EP407: Considering Comprehensive Primary Care at Humana, With Vivek Garg, MD, MBA

Okay … let me get real here for a sec. For a few reasons, I wanted to chat with Vivek Garg, MD, MBA. Dr. Garg is CMO (chief medical officer) of primary care at Humana. Dr. Garg is an inspiring and incredibly articulate individual, and I like to both learn from and also be kept on my toes by the likes of such folks.

But also, yeah, I’m suspicious of vertically consolidated payers. I mean, you listen to this podcast. I don’t need to recap what the financialization of the healthcare industry has done to patient care.

But you heard my manifesto in episode 400. It’s about trying to find the right path forward and being open to exploring options here. It’s considering what doing well by doing good actually means. It’s contemplating whether to celebrate some good stuff going on in the industry even if there’s some not-so-good stuff going on in that same sector or even in that same company.

Bottom line: We’re living in the real world here, and utopia is not on the table, at least anytime soon. So, that means there is always going to be one thing that we are always going to have to have to weigh in our consideration set, in our assessment equation that I talked about in my manifesto in episode 400.

What’s this one thing? It’s self-interested, shareholder-centric goal setting. In other words, just because I spot a self-interested, shareholder-centric goal doesn’t mean I’m automatically gonna get out my red Sharpie and cross off the whatever with a sour expression on my face because … yeah, if I did that, a whole lot of Americans are not gonna get, even incrementally, better healthcare.

The right equation to determine if something is net-net good is always going to be nuanced. The equation should weigh the impact of the self-interest, which is always going to be there, against the impact on patient care and patient financials and how the whole thing impacts clinicians at a local level or maybe a national level, depending on what’s going on.

I’d also suggest that there’s no real broad strokes here, because the equation for any given initiative or pilot or approach is really singular. I think it’d be a big mistake to lump together, for example, all payviders across the country and assume that their impact is all the same. Or all Medicare Advantage plans. Or anybody doing advanced primary care. All of these words/groups I just referenced are relevant to the conversation today. You have some payviders, for example, doing all kinds of crap with dummy codes and/or anticompetitive contracts and/or steering only to their own medical groups which they staff inadequately and/or blanket denials of anything that will throw off their medical trend calculations and/or prescribing and care pathways coinciding with their own highly financialized PBM (pharmacy benefit manager) formularies.

But then, on the flip side, you also have some interesting things going on that help patients and their communities. A key ingredient of these interesting things is taking into account longer time horizons. Longer time horizons are actually pretty key here for anybody trying to do anything preventative or anything involving forming patient relationships.

Also, of course, you have those who are doing some combination of the good stuff and the not-so-good stuff; and one of the reasons why the not-so-good stuff becomes so ingrained is that risk adjustment (especially if you’re a payvider) across the board has anything but a longer time horizon.

So, let’s dig into what Dr. Vivek Garg has going on at Humana Primary Care, which includes CenterWell Senior Primary Care and also Conviva Care Center. I ask Dr. Garg some pretty hard questions about balancing the tension between being a payer with a PBM with an incentive to deny care and a provider organization seeing patients that is also beholden to those same shareholders.

Dr. Garg taught me a new term, and that’s the “dyad model,” where you have doctors and admins working together or clinicians and admins working together. You get the clinical team to shadow the administrative team, and you get administrative team to shadow the clinical team. You teach doctors and others the business of medicine, and you teach admins what it’s like to be a clinician or a patient on the other end of some of those policies.

Now, if you have a good memory, you are probably also recalling that Eric Gallagher from Ochsner (EP405) talked about this exact same concept (ie, working together, ie, the scrubs and the suits coming together into this dyad leadership model). There’s a quote from Denver Sallee, MD, in episode 402 with Amy Scanlan, MD, talking about pretty much this exact same thing. And furthermore, this whole getting doctors up to speed on the business of medicine is gonna be the topic of an upcoming episode with Adam Brown, MD, MBA. So, yeah … this is becoming a thing—the idea of teaching clinicians the business of medicine. But the opposite should also get some focus—teaching admins the medicine of medicine.

Dr. Garg cites three pillars to improving an organization’s ability to sustainably deliver better healthcare, and these three pillars are (1) to focus on the patient experience, (2) to focus on outcomes, and then (3) to engage the clinical teams and really protect them, to protect this precious resource that doctors and other clinicians actually are.

Taken together, these three pillars coincide with the pivotal question here. And that pivotal question is: How much is any given entity actually investing in clinical leadership? Because in combination, great clinical leadership plus the three pillars (ie, a focus on experience, outcomes, and clinical engagement), you put all those things together and it adds up to each individual who works in the place to harness their own intrinsic motivation—to be able to explore and double down on and actually achieve the reasons why they went into healthcare to begin with and spent years of their lives in school in order to do so.

Dr. Garg mentions the latest Humana report in the show. And then I mention how I interviewed Steve Blumberg from Guidewell (AEE12) about the 2020 Humana report.

Also mentioned on this show is episode 312 with Doug Eby, MD, MPH, CPE, from the Nuka System, and episode 405 with Eric Gallagher from Ochsner.

You can learn more at humana.com, centerwellprimarycare.com, and the Humana report.

Vivek Garg, MD, MBA, is a physician and executive dedicated to building the models and cultures of care we need for loved ones and healthcare professionals to thrive.

He leads national clinical strategy and excellence, care model development and innovation, and the clinical teams for Humana’s Primary Care Organization, CenterWell and Conviva, as chief medical officer (CMO), where they serve approximately 250,000 seniors across the country as their community-based primary care home, with a physician-led team of practitioners, including advanced practice clinicians, nurses, social workers, pharmacists, and therapists.

Dr. Garg is the former chief medical officer of CareMore and Aspire Health, innovative integrated healthcare delivery organizations with over 180,000 patients in over 30 states. He also previously led CareMore’s growth and product functions as chief product officer, including expansion into Medicaid primary care and home-based complex care.

Earlier in his career, Dr. Garg joined Oscar Health during its first year of operations as medical director and led care management, utilization management, pharmacy, and quality, leading to Oscar’s initial NCQA accreditation. He was medical director at One Medical Group, focusing on primary care quality and virtual care, and worked at the Medicare Payment Advisory Commission, a Congressional advisory body on payment innovation in Medicare.

Dr. Garg graduated summa cum laude from Yale University with a bachelor’s degree in biology and earned his MD from Harvard Medical School and MBA from Harvard Business School. He trained in internal medicine at Brigham and Women’s Hospital, received board certification, and resides in New Jersey.

07:27 What does comprehensive primary care look like, and what can we expect from it?

07:39 Is the comprehensive primary care model the single biggest tool to help improve health?

10:41 How does a competitive ecosystem affect a comprehensive primary care model?

15:44 What is the impact of physicians and clinicians on the delivery of comprehensive care?

19:25 EP312 with Doug Eby, MD, MPH, CPE, of the Nuka System.

20:22 “What we need to do with the technology is actually support and enable the team.”

21:42 Why it’s important to create “space” in your comprehensive care model.

24:56 What three areas does every organization need to pay attention to?

31:03 Why the opportunity for alignment is greater than the potential for conflict.

32:48 Why long-term orientation is a key to success, even in an ecosystem that’s more short-sighted.

34:30 AEE12 with Steve Blumberg.

You can learn more at humana.com, centerwellprimarycare.com, and the Humana report.

@vgargMD of @Humana discusses comprehensive #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance

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