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Beyond the Stethoscope: Vital Conversations with SHP
Beyond the Stethoscope: Vital Conversations with SHP
Revisit: Impact of Value Based Care Trends | With Sean Cavanaugh - Part 2
We continue with part two of the interview that Mike Scribner & John Crew had with Aledade CCO / CPO Sean Cavanaugh. Where they will wrap up their discussion about value-based care: where it is going, how organizations like Aledade can help, and what this ultimately means for patient care.
Sean can be found:
Twitter @dc_cavanaugh
Learn more about Aledade:
Twitter @AledadeACO
The transcript of our conversation can be found on our website.
Credits
Production Assistance & Editing: Nyla Wiebe
Scripting by: Aaron C Higgins
Show Notes & Transcription: Aaron C Higgins
Social Media Management: Jeremy Miller
News Co-Hosts: Aaron C Higgins & Jason Crosby
Interview co-hosts: Mike Scribner & John Crew
Show Producers: Mike Scribner & John Crew
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Welcome to Beyond the Stethoscope Vital Conversations with SHP. As we take a summer break to prepare for Season 5, we're revisiting some of our most insightful episodes to keep you informed and engaged with the latest in healthcare.
Aaron Higgins:This episode Part 2 from our interview with Sean Cavanaugh, john Crew and Mike Scribner sit down with Sean to explore the evolving landscape of Medicare Advantage or MA, and value-based care. The evolving landscape of Medicare Advantage or MA, and value-based care. Sean provides us an in-depth look at the differences between traditional Medicare and MA, the unique challenges and opportunities posed by startups in the Medicare space, and how value-based care is shaping the future of healthcare, with a special focus this time on Medicaid transitions and the critical role of primary care. Sean offers valuable insights into the complexities of managing patient care across diverse populations. So, whether you're a healthcare provider navigating these changes or just curious about the future of healthcare in America, this episode offers a thoughtful and engaging discussion that remains highly relevant, even today. If you find this episode insightful, please rate and share this podcast in your favorite podcast app. It really helps the show. Thank you for tuning in. Let's dive back into this vital conversation with Sean Cavanaugh.
John Crew:It seems like to me, and maybe you can touch on this, there's a very distinct difference between the traditional Medicare patient they're in white, blue and the MA population, and what I mean by that is MA sort of varies from state to state in terms of how it's covered, how maybe a Part D is wrapped in Part B and others. Can you share just a little bit from your perspective the difference in the two models and what, if anything, is different for the physician to be successful in life science and the MA side?
Sean Cavanaugh:Yeah, as you said, ma is growing rapidly. It's a competitive market. You tend 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 working with Allidade. You might have three or four MA value-based contracts, but the STARS rating quality measures are going to be the same across all of them. So you're trying to do the same quality care.
Sean Cavanaugh: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 percent of the Medicare population and if it keeps going north of that, the differences, you know, 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 challenge for providers. As we have talked to, you mentioned those that are coming into the market, building the MA platforms, and there seems to be an awful lot of VC-funded organizations that are coming in and, to your point, there's those that are known and that there's a lot that's unknown. The one thing that seems to be a prevailing model 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 this natural instinct from providers thinking everything's a short-term relationship. Can you sort of talk to that 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, longstanding 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. 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 worry about the ones we roll our eyes at because, 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. You know, at Allidade, we're pretty wary about doing business with them.
Sean Cavanaugh:What you're 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 are 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 if they needed to but they seem to be in it for the long haul. They didn't suffer.
Sean Cavanaugh: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 it's not good for the patient if there's churning through plans. What they need, just like is a long, stable relationship, because the challenge with the seniors is managing multiple chronic diseases over. You know the course of their life and so hopefully the most stable thing in their life is their relationship with their PCP.
John Crew:Thank you so much. To piggyback off of that question, one of the things that we're being exposed to for providers that are in value-based medicine and excelling in value-based medicine, we are now seeing some of these companies who are beginning to come in regionally 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 a way to appeal to them. So 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, build another one.
Sean Cavanaugh:Do you see that as being a problem long-term? Potentially, as I said, that's certainly not the Allidade approach. Allidade approach is everybody who wants to do better by their patients can probably get better. The other thing I would say is the 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. It's some niche markets like that, not that that's so niche. It has a lot of people. But in MA, even though people are choosing the product themselves, 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 often gets more talk than reality.
Mike Scribner:Sean, not to kind of cut a hard left in the discussion, but I guess I want to spend 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 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 this group at CMS and the administration more broadly they spent a good part of their first year trying to put out a roadmap 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 services, and get them into a relationship with someone who cares about the total experience of care, both the cost and the quality, mssps being the largest example of that, but there's some other CMS models that would mean. 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 health equity, so not leaving some populations behind, whether it's in value-based care or anything, 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.
Sean Cavanaugh: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 in voluntary programs? We'll find out. And in health equity 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. Allidade's been committed to this. Over the past year We've been focusing on hypertension among African-American patients, because our, our founder, farzad Moshachari, says that's where we can save the most lives. And so we've been and 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 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 policy maker's perspective, two very different environments, but they'll be pursuing the same goals.
John Crew:I don't want to throw a curve here, so bear that in mind as I ask this question. So you know I appreciate that your expertise 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 guys experienced any of the Medicaid transition models going into value-based and, if so, can you talk a little bit about what the challenges of Medicaid value-based is versus Medicare?
Sean Cavanaugh:Yeah, oh, I'm so glad you asked John, because we have we've got, I think, 100, 150,000 Medicaid lives and risk contracts, value-based contracts. And this came about because we started working with federally qualified health centers in a couple of 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 plans where we're taking risks for Medicaid. We're really happy and proud to be in the space, but it's a learning experience. But it's a learning experience.
Sean Cavanaugh: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, go into an MA 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 many of them don't have an 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, you know, the management of multiple chronic diseases over a longitudinal period of time, where in Medicaid you're dealing with a lot of moms, a lot of kids, some single adults, you know, 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, 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 their experience of care, their total cost of care and the quality that they receive. So the needs are the same.
Sean Cavanaugh: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, deciding 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. So our clinicians, our statisticians, have been working on that, and so 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, 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, these folks need value-based care too, so we're going to be a provider of it.
John Crew:We're coming to an end. I have one quick question sort of relates to that both the care and the CAID models, states varied by or health insurers, let me get that at least 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. Is it more challenging coming into a state where products are sold that don't require gatekeepers?
Sean Cavanaugh:Yeah, we get that question a lot Like how are you going to control costs? There's no gatekeepers, and we remind people we've learned this business in traditional Medicare, which is the ultimate PPO, right Like there's no gatekeeping at all. 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. So, yeah, get the best thing for you, and spending more money isn't always the best thing. So, yeah, we're not worried when there's no gatekeeper. You know, that's where we learned our learned how to do this. Yeah, you can save some money that way, but you can get better care another way through better PCP, you know, better primary care.
Mike Scribner:Right, thank you, sean. We really appreciate it that was great.
Aaron Higgins:It was great talking to you guys. It is produced and edited by Nyla Weave. Our social media content producers are Nyla Weave and Jeremy Miller, and our executive producers are Mike Scribner and John Kroop. For more information about SHP and the services we offer, including the back library of episodes, episode transcripts, links to resources discussed and much, much more, please visit our website at shplccom. Thanks for listening.
