Day 3 Notes from the forty second Annual J.P. Morgan Healthcare Convention

Searching on the San Francisco skyline from the highest ground of the Westin St. Francis on Day 3 of the 42^nd Annual J.P. Morgan Healthcare Convention, the enduring Transamerica pyramid is just not too distant. However my thoughts, being chock-full of value-based care displays, rapidly imagines the constructing because the shining pyramid of affected person segmentation and danger stratification, envisioning the correct approach to kind sufferers for efficient intervention and whole value of care discount. John Kao, CEO of Alignment Healthcare, shared right now that solely 12% p.c of their Medicare Benefit membership accounts for about 74% p.c of their institutional value (hospital and facility prices), whereas conversely their “wholesome” membership of 74% accounted for under 5% of their institutional prices. As of late, institutional prices and pharmaceutical prices are virtually equal, in line with the Advisory Board, and collectively far outweigh skilled doctor and different supplier prices. Due to this fact, retaining sufferers out of the hospital and post-acute amenities as medically attainable and applicable and successfully managing medicines ought to lead to a big discount within the whole value of care, proper? So, what’s not taking place that needs to be?

So Apparent, However So Uncommon

The most costly section of the inhabitants typically is the advanced, polychronic affected person on 10-20 tablets per day who must be handled at residence resulting from being frail, restricted in mobility or cognitive perform, or in any other case burdened. In speaking with a number of main corporations, these sufferers sometimes have at the least 5-7 instances better expense than the typical affected person. There’s rising deal with this inhabitants section, with corporations like Landmark/Prospero and WellBe Senior Medical, however I used to be struck with a jaw-drop second whereas listening to Jeff Kang, CEO of WellBe current right now. After all, there have been the anticipated substantial medical expense discount and the 30% – 35% discount in hospital admissions by offering a ChenMed-like clinic expertise within the affected person’s residence within the area of a 60 to 90 minute go to. That’s nice, however that’s going to be desk stakes.

The shock got here for me when Kang detailed how WellBe had dropped emergency room visits per 1,000 members by 30%. WellBe maintains employed paramedics on employees who reply inside half-hour to Tier 1 pressing conditions. The paramedics drive a SUV that’s outfitted with every thing an ambulance carries (however they don’t present transport to the ER if wanted). By using paramedics to take a seat round and be quickly out there for emergent/pressing response wants, WellBe can present on-site decision of many healthcare points and keep away from ER and transport prices, to not point out the doubtless follow-on admissions in fee-for-service primarily based hospitals, leading to hundreds or tens of hundreds of value financial savings. By offering this and likewise the WellBe assigned doctor’s direct cellphone quantity, WellBe studies that its sufferers obtain a sense of private well being safety. Let’s dwell on that for a second. For these of us who’ve interacted with the healthcare system as sufferers or relations of a affected person, the system is just not set as much as make sufferers really feel safe and properly taken care of – and that’s why this reported affected person expertise stood out in my thoughts. 

The WellBe totally employed supplier mannequin is also properly engineered to construct retention. WellBe supplies its well being plan prospects with a assured decrement to base medical loss ratio (MLR), and the well being plan supplies the WellBe service to members as an incremental profit. WellBe providers aren’t a alternative of the first care doctor relationship, however the addition of this geriatric specialty focus. So, if a affected person is considering altering well being plans, they are going to lose the WellBe profit – and entry to the house visits and cell paramedic response. So, a win-win, one for the affected person with the entry to their very own geriatric targeted doctor (along with their main care doctor) and the cell paramedic speedy response, one for WellBe with its asset-lite method that doesn’t require the constructing of high-priced clinics, and one for the plan with better affected person satisfaction, probably increased Star scores, and a excessive barrier to member plan switching. Elegant, apparent and never widespread sufficient in right now’s market.

Shifting Down the Pyramid

Beneath the at-home section, there’s the excessive danger member section that usually is greatest handled in an extended go to in a main care or multispecialty clinic with increased frequency of visits (greatest practices are at the least as soon as per 30 days for comparatively steady excessive danger polychronic sufferers). Examples of this method are discovered with ChenMed, Oak Avenue Well being and others, however not often are discovered the place many sufferers and physicians congregate as of late – in hospitals and well being programs. 

It was heartening to listen to from Novant Well being, with rising operations in North and South Carolina, that they teamed with Ochsner in the summertime of 2023 to launch risk-bearing senior main care clinics which can be structured to present sufferers the time and a focus they want. As with ChenMed, affected person panels for physicians are between 300-500 members. This revolutionary method has not typically been undertaken by well being programs but, so the Novant/Ochsner initiative was a breath of recent air. Novant intends to proceed to develop this mannequin, which is meant to be a part of its “exceptional healthcare expertise.” Novant has been innovating with the creation of doctor strategic councils, a administration providers group partnership with Privia Well being, partnerships with physicians on ambulatory care networks and different initiatives.

The Curious Rigidity Between Entire Particular person Care and Specialty Worth-Primarily based Care

The excessive danger member section additionally might be segmented into power illness administration initiatives, akin to described on the convention within the kidney care sector by Attempt Well being, Somatus and Monogram, in addition to undertaken by Duo Well being. In a few of these fashions, there’s a pairing of each nephrologists and first care physicians, supported by a pharmacist, social employee, nurse practitioners and nurses, behavioral well being practitioner, nutritionist and numerous specialty physicians, akin to pulmonary, endocrinology, palliative care and geriatric. Due to the excessive degree of co-morbidities, this coordinated care “complete particular person” method can deal with the broader vary of affected person wants in a single supply method. It can also cut back gaps in care the place medical and different healthcare providers are a la carte and should be obtained by way of affected person initiative from numerous, disconnected care suppliers. As Attempt Well being famous, there at all times has been numerous info from these sufferers, however nobody was integrating the knowledge. 

Attempt urged that specialty value-based care (VBC) is the subsequent wave. Up to now, the switch of danger from well being plans has been occurring initially to main care, however main care by itself can’t totally deal with the high-cost illness states of a polychronic affected person and subsequently sure illness states could also be greatest managed by way of a specialty/main care targeted multi-specialty method. 

Excessive Value Persistent Circumstances and Threat

What are the highest three or 4 highest value circumstances that could be greatest managed beneath a specialty VBC mannequin? Attempt urged kidney care, most cancers, cardiology and musculoskeletal/orthopedics ailments (MSK). I’d agree, but additionally would possibly contemplate including in rheumatology as properly, given the excessive drug value and spend. We’ve seen a really excessive degree of exercise within the kidney care sector transferring towards danger. Lately, previously 12 months we have now began to see a resurgence of an earlier development to create VBC/danger preparations in oncology. We had labored with early fashions for that within the oncology sector years in the past, solely to see these efforts halted on account of sector M&A consolidation occurring. 

Cardiology additionally could possibly be a goal for VBC/danger, however the kind and design of the chance attribution will should be rigorously thought of, as, much like kidney care, cardiac care typically is for polychronic sufferers who might have diabetes, weight problems and MSK points. On the MSK facet, we’re persevering with to see aggregation of orthopedics teams, particularly by non-public fairness sponsors, and persevering with work with bundled fee preparations, however the presence of true risk-based preparations in orthopedics/MSK continues to be restricted. In Arizona, HOPCo (Healthcare Outcomes Efficiency Firm) lengthy has efficiently taken danger on orthopedics, however that mannequin has not unfold extra nationally – but!

That stated, the query stays as to find out how to greatest section and likewise coordinate the care, in order that we aren’t confronted with a v.2 of the “old fashioned” hospital paradigm the place a affected person is seen by a heart specialist who solely cares in regards to the coronary heart, an orthopod who solely cares in regards to the elbow and a proctologist who can’t inform an elbow from an…properly, you get it. We as an trade are persevering with to experiment however haven’t but achieved constant efficiency and consensus on when “complete particular person care” works and when specialty care works greatest. 

That is nonetheless a bigger downside systemically as properly, as industrial employers, in search of to restrain prices, are accelerating efforts to designate and like “facilities of excellence” (COE) that do sure issues properly however aren’t essentially coordinating or quarterbacking complete particular person care. For sure issues – like a joint alternative – this will likely work wonderful, however for multi-causal or multi-faceted illness states, one should wonder if the COE method is an finish level or a cease hole resolution.

The Multi-Specialty Group Resolution

It does seem clear although that for the best value sufferers a coordinated care, multi-specialty group method works very properly. We additionally see this mannequin not solely in a few of the examples famous above, but additionally in high-performing PACE packages that preserve seniors unbiased and out of expert nursing amenities, though their illness burden qualifies them for that costlier degree of care. Of their presentation, Privia Well being famous their strategic deal with the constructing and development of multi-specialty medical teams as their most well-liked go-to-market technique. 

Privia’s market entry technique typically is to enter with main care physicians at a minimal and so as to add specialists to construct a bigger built-in multi-specialty medical group. This method permits not just for coordinated care, but additionally addresses the crucial situation of downstream prices. Parth Mehrotra, CEO of Privia, famous that greater than 80% of prices sit downstream from the gatekeeper doctor, akin to specialist referrals, imaging, laboratory and different ancillary providers. Having an built-in group that may present real-time visibility and aligned compensation incentives permits for each high quality and consequence, in addition to monetary administration. Within the virtually 15 years that Optum has been buying doctor organizations, they’ve targeted additionally on multi-specialty clinic fashions the place attainable, akin to with Kelsey-Seybold, CareMount, Polyclinic, Everett and others.

Doctor Habits Change

Usually, the said choice of patrons for multi-specialty, employed doctor organizations is that the worker mannequin permits for higher doctor alignment, visibility and accountability. However, Aledade made the purpose that conduct change is feasible with out proudly owning the apply. Within the Aledade mannequin, they use their playbook, their cell app and the 150 coaches Aledade has throughout 46 states to coach and assist their physicians. The mixture of the app expertise and the non-public assist from the coaches can deal with doctor considerations and cut back inappropriate variability.

This standardization is a vital level. Recall the 2014 blockbuster article by Atul Gawande throughout the ACA adoption that identified the broad vary of variability in practices and pricing amongst McAllen, Texas physicians. It subsequently was intriguing to hearken to Monogram Well being focus on that they’re establishing a longitudinal care administration system to systematize scientific interventions. They’ve created 12 excessive worth protocols to be adopted by their medical doctors, together with order units for use in such protocols. Monogram believes that its distinct scientific interventions enhance high quality outcomes and reduce the overall value of care. It will likely be attention-grabbing to comply with their progress with this method and see whether or not it may be extra broadly relevant. 

As at all times, heaps to contemplate from the three days up to now of the J.P. Morgan Healthcare convention!