EP445: Can a Primary-Care-Only Practice Survive in 2024? With Tom X. Lee, MD

[00:00:01] [SPEAKER_01]: Episode 445 Can a Primary-Care-Only Practice Survive in 2024

[00:00:10] [SPEAKER_01]: Today I speak with Dr. Tom Lee.

[00:00:20] [SPEAKER_01]: American healthcare entrepreneurs and executives you want to know.

[00:00:24] [SPEAKER_01]: Talk, relentlessly seeking value.

[00:00:29] [SPEAKER_01]: Today I am talking with Tom X. Lee, MD, who has a long history in primary care.

[00:00:35] [SPEAKER_01]: He founded One Medical and then also most recently, Galileo.

[00:00:40] [SPEAKER_01]: Dr. Lee also was a founder at Epochrides, tossing that in for context.

[00:00:45] [SPEAKER_01]: I wanted to talk with Dr. Lee because so many RHV, Relentless Health Value listeners, are

[00:00:49] [SPEAKER_01]: trying to figure out how to sustain primary care as a standalone entity when the most

[00:00:56] [SPEAKER_01]: obvious and most common way to make enough money in primary care is to drive and maximize

[00:01:01] [SPEAKER_01]: the dollars from downstream volume of high priced service lines.

[00:01:06] [SPEAKER_01]: Which, if you think about it, undermines the entire point of primary care.

[00:01:11] [SPEAKER_01]: I'm starting to call this the paradox of primary care because when you start seeing

[00:01:15] [SPEAKER_01]: the promise of primary care have to erode if you're going to stay in the business

[00:01:20] [SPEAKER_01]: of primary care then yeah it's sort of a paradox.

[00:01:23] [SPEAKER_01]: Said another way, if you do primary care really well and use evidence-based preventative

[00:01:30] [SPEAKER_01]: care to curb the need for excess specialty care, i.e., you reduce specialty revenue

[00:01:35] [SPEAKER_01]: through primary care, now you're asking specialty to not only make less money but

[00:01:40] [SPEAKER_01]: use the remaining money to pay for primary care which is the entity that is

[00:01:44] [SPEAKER_01]: reducing its revenue. So again I am hereby coining the term the paradox of

[00:01:49] [SPEAKER_01]: primary care to express the conundrum for why a consolidated entity that

[00:01:54] [SPEAKER_01]: knows where its bread is buttered is going to do much if anything to empower

[00:01:58] [SPEAKER_01]: primary care with the technology and the staff and the time which if it goes

[00:02:03] [SPEAKER_01]: well is going to cannibalize its own major source of revenue.

[00:02:07] [SPEAKER_01]: Meanwhile, if you choose not to participate in this paradox within the

[00:02:11] [SPEAKER_01]: context of a consolidated entity it's kind of hard to stand up a pure play

[00:02:16] [SPEAKER_01]: primary care practice and I've heard this so many times most recently from

[00:02:20] [SPEAKER_01]: Dr. Paul Burins who said he wrote on LinkedIn my own primary care clinic

[00:02:26] [SPEAKER_01]: lasted independent from 1946 to 2017 and when costs were rising faster than

[00:02:33] [SPEAKER_01]: reimbursement with no alternatives available we sought out purchased by our

[00:02:38] [SPEAKER_01]: hospital giving up on trying to stay independent consolidation is not driven

[00:02:42] [SPEAKER_01]: by bad actors nor by quality nor volume savings but by the bizarre economics

[00:02:47] [SPEAKER_01]: of healthcare as a highly regulated but hardly rational market.

[00:02:51] [SPEAKER_01]: I just I simply don't get why knowing as much as we know about the importance of

[00:02:56] [SPEAKER_01]: primary care CMS and others continue to follow Ruck guidance on PCP rates how

[00:03:03] [SPEAKER_01]: much power must be wielded by the AMA or the AHA or who knows I don't know the

[00:03:08] [SPEAKER_01]: half of it admittedly listen to episode 437 with Brian Clepper for more on just the Ruck.

[00:03:14] [SPEAKER_01]: Also despite again all of the lip service about the importance of primary

[00:03:18] [SPEAKER_01]: care our current cohort of payers seems to have a thing going where they do not

[00:03:23] [SPEAKER_01]: offer value-based care contracts VBC contracts to the primary care folks who

[00:03:28] [SPEAKER_01]: seem most likely to succeed add to that the moving goalposts for ACO's and the

[00:03:32] [SPEAKER_01]: lack of available data to even know how you're doing and yeah here we are so

[00:03:38] [SPEAKER_01]: again the question is how to sustain primary care without falling into a paradox

[00:03:43] [SPEAKER_01]: that is the hard question that I ask Dr. Tom X Lee today I asked Dr. Lee flat out what it takes to stand

[00:03:51] [SPEAKER_01]: up a standalone entity doing primary care and he said enlightened leadership with a value mindset

[00:03:57] [SPEAKER_01]: combined with big-time chops in service operations I of course asked what does enlightened leadership

[00:04:04] [SPEAKER_01]: and mad skills and service ops mean exactly and specifically Dr. Lee broke this down part of

[00:04:09] [SPEAKER_01]: it he said is finding an eliminated hidden waste which according to Dr. Lee does exist in primary

[00:04:15] [SPEAKER_01]: care although maybe in a thinner layer than elsewhere and trust me I asked Dr. Lee what is

[00:04:21] [SPEAKER_01]: this waste exactly and specifically of which he speaks turns out a lot of it is cutting out

[00:04:26] [SPEAKER_01]: busy work like clicking 90 times to order a Tylenol or dumb paperwork or doctors doing stuff

[00:04:32] [SPEAKER_01]: that a nurse navigator could do in between visits or the medical assistant could do or

[00:04:36] [SPEAKER_01]: technology could just automate if you think about wasted time as capital W waste then yeah there's a

[00:04:43] [SPEAKER_01]: hefty amount of waste that could be cut this also comes up in episode 446 with Dr. Spencer Dorn

[00:04:49] [SPEAKER_01]: which is next week now you know me you start talking about getting rid of waste and I am

[00:04:55] [SPEAKER_01]: immediately going to ask you how you define value how you define what you value because

[00:05:01] [SPEAKER_01]: when cutting waste it's really easy to cut more than waste listen to the show with Kate Wellin

[00:05:06] [SPEAKER_01]: or Rick Renard or Dr. Will Schrank for more on that one so I get into a proper grilling with

[00:05:11] [SPEAKER_01]: Dr. Lee on how he defines value which leads us to talk about open access as one component of

[00:05:19] [SPEAKER_01]: delivering value but then of course I bring up yeah well access was Walmart and Walgreens hypothesis

[00:05:25] [SPEAKER_01]: giving patients access to care and they will come and that didn't work out so well the rebuttal

[00:05:32] [SPEAKER_01]: there is access sure but access to what and good point clearly there was a disconnect between

[00:05:38] [SPEAKER_01]: what patients thought good primary care should be and what was on offer and around the wheel

[00:05:44] [SPEAKER_01]: we go because again we're back to the delta between the promise of primary care and what

[00:05:50] [SPEAKER_01]: often exists again with the paradox okay now just let's sum this all up here because I really

[00:05:56] [SPEAKER_01]: want to get to the interview the trick to doing a pure play PCP or indie PCP practice without falling

[00:06:03] [SPEAKER_01]: into the paradox of primary care is enlightened leadership with a value mindset combined with

[00:06:08] [SPEAKER_01]: service operations to find the balance between human centeredness process and technology

[00:06:14] [SPEAKER_01]: that's kind of the big wrap up of a many pronged conversation that there is a balance here

[00:06:21] [SPEAKER_01]: Dr. Lee puts it this way he's like if you think about it as a paradox you're kind of creating

[00:06:25] [SPEAKER_01]: a binary what you want to find is the productive middle find the productive middle of primary care

[00:06:32] [SPEAKER_01]: and you can get rid of the paradox probably some of you are thinking direct primary care

[00:06:37] [SPEAKER_01]: slash DPC is a solution here and yet for sure but to do DPC well you still have to have enlightened

[00:06:44] [SPEAKER_01]: leadership and do a good job with service operations especially if you're thinking you want to work

[00:06:49] [SPEAKER_01]: with employers or others who are going to measure outcomes my name is Stacey Richter this podcast

[00:06:55] [SPEAKER_01]: is sponsored by Aventria Health Group Dr. Tom Lee welcome to Relentless Health Value

[00:07:00] [SPEAKER_01]: thank you thanks for having me I thought you would be the perfect person to talk about something

[00:07:05] [SPEAKER_01]: that I'm wrestling with and I know that a lot of our listeners are wrestling with and this is what

[00:07:10] [SPEAKER_01]: I'm starting to call the paradox of primary care this is the idea that the promise of primary

[00:07:16] [SPEAKER_01]: care is through evidence-based preventative care and by addressing issues early to prevent

[00:07:22] [SPEAKER_01]: or slow disease progression so specialist volume is there by reduced and therefore one might assume

[00:07:30] [SPEAKER_01]: that specialty revenue is reduced however one of the few it seems sustainable ways to pay for primary

[00:07:38] [SPEAKER_01]: care is by vertically integrating primary care into a consolidated stack and then using the money

[00:07:44] [SPEAKER_01]: from specialty care to subsidize primary care so I don't know I'm starting to call it a paradox

[00:07:49] [SPEAKER_01]: like why would a consolidated entity that knows where its bread is buttered why are they going

[00:07:54] [SPEAKER_01]: to do much if anything to empower primary care to cannibalize its own major source of revenue

[00:07:59] [SPEAKER_00]: yeah now I get it look I think the world is a slice into uneven slices and when you look at it from

[00:08:07] [SPEAKER_00]: a variety of lenses it looks out or maybe paradoxical that the two should cooperate certainly within one

[00:08:13] [SPEAKER_00]: combined entity and so I understand that maybe that might be one lens to look at it another

[00:08:18] [SPEAKER_00]: lens to look at it is if you improve primary care by itself there's an opportunity set there but

[00:08:25] [SPEAKER_00]: what's implied in the paradox is that you can't make primary care work better on its own and you

[00:08:30] [SPEAKER_00]: know that was the whole premise of starting up one medical was can you start a pure play

[00:08:34] [SPEAKER_00]: primary care concept that's not dependent on specialty revenue and otherwise to self sustain

[00:08:41] [SPEAKER_00]: itself in scale so there is an opportunity to do so by itself but certainly when you combine the

[00:08:46] [SPEAKER_00]: two then you need what I would call enlightened leadership to move off of fee for service

[00:08:52] [SPEAKER_00]: and more towards value but not all organizations can traverse those waters at the same time so

[00:08:57] [SPEAKER_01]: one of the things that you said there is that there is an opportunity to start a pure play

[00:09:03] [SPEAKER_01]: primary care practice on its own do you feel like that is a hypothesis that has been borne out

[00:09:11] [SPEAKER_00]: well let's just say this it's not easy you know one man of on gallo are somewhat exceptions

[00:09:17] [SPEAKER_00]: to the rule but it's possible the reason why it's hard to do is the world has become increasingly

[00:09:23] [SPEAKER_00]: complicated and it's increasingly hard to run an independent primary care practice without a lot

[00:09:29] [SPEAKER_00]: of sophistication and so through unintended consequences through the policies that we have

[00:09:35] [SPEAKER_00]: you know starting up to know especially practices it's almost as hard as primary

[00:09:38] [SPEAKER_00]: care these days so the hospital consolidation has been happening for a reason and so yeah

[00:09:44] [SPEAKER_00]: it's increasingly hard but it is financially theoretically feasible it's just it requires a

[00:09:49] [SPEAKER_00]: different mindset to care in service operations that most folks don't have training in when you

[00:09:54] [SPEAKER_01]: say a different mindset what exactly do you mean and you also use the term enlightened leadership

[00:10:00] [SPEAKER_01]: maybe we start here what are the barriers exactly and specifically and I know a lot of our

[00:10:05] [SPEAKER_01]: listeners are like obviously if you're for service for the rock has destroyed primary care so

[00:10:10] [SPEAKER_01]: you know everybody's immediately going to be going the incentive payments are low

[00:10:13] [SPEAKER_00]: with primary care what else yeah so the main thing to think through is a lot of the world

[00:10:20] [SPEAKER_00]: is kind of viewed as a zero sum or binary state world where it's either a or b meaning fee for

[00:10:28] [SPEAKER_00]: service or value and you can't do both at the same time the rad is you can do both at the

[00:10:33] [SPEAKER_00]: same time it just requires a bit more creativity and innovation and the way you do that is frankly to

[00:10:40] [SPEAKER_00]: lower your unit costs if you can lower your unit costs you can make margin on fee for service

[00:10:45] [SPEAKER_00]: and you can actually now increase your scope and do more across value with the extra infrastructure

[00:10:51] [SPEAKER_00]: and enhance resources so I think there's a lot of different ways you can do both fee for service

[00:10:56] [SPEAKER_00]: and value it just takes a slightly different mindset to believe you can do both and I think

[00:11:01] [SPEAKER_00]: so many leaders kind of have these binary talking points about you can have your foot in two canoes

[00:11:07] [SPEAKER_00]: and a lot of that can be done it's just you kind of have to unlock yourselves from these kind of

[00:11:12] [SPEAKER_01]: binary modalities so it's interesting what you're saying and we're talking about a pure play

[00:11:16] [SPEAKER_01]: primary care practice right now what I'm hearing you say you can do this if you have some value

[00:11:22] [SPEAKER_01]: based contracts some of them and you also have you know if you have some value based you're

[00:11:28] [SPEAKER_01]: gonna have some fee for service I was listening to I think it was a radio advisory show where

[00:11:32] [SPEAKER_01]: they basically concurred with exactly what you're saying they're like it's not a binary there's these

[00:11:36] [SPEAKER_01]: spots in the middle where you've got varying amounts of value based contracts with fee

[00:11:43] [SPEAKER_01]: for service and that's not going to go away anytime soon it's not this kind of like

[00:11:48] [SPEAKER_01]: messy middle on the way to some Shangri-La like it is the way it is so what I'm hearing

[00:11:54] [SPEAKER_01]: you say is you can do a pure play primary care if you have some mix of value based and fee for

[00:11:59] [SPEAKER_01]: service and leadership is able to contend with having value based contracts as well as fee

[00:12:05] [SPEAKER_01]: for service contracts at the exact same time but then it also sounds like becoming very efficient

[00:12:10] [SPEAKER_01]: and lowering costs is also part of this mix did I get that right close I mean again there's a lot

[00:12:17] [SPEAKER_00]: subtleties in kind of the terms when I say value it's not only about value based arrangements and

[00:12:25] [SPEAKER_00]: payment architectures value is more about a mindset can I do more for less can I be more

[00:12:31] [SPEAKER_00]: effective more efficiently and so that mindset can exist in a 100% fee for service architecture

[00:12:37] [SPEAKER_00]: or a blended architecture where some of my payments are at risk so all I'm saying is

[00:12:43] [SPEAKER_00]: within primary care you can what I call slim down your overhead run your practice more effectively

[00:12:48] [SPEAKER_00]: and efficiently and be in a fee for service world and that's still a value focused mindset because

[00:12:54] [SPEAKER_00]: you're trying to do more for less and that's how we started off with one medical is trying

[00:12:59] [SPEAKER_00]: to do more for less and then we realized that oh wow we can make margin in primary care by itself

[00:13:04] [SPEAKER_00]: and then you know scaled it from there and so again it's a bit of the awareness that there

[00:13:10] [SPEAKER_00]: is hidden waste everywhere across every layer of the ecosystem and granted primary care is a smaller

[00:13:16] [SPEAKER_00]: thinner layer within the health care ecosystem but there are still opportunities to innovate within

[00:13:21] [SPEAKER_01]: that layer by itself what are some examples of hidden waste in a primary care practice the easiest

[00:13:28] [SPEAKER_00]: anecdote I would use or maybe kind of shorthand is look at all the people around any service model

[00:13:34] [SPEAKER_00]: and for the most part let's use knowledge based workers and ask yourself what percent of their day

[00:13:40] [SPEAKER_00]: is their brain effectively utilized and if it's you know let's call it any reasonable percent

[00:13:47] [SPEAKER_00]: that's an opportunity and I would argue that most clinicians most administrative personnel would say

[00:13:53] [SPEAKER_00]: my brain is not being effectively utilized my body in busy work is being effectively

[00:14:00] [SPEAKER_00]: utilized meaning my busy work is very high but my effective work the the thing that I most skill

[00:14:06] [SPEAKER_00]: that is being underutilized and so I think that's where in almost all service models we don't recognize

[00:14:13] [SPEAKER_00]: untapped talent untapped potential and the lack of productivity because people are just

[00:14:20] [SPEAKER_00]: underutilized and or the work is not organized to be most effective and this is true of all

[00:14:25] [SPEAKER_00]: service organizations when we were starting up one medical I was looking at all different

[00:14:29] [SPEAKER_00]: types of service organizations and you just you can see organizations where workers are engaged

[00:14:35] [SPEAKER_00]: and workers are not engaged and we have a high percent of unengaged workers particularly in

[00:14:40] [SPEAKER_00]: you know office based settings because it's chaotic right and that chaos dwarfs the ability to

[00:14:46] [SPEAKER_01]: actually think and do productive work I could ask you like 40 questions right now so let me

[00:14:51] [SPEAKER_01]: contain myself I love what you said about having a value focused mindset and that doesn't just

[00:14:56] [SPEAKER_01]: mean in a value based care payment architecture that one can have a value focused mindset anytime

[00:15:04] [SPEAKER_01]: including it even if it's pretty much all fee for service as I contemplate that in order to have

[00:15:12] [SPEAKER_01]: a value focused mindset you kind of really have to think about what is value what are we trying

[00:15:18] [SPEAKER_01]: to do what are our goals and I've heard that there's only four categories of goals really

[00:15:24] [SPEAKER_01]: you know you can have financial goals you can have patient reported outcome kind of goals proms

[00:15:29] [SPEAKER_01]: you can have clinician reported outcomes right like what is an outcome that a clinician thinks

[00:15:34] [SPEAKER_01]: is something to be proud of and then lastly some kind of performance metric of some kind

[00:15:40] [SPEAKER_01]: like patient satisfaction etc so as I'm thinking about what constitutes this value focused mindset

[00:15:46] [SPEAKER_01]: probably part of it or the whole thing is gonna have to begin with what do we think value

[00:15:52] [SPEAKER_01]: is because if you try to be efficient without necessarily understanding what good looks like

[00:15:58] [SPEAKER_01]: then you wind up cutting corners in ways that actually diminish whatever you're trying to

[00:16:04] [SPEAKER_01]: accomplish beyond some financial metric would you concur there or how do you think about it

[00:16:09] [SPEAKER_00]: yeah dimensionally I think those are reasonable ways to categorize thoughts around quality

[00:16:16] [SPEAKER_00]: or performance the reality is that the decision making in any organization is much more subtle

[00:16:21] [SPEAKER_00]: than that you know let's just kind of pick a simple dimension such as access or service which

[00:16:26] [SPEAKER_00]: correlates with patient net promoter score otherwise right what's appropriate same day

[00:16:31] [SPEAKER_00]: appointments next day appointments one week appointments one month appointments what's

[00:16:35] [SPEAKER_00]: quality there depends right on the clinical situation the economic model the economic

[00:16:41] [SPEAKER_00]: affordability so you can say all you want about the dimensions but the judgments are

[00:16:46] [SPEAKER_00]: still up to the organization to determine what do they value and what can they financially

[00:16:51] [SPEAKER_00]: and operationally achieve based on that and if we used access as a surrogate for the quality which

[00:16:58] [SPEAKER_00]: again I'm not saying that it should be the industry is not doing great and so to me you

[00:17:03] [SPEAKER_00]: know when I think about care as a clinician if a patient can't reach me I've lost the job

[00:17:08] [SPEAKER_00]: at step one if they can't reach me then how am I supposed to be able to take care of them

[00:17:12] [SPEAKER_00]: how can I give them great care to me access is one of just the first steps to quality

[00:17:17] [SPEAKER_00]: and it precedes quality at some level we do so poorly of that across the industry so

[00:17:23] [SPEAKER_00]: to me access is one dimension of quality that we should start with separate from all

[00:17:28] [SPEAKER_00]: the clinical decision making separate from all the follow-through separate from

[00:17:32] [SPEAKER_00]: what are called the experience and outcomes of care so you just take a simple metric like

[00:17:37] [SPEAKER_00]: access and say well are we doing a great job you know probably could be better I'm

[00:17:41] [SPEAKER_01]: definitely going to loop back on some of other ways or kind of the process by which one becomes an

[00:17:46] [SPEAKER_01]: enlightened leader who has a value-based mindset but before I do reconcile for me you know the

[00:17:54] [SPEAKER_01]: hypothesis that walmart had and walgreens and some of these other let's put a clinic inside a

[00:17:59] [SPEAKER_01]: place that our customers slash patients slash members already are that is going to be great

[00:18:06] [SPEAKER_01]: access right like they're already in the walmart so they can just pop by and get some medical service

[00:18:13] [SPEAKER_01]: and you said this you said access is going to be an important metric but not the only one

[00:18:19] [SPEAKER_01]: talk a little bit about the experience maybe that some of these clinics found out the hard way

[00:18:25] [SPEAKER_00]: well I mean let's call it the retail clinics just broadly speaking which has you know been a

[00:18:30] [SPEAKER_00]: 20 plus year concept in general and has failed to what we call really truly deliver

[00:18:35] [SPEAKER_00]: great longitudinal primary care they've been convenient vaccine shops in you know what to

[00:18:42] [SPEAKER_00]: call minor urgent care type of clinics but very few have really become longitudinal primary care

[00:18:49] [SPEAKER_00]: destinations and that's the key difference right access is different from somebody who knows me

[00:18:55] [SPEAKER_00]: and can manage my care longitudinally as a true primary care provider most of the retail

[00:19:00] [SPEAKER_00]: clinics are really servicing as you know other versions of urgent care which there are plenty of

[00:19:06] [SPEAKER_00]: with plenty of access and so in the absence of what I call longitudinal access there's our

[00:19:12] [SPEAKER_00]: convenient options out there that are transactional if need be right including the er they aren't

[00:19:18] [SPEAKER_00]: the best places to get your care necessarily but those are other access points and so the

[00:19:23] [SPEAKER_00]: second point is really who is on the other side and what are they doing for me at this

[00:19:28] [SPEAKER_00]: location there's a separate issue just the economics of this when it's not your core business to run

[00:19:34] [SPEAKER_00]: a service operation it's hard to stand up a service operation and I think people don't

[00:19:39] [SPEAKER_00]: realize that service operations aren't a second job they should be your first job and I think

[00:19:45] [SPEAKER_00]: people tended to underestimate and I think still do how hard it is to run a service operation

[00:19:51] [SPEAKER_01]: particularly within primary care yeah I mean I have heard that in Walmart just to echo

[00:19:56] [SPEAKER_01]: this point they were looking at the square footage the clinic was taking up and deciding

[00:20:00] [SPEAKER_01]: they could make more money selling tires in that same square footage so yeah there's all

[00:20:04] [SPEAKER_01]: kinds of issues that were going on there but from what I'm hearing if we're thinking about

[00:20:08] [SPEAKER_01]: what is a value focused mindset that one of the first things to figure out like what are you

[00:20:13] [SPEAKER_01]: trying to accomplish and what does that look like and you're highlighting the idea of access

[00:20:17] [SPEAKER_01]: as a proxy for some performance metric but you also need to be really contemplative of

[00:20:23] [SPEAKER_01]: how do you become a longitudinal care destination it sounds like that's kind of like high on your

[00:20:27] [SPEAKER_01]: list to really think through what is a longitudinal care destination what does that look like I mean

[00:20:33] [SPEAKER_01]: probably relationships right like that seems to be a thing in and of itself that you sort of have

[00:20:38] [SPEAKER_00]: to get right yeah I mean it all depends on how you define primary care and for what reason the

[00:20:43] [SPEAKER_00]: reason why people like primary care conceptually is in theory again it offers a better way to

[00:20:52] [SPEAKER_00]: get value for your dollar in care that's true if primary care is delivering on its promise today

[00:20:59] [SPEAKER_00]: it's not delivering on its promise because it's been obviously low reimbursement and high complexity

[00:21:04] [SPEAKER_00]: overhead have really diminished the capabilities of most primary care offices in general but

[00:21:10] [SPEAKER_00]: if you were to say hey primary care's purpose is to be a general place of care

[00:21:15] [SPEAKER_00]: longitudinally to handle most issues that's the promise of primary care I think that's very different

[00:21:22] [SPEAKER_00]: than a minute clinic or some transactional system that's focused on convenience and so

[00:21:27] [SPEAKER_00]: that second dimension that we talked about after access is important and that is where the economics

[00:21:34] [SPEAKER_00]: really struggle you know open access is somewhat of an operational problem that doesn't cost

[00:21:39] [SPEAKER_00]: dollars that just costs management discipline you know open access is a concept that's been

[00:21:44] [SPEAKER_00]: based around for 20 30 plus years you just have to execute it but not many organizations execute open

[00:21:50] [SPEAKER_00]: access the second dimension is running a longitudinal primary care practice in a cost efficient manner

[00:21:56] [SPEAKER_00]: given the reimbursement architecture and that is challenging and what you include in the scope

[00:22:00] [SPEAKER_00]: of primary care not just kind of the label but the actual content matters and how you do it

[00:22:06] [SPEAKER_00]: matters and so that's where the service complexity starts to really take hold and

[00:22:10] [SPEAKER_00]: I think people tend to not really understand what that means in a traditional environment

[00:22:15] [SPEAKER_01]: so we're talking about the two dimensions that are super important to be contemplative of one is

[00:22:21] [SPEAKER_01]: access and convenience and then the other one is this how do you be perceived as an execute on

[00:22:27] [SPEAKER_01]: a longitudinal patient journey and now i'm going to go back to something that you had talked

[00:22:32] [SPEAKER_01]: about before which was also it definitely sounded like making sure that amongst the employees or

[00:22:40] [SPEAKER_01]: those that are working within the practice there's a lot of untapped talent potential and checking

[00:22:46] [SPEAKER_01]: to see what percentage of someone's day is effectively utilized and how much of it is

[00:22:51] [SPEAKER_01]: busy work and then getting rid of the busy work another way to say this which i don't like

[00:22:55] [SPEAKER_01]: because it's become a euphemism for all kinds of bad behavior but this idea of working at the

[00:23:00] [SPEAKER_01]: top of your license just making sure that everybody is cognitively able to deliver at the level that

[00:23:07] [SPEAKER_01]: they know that they can and not get bogged down into just bureaucratic madness that burns people out

[00:23:13] [SPEAKER_01]: and is often so frustrating for really good people who understand what they could achieve

[00:23:18] [SPEAKER_01]: and just the latent potential that's kind of lost so like that's kind of like one side of this

[00:23:23] [SPEAKER_01]: but then the other side i know you've talked at length about like the one medical app and

[00:23:28] [SPEAKER_01]: other things that that you've created on the technology side and then processes also

[00:23:33] [SPEAKER_01]: is that kind of the sum of what you're thinking about as you think about how do you efficiently

[00:23:38] [SPEAKER_01]: and effectively within the current kind of crappy payment models for primary care actually

[00:23:42] [SPEAKER_01]: succeed in a primary pcp or what am i missing or what do you want to dig into yeah i mean i

[00:23:48] [SPEAKER_00]: think some of the nuances on a service business are challenging for a lot of quote

[00:23:54] [SPEAKER_00]: traditional managers when you look at a service business the human beings are the service and so

[00:24:01] [SPEAKER_00]: you really have to think about the dynamism of it what it means to be a caregiver a team member

[00:24:06] [SPEAKER_00]: that's interacting with a patient there's that human organic dimension and then there's just

[00:24:12] [SPEAKER_00]: the basics of operations and finance on running sustainable practice and those two sometimes

[00:24:19] [SPEAKER_00]: work against each other in some places you see humans doing work that machine should be doing

[00:24:24] [SPEAKER_00]: as an assembly line and you know that's not a great use and in other situations you have people

[00:24:30] [SPEAKER_00]: that are purely just ad-libbing and that's not great from an economic perspective so you have to

[00:24:35] [SPEAKER_00]: find that right balance of operations and human centeredness to create the best service

[00:24:41] [SPEAKER_00]: organizations otherwise they feel like a machine and soulless or they have too much

[00:24:48] [SPEAKER_00]: organic behavior and they feel chaotic so that middle ground is where the service businesses

[00:24:54] [SPEAKER_00]: at least from my observation the best ones tend to thrive but you got to find that right balance

[00:24:59] [SPEAKER_00]: and this is one of those things that capitalism and business school don't do a great job at

[00:25:05] [SPEAKER_00]: which is kind of finding that gray middle where you get a bit of both working well together

[00:25:10] [SPEAKER_00]: and I think that's a lot of what makes to me services businesses you know exciting and challenging and

[00:25:16] [SPEAKER_01]: and dynamic how do you start that if you were going to give somebody some advice

[00:25:21] [SPEAKER_01]: who's sitting here thinking huh I would like to check and see how I'm doing with this

[00:25:27] [SPEAKER_01]: what's step one to figure out where that sweet spot in the middle is number one

[00:25:32] [SPEAKER_00]: and I don't know if this can be taught but you kind of have to give it I don't know

[00:25:35] [SPEAKER_00]: I can say this but you have to give a shit you really have to care about people if you don't

[00:25:40] [SPEAKER_00]: then you're you're going to be losing that side of the equation and so you fundamentally have to

[00:25:46] [SPEAKER_00]: believe in supporting your team and supporting patients as humans that has to be innate or at

[00:25:52] [SPEAKER_00]: least very high on the list of things you care about if you don't start there then

[00:25:57] [SPEAKER_00]: you're actually working against yourself the second I would say is just understanding

[00:26:02] [SPEAKER_00]: you know math and operations and basic machinery and those are the two ends of the pole and then

[00:26:09] [SPEAKER_00]: the beauty is using the tools of math and science and whatever to shape ecosystems that are more

[00:26:17] [SPEAKER_00]: likely to produce positive outcomes for your team and the patients we care about and so that's

[00:26:23] [SPEAKER_00]: kind of the nuance that at least you know most of the work I've done have at least so far

[00:26:28] [SPEAKER_00]: resulted in you know pretty positive ecosystems I definitely hear what you're saying that on one

[00:26:33] [SPEAKER_01]: side of our axis here we have you have to give a shit and also understand people and by people

[00:26:40] [SPEAKER_01]: we're including colleagues and being a good manager and then also patients and what good

[00:26:47] [SPEAKER_01]: patient care looks like the healthcare is fundamentally a very human operation it will

[00:26:53] [SPEAKER_01]: succeed if there's relationships if there's trust and that has to happen very much at a level where

[00:26:59] [SPEAKER_01]: someone's EQ is high enough to be able to do that I had a mentor one time that would would say

[00:27:05] [SPEAKER_01]: repeatedly you can't legislate the heart and I think that might be what you mean by that on the

[00:27:11] [SPEAKER_01]: other hand it's also understanding how operations works and math and technology what can be

[00:27:18] [SPEAKER_01]: automated and is there an API for that that site also becomes incredibly important because if you

[00:27:23] [SPEAKER_01]: have a human doing something repeatedly that's where we get ourselves in tons of trouble you

[00:27:28] [SPEAKER_01]: know it takes 90 clicks to do the right thing for a patient even the most caring person in

[00:27:33] [SPEAKER_01]: the world could be undermined so finding that middle ground is certainly not something

[00:27:39] [SPEAKER_01]: that's easy but I can see exactly what you're saying that is really essential to be able

[00:27:44] [SPEAKER_01]: to do is there any other kind of summary advice that you might give to someone who's now thinking

[00:27:48] [SPEAKER_01]: to themselves hmm I gotta dig in here yeah I mean the only other thing would maybe be

[00:27:53] [SPEAKER_00]: you know especially coming from a medical world where it's like research validate and then do

[00:28:00] [SPEAKER_00]: a lot of you know real-world innovation happens from trial and error and I think people tend

[00:28:05] [SPEAKER_00]: to underestimate that in service oriented clinical cultures and so you kind of have to always

[00:28:10] [SPEAKER_00]: be tweaking and figuring things out it's a dynamic industry that that is the challenge is

[00:28:16] [SPEAKER_00]: how do you continue to innovate and learn and change given all the human machinery it's easy

[00:28:22] [SPEAKER_00]: to upgrade software you just upgrade the software and that's there but how do you continuously

[00:28:27] [SPEAKER_00]: upgrade the service operating platform a little bit more challenging especially at scale how do

[00:28:32] [SPEAKER_01]: you put together this enlightened leadership team then that is able to do that is there a certain

[00:28:36] [SPEAKER_01]: composition of who's leading is there you know like they gotta work with patients three times a day

[00:28:44] [SPEAKER_01]: maybe what advice do you have to put together a leadership team that is capable of finding

[00:28:49] [SPEAKER_00]: that middle ground it's challenging I don't know if I've got the right playbook I've only

[00:28:54] [SPEAKER_00]: done this now twice but when my home gala we've relied on different talent different pools of

[00:28:59] [SPEAKER_00]: talent different equations so I don't think there's necessarily a one size if it's all playbook

[00:29:05] [SPEAKER_00]: I think it has to be adaptive to the strategy the operations in kind of the people goals

[00:29:11] [SPEAKER_00]: it's just like anybody who's being thoughtful about architecting their org it's at some level

[00:29:17] [SPEAKER_00]: a bit more intuitive I guess and imagining how things should work and what talent types you

[00:29:24] [SPEAKER_00]: do need so it's a little bit like cooking it's like what ingredients do I need it varies depending

[00:29:30] [SPEAKER_00]: on what you're trying to cook up so the ingredient mix at least for me has changed between one medical

[00:29:36] [SPEAKER_00]: and gala on between gala early stage and we're moving into middle stage of the organization in

[00:29:42] [SPEAKER_00]: terms of scale so the types of people and the types of needs are different I guess maybe the only

[00:29:47] [SPEAKER_00]: the corollary is I don't see a lot of talent you can hire and suddenly you have a instant

[00:29:52] [SPEAKER_00]: voila you know there's just the industry is so immature from my perspective that you

[00:29:57] [SPEAKER_00]: can't just find somebody and just bolt them in very often it needs to be a skill set or a mindset

[00:30:04] [SPEAKER_00]: that's being added and it needs to be shaped within the org dynamically it's very rarely just

[00:30:10] [SPEAKER_01]: plopped in it feels like what you're saying it's super important to make sure the leadership team

[00:30:16] [SPEAKER_01]: is purpose built to achieve the goals which are set forth which are clear because it's not

[00:30:22] [SPEAKER_01]: necessarily like oh this person checks all the boxes relative to skills so it's going to

[00:30:27] [SPEAKER_01]: work out here it's also do they believe the same things do they care in the same ways as well so

[00:30:34] [SPEAKER_01]: it's definitely it's going to be a special blend depending I mean even on what part of the country

[00:30:39] [SPEAKER_01]: healthcare is local right so there also could be a consideration relative to what the needs of

[00:30:45] [SPEAKER_01]: the local community are so maybe yeah I just want to go back to this longitudinal patient

[00:30:51] [SPEAKER_01]: journey thinking about you know you've got the access part of the equation which may in a

[00:30:56] [SPEAKER_01]: way if you can figure out how to operationalize it be somewhat of the easy part the other part here

[00:31:00] [SPEAKER_01]: is how do you pay for and have a sustainable business model around this longitudinal patient

[00:31:05] [SPEAKER_01]: journey given just kind of this paradox here that you may not necessarily get the help that

[00:31:10] [SPEAKER_01]: you want from entities who are downstream that in a way you're eating their cheese so if you're

[00:31:15] [SPEAKER_01]: thinking about this longitudinal patient journey I was talking to Dr. John Lee the other day who

[00:31:20] [SPEAKER_01]: was basically he had gone to some seminars a summit and they discovered that one of the best ways

[00:31:27] [SPEAKER_01]: to get heart failure patients to report their blood pressure in between ER visits and subsequent

[00:31:35] [SPEAKER_01]: readmissions was to have a nurse call him on the phone and ask him what their blood pressure

[00:31:39] [SPEAKER_01]: reading was but nobody was doing it or they're having a great struggle figuring out how to do

[00:31:44] [SPEAKER_01]: this because it wasn't paid for I could certainly see that if we're thinking about a longitudinal

[00:31:50] [SPEAKER_01]: patient journey that examples just like that would come up day in and day out because it requires

[00:31:58] [SPEAKER_01]: outreach you know the reason why a patient has uncontrolled something or other is because

[00:32:03] [SPEAKER_01]: they're not controlling it and they're you know like the patients that most need engaged are

[00:32:07] [SPEAKER_01]: the ones who are not engaged how do you think about that especially in light of what you

[00:32:12] [SPEAKER_01]: were talking about before where a lot of this world is still fee for service like if you get a

[00:32:16] [SPEAKER_01]: value-based contract great but if not what do you do yeah you know a lot of the work we did

[00:32:22] [SPEAKER_00]: one medical and at Gallo is if you can be efficient wherever you can be efficient you

[00:32:28] [SPEAKER_00]: generate extra margin where you can make incremental investments in quality that

[00:32:32] [SPEAKER_00]: aren't paid for so a lot of quality based metrics unless you're an ACO or value-based

[00:32:38] [SPEAKER_00]: arrangements don't really pay for themselves but they're important to do so a lot of times I'm

[00:32:44] [SPEAKER_00]: investing in quality programs through the margin you can generate through reimbursable services so

[00:32:50] [SPEAKER_00]: that's why you know being lean allows you to do the quality based care regardless of payment

[00:32:55] [SPEAKER_00]: architecture but that level investment varies depending on how labor intensive the quality

[00:33:01] [SPEAKER_00]: investment is and or you know the systems you have to support it all of that kind of

[00:33:06] [SPEAKER_00]: needs to fit as part of the thesis on what kind of care system you're trying to build

[00:33:11] [SPEAKER_01]: what I'm hearing you say is maybe you find services you can get paid for through fee for service

[00:33:19] [SPEAKER_01]: you figure out how to do those billable things as absolutely efficiently as possible then you

[00:33:25] [SPEAKER_01]: wind up with a couple of bucks leftover that you can throw in the pot of all right we're

[00:33:29] [SPEAKER_01]: going to outreach our heart failure patients even though we're not getting paid for it

[00:33:32] [SPEAKER_01]: correct does margin at a certain point start eating mission because I could see if you've

[00:33:37] [SPEAKER_01]: got private equity or you have entities in the mix here who are really really into value extraction

[00:33:42] [SPEAKER_01]: meaning get it making as much money as possible that they may not be super happy with that plan

[00:33:48] [SPEAKER_00]: yeah those are the trade-offs of mission and trying to achieve societal impact versus margin

[00:33:55] [SPEAKER_00]: whether it's third party capital or your own home equity loan to finance your practice it's

[00:34:01] [SPEAKER_00]: all the same thing financial incentives versus human and human factor dimensions and those always

[00:34:08] [SPEAKER_00]: are at some level traded off it's just an issue of what's the right ratio at what time frame and

[00:34:13] [SPEAKER_00]: can you make more of it work than less but yes true of almost all businesses at one form or

[00:34:18] [SPEAKER_01]: another how do you address that trade-off like if you are standing in front of a board of directors

[00:34:27] [SPEAKER_01]: who's basically saying make more money do you have any lessons to share yeah I mean I think

[00:34:34] [SPEAKER_00]: as younger innovators and entrepreneurs you just have fewer degrees of freedom to make that trade-off

[00:34:39] [SPEAKER_00]: on behalf of investors but as you get more experience and have credibility and frankly

[00:34:45] [SPEAKER_00]: you still need a financial equation on everything you can at least have a coach and dialogue with

[00:34:51] [SPEAKER_00]: investors but that is inherently the challenge and where more organically funded entities

[00:34:57] [SPEAKER_00]: have more degrees of freedom to do so I think that's just kind of the trade-off on

[00:35:01] [SPEAKER_00]: professional capital versus not professional capital allows you to you know scale quickly and and grow

[00:35:07] [SPEAKER_00]: and entity with one medical we knew there was inherently a trade-off by taking professional

[00:35:12] [SPEAKER_00]: capital but allowed us to scale the concept more rapidly and that was the trade-off we made

[00:35:17] [SPEAKER_00]: and same thing with Galileo at some level you're always trying to find that right balance

[00:35:21] [SPEAKER_00]: and dialogue it's the power of capitalism but also the the downside of it if it's unchecked

[00:35:27] [SPEAKER_00]: and so we always need to as humans try to find that right balance whether you're on the investor side

[00:35:32] [SPEAKER_00]: or on the operator side I think both sides need to find that right balance yeah it certainly

[00:35:37] [SPEAKER_01]: sounds like again we've got a situation where it's no binary right like there's no right or

[00:35:43] [SPEAKER_01]: wrong there's this gray area in the middle we've been talking about that earlier you have

[00:35:48] [SPEAKER_01]: to have people that have some level of autonomy and freedom but it can't be complete chaos also

[00:35:54] [SPEAKER_02]: you can't take your way out of a problem caused by tech a lot of times so there's a lot of edge cases

[00:36:01] [SPEAKER_00]: and yeah that's where the productive middle is we tend to underestimate that productive middle as

[00:36:06] [SPEAKER_00]: gray zone but that's where I think there's a lot of productive energy you know and not to make

[00:36:11] [SPEAKER_00]: it overly political but ideally the political system would be a little bit more actively

[00:36:16] [SPEAKER_00]: engaged in the middle as well to be more productive but these kind of binary states of the world are

[00:36:21] [SPEAKER_00]: just not productive for solving our problems and so we just need to kind of figure out ways

[00:36:26] [SPEAKER_01]: to find that right balance what's your message for payers and I'm thinking for example Medicaid

[00:36:33] [SPEAKER_01]: and I know a lot of your current work with Galileo I do believe I could be wrong is with

[00:36:38] [SPEAKER_01]: Medicaid and managed Medicaid maybe Medicare but you know a lot of the work that you're doing

[00:36:42] [SPEAKER_01]: should again if we're achieving the promise of primary care reduce the total cost of care

[00:36:49] [SPEAKER_01]: but there is kind of a short-sighted quarter by quarter thinking and then nobody's going to pay

[00:36:54] [SPEAKER_01]: for the nurse to call up the heart failure patient to keep them out of the hospital next

[00:36:57] [SPEAKER_01]: quarter right what would be your overarching message for them yeah so you know we work with all

[00:37:02] [SPEAKER_00]: program types commercial ACA Medicare Medicaid and operate within all the constraints on

[00:37:08] [SPEAKER_00]: reimbursement I think I understand the challenges in the sense that when you're running a state-based

[00:37:14] [SPEAKER_00]: Medicaid program there's a limit to what you can really do in shape you're mostly controlling

[00:37:19] [SPEAKER_00]: the reimbursement architectures and so whether through intent or not a lot of the reimbursement

[00:37:25] [SPEAKER_00]: on a fee for service basis in most states is unsustainable for most practices to achieve

[00:37:31] [SPEAKER_00]: any basic form of margin so when you do that you limit access to the upstream outpatient

[00:37:37] [SPEAKER_00]: medicine and then you have excessive utilization of more downstream resources like he ours just you know

[00:37:44] [SPEAKER_00]: everywhere we've under reimbursed in the upstream and the downstream is where most people

[00:37:50] [SPEAKER_00]: end up showing up so the constraints are harder frankly in a lot of these Medicaid programs

[00:37:54] [SPEAKER_00]: but we've been able to kind of innovate into that when we started Galileo the goal was to

[00:38:00] [SPEAKER_00]: service last small communities rural communities Medicaid communities because if we can do that

[00:38:06] [SPEAKER_00]: sustainably we knew we could take care of everybody else sustainably as well because it was

[00:38:10] [SPEAKER_00]: what we called the thinnest air and so that's been our North Star on innovation so if we can service

[00:38:16] [SPEAKER_00]: a higher quality model to all lives including complex Medicaid lives and rural lives then

[00:38:22] [SPEAKER_00]: everybody else serves to benefit so it's a harder challenge I wouldn't have done that

[00:38:26] [SPEAKER_00]: as my first company and doing one medical was hard enough but it allowed me the insight to

[00:38:32] [SPEAKER_00]: understand how to innovate into some of these more complex situations and what are the conversations

[00:38:37] [SPEAKER_01]: that you then have with these Medicaid plans who as you said have these unsustainable payment models

[00:38:44] [SPEAKER_01]: for fee for service obviously you've got some IP that's in this space so I don't want to ask

[00:38:50] [SPEAKER_01]: you anything untoward but how do you do that like as you said it's the thinnest air the

[00:38:55] [SPEAKER_01]: reimbursement levels a lot of times I mean not in some states but in others for sure

[00:38:59] [SPEAKER_01]: are incredibly thin is this kind of going back to what we were talking about before this kind of

[00:39:06] [SPEAKER_01]: people process finding that middle ground or is there something else going on here no it's a

[00:39:10] [SPEAKER_00]: it's the same mindset with more intensity how do we more effectively care for populations and

[00:39:17] [SPEAKER_00]: individuals more efficiently using tech and data we believe we have one of the most efficient

[00:39:22] [SPEAKER_00]: care models that can service lives across broad demographics across broad geos and then

[00:39:29] [SPEAKER_00]: we have high intensity services around high cost lives and so wherever we can get value alignment

[00:39:36] [SPEAKER_00]: or value arrangements we do that allows us to scale up our operations even in what we call

[00:39:42] [SPEAKER_00]: complex markets or low reimbursement markets so that's how we've generally operated it's still

[00:39:49] [SPEAKER_00]: early innings in terms of how do we validate this across every state but so far the early

[00:39:53] [SPEAKER_01]: data points seem promising and what message would you have for like cmmi or a policy maker who's in

[00:40:01] [SPEAKER_01]: this mix who may be hearing about these thin margins but also kind of stuck between a rock in a

[00:40:06] [SPEAKER_01]: hard place a lot of times there's not enough money to go investing in infrastructure paying

[00:40:11] [SPEAKER_01]: a lot for value-based care now to save money you know years down the line there's just not

[00:40:16] [SPEAKER_01]: this bolus of cash that's available right now so it is really hard but maybe through your experience

[00:40:22] [SPEAKER_00]: you have some sage wisdom i understand if you're at cmmi's position it's hard to watch all the

[00:40:28] [SPEAKER_00]: different kind of machinations and translations across each state particularly on the medicaid

[00:40:32] [SPEAKER_00]: side but there are operators that are working within the system to innovate on quality and

[00:40:39] [SPEAKER_00]: affordability as broadly as possible it does take time we should continue innovation grants

[00:40:44] [SPEAKER_00]: and other experiments but at the same time allow enough stability in the marketplace to

[00:40:50] [SPEAKER_00]: continue to evolve a lot of these innovations just take time more importantly is just the lack of

[00:40:55] [SPEAKER_00]: what i call operational understanding and operational wisdom in the broader industry that

[00:41:01] [SPEAKER_00]: that's where we need to you know even consider reinvesting our insights it's just a it's

[00:41:07] [SPEAKER_00]: a very challenging business hospital operations are complex outpatient operations are complex

[00:41:12] [SPEAKER_00]: insurance operations are complex they all need to kind of work together now having gone down the

[00:41:18] [SPEAKER_00]: rabbit hole and partnered with almost every type of institution you just have empathy for all the

[00:41:23] [SPEAKER_00]: different organizations and how everybody wants to do the right thing but they're trapped in

[00:41:28] [SPEAKER_00]: their own economics and the architectures and sure a radical reimbursement change and policy

[00:41:34] [SPEAKER_00]: might change things but politically that seems just untenable so we just have to figure out how

[00:41:40] [SPEAKER_00]: to operate within the system and ideally figure out how to you know get more collaborative

[00:41:45] [SPEAKER_00]: partnerships in place so that organizations can really validate what's possible we've been

[00:41:51] [SPEAKER_00]: partnered with a variety of different types of entities to validate this further so we can

[00:41:54] [SPEAKER_00]: make sure that we all are working cooperatively together from health plan to you know we view

[00:42:00] [SPEAKER_00]: ourselves as a provider group to employers and hospital systems we're all key parts of the

[00:42:05] [SPEAKER_01]: ecosystem I was just talking to Dr Scott canard and Pat done from the AHA and they just did a study

[00:42:10] [SPEAKER_01]: that showed if a patient has a advanced primary care visit and when I say advanced primary care

[00:42:17] [SPEAKER_01]: visit there was a bunch of specifications for what that constituted it took two years for there to

[00:42:24] [SPEAKER_01]: be any significant impact in health and cost savings but after that two-year mark it was

[00:42:33] [SPEAKER_01]: statistically significant so it's just interesting that knowing that you have to be working with entities

[00:42:42] [SPEAKER_01]: who can think in terms of two-year timelines and that's rough yeah some of those areas are

[00:42:49] [SPEAKER_00]: challenging obviously because the internal incentives are misaligned where there's

[00:42:54] [SPEAKER_00]: clear public goods where there's very little economic interest for the entities themselves

[00:42:58] [SPEAKER_00]: there's a way to help offset the costs of those types of services I think that could go a long way

[00:43:05] [SPEAKER_00]: to kind of improving on the long-term quality and long-term health of society but again even

[00:43:11] [SPEAKER_00]: that alone might be challenging to push through legislatively so you're the point that you're

[00:43:16] [SPEAKER_01]: making there is great that we know that but still you're going to have to figure out how to

[00:43:21] [SPEAKER_01]: operate within a context that values the short term to a much greater degree so figure out

[00:43:26] [SPEAKER_00]: how to do it within a fee-for-service model yeah that's our bias I mean we're trying to do more

[00:43:32] [SPEAKER_00]: within the ecosystem and it helps our providers feel better about our organization the fact that

[00:43:38] [SPEAKER_00]: we do focus on quality even regardless of how it's paid that's a positive thing as a provider

[00:43:44] [SPEAKER_00]: organization to be focused on especially in today's world where you talk about you know the

[00:43:49] [SPEAKER_00]: challenges of being a primary care physician today half of it's the busy work but half

[00:43:54] [SPEAKER_00]: it's just the realization that you're not really doing high quality work because of the constraints

[00:43:59] [SPEAKER_00]: of the system and I think that's what creates what we call moral fatigue or this kind of challenge

[00:44:05] [SPEAKER_00]: of purpose for a doc so many docs you know I just got back from my med school reign and it's just

[00:44:10] [SPEAKER_00]: like we went into the profession wanting to care for patients and this kind of vision is

[00:44:16] [SPEAKER_00]: increasingly eroded as just the operations have made the practice not just kind of

[00:44:21] [SPEAKER_00]: lifestyle unsustainable but just at some of them morally unsustainable yeah that's really

[00:44:26] [SPEAKER_01]: interesting that you say that and okay so now I'm connecting a dot back to what we were talking

[00:44:30] [SPEAKER_01]: about at the top of this conversation relative to the people are really important like you can't

[00:44:34] [SPEAKER_01]: process your way into amazing people who really care so if you're trying to recruit and attract

[00:44:40] [SPEAKER_01]: great doctors who really care which can solve for a lot just having people and colleagues who

[00:44:48] [SPEAKER_01]: are thinking about things in a really innovative way and able to build these patient relationships

[00:44:55] [SPEAKER_01]: etc so if you want to attract a great staff then doing some of this stuff may not be in air quotes

[00:45:01] [SPEAKER_01]: financially immediately rewarding but it could wind up in a very significant way contributing

[00:45:09] [SPEAKER_01]: to getting the right people who actually do in a direct way contribute to all the stuff

[00:45:14] [SPEAKER_01]: that we're talking about that is going to make a primary care practice a pure play both financially

[00:45:19] [SPEAKER_01]: sustainable but also in such a way that delivers on the promise of primary care yep exactly do you

[00:45:27] [SPEAKER_01]: have anything that you want to sum up here with any words of wisdom or advice just having done

[00:45:33] [SPEAKER_01]: and been as successful as you have been in the industry I do feel like a lot of people are

[00:45:39] [SPEAKER_00]: pitching value in an easy to consume way and I would just be sanguine and wary about anybody

[00:45:47] [SPEAKER_00]: pitching quote-unquote ROI or cost savings in a turnkey fashion I just think it's much more

[00:45:53] [SPEAKER_00]: complicated and challenging to truly do mean we're all interested in long-term total

[00:45:59] [SPEAKER_00]: cost of care reduction while improving quality I think it's harder to achieve than most people

[00:46:04] [SPEAKER_00]: realize and I think we should be somewhat humble by the opportunity and also the ability to get

[00:46:11] [SPEAKER_00]: there quickly that being said we're learning a ton and we're starting to see the needle moving on

[00:46:16] [SPEAKER_00]: a lot of populations from total cost of care and quality and so on the bright side I do think

[00:46:22] [SPEAKER_00]: it's quite possible for organizations to get there and I do think that the American society has

[00:46:28] [SPEAKER_00]: the potential to get there in a reasonable time frame let's call it the next five to ten years to

[00:46:34] [SPEAKER_00]: really validate improving of the cost trend while improving quality and hopefully the long-term

[00:46:41] [SPEAKER_00]: livelihood of our population and so I do think that there is light at the end of the tunnel

[00:46:46] [SPEAKER_00]: but we have to be patient and somewhat committed to working together on solving this thing but

[00:46:51] [SPEAKER_01]: I do think it is solvable great advice is there anywhere that you would direct our listeners

[00:46:56] [SPEAKER_00]: to learn more about your work Dr. Tom Lee? Yeah I mean outside of our website I don't have anything

[00:47:01] [SPEAKER_00]: else to point you to I tend to be kind of heads down so if anything this podcast and others but

[00:47:07] [SPEAKER_00]: that would be kind of a circular loop if I had you referred back here so listen to the show

[00:47:12] [SPEAKER_02]: again and again and again Dr. Tom Lee thank you so much for being on Relentless Health

[00:47:18] [SPEAKER_01]: Value today thanks Stacy so let's talk about going over to our website and typing your email

[00:47:23] [SPEAKER_01]: address in the box to get the weekly email about the show that has come out sometimes people don't

[00:47:29] [SPEAKER_01]: do that because they have subscribed on iTunes or Spotify and or we're friends on LinkedIn what you

[00:47:36] [SPEAKER_01]: get in that email is a full and unredacted unedited version of the whole introduction

[00:47:43] [SPEAKER_01]: of the show transcribed there's also show notes with timestamps just a prize in you of

[00:47:48] [SPEAKER_01]: the options that are available thanks so much for listening