Episode 66: Final Episode - Value and Primary Care with Dr. Asaf Bitton

Heather: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A monthly podcast for health care providers. I'm Heather Ward.

Mike: And I'm Mike Clark. Heather and I are practicing physicians and participants in the MaineHealth ACO. This month we welcome special guest Doctor Asaf Bitton, the keynote speaker for the ACO's upcoming Value-Based Care Symposium.

Heather: Oh, this is going to be good. Let's get to it.

Mike: Yep, let's do it.

Mike: The ACO's second annual Value-Based Care Symposium is coming up on May 14th. This year the theme is Care in Concert. We'll explore how the people and components of health care can come together, much like an orchestra, to offer high-value care to our patients.

Heather: We are very pleased that Doctor Assaf Bitton has agreed to be our keynote speaker. He is the executive director of Ariadne Labs, the Joint Center for Health System Innovation at Brigham and Women's Hospital, and the Harvard T.H. Chan School of Public Health. He is also an associate professor of medicine and health care policy at both of those institutions.

Mike: Yes. And in addition, a soft serves as a senior advisor on primary care policy to the center for Medicare and Medicaid Innovation and most important and closest to our heart, he is a practicing primary care physician. Asaf, it is a pleasure to have you here. Thank you for joining us.

Asaf: Oh, thank you for having me. It's wonderful to be with you.

Heather: We're super excited. Your work spans from primary care in the office to system level in the United States, and really internationally. Hearing about some of the interesting things you have to say about the work in Costa Rica has been really inspiring. And you know, as we mentioned in the intro, the theme of our upcoming conference is Care in Concert. And if we're going to go ahead and keep going with that theme, I am so curious to learn about what you understand to be the orchestra that comes around the patient, from the experiences that you have seen internationally and from a system level. Maybe you could describe for us a little bit what your experience has been and what you've learned that maybe we could apply here.

Asaf: Absolutely. One of the great privileges in my career has been to A., be a practicing primary care physician in a community clinic in Jamaica Plain, Massachusetts. Now going on almost 20 years and also be a primary care researcher and in some sort of way, a kind of primary care cartographer, trying to understand the different ways in which primary care is organized abroad and is disorganized, faces similar challenges, different challenges. And what I could say in summary, from these sort of travels over the last 20 years, in addition to the clinical work locally, is that primary care at its core is a fundamental component of any high performing health system. Put another way, I have never seen, and I don't think it's documented in the literature, a well-functioning, highly accessible, high outcome health system in the world that doesn't have a very strong core, foundational core, of primary care. It just simply doesn't exist. So, it's almost like a health policy truism. It's a it's almost like the closest we get in health policy to like laws of science. It just it seems to be a necessary and "cannot leave home without it" component. And the other thing that's quite interesting is that the features of what makes up that high-level of performance, or that strong primary core, primary care core, are fairly consistent. They include a system that is financed and attuned toward a reasonable balance between primary care and specialty care, and acute tertiary care. They include a primary care system that clinically is in tune with and has information and data flows to and with public health systems, and they include good strong management and information capacities to sort of flow metrics and flow information about how a given population is doing and present it sort of to frontline managers and frontline clinicians.

Asaf: And it includes probably most importantly, and I find this very heartening as a primary care clinician, they include being attuned to the sort of core four functions of primary care, which are, you know, first contact, access, provide the majority of care for majority of first needs, a coordination capacity to reduce fragmentation, a continuity capacity and function that allows people to have longitudinal relationships with teams over time, and a comprehensiveness so that people are seen not just as a particular vertical disease, but rather seen in their context of their whole health journey and in context of their family and community.

Asaf: You mentioned Costa Rica. I've done over a decade of work with them, and they're probably amongst the sort of top five primary care systems in the world. They encompass all of those realities with a very place-based community health worker integration with local primary care teams. Everybody has access to one of those teams. Those teams see you at least once a year in your house to integrate both your social drivers of health as well as your clinical and preventive needs, and they have really strong data sources, management and attunement to sort of those four core functions that Barbara Starfield and others laid out as being what primary care does. And as a result of that, Costa Rica, even though it spends less than a 10th of what we do per person on healthcare. They spend a lot more of that fraction on primary care, and they get outcomes that, quite frankly, are better than most of the US in terms of chronic disease control, prevention, life expectancy, efficiency, etc... So, I could go on with other examples, but that's certainly one that comes to mind, you know, as a sort of bright spot.

Mike: Wow, that that's incredible. And, you know, it's incredibly heartening to hear what they've accomplished by centering primary care in the overall healthcare enterprise like that. I am both, shocked and then not shocked, by those numbers and those outcomes. What strikes me too is you're highlighting not just the role of primary care providers, but a bigger vision of like a primary care enterprise of, for lack of a better word, that includes public health. That includes more the four key components that you laid out about that include comprehensiveness, coordination. So, it's a very interesting and very exciting to hear about that. And of course, it makes me think about our own system.

Mike: Let's pivot a little bit, if you will, to the US and our own system during this period of significant change as we've been trying to migrate from a, you know, this legacy of, of a system built around fee for service and trying to bend the model towards value-based care through changing incentive models or payment structures. Certainly, CMS is helping to drive this with the goal of having all original Medicare and most Medicaid beneficiaries in some sort of value-based arrangements by 2030.Tight now, as you look at where we're at, how do you think this transition is going, and what are some of the opportunities that that we have in your view.

Asaf: Well, let me just start by saying that, you know, I work at CMS and, the innovation center at CMS part time as a senior advisor. I'm not going to be speaking for them officially, but, you know, speak in my capacity as a primary care physician and researcher. But I think that there's a lot to sort of unpack from that, you know, so we have a top line goal nationally that for both for Medicare and Medicare beneficiaries. And the short answer to your question is that it looks like as a country, about halfway there, depending on the data source and the way that you describe a value-based care arrangement or alternative payment model, alternative to fee for service, about halfway there. We've got five plus years to get the whole way there. I would say that so far, the transition has been mixed. And I think it's important from a health policy rational perspective, from a quality improvement perspective, to face the successes and the challenges straight on, to name them, to not sort of sugarcoat them. What the healthcare industry or large parts of the health care industry over the last 15 years have been trying to do is nothing less than really kind of flip the script, change the way that care is organized, from and paid for, from actually first principles and that first principle, Mike, is actually that the design of the delivery system should be the goal that payment is attuned for, as opposed to the other way around.

Asaf: And let me break that down a little bit, because I think we don't often kind of look at the kind of 60–70-year history of healthcare in the US and sort of say, in large part we in some respects got here by accident. The combination of employer-based insurance plus a unit-based fee for service widget model of payment is not the norm across most of the other high-income countries in the world, and b, frankly, the way that one would design an efficient system that produces good outcomes for everybody at a sustainable cost trajectory. And so if we, and this is important for the value-based care discussion, because if we don't take it as some sort of fixed given that what we had was, was there for a really good reason, and therefore we have to lurch it away from that really good reason to another good reason, but rather it's the opposite. If we say we're changing the delivery system in a way that's attuned with the needs of our communities and our clinicians, and we want payment aligned with that vision as opposed to having payment idiosyncrasy drive a kind of design and delivery mechanism that, frankly, for many people, doesn't make a lot of sense or induces a lot of inefficiencies or a lot of pieces of the puzzle, which are good for one group and not good for other groups. That's an important, important first principle.

Asaf: The second principle on that actually comes back to primary care, which is that if you were to redesign the delivery system, as I think the examples abroad suggest to us, you can't pass go without going through an integrated core, upregulated, better paid, better organized part of primary care because primary care is at central integrating function. It's that interstitium of effective systems that can help make the rest of the system succeed.

Asaf: Now, that's not to say that the rest of the system isn't important. It's fabulously important. We need specialists. We need emergency and acute care. We need rehabilitative care. We need palliative care. It's not about one group being up or down, but it's about the notion that if you really want to look at the evidence in its face, you have to have a strong, robust primary care system to achieve system goals. You can't just sort of see it as an afterthought or worse, I would argue, as it has been seen in the US almost sometimes as a charity case. I've heard executives refer to primary care as a loss leader. That's factually incorrect. It's only a loss leader if the game that you're playing is about maximizing RVUs, and not trying to produce better outcomes, even if it's about maximizing RVUs. You have to ask yourself in the fee for service context, hard questions like where do those RVUs for downstream specialty and technological services and surgical outcomes actually come from? Well, in large part they come from referrals and they come from referrals from patients who are cared for by primary care clinicians in long term, trusted healing relationships.

Asaf: And so either way you look at it, whether you're in a strictly fee for service format, primary care drives downstream revenue. But hopefully as you're looking to something better and much more, I would say optimistic and not so unit based, if we're actually looking to improve the health of populations over time at a reasonable cost, you see that primary care becomes central to that endeavor. It's not a charity case or an afterthought and has to be thought of with the same level of rigor and precision that people think of when they build new hospital wings with beautiful new scanners, or new OR suites or new specialty service lines. It's the glue and the mortar that keeps it all together. And you basically ignore it at your peril. So, the final piece of that thought would then be, why have a target of 100% of Medicare and ultimately Medicaid beneficiaries in alternate payment arrangements? Because I think that the evidence emerges that you have to start somewhere and payment change moving to, you know, moving across the spectrum from straight fee for service to fee for service with some care management or pay for performance target goals to sort of global budgets that are adjusted for risk, that appropriately compensate both specialists and primary care, that are attuned to trends over time, and that center good outcomes over time for everybody, those take fundamental and careful restructuring of healthcare payment in order to be able to unlock different organizational arrangements to get us there.

Heather: That is so true. I have to tell you, like listening to what you're saying, I feel like we're in this time of I mean, obviously we're in a time of transition, but I feel like as a primary care physician, I am being asked to work both in the RVU widget, lots of visits, model, and also do all the work that is required for the value-based care models that are coming forward. And it's feeling a little stressful right now, to be totally honest. So, if you could help me a little bit here, I would love to hear, like where you think primary care over the next few years is evolving towards and like really what we should be doing to get there or what does primary care need to be thinking about in order to evolve?

Asaf: Well, I mean, first of all, I hear you. I feel that stretch and that strain myself personally. The team that I'm lucky to work with on a daily basis clinically, the connection or the sometimes distance between these, I would hope well proven or articulated concepts and theory and the practice every day where you're trying to get through. Still, we can all admit is feels like on many days a hamster wheel or, you know, you're racing against the hamster wheel. There have been more weights added to the wheel and more things to do. And by the way, that's a true statement that is empirically true, that we in primary care have more quality measures to target. We have more in terms of social drivers of health and screening for those making resource connections, following up on those, integrating behavioral health, the pace and the scope of advancements in prevention and chronic disease management, that we not only have to be aware of. I mean, yeah, it's a CME thing, but it's also a "doing more stuff in more concentrated visits thing." There are more screening tests and screening modalities to have good, shared decision making over and to track whether they were done, and then what to do with the equivocal results. And the worlds of GLP1s and the revolutions in chronic disease management that are happening that concentrate, I would say, disproportionately on primary care as well as the information overload, because everybody wants to send us their CC messages and they're just wanted you to know, and FYI and do you mind following up? And I'm not saying that primary care is the only high information overload specialty, but but we are we're in it. We're in it and a key node.

Asaf: How to get from sort of theory to practice and how to do it in a way that doesn't just feel undoable. I think the first step is to acknowledge that this is neither easy and that there are no trite answers. There's no, like, little platitude, I'm going to tell you that that's going to get next Tuesday to work better. But a year from next Tuesday, there are things that are happening and I think the first starts with a recognition in our community of primary care clinicians that for us, we need to make a decision and a commitment that if we are to be able to have a sort of general practice model, a general store model of primary care and not get sort of atomized to, you know, the primary care for only high cost, high need patients that are in Medicare Advantage or concierge care or, you know, work in acute urgent care. If we want the general practice model to work, we're going to likely have to commit to getting off of the fee for service treadmill because you can only spin it so many revolutions per minute. And there's actually empirical evidence. And I've been part of teams that have produced some of this evidence, that shows that it's actually just math, that would suggest that you actually cannot pay for all the expansive functions and needs of an advanced primary care practice on fee for service only through RVUs, even with some of the recent UP regulations for primary care and, you know, limited extra little bands of extra team based care payments, you actually have to pay at some level for this advanced care model with advanced payment models that sort of appropriately package and bundle a mostly longitudinal payment over, let's say, a year.

Asaf: That's risk adjusted for the conditions and realities of the patients that we serve, that pays for the team members, that don't just deal in visits but are critical to the work, and pays in a way that's prospective and predictable so that teams and practices can care for their panels. They can have the time to see people when people need to be seen, but also to do proactive registry management or quality improvement or social determinants work when that needs to happen, which sometimes just means you don't just turn visits for all that to happen. Takes us to sort of say, yeah, that's the North Star. That's where we need to go. That's the only way out of this at some level. And then it also takes smart quality and improvement and managerial and leadership, and it takes us being attuned to pick up, use and iterate on new tools that can get us there faster. I mean, I think that the ambient documentation, at least for me in my our practice has been a revelation. I, you know, have concerns about AI in other areas we can talk about.

Speaker3: But for to be able to document that much faster, check it because it always needs to be checked for accuracy, but spend less of not only my time, but my mental energy being a scribe and spend more time in relationship in attunement with the other person and then go on to the next set of tasks. That's a good start. And I'm fairly bullish on what some of the not just ambient documentation, but other AI enabled tools can do to open up the space, almost like give us that sort of diastolic space to do the other systolic things of primary care that are important and that are effective. I think being attuned and open to that.

Asaf: I think the third part is making very clear if we work in systems and if we don't, then with the payers who pay us, if we're in smaller practice or private practice arrangements, that we are not a charity case, that we are not an afterthought, that we are completely necessary, not alone, sufficient, but necessary to the end outcome goals and so need to be paid for differently, better and make sure that the funds flow correctly to support this work. And when that happens and when we're attuned with our specialists colleagues around common goals, then I think that magic can happen and that this burden that's been on our shoulders can start lifting and we can be the clinicians we always wanted to be with and for our patients.

Mike: Thank you. That is an incredibly validating description of a vision for primary care. I think every day. Right? We taste it. We taste that. What could be what we're straining towards. Right, in this value-based work? and I really appreciate that, and I appreciate how you brought that towards the end: the significance of how we work with our specialty colleagues. I have practiced during the transition from the time when we used to go round on our own patients in the hospital, we had this sort of organic relationships with our specialty colleagues. We knew each other on a first name basis. We could informally curbside consult and it lended itself to a community of providers who seemed to labor together on behalf of our small town of patients. But things have changed, right? And we now have hospitalists. I don't round in the hospital. And I feel like there is an opportunity in a value-based or population-based health care delivery system, to think about how primary care and specialty care work together and how we move our patients from this first contact sort of care, into the specialty world and back.

Mike: In our ACO, the majority of our participant providers are actually specialists. I'm wondering if you have some thoughts on how that relationship can be optimized so that specialists can contribute to the success of value-based care?

Asaf: Well, I think this is a really critical issue. And I think for me, it starts with the idea that value-based care is not shorthand for primary care and new payment contracts and team-based primary care. Value-based care really is an organizational and payment response to a series of predictable, visible, and growing failures of the health care payment and delivery system to meet people's needs. People i.e., patients needs, when they need them to be met. The first step to me is a very clear and deep acknowledgement that there's really no strategy without a sort of whole of healthcare strategy that is not just on the backs of primary care. You know, Heather, to your point earlier, this situation doesn't improve if we see value-based care in ACOs as something that, like primary care people do and administrators do, and then specialists are kind of like just watching from the sidelines, neither engaged nor core to its success. I would argue that the conversation that needs to be had first primes that relationship between primary and specialty care and says, we're all in this together. I mean, you know, at some level, we're actually in this together as an organization. We signed contracts, or signed contracts were signed on our behalf, in which we share goals, targets and consequences. And no one part of this organization can do it without the deep engagement of the other.

Asaf: And I emphasize the deep engagement. It might be true as it is now, that there are more quality measures, for example, that value-based care contracts have that seem to be in the realm of primary care versus specialty care. But that needs to change, and that can only change with specialists engaging to help us understand how, as an organization, we and as a healthcare community, we better measure the quality and the success of their work. The second part is to not fall for the false antagonism or the zero summing of this. Well, if I help primary care, then that means something comes out of my contract, or my workday, or my aggravation. The fallacy is to think that if that's true, then the answer would then be to just circle the wagons either as an antagonistic relationship, which actually deprioritizes the patient in all of this and makes it super doctor centric, which is not good for anybody. And number two is actually just wrong, because not only contractually are we all in this together, but with the complex winds of socially, politically, economically that we're all in. There isn't a lot, I would argue, of consumer and patient interests in these sorts of internal House of medicine squabbles, what people want when they tell us in surveys or when we talk to them in the exam room.

Asaf: What people want is to get care when they need it in a safe, reliable, humanistic and effective way that takes everybody. And if we're sitting here squabbling about, you know, who moved my cheese? And, you know, 2% of my salary is going to go to 2% of your salary. Neither is that a good look, nor is that sustainable, given the headwinds of this time period of uncertainty and tumultuousness that we're all in. So I often tell my specialty colleagues, it may feel like you may want to circle the wagons or this isn't your game or this isn't your bag, but it is. It is because value-based care is not going anywhere. If anything, it's just going to keep growing. So you can be, I would hope, a playwright. Or you can be on the sidelines as either a spectator, a critic or an uninterested bystander. And that's not good, because we need your voice and your expertise and your help figuring this all out. This is a whole of medicine, whole of healthcare endeavor. And so, you know, I hope from both the positive and also to avoid the negative, there's a case really that we need all hands on deck.

Heather: Yeah, that all hands-on deck I think starts to point to, you've also alluded to some other really positive things about the future of value-based care. I'm just wondering if you could just highlight for us what you are most excited about as we look to our future in value-based care?

Asaf: Well, I'm excited that we're headed toward payment models that actually support the delivery of the integrated, effective, safe, innovative care that we know is possible. That the revolution in biomedical sciences that's creating incredible therapeutics from the preventive to the curative. That we build delivery systems worthy of those advances and that deliver those advances to everybody, everybody who lives in in rural areas, in urban areas, in ways that don't break the bank, that don't make our businesses shudder under high premium loads or trust funds for the Medicare and Medicaid, unsustainable for the federal budgets that don't break state budgets.

Asaf: We know with grade A+ evidence that fee for service is just not attuned to those kinds of effective whole of population outcomes at a cost point that we can afford now. It works for some people, and I'm very sympathetic to that. But the alignment of delivery mechanisms that have a focus on integration, rather than fragmentation on safety and quality improvement, as opposed to duplication and useless competition, that focus on thinking about how to make people's health journeys effective and delightful. I mean, when do we talk about delight in healthcare? We're right now so mired in the things that don't work. And I'm saying that value-based care offers the opportunity, if done altogether iteratively, learning from things that don't work, as well as spreading the things that do work, an opportunity to for us to actually have health systems that work for everybody.

Asaf: But we need to be really crisp about the goals. The goals are not just to sort of, you know, maintain status quo, that works for some people in the healthcare system provides nice salaries for a lot of people and that they just want to protect, but that can continue to provide good salaries while also improving patient care in a way that reduces unnecessary utilization, that requires us to have clarity of purpose and combination of action so that everybody is on board. They see it all as part of their mandate and their book of business and their work, and they see it as being. And I think this is a challenge for us all.

Asaf: We have to be clear with what we even mean with value-based care. What are we actually talking about? Not a sort of grab bag for all good things under the sun, you know, and triple or quadruple aim kind of stuff, but rather very clear, like we are going to make it easier for people to get the kind of care that we would want for our families when they need it. And we're going to do it in a way where we're all working together and rowing in the same direction, as opposed to kind of squabbling and just protecting what we think is is our own turf. That's going to require some real conversations, and they're going to be people who don't want to necessarily move on that.

Asaf: But I would say to my good friends who have good questions and everybody, a lot of people have really good questions about this. Bring those questions in. Let's talk about them. Let's talk about what you're worried about. Let's fix what doesn't work about the directions of that angle on value-based care. Let's get crisp on the definitions and then let's move forward. The question isn't whether we're going to agree on everything. We're going to disagree on some things. But at the end of the day, can we disagree and then commit to work together to these common goals? That's what we're here for or are we just going to be all for our own interests and forget about the patient's interests and our community's interests? That's what we have to ask ourselves clinically. And then how do we do that in such a way where we don't have to be burning ourselves out and be heroes to do it? How do we make the system better, where you don't have to be a hero every day to make it better? You can make it easier to do the right thing more of the time. And that's the principle of a good learning health system. The challenges are steep, but the promise is clear, and the opportunity set is amazing for us to actually finally build the health system that I think we all trained thinking that we could work in to help our communities.

Mike: Yes. Thank you. Thank you so much. We're so grateful that you took time out to have this conversation with us. I'm tremendously encouraged by the things you've shared. It is so critical, isn't it, to cast that vision, that true north of centering our patient in what we're doing as a system and as an individual provider. Right? It's just been such a wonderful thing to have this conversation with you, Doctor Bitton.

Mike: We look forward to you joining our symposium. I hope this whets the appetite of our listeners to sign up in mass and continue this conversation together as a system. Thank you so much for joining us.

Heather: Thank you.

Asaf: Thank you for having me.

Mike: So thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our webpage MaineHealthACO.org/BACON.

Heather: This is normally when we say see you next time, but this episode is different. It's actually our last one for BACON. After six years and 66 episodes, we are bringing the BACON series to a close.

Heather: Mike, you have been a host since the very first episode in May of 2019. How's it feeling to wrap things up?

Mike: Wow, 2019 does seem ages ago. That was before the pandemic. That was at a very different stage before the health system had consolidated. We were at a different place now, and, it is a good thing to have done it, and it's a good thing to bring it to a close. But we should say that this is not goodbye for Heather and me. We're launching a new podcast with the MaineHealth ACO in May.

Heather: I am really excited about this. The new podcast is called Curbside Consult, and it's something we came up with in response to the diminishing opportunities for primary care providers and specialists to connect. Back in the day, we ran into each other in the hospital hallways and could talk informally. There are all sorts of opportunities to just chat about new ideas or what could be going on with a patient. We just don't have that anymore. And our goal is to recreate these curbside consults, these moments in this new podcast.

Mike: Yeah. So to see how this plays out, join us for the first episode featuring our conversation with pediatric endocrinologist Mike Dedekian.

Heather: Look for that at the beginning of May with more episodes to follow each month. Curbside consult will be available on the MaineHealth intranet homepage and out in the world via the usual podcast apps. Look for reminders in the Mako newsletter and other newsletters across MaineHealth.

Mike: So we'll see you for the first episode very soon.

Heather: See you soon.