David 0:00

In many groups, more than half of employees don't have a primary care relationship. What problems does this create, and what does reducing that percentage mean to your claims costs? We'll find out on this episode of Shift Shapers.

Announcer 0:16

Change either paralyzes or energizes. The choice is yours. You're listening to the Shift Shapers podcast. You're about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change you want to see. This episode is brought to you by Shift Shaper Strategies. In sales, if you confuse, you lose. Clarify your message so you win more clients, crush your sales goals, and build your practice. Learn more at ShiftShaper Strategies.com. And now here's your host, Story Brand Certified Guide and Chief Transformation Strategist at Shift Shaper Strategies, David Saltzman.

David 1:08

You know, in many groups, more than half of all employees do not have a primary care relationship of any kind. That's a huge impact both on their health care and also on claims. The question we're asking today is what can be done about that, and how do we start creating a bigger community of primary care providers so that there's better access across the country? And we've invited Ankeet Patel, who is president and co-founder of Perl Health, to join us to talk about just that. Good morning, Ankeet. Good morning, David. Really nice to be here. Thank you. Our pleasure to have you. Let's talk a little bit. I mean, I kind of gave a little tease at the opening, but let's talk a little bit about the scope of the problem, both in terms of patient access and also in terms of results that happen because we don't have those relationships.

SPEAKER_02 1:55

Yeah, so really again, thank you for having us here today. You know, we at Pearl have been on a mission to really help push primary care into what we think is the next phase of this shift that is happening in the industry. You know, for the longest time, especially over the last decade, the industry has been talking about providing more access to patients and shifting to what we call value-based care as opposed to structures in which providers are reimbursed based on the volume of services that they provide. You know, one of the things that's happening is that there's an increasing movement across the industry to shift the ways in which primary care doctors are paid. And rather than being paid on a straight, you know, per unit per service methodology, there's now this kind of notion of what I would like to describe it as almost like a Netflix type of model where you're getting a subscription service, you're getting a fixed monthly payment to the doctor for providing care to an individual patient. So Dr. Saltzman would be the doctor, Unkeith is the patient, and rather than me coming in and you billing for the services you provide to me, there's just a monthly revenue stream that you're receiving as a physician, and you're now responsible for taking care of my care in whatever setting that is most effective, in whatever manner is most efficient. It's almost in a way to think about it sort of a 24-7 type of model. And what we at Pearl have been really excited about is building out essentially a technology platform to help physicians sort of manage that transition across multiple different types of revenue lines, you know, and where that opportunity may be present for them to kind of better treat their patients.

David 3:28

So before we get into what impact that will make, am I wrong or does it sound like we're going back to the old days of the front end of capitated HMOs?

SPEAKER_02 3:38

Aaron Powell So this is the question that we get a lot. And to some extent, there are a lot of elements and principles, and I know that gives a lot of folks in the industry pause because that experience in the 90s, in many circumstances, did not end particularly well. There was one very large medical group that got a lot of press during that time when things didn't turn out the way they needed to, both from an outcome standpoint, but then also from a standpoint of financial solvency. I think the thing that is different this time is that we now have the technology infrastructure and the data to ensure that capitation is coming with accountability. And so in addition to receiving that fixed monthly capitated payment, physicians are now being measured on outcomes like hospitalization rates and readmissions to ensure that the allocation and the services are going towards improving clinical quality. But then in addition to that, there's a process by which, you know, different payers, different organizations have different ways of setting what we would in our industry call sort of the benchmark or the target amount of dollars and holding physicians accountable to that number.

David 4:42

Well, you know, I think in fairness, I think when Alan Enthoven and that bunch first envisioned HMOs as we knew them in the 90s, that was the original idea, although metrics were harder to come by. And it worked great until the accountants got involved. And then it kind of went downhill because we had denials of care and they made it even more difficult to get referrals and all of that kind of pattern stuff. But fairness aside, let's let's go back to what is that impact of not having this kind of population accessible to patients?

SPEAKER_02 5:10

I'll give you just a sort of personal example of my motivations and what I've sort of been very passionate about. So my family is actually British, and many of them practice medicine in the UK. And I've spent a lot of time, you know, as a child, you know, I used to spend my summers there. You know, I recently, before the pandemic, had just gone to visit my uncle. And the way his his practice operates is, you know, and obviously it's a different system, but you know, the NHS draws a circle on a map and says, Dr. Patel, these are your patients, and the patients get a letter and say, Your doctor's Dr. Patel. And he gets a capitated payment, and that capitated payment is adjusted based on population health metrics. And I very distinctly remember as a child spending time with my family, he would do home visits, he would get phone calls in the middle of the night and at 2 a.m. be in the car going out to visit a patient. You know, and I just remember I came back to the States, you know, I grew up in the Carolinas, got the stomach flu, and I just felt so awful. I was like 12 years old, and it's like, oh my gosh, I have to get in a car and physically drive 20 minutes to go see a physician, and I just never understood why my uncle was getting in the car over in the UK, but I'm the sick one getting in the car to go see my doctor. You know, on my last trip, you know, we went out, you know, into the local village and we got on a bus, and he knew the bus driver who's 26 years old and had a little chat with him, talked to him about, you know, his latest immunizations. You know, there was another group of individuals that were elderly that he had been treating for 30 days, and it's just sort of like he carries his doctor bag with him the whole time. And I think when we talk about access to patient care, what I believe has happened over the last 10 years is we have rightly moved the industry towards value, but we have done it in a way that has not really promoted access to patient care in a world where we are seeing a shortage of clinicians, an aging population that needs more clinical care, and increasing health disparities, we really need to start thinking about a system that can allow for providers to cover a broader swath of the patients in their community and to do so in a way that's improving the population health metrics that we care about.

David 7:09

I'm curious about something that you said. You said that the capitation amounts are changed based on or adjusted based on population health. Is that the population of patients assigned to the individual physician? Is that regionalized? How is that done?

SPEAKER_02 7:22

I will plead a little bit of ignorance. I mean, this is, you know, I can't speak in them not the expert on the NHS system, but what I will say is that what we are sort of participating in now at Pearl and working with physicians to support is Medicare has actually created a new program called the Direct Contracting Program. And a little bit about that program for your audience, you know, traditionally CMS, which is the Centers for Medicare and Medicaid Services, has had two main strategies for where beneficiaries are receiving care. They're going into in the Medicare traditional program, which is what we call original Medicare, and then there's the option to have a selection into Medicare Advantage. And for the longest time, these were two separate programs that had two separate and distinct features. And what the direct contracting program is doing is it's really opening up some of the flexibilities that have been available and made available under the Medicare Advantage program that have not been available to traditional Medicare populations, those who are in original Medicare. And what that means is that providers now have the ability to change and reduce the out-of-pocket costs for beneficiaries in a way that was only available in the MA program. They now have the ability to create preferred networks of specialists that the primary care doctor has identified as the clinicians that they partner with in the management of patients' care. And at least for us, what's exciting and why we're sort of making support for doctors who are entered into this program to your early point, you know, as it relates to sort of the 90s experience, you know, coupled with what we want to be seeing for patient access. In original Medicare, as you may know, there is not this strategy of doing utilization management. There is no sort of denial of care. This truly is an open access Medicare beneficiaries who are in Original Medicare can see any doctor that they want. And we're now really starting to see this move inside of Original Medicare to test out whether or not capitation can be the next evolution of this kind of value-based care movement to give better access to patients. You know, for us, we're very excited when we meet and come across, you know, physicians who are really, you know, taking a dive into this. You know, these are the entrepreneurs, the innovators in clinical practice who are looking for a new model, want to do things differently, you know, and our goal is to help support them with the right data analytics and technology to allow them to make the best decisions that they feel they need to be making for their patients without sort of the third parties kind of reviewing their claims and getting into the administrative burden that they're so accustomed to given the state of health reimbursement today.

David 9:52

Is this kind of a setup also contemplating or currently doing a good job of giving quality information to patients so that if they're referred or if there's a panel to which they can be referred, they can select one physician over the other?

SPEAKER_02 10:06

Yeah, and I think what this really ultimately comes down to is trying to find a way to help solidify the primary care and patient relationship as that patient is navigating and going through the rest of the healthcare system. You know, today too many primary care providers are dependent on third-party entities to help do that care navigation. And what ends up happening is that this idea of reducing the burden has just added more burden to them in the name of trying to coordinate across 16 different entities. For us, we think that what Medicare has done, and you know, we're not going to suggest that this is something that is, you know, the end-all be-all and a silver bullet for healthcare, but it is a meaningful step for us to test out ways in which we can actually give power back to the primary care doctors, let them be the owners and the managers of their own care management platform, and let them structure the relationship, not just with their patients, but also with the downstream specialist providers in the manner that works best for their own local communities and their patient population.

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David 12:09

What kind of a method do you or does Medicare employer contemplate employing to help Medicare beneficiaries understand the value of having a primary care physician?

SPEAKER_02 12:20

Yeah, so I think that there is a big push, and I'll speak a little bit just in in terms of what Medicare has been signaling most recently, and just some interesting facts, you know, for you, David, and the audience. So Medicare has done a lot of back and forth, and I'll get a little technical here for some of the wonky audience members. There's been this sort of big debate about who is a primary care doctor's patient, right? You have a patient who may live in New York, they travel to Florida, you know, during the winter months, they might be seeing multiple clinicians. Who is the provider that's ultimately responsible for that patient? What we have seen is that no matter how you decide to come up with that methodology, which in Medicare speak we call attribution, it's almost in markets, about 25% to almost a third in some areas where there is no identifiable PCP for a given Medicare beneficiary. And I think the recognition that that CMS has made and in some of the most recent documents and statements that they've made is, you know, an acknowledgement that some of the past programs have not done enough to actually get primary care doctors matched and paired with a specific beneficiary. That is a problem that they're they are looking to solve and they're trying to come up with new programs. You know, for us at Pearl, we really do think that when providers are able to leave the fee-for-service system, are able to operate in a model where they're getting a fixed monthly payment, it is the best next step that can allow us to ensure all patients in a given community can access care. A little bit about how we think about that strategy is from a platform perspective, we want to build out the tools that allow doctors to connect with patients virtually. We want to be able to have them connect inside of the skilled nursing facility or the local hospital where their patients may be seeing. We want them to be able to better engage the nurse practitioners and mid-levels that may be operating in their practice. And if we can set up that type of framework, we can really start pushing the individual practices in a local market to start encouraging them to actually start seeing more patients and taking on more accountability for a larger patient population. Generally, what we when you talk to physicians, you know, we we talk about the sort of number of quote active charts, you know, how many patients are you actively managing? Numbers will generally range from about 2,000 to 2,500. You'll find some areas where doctors will say I have 3,000 active charts, but usually not beyond that. If you just were to do a simple, you know, and we've done this at Pearl, just a simple division where I look at the total number of licensed doctors, you know, from medical boards, it's all publicly information. How many registered PCPs do I have? And then that's my denominator. And what I'm looking at is a total number of residents living in a county. You've got a lot of parts in America where there are about like 20,000, 30,000 patients for every one single PCP in that area. What is our solution? It's not going to be an old system where the doctor is just getting reimbursed and their cash flow and their ability to maintain their practices dependent on how many patients they physically see in a given day. We really got to start thinking more creatively, more broadly about how do we help that physician reach a broader swath of their community and their geography.

David 15:30

To your point, what kind of an impact do you think that this may make on rural areas? And is that a particular focus of Medicare in this program?

SPEAKER_02 15:37

I think Medicare is very much thinking about rural areas. I will say that Medicare has signaled a strong desire to help improve health disparities and health inequity. And when we talk about those terms, you generally see us talking about two populations. It's lower income and minority communities that don't have access to care. And now for Medicare, it's increasingly rural markets, which not only have a shortage of physicians, but if you think about the aging population, that's generally where the next generation of Medicare beneficiaries are more likely to be living. And you're seeing big jumps in the number of Medicare enrollment in those types of markets. You know, we at Pearl have been kind of working with all kinds of practices, and we certainly have a large footprint of physicians that we work with who are in those rural markets who are, you know, quite frankly, just asking for help, very excited about the direct contracting program, and very excited about the opportunity to really think about addressing the pressures that they're feeling from the increasing demand, but with no sort of you know requisite increase in the resources that they're getting to be able to support that aging population.

David 16:40

Do you see more primary care docs being attracted to this kind of a model? And and when they're not, what are their objections?

SPEAKER_02 16:48

Yeah, great question. So I think that we're getting a lot of traction to this notion of capitation for a couple of reasons. One is the reality of the last two years is that COVID has put incredible amounts of stress on primary care practices and providers across the system, just writ large. I mean, when you are on a volume-based system and a pandemic arrives and your volumes drop precipitously, it's a recognition that maybe we don't want to go back to the old way of doing things. I think the second side of it, for those doctors who did live through that managed care era of capitation in the 90s, they're very excited about the prospect of us being able to share with them more real-time data, more information that allows them to shift their workflow in their practice towards a new model of care that is aligned with that capitated model. You know, I think that, you know, to answer your question on the hesitations, a lot of people, a lot of in the healthcare industry, I don't have a better way of saying it, but but quite frankly, they've just been burned before. There are so many companies that have come through so many models, so many different approaches to doing value-based care, and it hasn't worked out. And you get a lot of folks who are very intrigued and very excited, but you know, they're a little bit risk-averse. I mean, they they've already seen this movie a number of times. You know, we're very excited to continue to work with them and partner with them, even if they're not ready to jump into capitation today. I will tell you the number one thing that I get is like, you know, who are the doctors in my community that are already sort of working in this space? And, you know, it'll be Dr. Saltzman and they'll say, Great, we'd we'd love to come back and talk to you in six months, and you know, would love to, you know, get Dr. Saltzman's perspective on on how it's going. And you know, we're happy to help facilitate that.

David 18:26

You know, it di especially since we're recording this during annual open enrollment for Medicare, the amount of advertising for MA plans is just every second level has been celebrity and athlete, seems to have a commercial, um, including Jimmy Dynamite Walker, pushing MA plans. How is Medicare planning to get the word out about this particular population and this particular methodology of hooking a patient up with a doc?

SPEAKER_02 18:54

I'm so glad that you asked this question. I mean, I'll just say that I you've had a couple of episodes in the past on MA versus E for service, and before I have any family members switching over to MA, I send them sort of at the Apple Podcast link to just say, you have to listen to this before you buy into um you know what this MA broker is is selling to you. I will say that right now, Medicare has been relatively silent. It's a conversation that we as an organization would like to engage Medicare on alongside our physicians. You know, I do not believe that Medicare to date has done a good enough job of communicating on behalf of original Medicare what the benefits are, what Medicare, traditional original Medicare offers compared to these MA plans. And you're exactly right. What has happened is that you've got a lot of marketing touting the benefits of MA. I'm not going to suggest that there aren't instances that where that is not appropriate for a member. I I've spent time working in the Medicare Advantage space, worked at a health plan myself, and you know, but I do think that Medicare, I believe, needs to do a little bit better about communicating to members the value of Medicare fee for service. I'll also say, you know, to my colleagues, you know, who are at Medicare, you know, it's a real important moment. And as they're doing, you know, thinking about the models for the future. They recently announced a kind of strategy reset for original Medicare. And the reality is that Medicare Advantage is continuing to grow. And our hope is that we have the flexibility within the regulatory framework for our physicians to be able to communicate to their patients. Here is what, and I'm going to speak beyond direct contracting. We think it's kind of the best program, but here's what direct contracting is, here's what an ACO is, here's what another primary care program means for you, and what you may be losing if you were to switch over to a Medicare Advantage plan.

David 20:38

And that's a great place to end our conversation for today. I'm Keith Patel, president and co-founder of Pearl Health. Thank you so much for sharing this interesting new program with our audience.

SPEAKER_02 20:47

Thank you so much. Really happy to be here.

Announcer 20:49

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