EP414: An IRL How-To for Delivering Better Care and Getting Paid for It—A Value-Based Case Study, With Justina Lehman
You can listen to the episode here.
[00:00:00] Stacey Richter: Episode 414 "An IRL, How-To for Delivering Better Care and Getting Paid For It. A Value-Based Case Study with Justina Lehman".
American Healthcare Entrepreneurs and Executives. You Want to Know, Talking. Relentlessly Seeking Value.
Here's why I think this interview with Justina Lehman is different. We get into the actual whys and how- tos of trying to be a specialist, like an OBGYN or an orthopedic practice, that offers coordinated care and gets paid to do so.
There's so many conversations that transpire at the 50,000 foot level, this one is far closer to the ground. And if you want an even deeper dive on this topic, go back and listen to the episode with Dr. Steve Schutzer. There are so many who put financial growth and doing, in air quotes, value based, coordinating care kinds of things at a counterpoint.
Like, oh boy, we need to make some money this quarter, so let's put all the VBC stuff on the back burner. The point that Justina Lehman makes, both implicitly and also explicitly, is that doing the right thing for patients, things we know are going to improve patient outcomes, doing these right things can also be a growth strategy.
And I don’t just mean offering access and convenience, I mean also doing things that defragment care and coordinating it. Things that will truly drive better chronic disease outcomes. This is what we talk about exactly and specifically today. How do practices work alone or band together into a kind of value alliance, I'll call it, to both improve patient care and make money?
All right, so here's the absolute simplest possible business upside that taking really good care of patients can achieve. Higher patient volumes at the practice. Patient. Who, I guess, could be called consumers in this example, want to go to such a practice. The practice is differentiated. Your marketing has to be good for that to happen, but yeah, turns out patients really like non fragmented care with a physician, a nurse navigator, and the rest of their clinical team who patients know, like, and trust.
Also turns out clinicians, ones who are purpose driven, They like to work at places where they can be part of a team providing great care. So you wind up with growth. You got your demand from patients who want to come to your practice. You got supply of clinicians who want to work there. Who would have thought?
So as long as practice leadership is also purpose driven, this can all be very opportunistic. But there's also some risk exposure for those who don't consider models like this. Dr. Will Schrank said on the pod last week. that any specialists who aren't figuring out how to work with capitated primary care docs are going to have some referral problems coming up here.
And how do you work with capitated advanced primary care docs? You demonstrate you have better patient outcomes. You cannot do that unless you do all the things that Justina Lehman talks about today. So there's risk in not doing some of this stuff. I'm going to summarize the process that Justina uses to level up care and also get paid for it.
And this is all in the show notes, by the way. Step one. Assemble a committee of purpose driven, committed physicians who want to improve care. Committees should self select. No one should be there who doesn't want to be there. Number two, define the situation analysis. What is care as usual? And then what's ideal care?
And then determine what the delta is between where we are now and where we want to go. Number three, design ideal care and the plan for how you're going to get from where you are now to where you want to be. What does ideal care look like? I actually gave the keynote at the PBGH symposium a few weeks ago, and I showed a slide that Justina Lehman had put together showing the ideal care pathway for a patient with gestational diabetes.
If you weren't there, here's the aha. Ideal care includes multiple physicians. It includes working with payers and PBMs and how you're going to do that. There's also going to be a nurse navigator involved. It includes standardizing certain care flows and choices and making sure that patients have the right information so that they can get to the right care settings at the right time.
The exam room, as Justina Lehman says, is but the start of the patient journey. It's not the beginning, the middle and the end of it. Step four, align the model to possible financials. First of all, consider two potential payers. Number one, self insured employers. You could offer a bundle if you see a lot of any given self insured employers members.
You also could go to a regular payer kind of payer. There's going to be two kinds of payers, engaged payers and not engaged payers. If there's an engaged payer who is actually trying to figure out how to work with providers in their network, then there's four potential opportunities with such a engaged payer.
Number one, you could start talking about prospective bundle payments. Number two, and less attractive, you could start talking about retrospective payments based on savings. Number three, there could be quality incentives that are a percentage of FFS withhold or a quality incentive that is in addition to FFS payments.
And lastly, number four, there could be specialty quality programs that are PM, PM. If you're dealing with a not engaged payer, then one potential move is to gang up with others in the area, create some kind of value alliance and see if you can inspire the payer to become more engaged. You also could try to align your care pathway to what is possible to get paid for within an FFS model.
Dr. Scott Kennard in an PCP standpoint, though. Step five, measure results. Step six, prepare the story slash value prop for payers. Number seven, get more docs on board. Create the meaningful stories that inspire additional doctors to want to become a part of this beyond your initial gang. And then eight, manage and maintain success.
Continue to evolve big takeaways for me. It's really important to engage payers and get them at the table early. Will Schrank, MD, in another point of alignment from last week's show to this week's, Dr. Schrank also was talking about this same thing. He said historically payers and providers have had a pretty adversarial relationship, but it can be really hard for a provider to migrate to a value based arrangement without the payer to provide data and to some degree shelter for providers who are along the transition to value journey.
Besides the show with Dr. Steve Schutzer and Dr. Scott Kinnard that I mentioned earlier, I'm going to leave you with two other interesting for further reading or listening references. One is a LinkedIn post from Dr. Benjamin Schwartz that also includes some pretty great comments and back and forth. In some, Dr. Schwartz wrote, we need to uncouple value from the payment model and focus on outcomes tied to diagnoses. Link in the show notes. I also thought a radio advisory show was thought provoking. This was with Ray Woods, Eric Johnson, and Daniel Kozmanowicz. The gist of it is, at one point, Ray Woods says, if I think about the very fragile financial state that a lot of these leaders are in, they're telling me, I've got to pull back on my value based care objective for 2024, maybe even 2025, because I just have to focus on my margin right now.
But what I'm hearing you say is that it's actually not the right mindset to have, dot dot dot. Again, link in the show notes. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. Justina Lehman. Welcome to Relentless Health Value.
[00:07:34] Justina Lehman: Thank you for having me, Stacey.
[00:07:35] Stacey Richter: Do you want to just start off talking about what you've been up to?
[00:07:39] Justina Lehman: I am a nurse practitioner by background. I have spent the majority of my career in this value based care, high value space, focusing on creating environments where physicians, advanced practice providers, clinicians with their patients can thrive and that we can truly deliver value to the communities in which we serve.
And right now I am looking forward to the future of how do we identify high value care, bring that high value care to patients and the communities in which we serve, and how can we replicate that across the country. And the key to that will be really bringing together purpose driven people. To create that magical space.
That is an inspirational message. Let's dig into this whole idea of high value care for a moment. Because obviously you've got, theoretically, what is high value care? And then the reality of how do you actually identify this so called high value? How are you figuring this out? So starting with evidence based practice, what do the practice guidelines say appropriate care is?
And then really meeting patients where they're at, and who is the appropriate provider to deliver that care, and where should that care be delivered, and what should the price of that care be?
[00:08:59] Stacey Richter: This is reminding me of the conversation with Dr. Robert Pearl from a few weeks ago about the art and science of medicine.
But if there's an evidence based treatment plan, then that's the science and we should be following it. The art of medicine is to think through patient preference and their individual needs and the relationship. So different doctors shouldn't be like switching up how much insulin some patient gets based on their own personal beliefs about insulin.
If there's a right dosage, there's a right dosage. But if the patient has a preference or personal factors, that's when things might get tweaked. But it's about the patient, not the doctor. So we've got, what does the evidence suggest? Is this the right path forward? There's I heard like 40 percent of the time there's actually a guideline.
And then you basically said also, what's the best place for this patient? So what's the appropriate care setting? What's the appropriate price? And then who is the appropriate caregiver there? Is this a data exercise, so effectively what you're doing, like if we're actually thinking about all right, how do we consistently, which is the other word that you used, how are we consistently making sure that this is happening?
What are your thoughts on just how do you do that?
Yeah, so we really look at what is the clinical design of ideal care or high value care and what is the data in each component of that equation are we going to need to collect and measure to keep moving towards high value. So we really look at what is care as usual and what is the ideal care.
And this is where we bring together these forward thinking, purpose driven physicians, advanced practice providers, and clinicians, right? So we create a committee and we look at what is the care as usual? What is the ideal care? And how do you look towards that ideal care? What are the steps we're going to need to take?
So, we really look at a clinical design. I think that's one thing one of my counterparts and I really focus on is we're going to do this clinically first. So, we map out that clinical process. We look at what are the gaps or the barriers to go from care as usual to ideal care and where are those areas of opportunity.
And again, it's a room full of like minded purpose driven clinicians saying we can do things better.
Thank you. It's interesting that you say that because Larry Bauer who was on the show over the summer echoed a kind of a similar thing. He was talking specifically about patients with heart failure. But he's like, there's two ways that you can go about that.
You can be shocked every time a patient with heart failure shows up in the ER. Or you can think through, look, you know, a patient with heart failure, there's There's certain, there is a disease progression here and there's certain things that are very likely to happen. So let's figure out what the best clinical map is for how we are going to create the ideal patient journey.
And then to your point, this is where we are now. This is where we want to be. What's the delta there? Once you've identified that, there's a really clear mission.
[00:11:56] Justina Lehman: Even after the program is designed, these committees continue to meet on a regular basis and we're constantly reviewing what is our quality, what are the outcomes, what is the cost, what is the current evidence based practice to ensure that we're managing success and advancing the programs as care advances.
So it's an ongoing commitment that these physicians and clinicians make when they participate in high value care. How are you figuring out what the benchmark is?
Starting with what is the engagement with the patient look like in care as usual? And then what is the care that we deliver? And what is the outcomes of that care in the current state?
[00:12:36] Stacey Richter: And when you say how are we engaging with the patient, what do you mean? This is really meeting patients where they are at, not where we want them to be and being really honest about it. How do patients engage in their cancer screening? How do they engage in the follow up of their cancer screening? The current fee for service model, Stacey, really doesn't allow us to maintain a journey with the patient, right?
It's moments in time that they receive their care and it's on them to show up in our clinics.
So taking that cancer screening as an example. You would think through, I'm trying to understand, like, what does this actually look like tangibly?
We are looking at, I'll use an example, if we have a patient who has a higher risk for cancer and we need to engage them in that higher risk care plan pathway.
When they leave our clinic, do they follow up? Do they engage? And what we're finding is, is there's not all patients engage and there's reasons for not engaging. We have seen patients who completely are paralyzed when they are told they have a higher risk for cancer and they physically cannot make those next steps.
So, just kind of going back to the process that you use as you're contemplating like how do we create a high value care patient journey. As you said, you know, you start out with the situation analysis, like really think through very clearly with a group of highly committed clinicians, you think through where are we right now, ie., we have a patient who is paralyzed and is not engaging and is not getting screened. So you look at where you are now, and you look at what the ideal journey should be, and the who, where, when, why, how of the whole thing. So, going beyond fee for service transactional care where the patient walks into our clinic, we see them a moment in time.
We send them with their care plan, right? How do we meet them where they're at and provide them the things they need to help them engage in that higher value care that is better for their overall well being? I think the other critical piece is nurse navigators, advanced practice providers, clinicians are able to say, here's a nurse that works within my clinic who's going to be reaching out to you.
So, the type of nurse navigation that you're talking about, and maybe more words are required here, like so many things, I feel like you say nurse navigation, you say value based care. You say team based care, right, and it can mean one of 700 things depending on who you're talking to. But specifically, the kind of nurse navigation that you're talking about is an extension of the physician practice.
[00:15:11] Justina Lehman: I'm a strong believer that care is local and we need to understand the communities in which we're serving. This is not a payer program. This is not a employer program. This is the nurse gets introduced while the patient is in the physician practice and the patient already has a relationship with the practice.
So it's clear that the person calling was previously introduced, which probably ups the odds considerably that the patient will even pick up the phone call to begin with in order to even start having a relationship.
Absolutely. And I think one thing we see, Stacey, in these models of care across the country is there's the physician and advanced practice providers relationship in that exam room with that patient can be really undervalued.
That relationship is really the anchor to the care that that patient's going to receive and what the future looks like for that patient health wise. And so we don't want to get in between that. We want to be a value add to that. And so how do we wrap that physician or advanced practice provider in that patient in a team where there's the purpose and the goals are all aligned and everyone's working together.
But that nurse needs to have the credibility with that provider that was in the exam room. That is a very critical piece. It sounds like that's something that one should not take for granted.
Absolutely, I think where we have seen fee for service take us and some of these solutions is they actually create more space between the physician, advanced practice provider and the patient and we actually need less space.
We need to bring them closer together. And wrap them in care that's value add, not distracting.
[00:16:50] Stacey Richter: You know, I never really thought about that before, but I could definitely see the point that you're making, that if the nurse navigation or the navigation isn't intimately connected with the doctors along the journey who are providing care, if there is a measure of distrust even.
Between the clinicians who are seeing the patient and then whatever is going on elsewhere, that's going to come through and make it so that the, there's, there's just no chance really that the patient is going to respond to the nurse navigation. Especially if the doctor's like, who are you talking to?
Like they said to do what now? I don't know that person. Yeah. And if the doctor's Don't worry about that phone call.
Right. Right. Like, especially if that Physician is worried that the navigator is going to navigate them away from that particular doctor. Absolutely.
[00:17:41] Justina Lehman: Interesting. Someone on your show in the past said all of the in-between spaces.
That was Dr. Amy Scanlon. That's really where this nurse navigation closes those in between spaces as an extension to the physician and the advanced practice provider. So all working together to close those spaces and move us towards higher value.
[00:18:01] Stacey Richter: So, what you're doing is you're looking across, like you, you go into a local market and you find these high, these committed doctors, you're working together with them.
[00:18:11] Justina Lehman: What we're creating is a high value network, like minded physicians and clinicians that are working together in a community. They may or may not be integrated practices and that high value network is taking all of that care, validating its value. And then what is the story as a group to the payer? What is the story as a group to the self funded employer?
And then to the community. And so it's creating this environment outside of fee for service, where like minded clinicians and physicians can work together to lower total cost of care in their communities and get paid for it by the payer or the self funded employer. So, let's just say we get all that done, right?
Like, let's just check that box. So, we've got an aligned team. We have a practice and that practice has employed navigation. Then we encounter the next really big issue, which is how do you get paid for this? I mean, I've had more than one person tell me recently that when they're trying to do the right thing for patients, something that they know is the right thing for patients, they literally have to sneak around in order to do it.
Because it tends not to be super profitable. So if I'm a practice and I have put in place this amazing ideal patient journey, how do I get paid for it? How do you think about that?
After we build the clinical design, we're looking at how do you align business operations and the financials. And going through that exercise, what is your relationship with the payers?
There's different levels of relationship. You can get a very highly engaged local payer that wants to be part of delivering high value to their community because they see the benefit to them as the payer and what they can sell to the employer. And then you have some payers that have zero interest. And I think the other piece too, and we're seeing this more and more come into play is Self funded employers are getting very innovative in how they see care for their employees.
And then I think direct to the consumer is if you're building high value care and you can measure and prove it, do you increase your patient market capture? Because patients want to see you.
[00:20:16] Stacey Richter: If we're thinking about getting paid, it sounds like we've got four avenues here, some inarguably better than others.
We can reach out to a highly engaged local payer who kind of already gets it, right? Like they already understand that there's some competitive differentiator for them. If they have high value providers in their network that they're working with, they get that. Um, maybe there's downstream costs that are being saved.
There's some reason that that payer already has in their mind that working with you is a plus for them and they're willing to provide shelter or money or something and I'll circle back on that. The next gang here is a not engaged payer who has zero interest in what you're doing who thinks that, you know, I've heard payers say that all fee for service is high value care so what's the point in paying for anything else, right?
I mean. Seriously? Mm hmm. Mm hmm. So that's number two. Then number three, maybe there's a self insured employer who's interested here, especially if the patient journey in question might be one which has been identified as being very expensive like muscular, skeletal, maternity care, the other usual suspects relative to when it's not done well, it's really expensive.
And then lastly, direct to consumer that if you can go out into the local market and authentically be able to state and get referrals and reviews in which patients are extremely happy and receive a level of care that is differentiated. Then you can increase your patient base. Did I get that right?
[00:21:54] Justina Lehman: Yes, absolutely.
[00:21:56] Stacey Richter: Let's talk about the highly engaged payers. What do the highly engaged payers come to you and seem most intrigued by and how does this help them? I think ultimately, if you can demonstrate we're delivering high value care that decreases total cost of care spend, that's something a payer can engage in.
And I think that's where it can be difficult on the practice side is we're not getting those cost of care claims. That's not something that gets passed back to the physician delivering care. And so having that relationship with the payer to say, here's what we're delivering quality wise, here's the outcomes.
Can we look at what the cost is on your side? And if we reduce that total spend, can we have some quality incentives or pay for performance dollars attributed to that patient population?
So the payer would really need to be at the table pretty early on because this is not something that a practice can figure out themselves.
The provider has to go to the payer and say, look, we're going to put this program in place. Will you be our partner here? And here's our attribution or however you're doing it. And can you give us the what benchmark is and then what the overall impact is of the program that we're doing from a cost perspective?
[00:23:06] Justina Lehman: Yes. I believe in very close payer relationships where as you're strategically looking forward understanding what are those payer goals. What is the payer clinically focused on? And does that align with what the practice is focused on? And if you can find that alignment, is there an area of opportunity?
So cancer screening is a great example of there are many payers saying, how do we engage the member earlier on? How do we ensure that they're getting the care they need? And that it's quality care and that we're decreasing cancer spend, you know, cancer and MSK, right, Stacey? They're one and two every year in top spend for employers.
So when you're talking to the payer and that's their goal, how can that practice align their clinical goals? And when they line up, that's where you can see that opportunity.
[00:23:54] Stacey Richter: And what do those programs typically look like? The one that I have heard is that there are certain payers that withhold a percentage like 1 percent of all fee for service payments and then if you can demonstrate that you have a quality program, they will give that 1 percent back to you.
Is that the kind of thing that we're talking about here or what are the different ways that a practice can get compensated beyond MSSP? So I think there's a few different avenues. A prospective bundle payment. Can you wrap a bundle payment around a well defined episode of care where you're shifting from one site of service to a lower cost site of service?
Total joints 10 years ago, moving from a hospital to an ASC, there was an opportunity to do a prospective bundle payment. So that's one avenue. The second is retrospective payment. And I know this isn't ideal. Because the claims adjudication can be so difficult, but it is an avenue to say, retrospectively, did we lower total cost of care?
If we did, do we receive some of those saved dollars back to the practice? The third would be quality incentives, exactly what you said of. Is there a percentage of the fee for service withheld? And once you meet those quality indicators, do you receive those dollars? There are also some payers that are seeing the value of specialty quality programs.
And so they're doing a quality dollar based on the per member life. So the attributed lives. which historically lives in a primary care space, right? When we talk around quality dollars for a patient population. But I have seen some payers start to say there could be potential of attributing some of those dollars to specialty care when we're focusing on a specific patient population.
So you said four things there. Let me just kind of go through. One of them is some kind of prospective bundle payment and obviously MSK is potentially leading the charge here. You know, there's the total knee replacement bundle and the total hip replacement bundle. So there's definitely bundled payments for MSK and I think it's starting to happen in other specialties as well.
So there's that number one. Number two, as you mentioned, the retrospective. payment. You also mentioned this could be potentially not ideal because there's just such a gap between the actions taken and the feedback to those actions, right? So it's like pretty hard if you figure out a year into the future, that's something that you did literally 12 months ago, resulted in something that's problematic, also just from a behavior change standpoint. It's tough. So, but number two, the retrospective payment is another way to do it. Number three, you've got, as you were talking about quality incentives.
[00:26:35] Justina Lehman: Two different quality incentives. One, it can be a percentage of your fee for service withhold, or it could be in addition to your fee for service.
[00:26:45] Stacey Richter: And you were talking over and above MSSP, like this has nothing to do with some kind of MSSP. Correct. And then number four, you've got seeing the value of attributed lives. Do you want to dig into that one for a sec? So, this was an evolution within a payer around when you look at incentive dollars based on number of lives that typically lives in a primary care space.
That said, if you're taking cancer, for instance, and let's say you have a specialty that is doing cancer risk screening over X number of lives, a payer may pay you a per member If you decrease that overall total cost of care for that specific patient population. If I'm thinking about that from a payer standpoint, I could wind up paying multiple providers or practices for the same cancer screening.
Yeah, I think so. There's the cancer screening at the primary care level, and then at the specialty level, there's the cancer risk screening. So you're actually risk stratifying patients in addition to, but you're absolutely right. You have to navigate those conversations around. Is the payer already paying incentives to the anchoring primary care practice?
Are they already paying incentives to an ACL or a clinically integrated network? And so really working through that process with that payer and that's where that close relationship comes in. And sometimes there is too much overlap where the incentive dollars are already going to another entity that's trying to target that population.
So just taking through the process again, number one, you start with that situation analysis. Then you need to find the ideal. Then you really have to get paid here. So figuring out what the business model is, and we've gone through four potential ways that a payer could pay in addition to going direct to self insured employers as another idea there.
But then the next thing is measuring this whole fandango, which we kind of talked about already, relative to you got to get the payer involved. I mean, there's almost no way for a bunch of these things that a practice can figure out how they're doing independently, or is there?
[00:28:53] Justina Lehman: The majority will be driven by the payer, but I think, too, we've seen programs advance where maybe a payer hasn't engaged because the practice is purpose driven and they know that elevating that care in the community will help strengthen and grow their practice.
But then, you know, what's the story that you would then go back to the payer? The one thing that I think is a little bit elusive is you come up with this great program, you come up with a way to measure it, you figure out the kind of the financials that you're looking for. What do you do? You set up a meeting with a self insured employer or a, um, a payer, like, hi, I have something to talk to you about.
Like, how many payers or self insured employers will take that meeting and what's your hook in a way? Okay.
Yeah, so again, going back to those relationships, I like to meet with payers quarterly. Here's what we're looking towards. Here's the work we're currently working on. You're not being reactive, right?
You're proactive planning almost in partnership. The self funded employers has historically been a difficult space, right? There's so much inertia. In self funding, but we are starting to see some innovative advisors that are looking for high value care, right? So if I can demonstrate to an advisor, here's high value direct to employer contracts that we can offer.
A highly engaged innovative advisor may see the value of that of bringing that back to their self funded employer. So we are starting to see more movement with self funded employers and those innovative advisors starting to move towards high value care. And let's not forget that there's some self insured employers who have like three employees in every given market.
So they're spread all over the place and it's very difficult for them to prioritize any given. geography, just given the geographic distribution of their teams. There's others who have a huge facility in some local geography. I would think that as a provider, it could be pretty easy to figure out if that provider has a percentage of their panel that's coming from a specific employer, because is it a winning message?
Like, hello, employer, like I'm treating hundreds of your patients. Like, can we talk?
Absolutely. And the care I'm delivering is of higher quality, higher value, lower cost than care as usual in this community.
[00:31:20] Stacey Richter: Is that a winning message? Like, have you actually called anybody up and said that and have had them take your meeting?
[00:31:25] Justina Lehman: Yes. I think if you get enough engaged physicians with enough impact to patients. Because you're not, obviously these employers are inundated by point solutions or tech or whatever who are trying to sell them something. But I think that What you're talking about is not the same, you know, one of these things does not look like the other, like you're calling them as a community based provider practice, physician practice or a group of them that their patients are already at.
And I think the meeting, it's critical for those meetings to be with the CFO, a CEO, or the business owner themselves. And many physicians have those social capital, those social connections to start having those calls. But I think it's who you ask for the call with makes the difference. A CFO, if I can tell them, we're going to reduce your MSK spend by X percentage, he or she will want to hear more.
[00:32:22] Stacey Richter: But I can definitely see what you're talking about there because there are CFOs who are engaged and regarded as part of the scope of their responsibility to deal with health care costs and health care benefits and then there are certainly others who would never take that call, right, because they feel like it's the HR's responsibility and their job is done if they issue some nasty grams about renewal rates once a year, right, so I don't mean to be cynical, but I can definitely see that this is not the whole market.
Let's just move to step six in your process, which is getting all the doctors on board with this. How does that work? And I'm thinking about this in the context of, you know, for example, Eric Gallagher from Ochsner. was on the podcast over the summer and one of the things that he said is sometimes bigger isn't always better.
You have to have alignment within the ranks. So if you have a physician, a practice who has a different bent or goal, That is misaligned with the intent, it might not be a good fit and just having numbers while their strength in numbers, there also can be chaos and an inability to actually succeed if you have too many working at cross purposes.
So like, how do you think about getting doctors on board or vetting them?
Yeah, so we're really focusing on those purpose driven physicians. They're motivated to advance the care that's delivered to their patients, very purpose driven. They want to have a seat at the table, they want to be part of those discussions.
Those are our really key physicians in designing ideal care. And then also advocating for ideal care. Those are also typically the physicians, Stacy, that set expectations for other participants. And what we've learned through the years is it not everyone needs to participate. And so physicians who want to participate, we want to ensure that they're aligning with the overall goal that the initial physician set.
But as we've seen across the country, there are physicians that do not want to participate. And so we do not make it mandatory to participate.
So when you say physicians who set expectations, what do you mean by that?
[00:34:36] Justina Lehman: They're ensuring that it is always clinically led because it is easy for some to say, how can this fit in to the fee for service space of being paid more to do more.
These physicians that are leading it are really setting the clinical expectation of we are going to be clinically motivated. This multidisciplinary team that we built is an extension of your practice. There needs to be handoffs between the patient in the exam room and the nurse that's part of the program.
So, it sets the expectation of how physicians are going to engage and participate. And is that easy to figure out? And I know we're talking about kind of a sensitive topic, but you also don't want to lump all doctors into the same group here, right? I'm gonna say that there is a majority of physicians who truly are looking to clinically care for patients, but there is also doctors who want to make a lot of money.
Like I was talking to somebody the other day who jokingly said, but he wasn't joking, he's like, how do I do well by doing well? And I'm like, that's actually not funny. Know your audience. So how do you just work with them a bit and then realize that they're not up to snuff? Like how do you figure this out?
That's a great point. Eric Bricker recently did a presentation on the bad apples. And for us, we do see overall the larger percentage wants to do the right thing by their patient. And they, they just gravitate towards our high value care. We don't force those who don't want to participate. Some over time as the programs continue to deliver high value and exceptional outcomes, you'll start to see other physicians join.
And it's just the change, right? 10 percent want to be part of the change. Then you have your 50 percent that are like, prove it to me and I'll participate. And then you have your 40 percent that are the laggards that say. I'm not doing anything different in my practice, I don't want to participate, leave me alone.
And so we see that journey of change but we really focus on being clinically led and we see physicians opt in or opt out and we just toe a strong line that it's clinically led.
[00:36:40] Stacey Richter: You're building this program, you have this committee of quality driven docs, these doctors self select. You say, we're going to do this, if you want to be a part of it, then we would invite you to be on our committee where we're going to run through what we want the ideal care pathway to look like, etc.
And we're going to have nurse navigators and then we're going to take it upon ourselves to figure out how. Everybody's going to get paid here. I guess wrinkle that I would immediately think of is that you may have a practice with multiple doctors in the same care setting, sharing a front desk, sharing medical assistants, sharing nurses.
You'd have a patient that would come into that practice and if they, that patient happened to see one doctor, they would have the follow up care. Very prescriptive patient journey that we're talking about here that's based on evidence, etc. That the clinical team figured out yet if a patient happened to see a different doctor within that same practice, there would be little follow up or whatever the baseline follow up is, those patients would be in the control group as it were.
How do you navigate that?
[00:37:47] Justina Lehman: Yeah. So in physician practices, physicians really have the autonomy to choose. And so they may do a different follow up for those patients outside of the high value program and you're going to have those differences. Does that make it harder though to actually succeed or is so much done in the in between spaces with the navigation that it almost doesn't matter?
The doctor visit itself is a moment in time and where the magic really happens is Stringing together those moments in time, right? So like, as long as the clinical visit is of a certain caliber, then it's the in between spaces that are really where it's at.
Yeah, and most of our programs are so robust and so proven that at the least you get just a physician that's more of a passive participant, but they're okay with the patient still going through the program.
So the patient is still getting that care navigation. You more so see surgically where they won't opt in or opt out, right, of if a program is based at an ASC and the physician says, I'm going to take that patient to the hospital, right? It's a surgical decision. But in the actual chronic disease programs, the programs are so strong and so robust that maybe we just have some physicians that are passive participants.
Justina, is there anything I neglected to ask you that you want to mention here?
The biggest point, Stacey, is people like you, people you've had on your show, the work we're doing, how do we all come together to actually make this a reality in our community? Historically, we've done this in small silos within our community, but how do you bring it all together?
[00:39:18] Stacey Richter: That is an inspirational message. Justina Lehman, if someone is interested in learning more about your work, where would you direct them?
[00:39:26] Justina Lehman: Thank Yeah, they can find me on LinkedIn.
Justina Lehman, thank you so much for being on Relentless Health Value today. Thank you for having me, Stacey.
[00:39:34] Stacey Richter: So let's talk about going over to our website and typing your email address in the box to get the weekly email about the show that has come out.
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