Care delivery innovation

Thank you Dave. We are here today for a discussion about care delivery innovation in action with our special guest, Dr. Amar Desai, Chief Executive Officer of Optum Health.

Great to be with you here, Ed.

Well, thank you. So Amar, you were recently named the CEO of Optum Health. As a healthcare leader who has worked across all parts of the healthcare ecosystem and as a physician yourself, what do you see as the largest opportunities to reinvent the care delivery system? Because that's what we're here to discuss today.

Yeah, Ed. I think that the opportunities for US healthcare are really around alignment, alignment between payment models that orient the health system towards value, and care delivery or innovation in care delivery, that allows providers to be able to coordinate services on behalf of patients in a much more holistic and seamless way. I really do believe that one of the real challenges in innovation at scale, is to really have both that innovation and care delivery and payment model change really align well, and align in a way that creates the opportunities for entire systems of care to reorient themselves around quality, around service experience to patients and consumers, and orient to creating a more supported, coordinated environment, and ultimately more fulfilling environment for providers, physicians, nurses, care teams to practice within.

So you mentioned alignment and of course that's the goal of value-based care. It's not new, but certainly the understanding of it continues to evolve. How do you view the spectrum of value-oriented models? And I would add how does the approach to care of change with each?

Yeah, I think it's important, Ed. History is important and where we come from as a health system is important to really be able to inform and be able to effectuate change going forward. The US healthcare system has obviously been grounded in a more fee-for-service, transactional-based model, and a number of the ways in which organizations, whether they're medical groups or hospitals or other parts of the delivery system as well as health plans are oriented, is around payment within that fee-for-service environment.

For the system to really evolve into broader forms of payment that involve value, obviously there's a spectrum that can be performance-based payments on one hand, all the way to full risk global capitation on the other end of the value-based spectrum. I think within that, capabilities to be able to take on more and more risk is a really intentional, purposeful investment that providers and organizations need to make. I think that within a globally capitated or full risk environment, there is an entire set of data information technology systems, clearly how provider workflows and the way in which systems of care are organized, that all need to really change to be able to manage that population in a proactive way.

Places within the spectrum that are maybe not as far along, may not require all of that investment. And many places, many different types of organizations are somewhere within the spectrum. My view is that to be able to really deliver on the promise of value-based care and to be able to do the things that the system needs from a quality and a cost and an overall sustainability standpoint, moving into arrangements where providers are investing in and orienting their organizations to be able to take on more and more "risk" or capitation type of payments, is the best way to be able to align providers, plans and the broader health system to do what's best for patients and populations.

Well, you mentioned data and of course data and analytics are key tools to do the kinds of things you're talking about. I know Optum Health has really invested heavily in these areas, more so than some other organizations, but what are the keys for physicians and healthcare organizations to getting the data and the analytics right, to implementing these key components?

Yeah, I think your first point there is exactly right. One, it is a significant investment and it's a longitudinal investment that requires real commitment over a significant chunk of time. I think, first and foremost, is getting foundational data from very disparate systems, unified. There's a number of ways to go about doing that, but getting that data into a singular place, whether it's claims or clinical or other types of data within the system, and having the rigor and fidelity to that data to be able to then be able to do analytics on top of it and generate the right insights for clinicians, care teams, operating leaders, financial and health economics, actuarial type of decisions, is critical. But if that foundational data doesn't have the right level of robustness, rigor, and harmonization across platforms, I think it becomes very difficult to get to analytics and eventually insights.

I'd also say that within that is the ability to work across systems of care. In any of our local geographies or in any of our care delivery organizations, we're obviously doing a lot within the context of our organization, but ultimately patients oftentimes are in other settings of care. So what type of interoperability do you have between systems to be able to share data and information around what is going on clinically with that patient? And be able to bring back information from what's occurred in another setting is obviously critical, also, to be able to holistically have a view on that patient or that member if you're a health plan.

And it's a big stumbling block for so many delivery organizations. And you mentioned payment earlier, getting the payment aligned. So much to that, that's the big challenge for so many organizations. How do you view it? How can physicians be compensated for outcomes in a way that aligns the incentives? How can the consumer payment experience be simplified?

Yeah, look, that it's an important question and it's a challenging one again, because you, you're really pivoting the way in which historical compensation or payment has traditionally been administered, or the expectations around it. First and foremost, I think that within the context of providers and physicians within value-based arrangements, really at a deep level aligning with the provider groups and your individual physicians around what is the shared goals around patient care, is critical. You can think about a number of different methodologies for compensation models, but if there's not a real alignment around what our goals of care are, what the mission within the organization that are connected to those goals of care, whether that's quality outcomes, whether that's member experience, whether that's access to care. And ensuring then that whatever ways in which you decide to implement towards those goals through your compensation models, that starts from a place of real shared, shared goals.

I think within that, I think it is oftentimes very challenging to live in both worlds of both fee-for-service as well as be compensated for value-based arrangements. But I think there's ways to do that because I think across those two "lines of reimbursement" there are things that do cut across very well. We want to provide great access to patients. We absolutely want to look at evidence-based guidelines and ensure that we're delivering care that is consistent with those guidelines. We want to ensure that in many of those cases, that a provider is taking care of a panel of patients, that we really orient their compensation or the way in which they're paid to that panel, to the full care of that patient.

And a number of areas that we have really focused on within our organization has been to really move away from just purely episode-based type of arrangements or incentives, but really to panel-based arrangements and incentives, where caring for that population and the way overall and for at a physician level that may be at the panel level for a primary care doctor as an example, is the way in which we want to structure and deliver incentives.

As it relates to the consumer side that you alluded to, I think enabling seamless payments for items covered by health plan benefits including food and medication and utilities on a singular card-based platform, is one of the ways in which we are trying to create a more easy, frictionless experience in payments for consumers. A swipe with one of these consumer cards can automatically apply to someone's health savings account is one example, taking some of the paperwork that is oftentimes involved in health savings accounts and broader health benefits out. The notion of creating benefits that really people can access easily and that they can also use and be able to track relative to their overall out-of-pocket spend, as well as their overall benefit, is critical in creating a more engaged consumer. And so those are some of the ways in which we're thinking about payments from a consumer standpoint.

[inaudible 00:12:24] lots of good tactics there that you've outlined, but one big takeaway is the goals have to be settled on first, organizational goals for care. So to close, I'd like to ask you a grand question. Can you provide our listeners with a roadmap towards a better care delivery system?

Yeah. Well, I think at a high level, I would say first and foremost, healthcare is profoundly local. And while I think there's principles for a roadmap, I think having a healthy level of respect for the local dynamics of your environment is super important. I think principles I would use to guide that roadmap, number one is investing in infrastructure. I think investing, we talked about IT, there are other types of infrastructure in terms of clinical data, clinical programs, that connect evidence-based medicine, principles of evidence-based medicine into the actual care programs you're delivering. I think that investment is essential to be able to deliver in a value-based construct.

Outside of those types of programs, I think we talked about alignment or shared goals. I think real intentional discussion around where we are today as a health organization or where your health organization is today and where you want it to be, and what needs to shift in terms of payment, what needs to shift in terms of your mix of arrangements with your health plans, what needs to shift in terms of where you make investments in your practice or in your broader organization, needs to match or at least kind of parallel your goals around how you want your broader organization to evolve.

And then last but not least, and I say this with a significant respect for the number of different providers, health plans, hospitals, every type of entity within a healthcare organization, there's a type of organization we have some type of partnership with. Partnership is really important. There's no one entity that does this well on its own. I really do feel like between providers and payers, around goals of quality and member experience and member retention and patient experience and patient retention, those areas are areas which one can align on. And so choosing within your roadmap where those entities within your local market or geography that really has some of these shared goals. And then building and investing in that partnership, I think, is another critical principle in being able to deliver both on the promise of value-based care, but also a broader roadmap to improving the health system within your home community.

Excellent. That is a roadmap [inaudible 00:16:05]. So thank you Amar for sharing your insights.

Thanks so much, Ed. Great to be with you. Appreciate the opportunity.

Now we welcome back Dr. Amy Compton-Phillips, President and Chief Physician Executive of Press Ganey Associates, and an editorial board member for NEJM Catalyst Innovations in Care Delivery.