Revisit: Impact of Value Based Care Trends | With Sean Cavanaugh - Part 1

In this revisited episode, we are joined by Sean Cavanaugh, CCO / CPO Aledade. Previously he served as Deputy Administrator and Director of the Center for Medicare @ CMS. You’ll hear his viewpoint related to today’s independent primary care physician, the impact of Value Based Care (VBC), and how Aledade supports their practices for success in their ACO.

Sean can be found:
LinkedIn
Twitter @dc_cavanaugh

Learn more about Aledade:
Website
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 & Nyla Wiebe
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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Production © Strategic Healthcare Partners, LLC.
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Transcript

Aaron Higgins: 0:36

As we gear up for the exciting Season 5 of Beyond the Stethoscope Vital Conversations with SHP, we're taking a moment to revisit some of our most impactful episodes. This one from Season 1. In this replay, we dive deep into the world of value-based care with Sean Cavanaugh, the Chief Policy and Chief Commercial Officer for Adelaide and Chief Commercial Officer for Adelaide. John Crew and Mike Scribner sat down and they shared valuable insights with Sean from his time at CMS and discussed how Adelaide is empowering independent physicians to thrive in the evolving healthcare landscape. So, whether you're curious about the future of primary care, the role of data and improving patient outcomes, or the transition to value-based care, this conversation is as relevant today as it was when we first aired it.

Aaron Higgins: 1:23

Don't miss this chance to catch up on a critical discussion that sets the stage for what's to come in healthcare. Tune in and get ready for more vital conversations when we return with season five. Oh, and before we go, don't forget to rate and like the show in your favorite podcast app. It really helps us reach more listeners. Let's listen to this vital conversation.

Jason Crosby: 1:51

Hey everyone, Welcome to Beyond the Stethoscope Vital Conversations with SHP. I'm Jason Crosby of Strategic Healthcare Partners, alongside our principals Mike Scrinder and John Crew, your hosts for today's episode. Today, our guest is Sean Cavanaugh, Chief Policy Officer and Chief Commercial Officer for Allidade, who, for the last several years, have provided the technology and services to independent physicians as part of their successful ACO ventures. Previously, he served as the Deputy Administrator and Director of the Center for Medicare at CMS. Sean, thanks for joining us today and welcome to the podcast.

Sean Cavanaugh: 2:27

Thanks for having me, guys.

Jason Crosby: 2:29

So with that we'll jump right into the conversation. We'll start off with John first.

John Crew: 2:33

Thanks. This is John, sean. We appreciate you being with us today. The question I have first is and I think, as Georgia experienced, as well as nationally, we're seeing primary care diminished, independent primary care physicians diminished. We're seeing more and more of the young residents coming out or preferring the employment model. When you look long-term at value-based care models, do you see a direct line where you would be working eventually with employed physicians in these models?

Sean Cavanaugh: 3:03

Yeah, I think anybody who's committed to improving health care, which means doing what's right for the patient, working within a business model where you get rewarded for preventing hospitalization rather than doing a hospitalization, I think we'd be willing to work with them and I think anybody should be willing to work with them. As you correctly point out, you know, in my current position with Allidade, we've very much focused on the independent primary care doc and that's because of alignment. We think they're already there in their mindset. They're fully aligned with value-based care and doing the right thing by the patient.

Sean Cavanaugh: 3:41

I think and you've probably experienced this for hospitals I have a lot of sympathy for hospitals. They're in a difficult position as the world transitions to value-based care. If we're really going to reduce hospitalizations, how do they change their business model? It's not as simple as it is for independent physicians, but in the long run I think they're going to get there and I think we'll be happy to work with them and not just us. We're not the only value-based company out there. Some already work with hospitals with some success. If this movement to value-based care is going to work, it's going to have to include everybody.

Mike Scribner: 4:23

Allidade's starting with the independent primary care position, because we think there's where you get the best alignment. Initially, sean, when you think about the independent primary care that most interests Allidade, what are the characteristics of them that kind of lead you to believe that they're going to be most successful with VBC in the first place?

Sean Cavanaugh: 4:35

Mike, thanks for that question. We get that question often from insurers as well. Like are you guys, you know, going in and finding the elite high-performing primary care practices and forming like a specialized, high-value network? And we're? No, you know, we're not taking just the high performers.

Sean Cavanaugh: 4:53

One thing we look for is some basics. People need to be on an electronic health record, which most people are, but not everybody. They need to have a pretty good track record as far as program integrity. You know, not prescribing tons of opioids, but those are fairly low bars, hopefully. Beyond that, what we're looking for is, you know, practices that are tied to their community, that know their patients tied to their community, that know their patients, that are looking for a better way to deliver care and are willing to consider the use. You know our tools. You know, as you know, we provide some data and analytics and some workflow tools to the practices. What we find is, if they give the tools a chance, they love them and then it doesn't take any coaching to get them to use them. But that's what we're looking for someone who's willing to try something a little bit different and, you know, do the right work for their patients. And what we find is typically with independent practices. They feel like they're doing that already, and so we're enhancing their ability to do it.

Mike Scribner: 5:50

Can you talk a little bit more about the kind of tools that y'all do provide and the things that enhance the practice's ability to be successful?

Sean Cavanaugh: 6:00

Sure, what I usually say is it boils down to two buckets. One is who's not in your practice. That should be in your practice today, right, rather than sitting and waiting for someone to come in. We're going to give you data about your whole population, but not just dump a bunch of data on you. We're going to show you very about your whole population, but not just dump a bunch of data on you. We're going to show you very specifically who just got discharged from the hospital. Yesterday that you should be reaching out to today.

Sean Cavanaugh: 6:25

There's all sorts of evidence that patients that get discharged from the hospital if they see their primary care physician within a couple of days much lower readmission rates, better for the patient, better for Medicare, better for the practice. Better for the patient, better for Medicare, better for the practice, in fact. I'll tell you a little story, a true story. From you heard at the outset that I used to work at CMS. When I was at CMS, there were studies coming out showing just that transitional care works. Patient gets discharged from hospital. Some see their PCP they do better than those who don't. So we created a new billing code in Medicare called transitional care management that specifically pays for practices to see those patients and pays pretty well, I think, compared to some other visits. And we waited two years and we looked at the data and no one was using the code. So you know, the greatest plans coming to failure. So I went around to the physician groups and I asked them why isn't anybody using the code? The first thing I heard from you know, the family physicians, the internist was we don't know when our patient's been discharged from the hospital. How are we supposed to do that? So sometimes it's as simple as that tapping into the local he to hie, tapping into directly to the hospitals and not just, you know, creating a very simple way for the practice to come in and turn on their computer in the morning, get a list of patients who left the hospital yesterday, their phone numbers and a work list, call these people, bring them in.

Sean Cavanaugh: 7:50

So, like I said, the first thing is giving you an understanding of what's happening to the patients who aren't in the practice. A lot of data analytics to show you which ones really could use some help if you reached out to them. The second bucket is we know who's coming into your practice today and who's in a value-based contract. What's the most important thing for you to know about these patients. What are the quality gaps they haven't had filled? What hospitalizations have they had recently? What specialists are they seeing? How many times that the PCP knew you were seeing three cardiologists? He or she couldn't do something about that. So we give this 360-degree view to PCPs. We let them do what they do best, which is provide great primary care. We don't, you know, interfere with how they practice medicine. They know what's best, but we're making sure they're seeing the right patients at the right time.

John Crew: 8:41

John, to that effect, data to be actionable, data needs to be as current as it can. Can you share a little bit about how you receive data and then how you disseminate that back to practices as real-time as possible?

Sean Cavanaugh: 8:56

Yeah, john, you're exactly right. You know, the ability to take timely action is only as good as the datatime as possible. Yeah, john, you're exactly right, the ability to take timely action is only as good as the data you've got. First of all, the tool we give practices and we literally give it to them, called the Allidate app. It ingests data from numerous sources. So, first of all, we get claims data from the payers we have partnerships with, and sometimes that's Medicare, sometimes it's, you know, a commercial insurer. We get notifications, as I said, of admissions and discharges and transfers from the local HIE or directly from hospitals. We get lab results from the major lab companies, just massive, you know, script part D results on drug utilization. Massive amounts of data.

Sean Cavanaugh: 9:42

But, as you said, what we're constantly fighting is the battle to get it faster and more accurate, because finding something out you know claims data can be two months lagged. Ironically, one of the things we found and I'm a little bit proud of this, having come out of CMS is the data we get the fastest from a payer on a claims data tends to come from Medicare itself. And we've been talking to the big insurers United, aetna and those guys and saying come on, guys, you got to be able to beat the government right, and the thing is they have these huge legacy systems that they're all working to upgrade. But what we try to convince them is it's in your interest too. The sooner these doctors know what's going on with the patients, the better the care your members will get. But we do have at times, you know, we can only be as fast as the payer partners.

Mike Scribner: 10:38

You know we can only be as fast as the payer partners, but we try to get as timely data as possible. Sean, as the ACOs you know have matured that you guys operate, has it been more difficult to when you get past the low-hanging fruit? Is it a little bit tougher to plow the ground to continue to have success, or does it catch a flow that just continues to improve?

Sean Cavanaugh: 11:03

Yeah, that's a very fair question. If we're only getting low-hanging fruit. There's more low-hanging fruit than I thought because we're still improving Even our earliest ACOs, which started in 2015,. They're still getting incremental improvements. They're getting—I think part of what you see is it takes time Like anybody who's thinking that you know this will turn around and a dime is wrong when we look.

Sean Cavanaugh: 11:27

We did a study and we've updated it several times. We looked at five different ACOs. We started in five very different states across the country back in 2016. And we followed them every year since then. And this is a study. This is not using CMS data. Then, and this is a study, this is not using CMS data. This is us using all Medicare claims data, matching those people against similar beneficiaries in their community, and we see consistently every year the same result and continuing to grow, which is people in an Allidate ACO get more primary care. So I think we're up to in the fifth year. Fourth year, it's 35% more than similar beneficiaries in the community 35% more primary care, and what that leads to is about 14% fewer ED visits, about 15% fewer inpatient visits. We haven't plateaued yet.

Sean Cavanaugh: 12:22

It is plausible, but that's why one of the things we're thinking about is like what's the second engine? Like, how do we expand the ability of these practices to do more? You know, physicians and their staff only have so much time in the day. Are there services we can augment to help them? So until today, allidade has always focused our services on the practice. What can we do for the practice? We've now created a subsidiary called Allidade Care Solutions, which will be patient-focused. What can we do directly for the patient?

Sean Cavanaugh: 12:53

But this is where there's an important distinction between us and Optum and some others. We're going to do it in partnership with the practice. The practice will get to decide when the Allidade services are used, who they're used for, and any data we collect about patients by servicing them directly will go directly back to the PCP, because we think that's key Keep the PCP in the driver's seat. So, to go back to your question, mike, yeah, there's probably low-hanging fruit out there, but there's a lot of it. We're still working on that and as we do, the problem with the phrase low-hanging fruit you forget. These are patients. They're getting better care. They're going to the hospital less. So that's important. But we think, with adding some services and helping the practices directly with patients, we'll be able to move beyond that too.

John Crew: 13:41

Sean, when you have markets that aren't as sophisticated as other in terms of the growth of value-based care and you come into it, there's this perception right, wrong or indifferent by providers that this is going to change my workflows within my practice. It's going to be more time consuming, I'm going to have to hire more people, and so I may or may not see a return. I'm sure you've been exposed to that. How do you deal with that as you first come in and work with providers to introduce them to the value-based model?

Sean Cavanaugh: 14:12

First of all, we tell them we have no interest in blowing up your practice and making your life miserable. We're going to take you stepwise through this. We're going to take you through different steps you can do incrementally. We're not going to throw the whole playbook at you on day one. So things will change because, let's be honest, rather than churning patients through the practice, like when you need to make more money right now, your incentive is to see more patients for a shorter period of time, to see the less difficult patients. Over time, not on day one your business model is going to change, where you're going to want to focus on the harder patients, you're going to want to refer out less when you're capable of treating them. But that'll happen gradually over time.

Sean Cavanaugh: 14:56

The other thing we tell them is there's some things that help you along the way. Our practice is when we have them doing more transitional care visits, more annual wellness visits, they see their Medicare fee-for-service revenue going up day one. So what we call good fee-for-service Like if you're doing these good preventive services, you can see practice revenue going up 10%, 15% before you get a shared savings check. So there is a transition here that we can work with practices. I know you guys have done the same. It's not turning things on a dime and it's not like seeing a drop in revenue while you wait for a shared savings check. There's a pretty good pathway here role of the specialist in that.

Mike Scribner: 15:47

I get that it's very primary care based and very cornerstone in that world. But what is an effective relationship with various specialists look like?

Sean Cavanaugh: 15:53

Yeah, that's a great question. One of the things I want to say is I think the whole country's grappling with that question I know CMS is. Cms has been struggling to come up with a specialist strategy and you know they're continuing to talk to people. What we found that works best is, you know, especially in smaller communities where there's not just a professional but often a personal relationship between the PCP and a specialist, is to sit down and have communication about expectations. So you know in some of our communities that literally we invite the specialists in and we explain we're doing an ACO, here's why we're doing it, here's what our goals are, you know, and the goals of the ACO are really good for the patient and so when the specialists see that they understand like they want what's good for the patients too. But what we find is PCPs often go into this conversation thinking they're going to lecture specialists. But if you're a neutral party in these conversations, you hear the specialists having very good demands of the PCPs too. When you send me a patient, be very specific about what you want. How many specialists get a patient walking in who said Dr So-and-so sent me why, I don't know. He just told me to come see you. So improving the communications and understanding what the expectations are. I'm sending you to the specialist for this very specific purpose. I want to hear back what the results are. I want the you know, an understanding of who's going to manage that patient. If this is cardi, you know. If you're referring to a cardiologist is. Am I turning over management of this problem to the cardiologist or do I just need a second opinion on something?

Sean Cavanaugh: 17:32

When we've seen these two-way communication, we've seen some bonds form that are really fantastic, where the specialist now becomes a preferred specialist because they're seen as a partner and their business does better. But I'm going to be frank with you. This is not true everywhere. I think sometimes there's a distrust is too strong a word, but misunderstanding what the purpose of the ACO is.

Sean Cavanaugh: 18:00

The other thing is and this is where we're all trying to get better is it's really hard to know who's a true high-value specialist. So the other thing is being transparent about the data. Here's what you know, allidade we provide our doctors data on specialists. You know outcomes, cost, but we encourage them to have a discussion with the specialist about it, and the typical PCP doesn't want to change their specialist like meaning switch. They want their specialist to be the most efficient and the highest quality. So I guess if I used one word instead of rambling on, I would have said communication, like the communication between the specialist and the PCP, is so critical, and it's hard because everybody's so busy taking a step back and talking about what are we trying to accomplish here together. It's hard.

Mike Scribner: 18:48

Where do you see the specialists being involved? Like where two part question. Where do you see CMS going in terms of coming up with value based incentives for them? And then what? Where is Allidade placed? Is there any sort of financial model around that within y'all's ACOs?

Sean Cavanaugh: 19:07

Yeah, so I'll answer Allidade first, then CMS. At Allidade we're experimenting. We have such a broad network now, you know, in 40 some states. Before we roll anything out to all of our practices, we test it in some markets. So we're testing a couple different specialist approaches. One is you know there are some companies that have started up that will give you real-time consults, you know, by phone or technology. That's one pathway. Another pathway is literally trying to create, trying to profile specialists in your community and create a preferred list of those who are signing compacts to work with the ACO, who are shown as high value. But it's hard work and so we don't have one single product. We're rolling out across the country, we're collaborating with doctors locally trying to see what works, and I think we're a small part of what CMS is going through.

Sean Cavanaugh: 20:01

So I'll tell you, when I was at CMS we got requests from all different specialty societies who all wanted a value-based model for themselves. So the orthopedists had some ideas, and the cardiologists and the nephrologists, and I think what CMS quickly learned is it doesn't have the capacity to create new models for every specialty. It doesn't have the capacity to create new models for every specialty. It has had its bundled payment for care improvement, which are certain hospitalization and post-acute care bundles that are typically specialist-oriented. But that's been a mixed bag.

Sean Cavanaugh: 20:39

I have seen them out in the community. This is CMS folks talking to the specialists, talking to the ACOs, trying to find a path forward. I do think they're looking for some model where you could embed a bundled specialist model within an ACO. What gets really hard there is pricing it accurately. A number of specialist models that CMS has tried have had either overly generous prices or the price has been too low, and so you've seen results all over the map. But I think that's what you're going to see is them trying to embed some sort of specialist bundles as an option or maybe mandatory, within ACOs. I don't know, but that seems to be where they're headed.

John Crew: 21:27

Sean, in your response I caught something that I want to ask you about. In your pilot programs you mentioned or at least I thought that you mentioned a model that maybe you're looking at telemedicine as part of that downstream, in terms of specialists consults, things of that nature. Did I understand that correctly, or is that something that? Do you see telemedicine playing a role in your models?

Sean Cavanaugh: 21:52

Yes, I think certainly telemedicine has a role, whether it's extending primary care or improving communication between primary and specialty care. The specific test that I was referring to is this group that is willing to. So if you're a PCP and you have a question about a patient's cardiac condition, you can get a specialist consult like within 10 minutes, and what the results we've seen from that are two-thirds of the time what the specialist is telling the PCP is what you were planning to do makes sense. So it's just reaffirming the instincts of the PCP, but giving them some comfort. And then there's a subset where they steer them a different way, like escalating the care or saying this person does not have you know, you don't need to refer them to a specialist. Obviously, that's one level of support you can give to PCPs.

Sean Cavanaugh: 22:45

It's not a solution to how do we integrate specialty care and primary care better, but it could be an interesting piece of it. And what we found in this test just because you asked is there are multiple versions of this. The one our PCPs liked the most was the one where they got immediate feedback, meaning they didn't send the patient home and wait 36 hours to get some feedback from a specialist. And that's hard to do, but it seems to be essential to get that feedback while the patient's still there and they can change what they're going to do while the patient's still in the office. But we have a lot more to learn here. I don't want to suggest we solve this puzzle here.

Mike Scribner: 23:27

I don't want to suggest we solve this puzzle, shown as as y'all have, you know such the breath that you do. Obviously we deal with practices that are both urban and rural based. What differences have y'all seen in the operations of your ACOs, rule versus urban, and what? What allowances have you had to make for that?

Sean Cavanaugh: 23:43

Yeah, well, as I said, so one of the differences is the options for specialists, options for facility partners. You know, in a rural community you know the options can be less. The upside is there may be a personal relationship there, so you might be easier to communicate with the specialist and have that sit down in the talk with the specialist. And have that sit down in the talk. We love the rural communities and we tend to operate more in rural communities than a lot of ACOs, and that's because we work with independent practices and when you get into the major metropolitan areas what you see is heavy consolidation where the practices have been bought up by the big health systems. So that's one of the differences we see. For us, in the near term, the opportunity to work in some of the major metro areas is limited. Going back to your first question, though, I don't think that's a permanent condition. I think everybody's going to be pivoting to value at some point and we will be working with people you know, employed physicians, health systems in the larger urban areas.

Mike Scribner: 24:54

I hope that answers your question. It does. It does kind of bring me full circle back to a question John asked way back at the beginning. Do you see value-based care and the financial incentives of that being so great as to shift that move toward employment in the first place to where independence is so much more financially attractive in the future that it just shifts that tide in general?

Sean Cavanaugh: 25:16

Yes, I do see that We've seen small aspects of it. So think of the world three ways. You've got truly independent PCPs, you've got independent PCPs who've joined a hospital CIN and you've got people who've sold their practice to the hospital. Those people face three different landscapes. We work with the first two. Quite a few of the physicians we've recruited in the last two recruiting cycles are physicians who were in that middle group. They've been independent but they've been working through the hospital CIN. So certainly we're seeing that shift where hospitals are losing some of their CIN physicians because and again I hope this is temporary they don't feel they have the clinical independence or the voice in that CIN that they would have working with Allidate or other independent groups that are truly physician-led.

Sean Cavanaugh: 26:12

I think you've seen a smaller to a much smaller degree, the more extreme which is in the third group, employed physicians, the ones who went either sold their practices or went straight out of training into hospital employment. But I don't think that means they're happy into hospital employment. But I don't think that means they're happy. We've talked to enough of them and we think there's an opportunity and we're exploring this If those physicians saw like a turnkey solution where they could come out of hospital employment.

Sean Cavanaugh: 26:41

What they don't want to do is look for real estate, have to buy an EHR. They want to practice medicine right? Imagine a world where they could walk into an office tomorrow, they could have in place an EHR, staffing and, more important, value-based contracts for their patients and they could build up a practice from a value orientation from the beginning and they could pay for all that stuff that they were given through future shared savings. I think if someone and you know, be frank, this is something Allidade's kicked around If someone developed a model like that, I do think you'd see that third group of employed physicians start to move out, because I think they went into employment for legitimate reasons, but I think they missed their clinical autonomy and the ability to do the right thing, their clinical autonomy and the ability to do the right thing.

John Crew: 27:29

Sean, I have a question. In relationships specifically to the MSSP and the successor models, we are seeing at least with our client base we're seeing a significant shift of the traditional red, white and blue moving to MA. So we're seeing a decline in the traditional model and a significant increase in the MA Long term. Do you see there being continued long term success for models that are associated strictly with the red, white and blue?

Sean Cavanaugh: 28:08

if you want to be successful in senior care specifically, you're going to have to be able to do both. You're going to have to be good at MSSP, which is the ACO program, but you're going to have to learn how to work in MA as well. And I think some practices don't want to hear that and I don't blame them. The Medicare fee-for-service patient is their last patient where the insurer's not requiring prior auth and all that. But the world is just changing. As you said, medicare itself is still growing dramatically with the aging of the baby boomers. So senior care as a field is growing. But, as you said, the part that's growing is the MA enrollment Seniors choosing to remain in what I call traditional Medicare, some people call fee-for-service. They're actually declining somewhat in an absolute sense. So even as the program as a whole grows, an absolute number of people in traditional Medicare is going down.

Sean Cavanaugh: 29:00

So we've talked in our practice quite a bit at this. If you're going to be really good at senior care, you're going to have to learn how to do MA and at a clinical level it's very similar, right? It's the same patients. It's more the STARS measures getting good at that and getting good at complete and accurate diagnoses, which is the risk adjustment part of MA and, as you know, that's where a lot of people trip up. There's some who get tempted and do fraudulent things. We're very careful to tell our doctors we're going to do this the right way, you know, and and we're coaching them on how to do that today You've been listening to Beyond the Stethoscope vital conversations with shp.

Aaron Higgins: 29:53

This has been a production of strategic health care partners, your news host today for jason crosby and me, aaron higgins. 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 scrivener and john crew. Thanks for listening.