[00:00:00] Stacey Richter: Episode 393. How do you know if a practice or a C I n A clinically integrated network is actually clinically integrated? Today? I speak with David Stein.
[00:00:30] Stacey Richter: Hey, thanks so much to K Web's 14 for your super nice review on iTunes the other day, K Web's wrote, I have learned so much, shared so many episodes with colleagues, clients, and gained so much value from regularly listening to Relentless Health.
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Alright, so. Today we are going to answer an faq, a listener question. I have gotten a lot lately in various forms, let me common denominator, the inquiry, what does it mean to be clinically integrated and how does a provider organization slash practice slash c i n, clinically integrated network? No, if they are actually clinically integrated or.
Also the corollary to this question, which is how do cis or anybody really know if they are clinically integrated enough to start thinking about taking on downside risk? I asked David Stein this question, and then we talk about his answer for 25 minutes. So like most things in healthcare, it is filled with nuance.
But if I was going to oversimplify his answer in one sentence, it's. Did the practice change how they are practicing medicine in order to drive predetermined outcomes? This is the litmus test for whether care is integrated. Did practice patterns change within participating entities from whatever they were before to a new way of working?
Did the team or teams reorient with a goal to attain some documented patient outcome? Be those outcomes, patient satisfaction and or clinical endpoints and or functional endpoints. If no sort of fundamental change happens, probably it's a no on the clinical integration question. Another litmus test question I've also heard is this, is the practice looking to get paid more for successes?
They've already had an upside risk arrangements with kind of little or no desire to transform the practice into a new practice. If yes, then again, it's gonna be a no on the clinical integration question. The thing is, with all of this, well, let me quote Dr. John Lee who said this pretty succinctly on LinkedIn recently.
He said, downside risk fundamentally changes how you have to think as a physician and how you manage your patient cohort. You start thinking about team-based care and using a. Yes. Interesting. The point Dr. Lee is making, which is kind of inferred actually in the listener questions. So let me just state the obvious, which is so obvious it could easily be overlooked.
If you are able to take on downside risk and succeed, you're probably clinically integrated. If you're not, you probably aren't. Set another way. This might get a little chicken and egg. E. Do you clinically integrate so that you can get the kind of risk-based contracts that enabled Ara, for example, to represent 5% of one medical's patient base, and 50% of its revenue? Have heard similar profitability stories about ChenMed and Oak Street.
They all have capitated downside risk, accountable care contracts. And have you seen what some of their leadership teams are minting? Obviously, the capitated downside risk when your integrated gig can be highly profitable. But seems like also the community and outcomes are kind of great. Are they doing well by doing good?
I'll grant you, I might be convinced, based on what I've seen, Galileo is another one city block. But the fundamental question is do you integrate first and then go after the contracts, or is it best to wait until there's a decent accountable opportunity on offer and then sufficiently incented change the.
I do not know. I do know, however, what Dr. Scott Connor said in episode 3 91. I will poorly paraphrase. He said that if better patient outcomes are desired, there must be clinical integration and practice pattern changes. He said his practice went ahead and instituted these changes to improve patient care and did so within a pretty full on f.
S. My conclusion with all of this, it takes strong leadership with team building skills and a strong family slash community-centric mission to pull off a successful foray into accountable care with downside risk. These same talented and mission-driven leaders probably could manage to improve patient care at lower costs in an FFS environment.
As. The converse of this is also likely true. Weaken and effectual leaders can make a quadruple nothing burger mess in even the best v BBC value-based care model. Yes, lots to unpack there. I am interested in your thoughts. Today as mentioned, I am speaking with David Stein, who is the Chief Research and Innovation Officer with Health Management Associates or H hma.
He has spent the past decade plus studying ACOs and value-based care, trying to understand what works, what doesn't, and how you change the business models to be successful under these new. Models of payment. Here is a short version of David's advice to clinically integrate and be ready for downside risk.
Step one, understand where you are. This includes doing a very clear-eyed self-assessment. Step two, assess the needs of your patient population and focus on things where your capacity meets the needs of the population that you serve in the most impactful. Step three, take the outcome of step two, which is basically what you gonna do to fix the most consequential problems that your patients have, and identify the processes by which you will do this.
Step four, do not boil the ocean. Start with a subset of patients and figure out the exact plan to do better to manage that population. Easier said than done of. Betsy Seals, by the way, said something along these exact same lines in the shows, giving advice to Medicare Advantage plans, and Karen Root also alludes to something similar as she talks about how to socialize innovation so clearly this advice can be universalized.
My name is Stacey Richter. This podcast is sponsored by Aventria Health.
David Stein, welcome to Relentless Health Value.
[00:07:46] David Muhlestein: Thanks, Stacey. It's great to be on today.
[00:07:48] Stacey Richter: Let's answer this listener question that I have received many times in many different iterations. Actually, here it is. What does it mean to be clinically integrated?
Kinda spiraling around that basic question or the various why's, as in why are people asking this question? And one of the why's is to assess downside risk readiness. Is an organization ready to take downside risk? And they're making an assumption there, if you think about it, that clinical integration is a requisite must have in order to take on downside.
[00:08:27] David Muhlestein: Yeah. The first is, the definition of clinically integrated networks is very, Different, depending on who you ask, you can ask seven people and you'll get 10 responses about what that means.
The reason is, is because people look at it from different perspectives. There's the perspective of you are a, you have common ownership across hospitals and physicians, primary care and specialists, plus post acute care, and you say, look, we are commonly owned. We work together in some sort of way, and we are integrated in that.
Well, that may be true that you have common ownership, but are you really working together to directly provide care across all of these different locations and coordinating that care and managing that care? Other people think that it's all about just the clinical side of it. You have best practices for discharges and communicating across care teams and the like, and that may be the case as well.
What I like to think about it is, is, are. Changing how medicine is practiced at the bedside so that you're leading to better outcomes and that you're somehow measuring those and making sure that patients are seeing value from their perspective as well. Now, that's not a great definition either. I grant that, but I think the focus is around changing the delivery and the practice of medicine as opposed to changing the organizational structures.
[00:09:40] Stacey Richter: You, you said there. Maybe canonically two, maybe more common definitions, but you tend to go with a third. If I'm understanding you correctly, common ownership was the first thing that you said, that if a bunch of entities have common ownership, just go ahead and check the integration box. And then the second definition of clinically integrated might mean if.
Ways that entities are communicating with one another or working together somehow, then that could be a way to define clinically integrated. But then the third definition, which you think of is best, if I'm understanding correctly, is when entities actually change their practice patterns. Let's dig into that one for a sec.
Let me just chuck one point in here. If we're thinking about like MIPS today or upside risk today, you can do very well in mips, frankly, without changing practice patterns much, which I think is one of the criticisms of mips. Right? So you said changing practice patterns is definition of clinically integrated, and I guess my first question would be changing it from what to what?
Like the before is upside only risk. That's our practice pattern starting point, or how are you thinking about that?
So I think it's a little bit different.
[00:10:52] David Muhlestein: It's not just about the risk side of things, but it's the promise of value-based care that people talk about. It is that if you take better care of a population, you coordinate it, you manage it, you get people the right care at the right time.
You're going to see better quality results, better patient satisfaction, and lower costs. That's the theory behind it. And so what I think it is, is it's how do you change that delivery of care so that you are doing the steps necessary to get those better outcomes, whether it's cost, quality, or satisfaction.
I think that's the issue of clinical care and the way you do it is you don't. A retreat and people get really excited about taking better care of patients or having care teams. It's you have to be doing things at the point of care that are different than you were before that are going to lead to the outcomes that you're seeking.
And I think that's the hard part, is how do you get people to change what they were doing from before to now that's better so that you have measurable improve. In how patients are receiving care. That's that challenging part. It's really easy to get people excited about it. It's really easy to get a new technology system relatively easy.
It's hard to get people to change and work together in a way that they weren't before, that actually leads to better outcomes.
[00:12:06] Stacey Richter: And when you say better outcomes, is there some kind of, I'm not sure if this is, it's like I'm begging the question here. But what does that mean? Is there a metric for the better outcomes or some kind of standard that you're using there?
I mean it. What do you mean by better outcomes?
[00:12:23] David Muhlestein: Yeah, so you talk about patient satisfaction and quality of care and costs. When I talked about clinical care, I mentioned that it's both from the side of the patient's view. Not just the care provider's view of, of improvements as well. And this is where it gets a little bit tricky.
So when you ask a patient what matters that might vary significantly from the provider's, view of, and this is one of the things that I think about is what are the range of of things that you can be measuring that might matter? Well, I'll just go through a range of potential outcomes. So one range of outcomes is patient satisfaction, and this is where it's generally patient, physician bedside manners, staff attenti.
All of the sort of things that really do matter, but may not necessarily relate to the clinical outcomes of the care. We've all heard stories about the doctor who has great bedside manners, but is killing people in the operating room. The next level of outcome might be a clinical end point. So you're looking at A1C level for diabetics where you're, you're looking at whether you've been able to successfully change diets and change disease management in a way that people's populations, A1C levels are improving another outcome.
From the, the patient perspective is the functional outcomes. So somebody that has heart failure can't go up a flight of stairs without becoming short of breath. Well, after you've treated them and you've worked with them and you've improved their ejection fraction, which is the clinical endpoint, can they now go up the flight of stairs without being short of breath?
That's the sort of thing that matters to the patient much more than their ejection fraction, but another outcome. Is the cost of care. Sometimes it matters to the patient, the cost to their insurance company, but oftentimes it's what is their own cost that's there because that directly impacts them. And so when you're looking at all of these outcomes, ideally you would say, we should focus on all of these.
We should have. Better patient satisfaction. We should have better clinical endpoints. People should be happy with the functional outcomes that are are happening, and then the cost should go down as well. The challenge is, is that rarely can you kill four birds with one stone. And so what's the most important outcome for this?
And at least from the policymaker's respect today, it's gotta be the cost. So the others are important, but maybe not as important as the cost outcomes.
[00:14:36] Stacey Richter: So ranges of outcomes include patient satisfaction, but that can't be the only measure or metric here because there are doctors out there. I think Dr.
Robert Pearl put this really well in the show that, that we did a while ago. There's doctors who have great, I think he said user interfaces, but terrible backend programming. He put it better. But you have surgeons who patients love, but who are frankly terrible surgeons. So you, you have to include a clinical endpoint outcome in the mix here, which may or may not matter to a patient, like for example, lower A1C or hypertension.
They call them silent killers for a reason. So what's really gonna matter to patients are, as you said, functional outcomes. Like can a patient walk up a flight of. Let me ask you something here. I get the feeling that outcomes must be part of a larger framework. Like you can't think of outcomes in isolation.
And somehow we got from my original question of are these entities clinically integrated? To outcomes . Um, inferring that there's a missing link here, what, what might that be?
[00:15:42] David Muhlestein: There's a framework that's used. Donabedian created this looking at quality, and it was about structure, process, and outcomes.
And I think this is really useful here. So structure is the organization, how you're, it's the, you've got hospitals and physician groups and how you come together and what you look like the processes are. What are you. And what are you changing? And then the outcomes are obviously what's generated from those, starting with the structure, changing those processes, and then creating those outcomes.
[00:16:06] Stacey Richter: And let me just reiterate, there's three factors at play here, or three large inputs relative to. What does clinically integrated mean? And how are organizations ready to take downside risk or improve patient care? Those three factors are how is the organization structured? For example, is it owned by one entity?
Is it owned by many entities, for example, so like, is it owned by a hospital or is it different physician groups that are actually the owners? So structure it is one aspect. Then processes, as you said, what is going on here relative to the standard operating procedures or, or how the care is being delivered.
Are we using best practice guidelines? Are we not? Are we working together? Are we not? And then lastly, what outcomes are we striving for here? Like how are they quantified and what are they? And you highlighted the reduction of the cost of. Which I think is actually a really good example because as everybody knows right now, if a hospital hasn't reached the value-based care tipping point.
They tend to not do very well in any sort of shared savings or any sort of cost reduction efforts, ? So just right there, the structure of the organization is gonna diminish the outcomes.
Right. So like these three things really interplay with each other and, or maybe even to some degree predictive of what's gonna happen.
[00:17:35] David Muhlestein: Yeah, and I'll, I'll give an example of that. Using the hospital. So if you have somebody that's built around hospital that is primarily being paid by fee for service, then their structure is dictating what they are going to prioritize.
What they need to do is to keep the lights on. They need to make sure that. Put heads in beds, and so they're going to create systems and processes that encourage getting patients and getting them into the hospital and then afterwards efficiently discharging them. An alternative model might be say, well, if you are a primary care practice, your focus may be, how do I proactively get my patients in for their annual wellness visit, which then.
Help me understand what their needs are so that then I can potentially prevent hospitalizations down the road. So that structure is really influencing the processes and what their focus is of the organization, which is going to lead to the outcomes of interest. And this goes back to when you're clinically integrated, who are you responsible for and who are you managing?
So, I could argue that an organization could become clinically integrated, but they don't have any idea of a population payment. They just say, if a patient comes and sees us, we're gonna make sure that they get really good coordinated care across the spectrum of services. I don't think that's sufficient for value-based care, because for value-based care, you have to have a population that you're going to be managing.
And being incentivized proactively take care of even when they haven't presented themselves in front of you. And I think that's a really big issue. If this is not, how do you care for the patients that come to see you, but how do you care for the patients that have yet to come and see you? The people that need to be seeing their doctor, that need to be getting that care, getting that care coordination.
How do you manage that part of the population? And that's where I think value-based care with clinical. Integration really come together is you've got the population, you have the the tools to take care of them. So you're going to take care of them and hopefully prevent the high cost services.
[00:19:26] Stacey Richter: Okay, so I'm gonna distill this down into my takeaway, which may or may not be yours in an F F S fee for service world.
While it is possible to work the fee for service payment system to deliver patient care for sure, and also actually make. The system itself doesn't inherently incentivize that way of thinking. So then therefore it is incumbent upon the provider organization to be, and their leadership to be mission driven enough, strategic enough, and have adequate leadership that is strong enough.
To change the culture and the sociology of the organization to take advantage of those possible incentives to work the system so that the patient benefits that they're trying to achieve are financially possible. And it's easy to get sucked into revenue maximization pursuits. It's, it's just like Dr.
Scott Kenard elucidated so poignantly in episode 3 91. So you have the potential to do right by patients and, and produce very high value care within a fee for service environment. It's not necessarily what fee for service directly incense. So, as I said, it's, it's incumbent upon a very mission driven, very operationally savvy practice to pull that.
Meanwhile, if we have a good value-based program, then that is like, for example, a capitated program for primary care that more directly incense, the practice pattern changes that are more directly related to high value. Care. So it's easier to connect the dots. So along these lines, somebody wrote on LinkedIn the other day and, and I don't think this is uncommon, this way of thinking, so let me ask what your response is to this.
It sounds like this meaning value-based care, accountable care in which providers are responsible for performance or downstream. It sounds like this is a form of insurance that has little to do with delivering care and everything to do with accounting for things that we cannot control.
[00:21:25] David Muhlestein: It's a very common, and I would say cynical way of looking at it.
And the reason for that is it's looking at it from the perspective of an individual, and if you are a primary care doctor or a specialist or a hospital administrator, you say, I'm responsible for so much and I have so little that I can do, and I would agree with that person. You're right. As an individual, it's very hard to do that.
When you are clinically integrated, you are not operating alone. You're operating as part of an organization that has significant capabilities and ability to influence things that it's much greater than any any individual person. An analogy that's not perfect, but I think is useful is to compare this to the supply chain where.
Anybody who is trying to build something today is building off of the work of dozens of other people that have done something. So if you look at your phone, it's got copper that was mined in one on one continent and it was probably assembled in another one, and the glass was manufactured somewhere else.
Nobody has the ability to create everything. By themselves. They're dependent on so many other people. But in modern medicine, many people view it from the perspective as, what can I do cuz I'm alone. When you're integrated, you realize you're not alone, and it's much more than just a care team. It's the organization that is able to support all facets of care that that population is going to need.
Yes, this is a kind of a pipe dream right now. There aren't very many organizations that really have this, but there are organizations that are much more focused on what can we do together collectively as an integrated entity as opposed to those that say, we let our doctors go and be free agents and do whatever they want whenever they want.
[00:23:06] Stacey Richter: I think there's a bunch of nuances here. As there always is, right, and I think one of them is probably a med school comment that I will chuck in here first because it's not like medical schools in this country teach for the most part, leadership or teamwork. And I've heard that from multiple guests on this podcast.
So I hope I'm not out of line parroting what I've heard so many doctors and professors of medicine. Say, so it might start really early, the barriers to, to working as a team and just the whole thought process that goes behind how that winds up happening. But I also think it's a bit of a continuum. A good, intimate and longer term relationship with a patient is better than bad care from what is masquerading as team-based care, but really isn't team-based care because there really isn't a team, a functional team, right?
Like I think one of the issues is, Language has gotten very blurry, and there's a lot of people in air quotes saying team-based care, but it's really not team-based care. The care really isn't integrated, but good care is depending upon it being integrated. So in the absence of really dedicated clinicians who take a ton on themselves, and even if they do, the deck is kind of stacked against great care happening, there's just not.
Infrastructure or the process for the hoped for outcomes.
[00:24:30] David Muhlestein: Yeah. And this goes back to that thing of what does the patient actually want? And are we satisfying what their needs are? And so I'll use a couple of examples that I think are indicative of kind of the nature of this. If you ask a room of people who's ever accidentally bought something on Amazon or knows somebody who has, many hands are going to go up because it's just so easy to buy something and it just shows up in a cardboard box on your front porch
How many people accidentally have a primary care visit scheduled or accidentally are able. It's so simple that they're able to access the healthcare system and get what they need when they need it. That's, I think the difference is that. Industries have really focused on what the consumer wants and what the consumer needs, and they've then tried to build around that because they know who their patient is.
One of the challenges I view in healthcare is that many people don't know who their customer really is. If you ask anybody, they're gonna say that it's the patient. Is it really? So if you're a hospital system, is it the patient that you're treating? Is it the insurance company that is going to reimburse you?
Is it potentially their employer that's funding the insurance company or maybe their real client or customer is the doctor who is bringing the patients in so that they get admissions? It changes. And so if we focus on not just the lip service of team-based care, but we say what is it actually that the patient wants and needs and how are we going to make it easy for them to get the care?
That's when things start to change. It's really requires a pretty significant shift in thinking for the whole organization, that whole mindset. Has to change if you're going to build it around both the needs of the patient as well as trying to achieve that broader aim of lowering the cost of care,
[00:26:19] Stacey Richter: However, If the hospital's customer are providers referring into profitable service lines, they might find it difficult without significant change management to convince orthopedic surgeons to do surgery on Saturday afternoon instead of Tuesday at 7:00 AM
How do you think about , for example, the reach.
Program in the news right now, there's a lot of M S S P, you know, kind of garden variety ACOs who are scratching their heads and wondering whether they should try to get themselves into the REACH program. And by that latest report that just came out the other day, it doesn't look like many of them are actually moving towards the REACH program.
The number of practices who signed up for reach was pretty dism. I thought based on the latest report that I saw, considering just how much effort c m s has put into the whole thing. So how do you figure out whether you're ready for something like breach or downside risk in advance of actually trying it and it not?
Going so well. Yeah,
[00:27:19] David Muhlestein: so this is where obviously talking to other people is incredibly useful. And so one thing that I encourage people to do that are trying to do this is find friends that have been there before. Somebody that you met at a conference, somebody from your medical school that works in a different state.
Talk to people and don't just talk about what they did, but talk about how their organizations were different and what they were able to do giving, given the context of what they were starting with. And so that's one of those is. Great to go do an actuarial analysis and think of how you might do, but the actuarial analysis doesn't build into that.
What are the different capabilities between three different physician groups that all have 50 primary care doctors? Just because they look similar doesn't mean that they actually structurally are the same and can do the same things. And so talk about it. Learn as much as you can, and part of that is doing your own self-assessment.
I've seen this before. People feel like they know their organization, but they don't really know their organization until they've compared their organizations to others that are similar and actually identified what those differences are. And so taking that time to do the internal self-assessment, talking with others with their experience is going to give people, I think, I don't wanna say that you don't need to do the actuarial analysis in advance too, but it's equally as important to do.
Self-assessment as it is to do those external financial models
[00:28:41] Stacey Richter: and probably also think about what in what your goals actually are, right? Like what the organization culturally is ready for a as well, which I think is a really big deal.
David Milstein, is there anything I neglected to ask you that you would wanna mention here?
[00:28:56] David Muhlestein: I think one of the questions going forward is what does. The country need to do from a policy perspective to actually make this change happen. And this goes back to what I think of is a major challenge that we have with value-based care today a lot of this is being driven by C M S and a lot of their policies are also filtering down.
We're seeing a lot of commercial activity that's doing this, but they are looking at this usually from the perspective. Of a payer to really be successful, you have to bring all of the different facets of healthcare together, not just the financial side that's coming from the payer and from their pain points.
You have to bring it from the delivery side, from the structural side, from the regulatory side, but bring these different groups together and not just talk to each other, but learn together and then be able to create the policies that are better. I view so much of value-based. As a payer driven initiative from one side and then a provider driven initiative from the other side, it really needs to be jointly driven with partnerships and learning together and, and doing that.
But that's how I think we move forward is. We have to recognize that truly integrating care in America is going to require us to come together. And if we can't do that, then I don't think we're going to be successful.
[00:30:18] Stacey Richter: Well, thank you very much for asking yourself such an impactful question and then answering it so very well.
And, and I love the point that you are making, which was also said by Dr. Rishi Wa in the show about H R R P, the Hospital Readmission reduction program, that what might work better than a payer setting up quality measures and penalizing hospitals that don't do well, or penalizing provider practices that don't w do well.
Baby instead of the hat. We should actually help the hospitals and practices to figure out why they aren't doing so well and then help them improve to use our resources that way. David Stein, if someone is interested in learning more about your work, where would you direct them?
[00:30:58] David Muhlestein: Easy thing is to email me d mulestein health management.com or uh, shoot me a link on LinkedIn.
[00:31:04] Stacey Richter: David Mulestein, thank you so much for being on Relentless Health Value today. Always a pleasure. Thank you.
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