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Becker’s Healthcare Podcast
Redefining Primary Care Through Value and Culture with Dr. Rob Bessler and Amy Perry
00:34:51
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- [00:00]
A
This is Scott Becker with the Becker's Healthcare Podcast. I'm thrilled today to be joined by two remarkable leaders. We're joined today by Amy Perry. Amy's the president and the CEO of Banner Health. We're also joined by Dr. Rob Bessler and Dr. Bessler is the CEO of Honest Health and he'll tell us about that journey as well. We're going to talk about redefining primary care and what the next chapter of primary care and value based care. Value based performance looks like. And such an important subject given the shortage nationally of primary care physicians and the changes in transformation that's happening in the delivery of primary care. Before we get started, I'll ask Amy and Dr. Bessler to take a moment to introduce yourselves. Amy, let me ask you to kick us off as president and CEO of Banner Health. Take a moment and tell us about yourself and about Banner health. And then Dr. Bessler, so glad to see you again. We'll give you a chance to do the same thing. Amy.
- [00:56]
B
Thanks Scott. So Banner Health is sort of a ecosystem that contains all of the potential elements you could possibly put into healthcare, from acute care hospitals to outpatient everything and everything in between. Academic medicine, community, rural physician enterprise. And on top of all that we have an insurance company. So. So we are sort of a potpourri of everything anyone could possibly need for their care and coverage here at Banner Health.
- [01:35]
A
Thank you. Banner Health developed just this tremendous reputation over the last couple decades. So thank you for the introduction and thank you for that. Dr. Bessler. You've done an amazing job with Honest Health. Tell us about the generation of Honest Health, how it started and about yourself.
- [01:51]
C
Thanks Scott and great to be with you. And Amy, my journey to Honest health starts with being an emergency physician many moons ago, generation ago I guess. And from being an emergency physician to being challenged that nobody wanted to admit my patients and those doctors that did I thought were practicing from evidence from 20 years prior. I founded and led Sound Physicians for 23 years across and grew that from one hospital and three doctors to about 450 hospitals in 42 states and over 5,000 providers at the time. The thing I learned over running hospital based services and a very big value based care business across both bundled payment and ACOs was that our hospitals partners kept coming to me in particular and saying well, what about primary care? And the what about primary care was a combination of docs feeling like they're on the treadmill of volume. Hospitals employing 70% of the nation's primary care providers, hospitals recognizing they lose money on every medical, Medicare or Medicaid admission and subsidizing primary care to the tune of a quarter million dollars a provider. And so when I went around the country looking at various enablement models and most of them were focused on independent primary care, and I joined onis, invested in the business and pushed for a pivot to focus on using that infrastructure to serve health systems. And the idea is quite simple. How, you know, every health system's on a different place on that journey from volume to value, and how can and everybody kind of believes and understands that there's a recipe to deliver on that promise and that journey to value the ingredients and whose ingredients they are is less important. And since everyone's at a different place on that journey, our job is to make sure that you don't leave out the, you know, the baking soda or the flour or the physician leadership component or the analytics, etc. For that recipe. And it turns out there's a big opportunity and very few health systems in the country have invested fully in what it takes to make that transformation. And so that's what we're doing at Honest.
- [04:23]
A
Thank you so much. I'm going to start off with asking you each two questions and I'll start with Amy here and then pivot Back to you, Dr. Bessler. Amy, talk a little bit about how primary care fits into your current business model. And you know, it's a, it's a general question, but a big question given the size of banner and what you're doing. And then also we've talked about the transformation of primary care as a way to transform the nation's healthcare delivery system. What does that mean in practical terms, from your perspective? And I'll ask both you to comment on this. But Amy, let me start with you and then go to Dr. Bessler.
- [04:56]
B
Sure. Thanks so much. So for us, the whole primary care provider piece of what we do is largely about access, right? How do people connect with their healthcare, how do we provide care navigation for what they need? It usually starts somewhere in that primary relationship. And I say that very specifically because there's some models of primary care that are much more transactional. If you're, you're going to be just a pure telehealth client or, you know, with a different provider every time you visit, you know, you need something urgently. I think that our primary care access and relationship is so critically important for having a shot at keeping people well, having them navigate the system more efficiently, which is critically important. Now, going into an era where we're gonna have so much less resources. We need to learn how to maximize these our providers. And by that I don't mean having them work 14 hours a day. That is definitely not where we're at. We're at how do we have people work more efficiently? How do we give them the technology tools, whether it's ambient listening or team care, pairing with apps and pairing with technology so that we can provide access in a more effective way. So our primary care physician team is critically important for having that connection to the communities we serve. It's also critically important from an efficiency perspective when we are getting a per member per month as part of a premium, as part of our insurance plans. We really rely on our primary care physicians to be that quarterback. And we're trying to make it easier for them because it's a very, very heavy burden. And we want to try to make their lives more enriched because they can actually spend more time with their individual relationships keeping people well. And this is sort of the stark, I think, difference or uniqueness of Banner in being an insurance company because we can actually make the economics of those kinds of investments work. So, you know, primary care is actually such a big, broad word, and we're actually making it broader because of the lack of specialists in certain areas. We're relying on our primary care physicians to be part of the behavioral health team, to be part of the cardiology team with heart failure management. We expect so much of our primary care physicians now to be that connector to our communities. We can't do enough for our physicians and. And we keep training them. I mean, one last thing I'll say is Banner has made a huge investment. We train 1300 residents and fellows. We just added 250 more primary care physicians to our training program. We train apps, we train about 7,000 nursing rotations here. We're trying to populate Arizona and beyond. In our other states we serve, we have academic relationships, Colorado, Wyoming, some of the other states that we're in. So this is a community effort. We all have to come together to try to break through some of the barriers that have been put up of late that are changing our reimbursement structures.
- [08:39]
A
Thank you. You mentioned several things, one of which I find fascinating. You do see this movement towards this transactional model of care where episodic. Somebody goes to the urgent care, sees a primary care physician, they have no ongoing relationship with that person. It might be similar by some of the national telehealth agencies. You talk to somebody, you never talk to that person again. And obviously that's suboptimal it fills a gap, but it's not what we prefer. We prefer that longer term primary care relationship, whether it's with a physician, an advanced practitioner or so forth. How do you sort of view that transition or that ability to continue to provide that longer term relationship versus the transactional relationship in a very changing world, in a labor scarce world.
- [09:23]
B
Right. So I think there's a couple things. Number one, you have to be value. You have to provide value to a human at some level. So much value that they want to be part of a relationship with you. Either you're helping them achieve their fitness goals, their nutrition goals, you're helping them stay on their blood pressure medicine, you're helping them reduce their A1C3, you're making a palpable change in their life so much that they value the relationship to the extent that they're just looking for a transactional. We still provide that banner is here with 50 some urgent care facilities. And if you want to experience us in that way, we're there for that approach as well. We're really dealing with an enormous variation in generations right now and what they expect from us. So we need to be different. We need to be so much different depending on whether we're dealing with our Gen Z's. I'm looking at my kids or the millennials or the boomers who have different expectations as well. So being an effective health care delivery provider right now is really delivering the care that people want. And that is not one definition.
- [10:51]
A
No, I love that explanation because it resonates so true with all of us, this concept of it. At my age, I'm so used to my long term relations with my primary care physician. At my children's age, they're very happy to go into the urgent care, get what they need and get out. And it really is, there is a piece of that, that you're serving multiple different communities. Dr. Bessler, how do you sort of see primary care fitting into what you do at Honest Health and also how you see the transformation of primary care system in health care in practical terms. What are some of your observations?
- [11:23]
C
Yeah, so I think I've seen the access problem for the last 30 years and some would say, well, how is an ER doc running a pop health organization? And the reality is in the emergency, I always thought if you brought politicians to the emergency department, you could see what the challenges are in our country in one shift. And without a doubt, access is a huge issue. But we're not going to create. I think most experts would agree that there's no way to create enough primary care providers to handle our population. But what most don't realize is we should be doing a lot more around risk stratification of who needs to see the experienced primary care provider with 25 years of care under their belt versus someone else that doesn't have that. Another example is we're using technology to text all of our seniors and instead of our care coordinators getting hung up on because they think it's a spam call, they're interacting with this AI texting tool and then opting in for a phone call from a nurse. We're able to, Instead of contacting 2,000 patients, we can contact 8,000 patients because they didn't spend all day calling people that don't pick up. And so I think it's about risk stratification and using our time more effectively to give the right people access that, you know, the heart failure patient needs to be contacted weekly and monthly, whereas the 72 year old out on their bike, on a bike path near Amy's hospital, you know, might want urgent care and an annual wellness visit and making sure their blood pressure medicines are kept up to date because they're not a high utilizer. And so it's, it's really a risk stratification opportunity.
- [13:17]
A
You make a point there about so many things. But I'll talk for a second about texting versus phone calls. When somebody gets a text, we get it, we almost always read it or respond to it. You get a phone call today, if you don't recognize the number, there's a very good chance you're just not picking it up. So somebody knows who it's coming from. You're just not picking it up today. Once I get a call from somebody like, oh my God, am I glad I picked that up because it's actually somebody needed to talk to, but you just don't expect it. They were at least a text, you know. But trying to find these different modes of working with people based on a situation seems so critical to the stratification you're talking about.
- [13:53]
C
Exactly. You know, I mean, Apple, this latest iOS system has a feature that under phone where you can, if the number is not in your context, it doesn't even ring anymore.
- [14:05]
A
Right.
- [14:06]
C
Literally.
- [14:06]
A
Remarkable. And doctor, let me start with you on this next question. We've talked about value based care for literally a decade, two decades. In a lot of ways it's progressed and not progressed. I mean, even with Medicare Advantage, so many different challenges right now that are coming to fruition. Everybody thought everything was going to move towards Medicare Advantage. But so many different challenges. How does tighter alignment between financial accountability and care delivery, how can that drive better performance while keeping the medical system, while keeping it practical, the system for people to use. How can we align finances and clinical and actually make a difference or make it work?
- [14:46]
C
Yeah, I think it's about the Venn diagram of where this good for the patient, which is kind of the easiest one. Where is this good for the payer and where is this good for the provider? And we all my whole career has been focused on putting the doc, the provider at the center and like how do you drive results? And you know, it's a pretty easy sell to the provider to work at the top of their license, have a team around them doing the tasks that are not as much why they went to medical school and getting paid to keep people healthy. Right. Or to help them, those that want to stay healthy, I guess. But it's, that's the real opportunity. And so we always start our model with are the processes that we put in place going to make the providers more proud of the care they provide. And really that's where it starts. The second piece to that puzzle is, is comparative data, right? So how, like how do I drive performance for providers? Like well, nobody wants to be last. We're all competitive, a lot of type A's. And then the third one is financial incentives. And what turns out is if you keep things simple on those incentives and really focus on the behaviors that really make a difference for the patients, you can put meaningful dollars upfront to the providers to get. Because the other part is you can't wait 18 months to show people the money from all the savings like you. You know, it's just that they're, they're human. That's too long. And so we have to put near term incentives in. But you can't put them in the opposite order. You can't start with incentives. You really have to start with are they more proud of the care?
- [16:37]
A
But I love that that that concept of three different concepts. Are they proud of what they're doing? Do they have comparative data and are there financial incentives? And then I love your point of financial incentives. We've all seen people draw up incredibly complicated financial incentives that at some level make sense, but they're almost useless because if they're not simple to understand, you get people focused on too many indicators, it doesn't really work. So simple to understand. Simple to use comparative data, proud of what they do. Amy, let me ask you a similar question. Driving Clinical alignment together with financial accountability, you're one of the systems remaining with a large insurance operation to go with a large health system in some ways, trying to make that Venn diagram work between what the insurance company's trying to do, the providers want to do, the patients need, and making that all work. How do you sort of see this alignment among sort of finances and clinical and so forth?
- [17:31]
B
Well, I'm just gonna build a little bit on what Rob said. You know, first of all, a great deal of what we get done at Banner is because of the purpose. You know, people generally get into healthcare because they care. They care about what they're doing, they care about making a difference in people's lives. And so that connectivity with our providers and showing them a way or providing the environment where they can make investments in things that make people's lives better, that feeds on itself. So there is a natural movement or want physicians wanting to have that. So being able to give that opportunity in a little bit more streamlined way is still something we're working on. But I think it's critically important. The models, they do conflict in a lot of ways. And I think that's why you've seen a lot of health systems not stay in for the long run. You know, I love the Rob Venn diagram idea where when we look at it, we have things that work in the fee for service side, things that work in the value based care side, and then we have this center where it works in both worlds. And that's to me how people get started. Right, what works? Well, let's focus on length of stay, let's work on discharge planning, let's make sure people have a safe transition to home. You win in every model in that kind of approach. So look at those things where you win and get good at those and then you can extend. We're trying to flip our model. As you know, Scott, we are so dedicated. We're about a third value based care or premium based revenue and we're about 2/3 fee for service. We're moving like a freight train to try to make that 2/3, 1/3 because it's so much more rewarding. Going back to the purpose question to make sure that someone is cared for with their chronic diseases, to give people access, prevention, all of those things. And by the way, that's the only way we, in my opinion, we are going to meaningfully change the cost curve in this country. The financial incentives are not, they are not based at all in wellness. They are only based on transactional sick exchanges in a commercially insured environment. And so we have an opportunity right now, we have an opportunity to show that there's a better, more cost effective way, more rewarding way for people to take care of our communities. It's going to require some policy changes, some reimbursement changes, some acknowledgement of regional health care providers like Banner that do provide this movement, this, this hopeful shift in how health systems are reimbursed. It's not going to happen without a lot of direct intervention.
- [20:38]
A
Thank you. There's so many things you said there that resonate. One of them that I loved is, is that ultimately great care taking care of people really? Well, it shouldn't be. System should be system agnostic that you're taking great care of people, whether in their fee for service, whether they're premium revenue, whichever it is, that at the heart of everything is great care. And then figuring out how you get paid for that care is a next issue. But I think that Venn diagram, so much of it starts with is great care being delivered. Amy, let me start with you on this next question for moving. If we're trying to move the needle to more value based care or at least premium based care versus free for service and system leaders evaluating their next step in value based care. And I'll ask Dr. Bessel the same question. Where should systems focus first? Let me ask you first, Amy, and then Dr. Bess. Let me ask you, how does system start to approach this? Obviously you're doing it at scale. Some systems are doing it at much smaller scale. But how do you approach that? Where do you focus first?
- [21:39]
B
Well, I think there's a couple things. First of all, I would focus on that center of the Venn diagram. Right? The win wins, I win. If we accomplish a strong quality care experience, inpatient, you will have a shorter length of stay, you will win on fee for service, you will win in value based care. There are a lot of examples where smart quality care wins on both sides of the equation. So that's not even controversial. Whether health systems want to or not, they are now clearly in the risk based space. Because if you just look at the state of Arizona, 400,000 people lost health insurance in the last 60 days. Those 400,000 people are now a risk based population for all providers in the state, whether they're health insurance companies or not. So how do we care for those people that don't have access to a reimbursement system to get their care? And do we wait for them to show up in our emergency rooms? Not probably the most practical or smart. So we may have to do things differently, we may have to connect with our populations in different ways. That puts all health systems at a bit of a risk. And so now how are we going to care for that population? How are we going to care for the people that might not have access? It's the same concepts. We need to keep them well. We need to make sure they have food security, we need to make sure that they have access to chronic disease medications that might help them stay well. So that's a different approach that is in how we manage that can be applied throughout our whole health system. So I think everybody that may not have thought they were in the risk based business are sort of going to be in the risk based care business just because of the increasing number of people that don't have any other way to get health care except through our traditional hospital infrastructure.
- [23:56]
A
I think that's a fascinating perspective, that if 400,000 people lose coverage in Arizona, that whether we want to or not, I mean, we do want to, but we're in the business of taking care of those people and doing so as efficiently as possible. They got to get taken care of. And if we waste resources doing so, we can bankrupt the system. And so we have to take care of them as efficiently as possible. So whether you want to be in value best care or not, you're in value based care. Then it's trying to transition or transform and use those lessons for everybody, not just those that can't pay, but using them for everybody. Because so many things that work, work for everybody. Not just the concierge population, they work for the energy population. The same concepts are at play. Dr. Bressler, where would you look at in advising health system leaders? You've been a leader, you're a leader now. Where should people focus first when they look at value based care and sort of next steps?
- [24:53]
C
Well, the first thing I ask them, they say they're not in value based care. I kind of have a similar comment to Amy's, but I say, you know, if your self pay population, your PMPM payment, your premium is zero. So you're in the business with no revenue, just all the cost. And all joking aside, I think, you know, we think that every health system's at a different place on that bell shaped curve or the journey meeting people where they are. Keeping things simple is a very important theme and getting some quick little victories. So it could be as simple as getting primary care into an ACO, which isn't simple to deliver on, but it's simple in the sense of, hey, we're not going to try to boil the ocean day one, but we're going to put meaningful dollars into both the hands of the providers and to the back to the health system on a subset of the population and show what's possible and then how do we expand from there? Because what ultimately the primary care doc wants, they want one process of care in their office, not by patient selection. Right. And so it turns out care coordination is good for a subset of all patients. It turns out that good documentation is good for every patient. It's better care. When you identify diagnosis in patients, it's not a coding game, it's oh, by the way, you didn't document that they actually had heart failure, so how can you treat heart failure or their kidney disease that's been chronic in nature and progressing? And so it's how do we tie some of the financial drivers to better care and really get people to understand the why and just meet people, meet the health system, meet the people where they are on that journey. And there is a wonderful flywheel effect that we've seen because once they start seeing the results and they start seeing the benefit, you know, we know we're winning when the doc walks out of the room and says, hey, this patient should have a care coordinator call Susan or John, you know, that's a, that's attached to their clinic, you know, and that's when we know we're winning, is when they start to think about it as better care.
- [27:12]
A
And Rob, Dr. Bessler, let me ask you a question. You've worked at large, large companies and you work with very large systems. We talk about this concept of starting with small victories. How do you translate some of those small victories to enterprise wide efforts? Because that seems to be, at the end of the day, we've got to get momentum, we've got to get the flywheel going. And at some point we've got to make these things not just one off, it's not just being done with that primary care group in that office, but we're doing this as a system. How do you think about making things work as an enterprise versus individually? And I know you had a lot of experience with that in complex large organizations.
- [27:51]
C
Yeah, I think that, I think you do have to start small and you have to find the providers that are ready and want to go, take risk or that feel they're ready to do that and be successful with a subset of the providers and show what's possible. Every doc, you know, I'm sure, me included, said my Patients were sicker than yours. But the reality is we all are facing very similar challenges. The priorities might be different that day, but showing that it's possible, getting some wins, building belief and not making it more complicated. Right. I think constantly studying clicks that the doc uses. How do we streamline the tool? The AI tools are moving so fast. We, you know, the ability, for example, for our care manager to get data in real time from all the local EMRs, the pharmacy, the claims information, the ophthalmologist, that's not part of the network. All, you know, with one click and see it all in a very organized fashion is the reality we're living in today. It's fantastic. And you know, a year and a half ago, that nurse was spending a half hour trying to figure out what's going on with the patient before calling them. And now it happens at that point, you know, in a millisecond. And so I'm super optimistic about what's possible. But you do have to start small.
- [29:17]
A
No, it's a, it's a fascinating discussion because in some ways the overload of information at one's fingertips feels like helpful and daunting at the same time because all of a sudden you're getting stuff that's useful quickly and you have to do that at scale in an enterprise way.
- [29:34]
C
But think about that. Yeah, right. Think about the physician with 3,000 patients on their panel. 400 of, well, maybe in Maricopa County, 500 of them are seniors on their panel, but only 50 of them are the top 10% risk stratified patients. So it's like we got to focus first on those 50, and once we have good processes on those 50 out of the 500 in that PCP's practice, then we'll go to the next tier. But we don't have to over engineer day one. Right. And, and, and I learned this, you know, a long time ago that every dollar you save is savings. Doesn't matter where it comes from.
- [30:12]
A
But it's a really great perspective on how to look at this both small and large, that we don't have to be fixing everything today for the, the 5 million patients in the state or whatever the number is.
- [30:25]
C
Exactly.
- [30:25]
A
But if we could focus on the 500,000 of a chronic condition or start there with the right data. Exactly. Start to move things in the right direction. I love that perspective. And it's, it's.
- [30:35]
C
Sometimes people hope you got to, you got to show them that they can make it happen and not try to overwhelm.
- [30:42]
A
I know, I love that perspective. Before we close, let me ask each of you, you know, a quick round here. Anything we've not touched on that's important for the audience to understand as things move forward. Amy, let me start with you. Anything that you'd like to add. And then, Dr. Besser, I'll ask you the same thing.
- [30:59]
B
Well, I'm going to pick up on something that I think Rob talked about and why Rob's been very successful, and that's in culture development. You know, what we're talking about here. We tend to talk about everything in economic terms, and we do as well because we have a very tight margin. We have to make this work. But I think that what's different about Banner is the culture, and a culture that together is trying to change things for the better. That approach where we don't sit back and say, gosh, woe are us, and this is complicated, what are we going to do? We say, this is complicated. We need to figure it out. We need to move forward, we need to change together, we need to pull forward together. And having that approach, that culture of innovation, of drive to make things better, I think is going to help Banner forge through into this next generation of reimbursement and care in a different way. And I can't understate how much, how important it is to be able to balance the compassion part of what we do and the business model. Because at the end of the day, when we can tie those two tightly together, we will accelerate our progress.
- [32:27]
A
It's one of the reasons why Banner is an extraordinary system, is that desire to do both, to be compassionate and to run in a practical way, to be both, to be very great with taking care of patients and to be at least cautious of where the budgets lie and how things work and to tie those together. Dr. Bessler? Yeah.
- [32:46]
C
I'd say two themes throughout my career that have been good guideposts for me. Number one is very common one, but how culture trumps strategy, Right? And like, if you. And if you can really get people to understand the why, you know, that's a tremendous benefit. And the second one, I mean, this very seriously, is like, do not make perfect the enemy of good. And what I mean by that, especially with health systems, is, you know, oftentimes when I have the first conversation, people are worried on the other side about, oh, my gosh, their hip surgery volume or spine surgery volume is going to drop. And I have to reassure them. What we're talking about is low value care. We're talking about people getting readmitted for chronic conditions that are preventable. Nobody wants those people admitted. They clog up the system, the hospitals lose money on them. It's not satisfying for anybody. Like we have so far to go before we ever have an intervention model for complex spine surgery. Right. In our, in our value based care journey, there's just tremendous opportunity where, you know, you can really deliver for our country, for our patients, for providers, et cetera. And so I'm, I'm quite optimistic about our future.
- [34:08]
A
No, and I, and I love that. And anybody that's done anything for a long time knows that perfection is the enemy of the good. You want to keep on getting better, but you have to get started. You have to get moving. And that kind of paralysis, thinking by too much analysis, too much aim for perfection doesn't work. Dr. Bessler. Amy, I know I kept you guys longer than expected. Thank you so much for joining us. Amy Perry, CEO, President Banner Health. Dr. Rob Bessler, CEO of Honest Health. Thank you so much for joining us today on the Becker's Healthcare Podcast. We appreciate your time and what you're doing so much. Thank you very, very much.
- [34:44]
C
Thank you all. Have a great day. Thanks, Scott. Thanks. Am.