Crisis in Care: Solving the Primary Care Puzzle for Employers – Part 2

In part two of our three part series on the mounting primary care crisis, we will continue our discussion from August on the impact on employers. Our panel of experts will provide insights into how carriers are addressing the shortage, as well as what they believe employers can do to help combat this crisis. 

In This Episode, You'll Learn:

• A carriers perspective on why we are facing such a crisis 
• What strategies have been put in place to help reverse these trends
• What has worked effectively and where are efforts falling short
• How employers, the payors of healthcare, may be able to influence these trends

This is a must-listen for HR leaders, benefits professionals, and executives seeking sustainable healthcare strategies that work for both their people and their bottom line. 

Transcript

0:05

Welcome to The Pulse, where we keep pace with what's trending in employee benefits. I'm your host, Mary Delaney, managing partner of Vital Incite an Alera Group Company. This series was developed to bring together nationally recognized subject matter experts from the health and pharmacy industry, as well as top academic and research institutions. Our goal is to provide unbiased information and offer scalable strategies that give you clarity amid the chaos, and provide answers to your most burning questions. Today is Part 2 of our discussion, Crisis in Care, Solving the Primary Care Puzzle for Employers. This crisis is so critical that we've continued the discussion to give employers the insight they need to develop effective strategies when the current solutions are falling short. To set the framework, let me restate some facts discussed in our last podcast. The ideal ratio of primary care providers to specialists is 1-to-1. But according to Kaiser Family Foundation, only 24% of US healthcare providers practice primary care. That imbalance alone should give us pause. And the challenge is only growing. Fewer medical students are choosing primary care due to lower reimbursement, overwhelming patient loads, and the increasing difficulty of delivering quality care in that environment. It's a vicious cycle. The fewer providers we have, the more strain we place on those who remain, and the harder it becomes to fill those roles. Let me hit you with a few more numbers that bring this crisis into focus. The ideal provider-to-patient ratio is 1-to-1000. In the U.S., primary care providers are often managing 2,500 to 3,500 patients – more than double and even triple what is ideal. And even with that, about one third of our population doesn't have a primary care provider at all. In the rural communities, the shortage is even more severe. Nearly 8% of counties in the US don't have a single primary care provider. This crisis has a ripple effect on employers, resulting in poor preventative care compliance, later stage disease diagnosis, poor chronic condition control, increase in non-emergent ER use, and even more specialty provider engagement. Because of this, employers are trying different strategies, including leveraging concierge services, DPC direct primary care, on-site and near-site clinics, and even virtual primary care. And as we have always seen in the US healthcare system, while the demand continues to grow, we're seeing new vendors and models of care popping up everywhere. But we need to ensure that these solutions are designed for long-term success, not just short-term gains. In this discussion, I'm joined by two experts in healthcare innovation working on the carrier side. These experts will provide insight into how carriers are addressing these shortages, as well as what they believe employers can do to help combat this crisis in ways that are sustainable and have a long-term impact. So with that, let me introduce you to these incredible panelists. Laura Fox, MPH is the Director of Payment Innovation at Blue Shield of California, and is the leading expert in value-based care. Laura leads a dedicated team within the healthcare quality and affordability unit. Her team is focused on designing, building, testing, and expanding innovative approaches to pay for healthcare. Under Laura's guidance, the payment innovation team has successfully developed and scaled more than 18 value-based payment models for primary care, hospitals, and specialty services throughout California. Laura has a background in public health and believes that changing how we pay for healthcare will help us improve health for the entire population. Laura, I hope you're right and I hope we get there. Thanks for joining us today. Thank you. Very happy to be here and join the discussion on primary care. Great. Well next we have Dr. Amy Milewski, MD, MBA. Dr. Malewski is board-certified family medicine doctor with more than 13 years of experience in private practice and over 10 years of experience in healthcare administration and clinical leadership. Dr. Malewski joined Blue Cross Blue Shield of Michigan in 2013. Her team is responsible for providing clinical leadership for provider value-based programs in risk contracting. She also leads the behavioral health strategy and planning team responsible for development and implementation of the behavioral health system for Blue Cross Blue Shield of Michigan. Dr. Malewski, thank you so much for joining us in this very important conversation. Thank you, Mary. I'm glad to be here today. So with that, let's get started. So clearly both of your organizations have seen the value in primary care, since your companies have invested in strategies to create change. Can you summarize from a carrier perspective why solving this crisis is critical to your organization? What value is there in primary care? What does a valuable primary care relationship look like, and what value does it offer? Yeah, Mary, I can jump in and start. So we at Blue Cross Blue Shield of Michigan very much feel that primary care is the foundation of our healthcare system. There are a lot of challenges to that, which I'm sure we're going to get into today, but the value that a primary care relationship has is tremendous in terms of…there's many, many studies going back 20-plus years showing the value that primary care delivers to communities and to populations. It improves quality of life. It improves longevity. It improves the efficiency of the care that we receive. Which means it makes care more affordable, which now when we look at all of our premiums as we try to pay for healthcare as a family, you know, families are wrestling with premiums that range, you know, in the thousands of dollars, right? In the level of…equivalent to their mortgage payments. And so it's really important that we, you know, while we think about the quality of care, that we're also balancing that with making sure that everybody can afford it as well, as we move forward, and that's something that primary care does well. When you look at what, you know, how does, should a primary care relationship look in terms of delivering that value, it's really tied to the longitudinal relationship. So that care that's delivered over time by a practitioner who knows you, knows your family system, knows the social supports that you have. So it really is all about that relationship that helps to manage that dynamic. And then also, taking a patient-centered approach. And when we say that, what that means is it's, you know, I'm your guide as their primary care doctor. And my job is to empower you with information so that you can make the best decision for what's important for your life and help you to enable around those medical decisions. Because what's important to me might be different than what's most important to you in terms of you know, an outcome. And so that's what our goal is – kind of keeping that patient center, empowering them with information so that they can partner with us, you know, in making decisions about their healthcare. That's great. Thank you so much. Laura, anything to add to that? Yes. No, Amy, great, great points. And Blue Shield also does believe, you know, primary care is the foundation of the healthcare system. And there was a great report that came out a few years ago, the National Academy of Science and Medicine. The NASEM paper that said, you know, this is how we should be paying for healthcare. This is what a advanced primary care looks like in high quality care. And it's what we've done as a payer is that, okay, how do we embody that? How can we take all of the data, the research and really think about how do we make primary care the foundation of the healthcare system so that we can improve quality, affordability, both patient and provider satisfaction? You know, how do we take our key role as a health plan in the state of California and drive high-quality primary care? And there's many things we have to do in order to drive that high-quality primary care. As Amy called out, there are many papers that said the more you link to primary care and invest in primary care, the better outcomes. So how do we as a health plan really set that up and support that? So we've developed different ways we pay for healthcare and primary care. Meeting our providers where they are, from small independent providers to large healthcare systems, really understanding that difference so that we can make sure that we're setting up that stickiness between the provider and the patient for that long term, that longitudinal relationship that we know is so important in order to receive those health outcomes. And as part of that, we have to do it in a multifaceted way. We have to set up how we pay for healthcare. We have to help support our providers in terms of being successful in that delivery, as well as sometimes maybe we can't do it alone. And who are those key partners, or even competitor, that we have to partner with in order to achieve optimal primary care, because it is so vital and important. So it's interesting. Both of you brought up the longitudinal aspect of this. So I'm going to jump right to right now, the employers are all putting in place, you know, a virtual primary care provider or a near-site clinic, or, and I see you both smiling. So tell me, what are your thoughts about that? Are we disrupting and creating more fragmentation in care or is that beneficial? Yeah, it’s…I understand the need for the solutions, and that's, you know, because we have seen, like as you mentioned at the outset, Mary, lower numbers of primary care than what we need in our country. And so I think that that drives a desire to find solutions. But it is really important to me that primary care is about that relationship and that ongoing relationship. So if somebody's just walking into a clinic and seeing somebody different every time, or if there's not access to prior records, that does lead to fragmentation. So it really depends on how the solution is set up. I will say that the more solutions that people are going in and out of, you know– I'm going to my primary care once, I'm going to an urgent care, then I'm going to a near-site clinic – that does tend to lead to fragmentation and not necessarily the outcomes that we're trying to pursue. I think that it's a multifaceted solution. We do have to meet our patients where they are in many respects. And for some, that is getting 100% of your primary care done virtually. And so if you can set up that longitudinal relationship with that provider or with that provider in the long-term clinic, that's really what we're hoping to drive for. Right? If we said, who are you most affiliated with? They might choose a virtual provider because that's what matters to them, or it might be the on-site. But I agree with Amy – we have to make sure to help people encouraged to go back to the same doctor, the same practice so that we have that longitudinal kind of care plan. I think about my own family, you you take your kids to the pediatrician, for example, it's so important to take them to their well visits. You know why? Because they can see the difference then when they're sick, right? And having that long-term relationship of who it should be, but we should help patients decide what's best for them and where they feel most comfortable getting that care. Very good. Now, I had an interesting conversation this week that I thought was very timely to bring to this discussion. I had an advisor – and I've heard this over the years – say, I'm really afraid to incentivize physicals because I feel like once we open the doors to the healthcare system, they're gonna be swept in and then it's gonna be how many dollars can we capture? It just felt like they were gonna be put on a treadmill and now we've opened the door for a lot of cost. Comments on that? Yeah, getting prevention and preventative care is key. If you can get someone into preventative care and get some of these screenings done, you know, if you are, you know, 50 years old and you need to get your colonoscopy, that's important. You go to your wellness camp because if we find colorectal cancer earlier, that's better outcomes for that patient. And so having that practice of going and getting into primary care and even for a well visit if you're healthy, allows you to, again, start to establish that long-term relationship with that primary care doctor, so that inevitably when you do get sick, you think about, should I call? You're going to think about that primary care doctor versus going to an emergency room. Yeah, I 100% agree. I mean, the earlier that we find conditions or identify things and, you know, there are things that we know that we all need to be doing from a screening standpoint because some things don't manifest in symptoms, you know, until, you know, it's a very late stage in the disease process. So identifying someone who has type 2 diabetes or blood pressure where they might not have any symptoms can prevent much more costly care as well as improve that patient's outcomes and avoid, kind of long-term consequences associated with those things. You know, I made the point, too, to the advisor that there's such a shortage of providers that it's not like providers are worried about filling their schedules. They are just doing their best to get by every day. So I appreciate both of your comments on that. That's very helpful. So if primary care is so valuable, what are the barriers that are allowing these providers to provide the care that they really need? What do you guys see as like the overall arching issue? Do want to go first, or… Okay. Yeah. From, you know, a payer perspective, I think one of the big things is actually how we pay for healthcare. If we pay just based on fee-for-service and not pay based on long-term relations, it's hard to get out of the hamster wheel of healthcare today. But I think that's one of the largest barriers. And really, even as we shift to pay for healthcare differently, are our providers set up to receive payments that aren't fee-for-service claims? Right? How do we get the whole system to be set up? And as we link more of our healthcare payments to paying for quality utilization and patient experience, are we set up to be able to provide our data, our providers with the right data to understand that? We've gone to multiple providers and shared with them, this is who needs a breast cancer screening at your whole panel. And they said, I've never seen data like this before. Right? So we can't expect different outcomes unless we set up our providers with the right tools, data, resources, and also payment in order to make the time to be able to do this. Yeah, I agree on the reimbursement front. It's really important in how we pay. And the NASEM report that Laura cited earlier has basically come out and stated that we really need to be considering how we pay primary care differently, and moving to more of a hybrid payment model that recognizes that primary care is really important in caring for populations and communities over time, and recognizing that in the way that we pay. I will also add that, you know, it's just an item to consider is the high cost of training for physicians. You know, as they are selecting into fields, you know, the reimbursement has to be something that, you know, it makes sense for them when they're taking on like a lot of debt or paying a lot to get through school. The other thing that I will add though is, you know, there's a lot of additional burden in terms of administrative burden for primary care, as we all have worked on measuring quality and we, you know, we have a lot of accountability as plans and that makes for a lot of accountability for our provider partners in terms of quality of reporting and metrics and measurement, and all of those things are good. However, there is a ceiling of the amount that we can actually measure, right? And make it make sense. And, you know, there's been some studies out there that if a primary care provider who has a standard panel of 2,000 or 2,500 patients, you know, was to do everything that they're supposed to do for that panel, that they would have to work, you know, over 24 hours a day. It's just not even feasible. And so the way that we set up our models of care within those practices to support the primary care provider, bringing in additional team members, whether that be nurses or dieticians or pharmacists or medical assistants to be able to help out, to help out with the documentation, but then also to be able to take on some of the touch points in between primary care visits. I think it’s really critically important in helping to overcome some of those barriers that we have today because it really has become a team-based sport in primary care, and it has to be, with the care that is needed, and, you know, hitting all of the measures and all of the quality things that need to be done to take care of a population. So Dr. Milewski, will you go a little deeper into the touch points between the primary care visits? Because I think that was something interesting as we prepped for this that both of you brought up, how critical and how valuable that can be. Yeah, so we talked a little bit earlier about, you know, meeting patients where they are at. And so as you care for a population, you have patients who have all different needs. You know, I'm a family doctor, so I would walk into one room and I would see a you know, a new baby visit, you know, where you're educating a mom. And then I go into my next room and that patient's on, you know, 10 different medications and came out of hospital, and, you know, maybe English isn't their first language and their daughter's there and helping to interpret. And then my third room, you know, is a woman who is, you know, going through a divorce and having challenges and may not have a lot of medical issues, but has a lot of social needs and struggling with depression. And I have like, you know, 10 minutes to spend in each of those rooms. And that is not going to be sufficient to be able to meet all of those needs. And so being able to identify those additional needs and then partner those patients, you know, my mom who's depressed, maybe she needs a consult with a behavioral healthcare manager, and having one of those people in my office then would help get her the additional support she needs and help keep me moving to be able to take care of my entire panel of patients, you know, the woman who was discharged from the hospital, she may need additional support in helping to fill her medications, or finding the resources to be able to afford her medications. Those are things that bringing that additional team around a primary care physician can help take the load off and help put the appropriate work, you know, so that we're all working. I know people don't necessarily love this term, but top of license or, you know, however you want to look at it, but bringing additional support is kind of more the way that I frame it in my head. And, you know, I'm not necessarily the best person to be able to go and navigate, like, how am going to help find the medication management or assistance programs to be able to help that patient afford her medications? But I have people in my office that know how to do that work and are very efficient at it. So bringing in those additional touch points. And then that also allows for, you know, for patients, typically we will see people a couple times a year. Sometimes that's not enough. And so identifying who in your population is at higher risk, and then getting those folks paired up with additional people in your office to provide those additional touch points can really be helpful in avoiding, you know, unnecessary emergency department visits, detecting something that's off before they come in for their next appointment, rechecking a medication and the effectiveness of that. So it's a very effective model. I love it, but as someone who used to consult for primary care, you know that most primary care providers don't make enough money to be able to afford this expanded team. So kind of what thoughts or strategies have you guys considered to help support that? So I can start and then I know Laura probably has some thoughts as well. We actually, a number of years back, developed with other payers in our state a multi-payer model and we termed it provider-delivered care management. A lot of people call it team-based care. And we actually have codes that we pay for that care. Now, that was kind of our initial foray into that, and we also incentivize our providers for delivering that type of care because as one of the things that was mentioned also earlier in the call, advanced primary care, we know that that type of care model delivers better care. And what's embedded in that advanced primary care is this team-based type of model. And we have…we've been able to validate those results. So we know it's a more effective model. It delivers higher quality. It's more cost effective. So we're willing to pay for it. And we're willing to incentivize it. And we are looking, you know, future state, at how do we now think about how we pay for this for populations through more hybrid types of payment and prospective payment type models. And I think if I could just, on that point is just, and what was great about what you did is that you got multiple payers to agree to that model, so that if you're a physician in California, you really don't have to do different reporting for each different carriers– you can really have one strategy. Is that correct? Yeah, so in our, oh, sorry, in our model in Michigan, sorry, we did do the multi-payer alignment, but I know Laura has some experience on that as well. Yes. So in California, we also had launched a multi-payer really similar to what Amy did in Michigan around how do we come together because one payer might not be enough in terms of a payment to transition the whole payment to really being able to achieve advanced primary care. So we got together with two other large national commercial payers in the state of California and came together and said, okay, how do we align on measures, payment, one data platform as well as technical assistance for these groups? So that way, where all of our dollars come together and it actually can lead to better transformation. This only launched this last year. We don't have our evaluation results, but I anticipate it hopefully being really similar to what Michigan saw that really when it comes to primary care, we have to do something different and come together. It's not an area that we can all disagree on, right? Better primary care is better health outcomes. And that's just a vital focus for everyone here. The only other thing that I would like to call out as part of coming together is that we at Blue Shield of California, we launched a hybrid payment model, very similar to what NASEM talked about. We were out there. Many of the providers said, where have you been my whole career? Right? We've been wanting to get paid like this. And others said, this is very different. I've done fee-for-service my whole career. This just feels too transformative. And we're like, look, but this is what NASEM, this is what everyone is saying for that better outcomes. And so that's also another reason why we tried to push and did push for multi-payer alignment. Look, if other people come, those that are a little bit more resistant to this future state of payment will better understand so that we're not making it a huge change for them. And it's a really great model in terms of being able to pay for that long-term longitudinal member for their duration of their health continuum as long as they're going to that practice. Let's pause to thank our sponsor. This podcast is brought to you by Alera Group. Vital Incite is part of Alera Group, an independent financial services firm offering comprehensive property and casualty insurance, employee benefits, wealth services, and retirement plan solutions to clients nationwide. Working collaboratively across specialties and across the country, Alera Group's team of more than 4,600 colleagues offer unique solutions, personalized services, and proactive insights to help ensure each client's business and personal success. For more information, visit aleragroup.com and follow us on LinkedIn. Alright, so now I'm gonna kind of switch directions a little bit just for a second and talk about the adolescent population. You know, in an employer world, we really are focused on employees and spouses because they're of the age where they're gonna start to have chronic conditions and that, and that's really where we create incentives for physicals. What's interesting is lately we've seen a spike in adolescents, dependents in our commercial plan world not accessing primary care and not being seen by providers on a regular basis. I feel like maybe a little bit of that is some of the confusion in vaccines. But in our world, we're also seeing depression at a much higher rate, obesity, type 2 diabetes, etc. So kind of thoughts on that. Has either of your organizations really paid much attention to strategies related to the adolescent population? Yeah, it’s a great and important question, and we absolutely have thought of strategies. We actually consider our pediatricians like, you know, our primary care providers as well. And so as we are designing our incentives, they aren't necessarily, the metrics may not be the same, right, as what we need in the adult space. And so we have also seen growth in obesity and have designed programs and metrics around addressing that, the mental health crisis as well. I think particularly what I have heard from the pediatricians in our state is just the significant challenge they have had in getting support and behavioral health resources in this space. And so as we started rolling out programs around behavioral health integration, we were very intentional about making sure that we included our pediatricians, which has just been a critical lifeline for them, because for a lot of them, and Michigan's a big state, I know California is as well, you know we have a lot of rural practices where, you know, if they want to refer, even if they can get somebody in, it's, you know, it’s weeks wait and it can be a very long drive for the family. And so having behavioral health integration models where you have a psychiatrist who's supporting from the side as part of this team – what we call the collaborative care model – we've kind of nested that under the umbrella of our team-based care models – has been really a really important strategy in helping to support our pediatricians and our pediatric population here in Michigan. Very good. Laura? Yeah, in California, too, we consider our pediatricians part of our primary care physician panel, right? It's our pediatricians, it's our family practice, general practice, internal medicine, right? It's the full spectrum of who's delivering primary care. So we actually include them in all of our payment models. We link to the right outcomes, too, such as immunizations, well visits, depression screening – just the core measures that really matter, and really thinking about, again, that long-term relationship and those practices, working with the providers to make sure that the patients come in every year so they don't fall off their attribution, they stay connected in advanced primary care relationships – again, so that if they get sick later on, they know who to come to. They know who their provider is. And really making sure that our providers know who are the patients that we consider theirs? So by also telling them, look, you haven't seen Laura in 17 months. She's about to fall off your attribution, right? It's a way for that practice to say, oh my goodness, I didn't even realize I haven't seen Laura in this long. Let me reach out to get them re-engaged in my practice’s care. So I'm assuming that the investment in this, even for the younger adults, or younger than really children, is that there's still a return on investment as an insurance company to make sure these people are cared for appropriately. Is that correct? Yeah, absolutely. I mean, it’s, you know, we look at it from all facets when we're looking at our outcomes, right? I want my patients to have – and my members now – to have higher quality care. I want them to have better outcomes. I wanna make sure they're getting their vaccinations, they're getting their well visits, they're getting in and getting screened; if they have diabetes, it's getting treated. So we're monitoring all of those things. But we are also, you know, we have a responsibility, right? Of like, the dollars that we have are not unending. You know, we just recently did a campaign in education of our market around affordability. And, you know, over the last several years, as we kind of looked at this, for every dollar that we're bringing in revenue, we're putting out a dollar for. And most of that's going into hospital and pharmacy and taking care of our members. And that's not sustainable. So we have to make sure that we are being judicious in the way that we are spending, as well as developing programs to ensure better member care that is gonna be affordable for the future so that our kids and grandkids can continue to pay for their own healthcare as well. So, but as I mentioned, those team-based care models, we're able to measure that and do it in a very robust way where we do it as a comparison group. And I have lots of smart people, data analysts that have looked at this. And what they have found is that delivering care in this way has been able to reduce patients going to the emergency department unnecessarily. We're seeing reductions in inpatient admissions compared to our control groups. And that all results in total cost of care savings. And that's like all the costs that we measure together. That's hospitalizations, that's medications, that's outpatient visits, that's hospitalizations. And it's significant. It's, you know, inclusive of everything that we pay for the program and all the incentives that we put in. We were able to demonstrate that this type of model, care model, delivers a 2.2–2.3% savings on total cost of care. That is a significant…and over the lifetime of the program, that's like $1.25 billion of avoided costs. And so these care models are really critically important because, you know, not only are they saving money and keeping healthcare more affordable, they're keeping people out of places that they don't wanna be. We don't want them in the emergency department where they're sitting next to somebody with pneumonia and then catching something they don't need. You know, we want care to be in the most appropriate place. And that's what having that relationship and that advanced primary care practice is all about. That's very helpful. Thank you. Yeah, very similar here in California. It’s, it is the…all the members and patients matter, right? And same thing with the pediatric members, right? Getting them in that long-term relationship, we have also seen that it leads to lower uses of emergency room, hospitalizations, urgent care usage, right? Getting that long-term relationship with the pediatric provider and the patient – and the parent, right? Having that trust for that long term is better health and better healthcare. And we are focused too always on affordability, quality, and patient and provider experience. We need all of those things to be optimal for a healthy healthcare system to exist. I'm really glad that Laura added patient and provider experience, because we've measured those as well. And, like, I've had providers come and talk to us, talk to the plan and talk to me specifically about the, you know, when they were practicing under a model previously versus what it has done to their practice to adopt a team and have the support and the ability to put a team-based model in, and how it kept them in practice. You know, some of them were considering retiring earlier. This restores, along with other things that we're doing, you know, the joy of practicing medicine again, and by removing some of that burden and bringing the help that primary care doctors need. Thank you. I really appreciate that both of your organizations have focused in on that because there's nothing we can do on an employer level if there's no providers around. So it really is going to take all of us to change this. Now, Laura, you brought up 6 measures for quality. Do you mind running through those for me? Yeah. Happy to, and I just want to take a moment and talk about why alignment of measures matters, right? If we all go to practices and have a list of 30 measures, what can they actually focus on? Not 30 measures, right? They can focus on transformation– really changing their practice flow per year of 1-2 measures. So really thinking about what matters the most. So we've aligned, and in California there's been this huge push for alignment between Covered California, which is our exchange population, CalPERS, which is a large employer in the state of California. They’re our government-sponsored state of California insurance plan, as well as our Medicaid agency, DHCS. They aligned on a core set of measures as well. So what that does is essentially says our largest employers, they've aligned. Now we've aligned in how we do our reimbursement as well, so that it can drive to faster transformation. So we aligned on colorectal cancer screening, blood pressure control, diabetes control, childhood immunizations for both the adolescent and pediatric. And we did have breast cancer that is being retired because we've reached a new level, and we'll be adding in depression screening – as one measure gets retired, another gets added. What those measures do though is that they align with what the other carriers are doing in the state of California. It aligns what our purchasers are asking. And what you're able to see is faster movement in the measures. If we can just align on what really matters, let's drive transformation, and then we can recycle and add in new measures to focus on. Perfect. Dr. Milewski, anything to add to that? I just, I think it's so important. You know, we went through a period of time of like, hey, we weren't measuring anything, to now we have the ability to measure. And then I think we went into a phase of let's measure everything. And we had, you know, 2, 3 hundred measures to select from, and incentive programs with 30 or 40 measures. Laura's 100% right. You know, you can only focus on so many things, and coming up with these very refined, very focused core measure sets, I think is really critical. They also serve as a proxy of the care that that practice is delivering across all lines. Absolutely, we can think about retiring measures and substituting measures, but we do really have to get focused for the practice’s sake, because at the end of the day, they're taking care of the patient. That's the most important thing. We want to be able to measure that, but I also want them to attend to the care and the relationship with that patient and not be so focused on administrative tasks that, you know, that that gets lost. Oh, thank you for saying that, too. That's an important part of this whole thing. I think one of the measures that I don't know that we mentioned was the decrease in non-emergent ER utilization, and inpatient admissions too is one of the value-based things that we found, correct? Yes, we also have those utilization measures, especially the emergency room measure. We have that for both our adult and pediatric population, because that's something that really, if our patients are taken care of and they can get in to see their primary care doctor, we see that decrease in emergency room visits. Emergency rooms are there for a reason, right? In an emergency, patients need to be able to get care, but there is a lot of care that can be done within our primary care provider’s practice. And so we do have that as a proxy measure as well as our inpatient admins for our adult populations. Perfect. And so as I'm thinking about how this is going to translate to an employer, a commercial health plan and how they're going to structure things, I believe that having those measures of quality within their program are really important. So, if I'm hearing you correctly, we want to incentivize getting a depression screen, a colorectal screen, having a physical, childhood immunizations, things like that, so that it is along the same thing that you've already spent a lot of money proving is important. And if we just follow along, that is probably really beneficial. Would you guys agree? Yeah. Yeah. Well stated. Yeah. Very good. So is there anything else that you could think about that you would suggest to employers? What can employers do to help move this forward? Yeah. As an employer, you're paying for your employees to have better healthcare, right? High quality, best utilization, and best patient experience, right? That's what you want for your employees. And just think about that that might not look the same as it always has looked before. That it doesn't come through always on a straight claim, right? And to be ready and to embrace that we do need to pay for healthcare differently in order to have different outcomes. And so in those outcomes are again, are high quality, best utilization, the right care, the right time and the right place and that great patient experience that we all want for our employers, our employees and as patients ourselves. Yeah, I would agree. I think the…the idea around helping to support payment evolution, particularly in primary care, and that looks like paying for care for populations, and things that are not necessarily connected to that fee for service, but looking at more of a perspective-type of payment model that's mixed with fee-for-service. So part of the care that's being delivered is really around like, making sure that you're surveying your population, understanding who you haven't seen in 17 months, as Laura mentioned earlier, right? And then outreaching that patient and saying, you know what, it's time for you to get in for a visit so that those people aren't being lost to follow-up. So that care all, like, sits outside of like a traditional fee-for-service mechanism, but it's really critically important when you're caring for a primary care population. And so thinking about how we pay for that differently, I think, is really where all of us are kind of moving toward. So the support for that, I think, will be really helpful. I love it. And I knew you would be a wealth of information. That you two women are doing so much to change healthcare, and we're really appreciative of it. I tried to take notes, and my page is so full. I'm not even sure I'm going to be able to read my writing, but I want to kind of summarize things that you have said today. So the big thing for me is that longitudinal relationship is so important, and how that is really critical and employers have to be really careful not to be fragmenting that, or steering people to different pieces, and making sure they have to, we can align on the quality metrics that we talked about, with reduction in ER utilization inpatient admissions, blood pressure and diabetes control, colorectal screening rates, depression screening, childhood immunization. So that's one thing that employers can do. It sounds like we really need to think about employers offering behavioral health support. You talked about the different things. That's something that there's, it's there, and virtual care is something an employer really can put in place. And maybe that could support them, the provider, in what they're leveraging and then be open to different models of payment. So when your carrier comes up and tells you, hey, we have this another new strategy, just like you've asked the providers to do, the employers have to be open to taking a chance because the same old thing isn't going to get us any further. I just, there's just so many good points that you guys have made. Prevention is key. Early identification is important. The relationship is so critical. The big issues are the pay for service and the administration…administrative burden. Dr. Milewski talked a bit about that. And then I love the idea that team-based care, you both have talked at length at that. So I believe what I'm really hearing is that's the first step in moving us forward is that team-based care. Is there anything else I've missed in that? Yeah, that's a wonderful summary. Yeah, you hit all the high points. There was a lot…you guys gave me a lot of information. I'm such a believer in primary care, but it's so hard to figure out the right way to go about this. So I think you really opened our eyes into having a different perspective, which is what we wanted out of today's discussion. So thank you so much. With that, I just want to thank you both for joining us, for taking the time out of your very busy schedule and your most important work to share some of that insight. For the rest of us, hopefully we've created better partnerships now within your states with, that we have employers that can also come along and create change. So, and to our audience, I hope you enjoyed today's conversation and it's given you valuable insight to reflect on your current strategies and perhaps even spark some ideas about where their next best steps could be. Thanks for listening to this episode of The Pulse. If you enjoyed it as much as we did, please be sure to subscribe so we can stay up to date on our most recent conversations. Share the link with others so we can all start to demand something new, and follow us on LinkedIn. Ladies, thank you again for joining us today. Laura Fox, Dr. Malewski, you guys have been really exceptional. Thank you so much. Thank you. Thank you. The Pulse is produced by Vital Incite, a member of Alera Group. Alera is on a mission to help organizations identify medical spending waste through data-driven strategies, while helping to improve the health of their employees. If you want to make healthcare easier to understand and manage and improve your organization's bottom line, reach out to us at vitalincite.com. I'm Mary Delaney. Thanks for listening.