Transcript for Beyond the Stethoscope Vital Conversations with SHP Episode 4 – Impact of Value Based Care Trends | With Sean Cavanaugh – Part 2

John Crew

It seems like to me and maybe you could touch on this There’s a very distinct difference between the traditional Medicare patient, they’re white blue and the MSA population and what I mean by that is in a sort of varies from state to state in terms of how it’s covered how maybe a Part D is wrapped in in part, B and others. Can you share just a little bit from your perspective the difference in the in the two models and in what and if anything is different for the physician to be successful in those things.

And the and the MA side, I apologize.

Sean Cavanaugh

Yeah, as you said MBA is growing rapidly. It’s competitive market with E 10 to have four or five big national companies and then often.

A long tail of smaller plans locally within a market. You tend to see a convergence on the types of benefits being offered but they can vary from market to market.

What we’ve told our practices is you know the good thing about MMA is even though it might be you might have working with Aledade you might have three or four MA value-based contracts. But the Stars rating quality measures are gonna be the same across all of them so you’re trying to do the same quality care.

As you said the populations can be somewhat different you know what is attractive about Ma Ma is good for people who need financial protection? Who are willing to work within a defined network of providers, but don’t have a lot of money out of pocket and specifically can’t afford a Medicare supplemental policy so you do see.

Often, lower income communities gravitating toward that product, but you know as we approach 50% of the Medicare population and if it keeps going north of that the differences will not be that stark. It’ll be more like the Medicare population as a whole. But we do see that particularly in certain regions of the country.

John Crew

You know you touched on something there that really is a a challenge for providers as we’ll talk to them. You mentioned those that are coming into the market build and then made platforms and they’re seems to be an awful lot of VC funded organizations that are coming in and they’re as to your point. There are those that are known and that there’s a lot. That’s unknown. The one thing that seems to be a prevailing model is in in terms of exposure for physicians are these that come in. They’re either looking to build a model.

And sell it to someone else or they’re looking to maybe build it and go public either way. There’s there’s this natural instinct from providers thinking. Everything’s a short term relationship? Can you can you sort of talk to that in a minute?

Sean Cavanaugh

Yeah, I think what you’re getting at is because MA is growing so much and because the big companies are you know long standing you know legacy. Companies like United and Aetna. There’s a perception that there’s an opportunity for smarter startups to come in and beat them at this business.

I’ve seen some good one, it’s like a lot of businesses. You see some really cool. Interesting ones, and you see some that you roll your eyes at and I think. I worry about the ones we roll our eyes at cause as you said. Medicare Advantage can be so lucrative you know you could start a business enroll a bunch of people and just sell the company and probably get rich. At Aledade, we’re pretty wary about doing business with them.

Which are also seeing though is some separation of the wheat from the chaff like?

Those same companies that looked at United and said look at that big dumb legacy company. Our learning that United is not so dumb and there’s a reason. They got big right. Maybe we don’t all support the reasons they got big but they know what they’re doing, and beating them at their own game is harder than it looks but you do see some promising ones. One we’ve known for a while for example, is a plan that’s small but growing called devoted health and I think they have the right values and.

Are in it for the long haul? They could have sold probably they could be rich? By now they needed to, but they seem to be in it for the long haul. They didn’t suffer you know last year. A bunch of them. The startups that went public suffered tremendously in the stock market. So I think over time you’ll see.

You know you’ll be able to separate the good from the bad and there will be some good ones. But we are very careful who we do work with for that reason like there’s no it’s not good for the patient if there’s churning through plans what they need just is a long stable relationship because the challenge with the seniors is managing multiple chronic diseases over the course of their life and so hopefully, the most stable thing in their life is their relationship with their PCP.

John Crew

That’s that thank you so much to piggyback off of that question one of the things that we’re been exposed to for providers that aren’t value-based medicine and excelling in value-based medicine. We are now seeing some of these companies who are beginning to come in regionally back and try to pick up the best of the best in each of the areas that they’re located in and build a new model that’s you know that is all with successful value-based providers using benchmarks from other areas as way to appeal to them.

So you’re you’re beginning to have instead of having a organization that was built and sustainable. You’re having those trying to pick it apart take the best out of it and build another one do you see that as being a problem long term?

Sean Cavanaugh

Potentially, as I said that’s certainly not the Aledade approach validate approach is everybody who wants to do better by their patients can probably get better. You know you don’t.

The other thing I would say is that limitation of that approach is the big plans aren’t looking for narrow networks in MA because that’s not consistent with growing their membership so narrow networks have been popular like in some of the ACA exchange marketplaces where people are paying out of their own pocket.

In some niche markets like that, and not that that’s so niche. It has a lot of people but but in MA even though people are choosing the product themselves. They people are not looking for narrow networks and so I don’t think that approach will have.

A long life in MA unless something changes that we haven’t seen yet. But there are places for narrow network high performers, but it’s not it often gets more talk than reality.

John Crew

Thank you.

Mike Scribner

Sean not to kind of cut a hard left in the discussion. But I guess it when it’s been the last few minutes kind of talking about. From a CMS perspective in general. What do you think is the future of value-based care from from their perspective and where’s the innovation institute going those kinds of things can you talk a little bit about that?

Sean Cavanaugh

Yeah, I think the this group. It’s CMS and the administration more broadly. They spent a good part of their first year trying to. Put out a road map and a statement of values and I think the important things they said were two things one.

We believe in value-based care and we have a goal by 2030 of getting everybody in Medicare and value-based care of some sort and they were a little vague on what that meant but I think what it means is get out of the traditional fee for service world where people are just paid to produce.

You know to produce services and get them into a relationship with someone who cares about the total experience of care both the cost and the quality. MSP’s being the largest example of that, but there are some other. CMS models that would need so that was the first thing they said. Not really that new right the Obama administration said that the Trump Administration said that maybe not in the same words, but said something similar.

The thing they said that was different, though, and that’s you know gotten a lot of attention across the country is a greater emphasis on HealthEquity so not leaving some populations behind whether it’s in value-based care or anything else or an access to care.

And so I think that’s what you’ll consistently see in every action they do is how do we get more people into these models and how? Do we design. These models so providers sign up lower income people providers improve care for lower income people or any community that hasn’t gotten the highest quality of care in the past.

I think both of those are incredibly laudable goals and we support them. They’re also very difficult goals. One you know value-based care, which we’ve dived into wholeheartedly, but you know it’s been a voluntary program. How far can you get involuntary programs.

We’ll find out and in HealthEquity first of all we will not make any progress unless they were shining a light on it unless they’re designing new programs around it. So more power to them, but we also know it’s hard Aledade . It’s been committed to this over the past year. We’ve been focusing on hypertension among African American patients because our founder far as I’d most Shari says that’s where we can save the most lives and so we’ve been we’ve made some improvements, but it’s been hard.

And the physicians love it like they love making a difference in their communities, but it is hard work.

So I think you’ll see, those two themes and in whatever form you know, whatever they’re doing out of the administration. Those will be the themes whether they’re working in traditional Medicare or MA, which are two from a policymaker’s perspective, two very different environments, but they’ll be pursuing the same goals.

John Crew

I don’t wanna throw a curve here, so bear that in mind as I ain’t asked. This question so you know, I appreciate that, your expertise is has been in the Medicare side what we’re experiencing in the various markets. You’re seeing the transition of Medicaid going into value-based models. So have you. Have you guys experienced any of the Medicaid transition models going into value-based and if so can you talk a little bit about what what the challenges of Medicaid value-based is versus Medicare.

Sean Cavanaugh

Yeah, ohh. I’m so glad you asked John because we have. We’ve got. I think hundred 150,000 Medicaid labs in risk contracts value-based contracts. And this came about because we started working with federally qualified health centers in a couple markets in a big way. And we started working with them for Medicare but they quickly said. Hey, you know, we’ve got all these Medicaid patients, so we have a relationship with a couple of plans where we’re taking risks for Medicaid and we’re.

We’re really happy and proud to be in the space but it’s a learning experience. One of the things you find is you know someone gets on Medicare they’re on Medicare for the rest of their life? So they may move through fee for service going to an MSA plan, but they’re in Medicare. The Medicaid population there’s much more churning. There’s less of a traditional attachment to a provider so you know Medicare patients tend to have if anything, too many physicians. Where in the Medicaid population. They many of them? Don’t have usual source of care so you’re trying to establish that.

And then just the clinical differences of you know Medicare population what they’re dealing with are as you know the management of multiple chronic diseases over a logical 2. No period of time. Where in Medicaid, you’re dealing with a lot of moms. A lot of kids some single adults and then the expansion population. But just clinically. It’s the interventions are different, but the good news is if you take a step back.

You know, some of the stuff they need is the same thing they need someone who’s got a 360 degree view of their health? What’s happening to them someone who’s looking at the data seeing when they’re in crisis and reaching out to them and wrapping them in the arms of primary care.

Someone, who’s accountable for the experience their experience of care they’re total cost of care and the quality that they receive so the needs are the same. The tools have to be adapted. I’ll give you an example. Like we in Medicare. We target what we call high priority patients for annual Wellness visits well bring.

The siding, which senior needs to come in for an annual Wellness visit is very different than deciding which six year old child needs to come in for a Wellness visit. O our clinicians. Our statisticians have been working on that and so that the intelligence works its way into our tools over time. But it is a new space. John you’re right like we don’t see a lot of other organizations rushing to take Medicaid risk.

But I think we felt like one we had to service our partners or the federally qualified health centers. If this is important to them. It’s important to us. But also you know, t hese folks need value-based care, too, so we’re going to be provider of it.

John Crew

I know we got it. I know we’re coming to an end. I have one quick question sort of related to that in both the care and The Cave models.

States varied by our health insurance. Let me go back to these varied by what models they have for example, in Georgia. We used to have a lot of gatekeeper models and we no longer have that because it more challenging coming into a state where we’re products are sold that don’t require gatekeepers.

Sean Cavanaugh

Yeah, we get that question a lot like how are you gonna control costs there’s no gatekeepers and we remind people? We learned this business in traditional Medicare where which is the ultimate PO right like there’s no gatekeeping at all. I think you know what I remind people is.

There was a backlash to the gatekeeper models throughout the whole country and people gave up on that for a while with good reason because it was used as a pretty blunt instrument.I think you can get a lot done with you know with your PCP being the gatekeeper your PCP who has your best interests in mind, and it’s not like a regulatory or contractual gatekeeper. It’s more of a quarterback. I’m here to get the best thing for you and spending more money isn’t always the best thing. We’re not worried when there’s no gatekeeper. You know that’s where we learned how to do this and. Yeah, you can save some money that way. But you can get better care. Another way through better PCP, you know, better primary care.

John Crew

Right answer.

Mike Scribner

Thank you. Sean we really appreciate it that was great.

Sean Cavanaugh

It was great talking with you guys.