EP393: How Do You Know if a Practice or a CIN (Clinically Integrated Network) Is Actually Clinically Integrated? With David Muhlestein, PhD, JD

Hey, thanks so much to kwebs14 for your super nice review on iTunes the other day. Kwebs wrote:

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Alright, so in this healthcare podcast, 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/practice/CIN (clinically integrated network) know if they are actually clinically integrated or not? Also, the corollary to this question, which is how do CINs—or anybody, really—know if they are clinically integrated enough to start thinking about taking on downside risk?

I asked David Muhlestein 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 this: 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(s) reorient with a goal to attain some documented patient outcomes, be those outcomes patient satisfaction and/or clinical endpoints and/or functional endpoints?

If no sort of fundamental change happened, 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 in upside risk arrangements with kind of little or no desire to transform the practice into a new practice model? 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 analytics.”

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.

Said another way (this might get a little chicken and egg-y), do you clinically integrate so that you can get the kind of risk-based contracts that enabled Iora, for example, to represent 5% of One Medical’s patient base and 50% of its revenue? I 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 you’re 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. Cityblock.

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 practice?

I do not know. I do know, however, what Scott Conard, MD, said in episode 391. 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 FFS (fee-for-service) environment.

My conclusion with all of this? It takes strong leadership with team-building skills and a strong family/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 and lower costs in an FFS environment as well. The converse of this is also likely true: Weak and ineffectual leaders can make a quadruple nothing burger mess in even the best VBC (value-based care) model. Yes … lots to unpack there. I am interested in your thoughts.

In this episode, as mentioned, I am speaking with David Muhlestein, who is the chief research and innovation officer with Health Management Associates, or HMA. He has spent the past decade-plus studying ACOs (accountable care organizations) 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 1: Understand where you are—this includes doing a very clear-eyed self-assessment.

·       Step 2: 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 way.

·       Step 3: Take the outcome of step 2—which is basically whatcha gonna do to fix the most consequential problems that your patients have—and identify the processes by which you will do this.

·       Step 4: 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 course. (Betsy Seals, by the way said something along these exact same lines in the shows giving advice to Medicare Advantage plans. And Karen Root [EP381] also alludes to something similar as she talks about how to socialize innovation. So clearly, this advice can be universalized.)

You can learn more by emailing David at dmuhlestein@healthmanagement.com and by connecting with him on LinkedIn.

David Muhlestein, PhD, JD, is chief research and innovation officer for Health Management Associates (HMA). He is responsible for the firm’s self-directed research and supports strategic planning and innovation.

David’s research and expertise center on healthcare payment and delivery transformation, understanding healthcare markets, and evaluating how the broader healthcare system is changing. He is a self-identified data nerd and regularly speaks and writes about healthcare system evolution.

David joined HMA via its acquisition of Leavitt Partners in 2021, where he was the chief strategy and chief research officer.

Additionally, David is a visiting policy fellow at the Margolis Center for Health Policy at Duke University, adjunct assistant professor at The Ohio State University College of Public Health, and a visiting fellow at the Accountable Care Learning Collaborative. He previously served as adjunct assistant professor of The Dartmouth Institute (TDI) at the Geisel School of Medicine at Dartmouth College.

David earned his PhD in health services management and policy, JD, MHA, and MS from The Ohio State University and a BA from Brigham Young University.

07:57 What does it mean to be clinically integrated?

10:23 How does changing practice patterns count as becoming clinically integrated?

11:11 How do you change the delivery of care to get better outcomes?

12:05 What does it mean to see better outcomes when becoming clinically integrated?

14:46 EP176 with Dr. Robert Pearl.

17:42 “Their structure is dictating what they are going to prioritize.”

19:02 “How do you care for the patients that have yet to come and see you?”

20:16 EP391 with Scott Conard, MD.

22:38 “When you’re integrated, you realize you’re not alone.”

25:50 Why does clinically integrating require a significant mindset change?

28:55 What does this country need to do from a policy perspective for this change?

30:24 EP326 with Rishi Wadhera, MD, MPP.

You can learn more by emailing David at dmuhlestein@healthmanagement.com and by connecting with him on LinkedIn.

Recent past interviews:

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Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375)