EP414: An IRL How-To for Delivering Better Care and Getting Paid for It—A Value-Based Case Study, With Justina Lehman

For a full transcript of this episode, click here.

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 specialists, like an OB/GYN 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 Steve Schutzer, MD (EP294).

There are so many who put financial growth and doing “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 [value-based care] stuff on the back burner.”

The point that Justina Lehman makes, both implicitly and also explicitly, is that doing the right things 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 in this healthcare podcast: 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?

Alright, so here’s the absolute simplest possible business upside that taking really good care of patients can achieve: higher patient volumes at the practice. Patients, 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 nonfragmented 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, 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. Will Shrank, MD, said on the pod last week (EP413) that any specialists who aren’t figuring out how to work with capitated primary care docs are gonna 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 in this healthcare podcast. So, there’s risk in not doing some of this stuff.

I’m gonna summarize the process that Justina uses to level up care and also get paid for it.

1. Assemble a committee of purpose-driven, committed physicians who want to improve care. Committee should self-select. No one should be there who doesn’t want to be there.

2. 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.

3. Design ideal care and the plan for how you’re gonna 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 (Pittsburgh Business Group on Health) 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 (pharmacy benefit managers) and how you’re gonna do that. There’s also gonna 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, middle, and end of it.

4. Align the model to possible financials. First of all, consider two potential payers: self-insured employers … you could offer a bundle if you see a lot of any self-insured employer’s members. You also could go to a regular payer kind of payer.

There’s gonna 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 an engaged payer: (1) You could start talking about prospective bundle payments. (2) Less attractive, you could start talking about retrospective payments based on savings. (3) There could be quality incentives that are a percentage of FFS (fee-for-service) withhold, or a quality incentive that is in addition to FFS payments. (4) There could be specialty quality programs that are PMPM (per member per month).

If you’re dealing with a not engaged payer, then one potential move is to gang up with others in the area, create some sort 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. Scott Conard, MD, in an earlier episode (EP391), talks a little bit about that. He’s talking from a PCP standpoint, though.

5. Measure results.

6. Prepare the story/value prop for payers.

7. 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.

8. 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 Shrank, MD, in another point of alignment from last week’s show to this week’s, Dr. Shrank 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 Conard that I mentioned earlier, I’m gonna leave you with two other interesting “for further reading or listening” references. One is a LinkedIn post from Benjamin Schwartz, MD, MBA, that also includes some pretty great comments and back and forth. In sum, Dr. Schwartz wrote, “We need to uncouple value from the payment model and focus on outcomes tied to diagnoses.”

I also thought a Radio Advisory show was thought provoking. This was with Rae Woods, Erik Johnson, and Daniel Kuzmanovich. The gist of it is, at one point, Rae 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’s actually not the right mindset to have.”

You can learn more by connecting with Justina on LinkedIn.

Justina Lehman, CNP, DNP, founder and president of Revolution Health, is a proven visionary leader at the forefront of transforming healthcare and fueling people’s passion for high-value care. With over a decade of leadership experience, she has devoted herself to urging forward a revolution in healthcare. She stands as a staunch advocate for physicians and clinicians eager to join the movement toward high-value care. In an evolving healthcare landscape, Justina serves as a guiding force, reigniting the passion of physicians and clinicians and accelerating them toward a future of high-value care that is transparent, accessible, and transformative for all.

07:35 What has Justina been up to, and why is it relevant to this conversation?

08:23 What is high-value care, and how do we figure out what it is in reality?

08:59 EP412 with Robert Pearl, MD, on the art and science of medicine.

10:08 “What is the clinical design of … high-value care?”

10:21 Care as usual vs ideal care.

11:11 Summer Shorts 8 with Larry Bauer.

12:23 How does Justina figure out what the benchmark is for high-value care?

12:36 Meeting patients where they are at, not where we want them to be.

17:42 EP402 with Amy Scanlan, MD.

18:28 “What is the story as a group to the payer? What is the story as a group to the self-funded employer?”

19:19 How do you align business operations and the financials?

20:16 What are the four avenues for getting paid for high-value care?

21:58 What are highly engaged payers most intrigued by in high-value care?

24:11 What are the different ways a practice can get compensated?

28:52 Are there programs that have advanced without payers leading the way?

29:37 What’s the “hook” for payers?

31:12 What’s a winning message to payers and employers?

33:04 Summer Shorts 4 with Eric Gallagher.

34:13 “Not everyone needs to participate.”

38:24 Can a program be successful even if a physician is a passive participant in the program?

You can learn more by connecting with Justina on LinkedIn.

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano