small practices aren't gonna be part of the solution. You know, in in American healthcare, the answer is, is a, is a heterogeneity of answers. There's no one answer. They're gonna be the practices that segment toward high cost, high need. They're gonna be the. You know, health systems based integrated practices, they're gonna be the group practices, they're gonna be the small practices, the question and the thread that connects them. Is how do you engineer and, and create the right and mill you for it not to be harder to do the right thing every day when you are on a 15 minute, you know, a hamster wheel schedule because you make your living on, on, you make your tiny margin on fee for service. There is no extra capacity to do all the right things that we need for our patient population. When you start to break the hamster wheel. And move from a hamster wheel to a car that's hopefully powered by an electric battery. That's the kind of team-based care. I don't care if it's a small car with two [00:12:00] dog practices and five total. You know, FTE's to 40 FTE practice. It doesn't matter. The same principles, the same kind of core hygiene of good primary care transformation. Do you have teams? Are you paid to to not just see visits, but actually to care for people? Perspectively, do you have a quality improvement method? Do you use registries? That kind of stuff can be small. It can be large. Brian C.: Yeah, we often like to talk about the role of behavior change and looking at behavior change in, in three buckets. You're looking at the, if you're looking at an elephant going down a path, that's the elephant itself, or you're trying to change the elephant, are you trying to change the rider on top of the elephant? Or you're trying to make the path just easier? And it sounds like there's so much work to be done in making the path easier and more direct to this kind of empowered team-based primary care future that we're trying to get. Dr. Bitton: I love that analogy. You know, the heath brothers who, who, who created that analogy have been, you know, very astute mentors and, and guides in, in, in the way that I think [00:13:00] about behavior change at a practice level. And, and it's all three, right? I mean, I think that, you know, every time you, you, you see someone, they're like, it's all about the incentives. They say, which one? You wanna talk about extrinsic incentive? Sure. Here, here's 40 years of pay for performance literature across the world. Summarize for you, you get marginal benefits for a short term, often with unintended consequences. So do you need to pay more for primary care and do you need to, you know, emphasize outcomes? Sure. But that's like a, that's like a, you know, that's, that, that's a rider issue. Now. The elephant is like, how do you, how do you create the milu to, to make it easier to do the right thing? Well that's, you know, get people off the visit churn and onto the population basis. You know, you guys and others are, are really good at doing that, and that's the elephant part. But the pathway is like, what in the heck are we doing all of this for and how are we organizing ourselves? And so part of that is macro policy, but part of that is like, hold on here, we're [00:14:00] engaged in an operat. To in to work with our communities, to hear our communities, to meet their needs and meeting their needs is not just stuffing more visits in a schedule or moving two points on a needle that may or may be the right needle. It's about finding the biggest outcomes and using the variety of mechanisms. You know, I say like what is teach, what is being a primary care doc or practitioner teach you about, be about behavior change in organizational. I say motivational interviewing, so we use that with patients all the time. You meet people where you, where they are, you roll with resistance. You assess confidence and motivation and change, and there's always adaptive learning, right? Same thing with behavior change. You're doing the same thing. You, you can hit people over the head. Organizationally, it'll work even less well than when you hit them over the head in clinically. So, so to me, organizationally, what we're trying to do is if we're in a, and we're trying to get to. People make the mistake that, you know, the step from A to B is to go from A to B, but I [00:15:00] always tell them the first step from A to B is actually A to not A right. You first move to not A, and most of the time it's not B, right? So you gotta do another, not A, and then another, not a. And maybe if you're lucky and you're smart and you're listening and you're humble and you have some of the right incentives starting to align extrinsically and intrinsically, then you can finally get to. Josh I.: You mentioned some important potential changes for payments that could improve the system, but within the way that care is currently delivered and paid for at an aco, I wonder what your thoughts are, how ACOs can improve the system. You know, we, we certainly know that right now it is still based on a fee for service chassis with some significant benefits. If you can keep your patients healthy, if you can do that population health work. But besides team-based care, what are some ways that ACOs might be able to, to move? Dr. Bitton: Yeah, so, so I think this is, this is, you know, what I feel really passionately about and, and [00:16:00] this, you know, hopefully some of your listeners who, who have some of the levers of control or thinking about this can be motivated to action. So the first and kind of overlaying thing is asking yourselves if you're in a position of ACO structure financing. You know, have you actually looked under the hood at how you pay your primary care teams? And is your assumption. That the, that the same value based structure that you signed up in, in terms of your overall contract commercially or federally or whatever, is actually being translated down to that, that community based practice. Because I often find that you ask a leaders and they say, oh, yeah, yeah, yeah, no, no, everyone's on value based care. Go, go talk to your primary care doc down the street. And she says, no. I'm like 80% on, on volume. I know we signed these contracts, but like now I haven't seen it and we're still wrestling over war. Whether we could get a second MA and have a nurse to do, you know, proactive post discharge follow up, right? So the first issue is [00:17:00] just asking the question. And then the second issue is, okay, can you build a panel based prospective payment? You know, even a partial way, you know, it's hard to flip to capitation overnight, but if you want teams to care for populations, you have to pay for teams to prospectively care for populations, which doesn't mean just run visits. The third thing is asking yourselves, okay, in the intersection, Between primary care and specialty care. Is there a mechanism for your aco, whether you, you know, own the specialist contract with them, you know, are friends with them, is there a mechanism for primary care to engage with them in a more intelligent and useful way? And I, and I offer that eConsult seem to be really promising, right? They're good for primary care, they're really good for patient. They're good for specialists, you know, for a lot of reasons we probably don't have time to get into. So can you set up an e-consult system, which is not the most expensive thing in the world. It's [00:18:00] organizationally, you know, of a medium complexity, but it's doable if there's alignment and intention. And I would argue it works better than, you know what a lot of people do, which well just, we'll give primary care data on, you know, which specialists are the most efficient. Well, that's, that's a good intention, but it doesn't work. You create a system for engag. More iteratively and intelligently with specialists. That works. That's econ. And then the third thing that I would argue you should take your investments in primary care and create is, is in the worlds of. Of of, of navigation and integration. Now, this has two levers. One is you have to have a behavioral health integration strategy, but I know I don't need to tell your listeners that and you guys that, I mean, that's obvious. Now. It's really hard to do, but you need to work at it. You have to have a plan for it, and there are lots of different ways to do it. The second way that you might not think you could use your investments, but I think increasingly is really necessary, especially for practices that care for patients with, [00:19:00] with high needs or, and for whom there's a lot of either disadvantage or, or structural racism or, or social challenges for, is to build a community engagement and navigation strategy through community health workers. They can be defined in type, they can be trained well. There are good protocols and mechanisms for doing this. There's also a lot of flexibility in different markets and different dynamics for what a community health worker might be. But those four things, knowing how you pay for primary care, moving to team based payment in a prospective fashion. Building the real specialty integration strategy through econs and then paying for community engagement navigation with behavioral health integration and CHW seem to make sense and have an evidence base for. Brian C.: Yeah. I love some of the points that you've really been hammering home, both in your talk and on your, on your Twitter feed and kind of really emphasizing that that payment is an essential but not sufficient way to start making some of these changes. That there is a mindset of empowering teams and team based care that has to go along [00:20:00] with the payment structure. One of the things that you brought up, community health workers and. I was looking at the, the five recommendations for the National Academy's work that you guys had done. One of them that really stuck out to me was, I believe it was recommendation three, if I'm remembering right on workforce and specifically looking at bringing primary care teams to where patients work and live. And I found it really interesting in, you know, such in, in an era of telehealth and zoom meetings and you know, the digitization. Of healthcare. This idea of empowering workforce with proximity and close to where patients are just seemed really interesting. I was wondering if you could maybe unpack the importance of proximity, the importance of geography and, and making primary care, you know, more accessible to patient. Dr. Bitton: Yeah. I appreciate you bringing that up. You know, I think that that most people in primary care or who care about primary. Would, would agree with the statement that that primary care is a relational enterprise. Right? And [00:21:00] what? What's our value proposition we create when we do it well? We create long-term healing relationships at Foster Trust and enable behavior change to happen at the individual level, as well as an engagement with communities in identification and meeting of their problem. So none of that had to do with service lines or A1C metrics or, you know, blood pressure control. Although all that stuff is important. You know, basically the, the things that we are offering in primary care, they move at the speed of trust. So if you want, we have this wonderful breakthrough innovation with mRNA vaccines. They're gonna essentially kind of save the world right from this horrible pandemic you want to deliver. Your vaccine's worthless unless it gets into someone's arm. And whether it gets into someone's arm, especially somebody who's lived experience suggests out a very reasonable mistrust in a system, well that's gonna happen or not because of the trust they have [00:22:00] in the person offering that potentially valuable lifesaving service. So if that's the case, then what we know from decades of experience is that proximity language and cultural concordance and empathy. Are key. And of course, telehealth is not like orthogonal to that. I mean, you can get those elements through telehealth, but you still, you still gotta walk the walk and you have to be open and welcome in a community framework and understand and be humble and curious about the community. And so that's why we basically summarize years worth of evidence on concordance and trust and humility around this idea that we wanna train. We want to train primary healthcare practitioners where people live and work. So it's not an because we're pragmatists here, like it's not enough to say there should be more primary care docs and nurses. Okay. That's really nice. I agree. But they should be of the community. You want community [00:23:00] health workers. You wanna build and work with workforce pipeline that develop, you know, from high school on up and medical assistants, nurses, doctors, all the health professions that intersect and interact to create effective teams. And in order for these kind of theoretical principles navigation, whatever the heck that means. Well, it means accompaniment. And if you wanna accompany people, you actually look in the global health literature and it will tell you they have to be of the community. They have to be trusted AERs and members of the community in order to, to be worthy of being trustworthy. Josh I.: Asaf, I know you have also done some work globally. Any lessons from your work there that apply to American Healthcare and ato? Dr. Bitton: I think there are a few lessons that are actual, pretty hopeful and, and I offer them with the, the, you know, caveat that of course all health systems are different and health system comparison is a difficult endeavor. The exciting thing from the perspective of primary care is that [00:24:00] actually most countries have many of the same problems and there's some really good ideas out there on how, how they've addressed them and in many ways, fixed. The first thing that we can offer from a global comparison is that there's no health system deemed to be effective, responsive, and efficient in the world that we know about. That doesn't have a very strong and well financed part that is primary care. So I'm still waiting to find it there. And so that's a real lesson for policy makers here to say that when you're paying between three and 5% of total healthcare spend for primary. That's probably too low and the form in which you're paying is probably wrong. So, you know, don't take my word for it, you know, look abroad. The second part of it is that, is that, you know, primary care, when looked at through its functional lens, you know, does it provide first contact access, continuity, coordination, comprehensiveness, and first center and person [00:25:00] centeredness When it does those functions by a variety of. It produces better outcomes with equity at lower costs. That's like a, like one of the few truisms of global health policy. So that's really cool because we know how to measure those functions. We're sometimes aiming for them in the US and ACOs have a particular capacity to foment their, their production and their achievement through their structure. The final lesson is that most effective healthcare systems that have really good primary care systems use team-based models with at some level community health workers. So again, if you hear a theme, it's not just like a soft batons rant and raves and like eats things that I like to dream up in some corner of Jamaica Plain Massachusetts. It's by studying, you know, dozens of countries and saying, gosh, there's a real pattern. Community health workers, when they're paid, when they're trained well, when they're [00:26:00] adequately supervised, and when they have protocols to implement and get out of the four walls of the clinic reliably produce incredible results. So maybe we should bring that home. And the good thing is that it's already been brought home. They're wonderful CHW models around the us. We just have to look at them and then drive their application into our communi. Well, Brian C.: as much as Josh and I would love to keep this conversation going, I think it's time for us to also bring this home, Dr. Seth Bean of Ney Labs of Harvard University. Of Brigham and Women's Hospital, but most importantly, a primary care physician. Thank you so much for taking the time to speak with us today on the ACO Show. Dr. Bitton: It's been a pleasure. Thank you for having me. Stuart T.: This episode was produced by Lianne Horst, Alanna Coogan and Stuart Taylor. You can find more episodes of the ACO Show wherever you get your podcast. Thanks for listening, and join us next time.