In this second take on episode host Stacey Richter speaks with Dr. Tom Lee, founder of One Medical and Galileo. The discussion centers on the survival of independent primary care practices in the current healthcare economy, the associated challenges, and the paradox of primary care.
Topics include reducing ER visits, managing downstream specialty spend, and the imbalance between CMS and commercial carrier payments to primary care practices.
Dr. Lee highlights the importance of 'enlightened leadership' and a 'value-focused mindset' in balancing efficient service operations with quality care. He also touches on the complexities of integrating technology and human-centered care, the importance of operational efficiency, and the challenges posed by current reimbursement models.
For a bonus sidebar conversation with Dr. Lee, click here.
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✭ X https://twitter.com/relentleshealth10:30 What is the paradox of primary care?
12:47 Why is it hard to run an independent primary care practice?
13:29 What are the barriers to running an independent primary care practice?
14:09 Can you have fee for service and value?
15:53 “Value is more about a mindset.”
16:49 What hidden waste is there in a primary care practice?
18:36 What do you need to have a value-focused mindset?
20:41 Why does access precede quality?
22:40 What are the nuances of a service business that make them challenging for managers?
23:27 How do you find the balance between fee for service and value?
30:07 EP438 with John Lee, MD.
31:04 How can you invest in quality without a value-based contract?
33:09 How do you address the trade-off between fee-for-service finances and investing in value-based care?
34:26 Where is the “productive middle”?
35:18 Dr. Tom Lee’s message to payers.
38:45 Dr. Tom Lee’s message for policymakers.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
"Take Two. What Does It Take For An IndiePrimary Care Practice to Survive Right
Now." Today I speak with Dr. Tom x Lee.
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
(00:23):
Relentlessly Seeking Value.
Let's take a second.
Listen to this interview with Dr. TomLee that originally aired last summer,
but listen to it this time withinthe context first of how primary care
can or should reduce ER visits andalso downstream specialty spend, et
cetera, which is one of the throughlines that I, along with you lot have
(00:47):
been exploring a lot this past year.
And much of this conversation isabout how primary care can survive
in these unfavorable times whereCMS and commercial carriers complain
about the rates that they have to payconsolidated entities with market power,
consolidated health systems, but thenthey actively underpay in the practices.
(01:08):
That is very illogical.
I'd say at a fundamentallevel, it's not tricky math.
Do not force out of business yourpotential best partners, and then
wonder why you have so few of them left.
Dan O'Neill was talkingabout this the other day.
I will link to it in the show notes.
So that is one context to kind oflisten to how does primary care survive,
but then also listen to this show inthe context of my latest tear which
(01:33):
is this mission versus margin tear.
Some of the same themes come up as inthe show with, for example, Dr. Ben
Schwartz from a couple of weeks ago.
How do you ensure that if you want toachieve scale, and you can only achieve
scale, when you take professionalcapital from private equity or VCs
or even a consolidated health systemwith a venture fund or an innovation
(01:55):
studio, how do you take their money,but not wind up with some board member
sitting at the conference room tabletalking about a mission like you
know, Jeff Bezos is where he said,my mission is other people's margin.
How do you tow that line?
Rushika Fernandopulle talked about thisa little bit too, that you need money to
(02:16):
scale, but once you get money, it's easyfor mission to get kicked off the bus.
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
This is my originalconversation with Dr. Tom x Lee.
Today I am talking with Tom X Lee, MD,who has a long history in primary care.
He founded One Medical and thenalso most recently Galileo.
(02:38):
Dr. Lee also was a founder atHippocrates tossing that in for context.
I wanted to talk with Dr. Lee becauseso many RHV, Relentless Health Value
listeners are trying to figure out howto sustain primary care as a standalone
entity when most primary care docs thesedays are employees of health systems.
(03:02):
And that makes sense because thesedays the most obvious and most common
way to make enough money in primarycare is to drive and maximize the
dollars from downstream volume ofhigh priced service lines, which
if you think about it underminesthe entire point of primary care.
But is also a really good motivation fora consolidated health system to purchase
(03:23):
all of the primary care docs in the area.
I'm starting to call this the Paradox ofPrimary Care because when you begin seeing
the promise of primary care have to erode.
If you're gonna stay in thebusiness of primary care, then
yeah, it's sort of a paradox.
Said another way, if you do primarycare really well and use evidence-based
preventative care to curb the need forexcess specialty care, i.e. you reduce
(03:47):
specialty revenue through primarycare, now you're asking specialty,
high profit health system servicelines that is, to not only make less
money, but use the remaining moneyto pay for primary care, which is the
entity that is reducing its revenue.
So again, I am hereby coining the term,the Paradox of Primary Care to express the
conundrum for why a consolidated entitythat knows where its bread is buttered,
(04:11):
is going to do much, if anything, toempower primary care with the technology
and the staff and the time which, ifit goes well, is going to cannibalize
its own major source of revenue.
Meanwhile, if you choose not toparticipate in this paradox within
the context of a consolidated entity,it's kind of hard to stand up a
(04:31):
pure play primary care practice.
And I've heard this so many times mostrecently from Dr. Paul Beahrens who said,
he wrote on LinkedIn, "My own primary careclinic lasted independent from 1946 to
2017, and when costs were rising fasterthan reimbursement with no alternatives
available, we sought out purchase byour hospital, giving up on trying to
(04:56):
stay independent. Consolidation is notdriven by bad actors, nor by quality,
nor volume savings, but by the bizarreeconomics of healthcare as a highly
regulated, but hardly rational market".
I just, I, I simply don't get, why knowingas much as we know about the importance
of primary care, CMS and others continueto follow RUC guidance on PCP rates.
(05:19):
How much power must be wielded bythe AMA or the AHA or who knows?
I don't know the half of it admittedly.
Listen to episode 437 with BrianKlepper for more on just the RUC.
Also despite, again, all of the lipservice about the importance of primary
care, our current cohort of payers seemsto have a thing going where they do
(05:39):
not offer value-based care contracts,VBC contracts to the primary care
folks who seem most likely to succeed.
Add to that the moving goalpostsfor ACOs and the lack of available
data to even know how you're doing.
And yeah, here we are.
Hi, this is Tom Nash, editorand producer of the RHV Podcast.
You've probably heard me say thispodcast is sponsored by Aventria
(06:02):
Health Group, and that's true,but there's more to the story.
Aventria is our day job, and the peoplethat make this show happen are Aventria
employees generously donating their timeand talent on top of everything else
they do to get each episode out the door.
So yes, Aventria underwrites theproduction, but in many ways, Relentless
Health runs like an unofficialnonprofit, a very, very nonprofit.
(06:22):
Aside from the occasional and deeplyappreciated episode sponsor and our
wonderful listeners who donate to the TipJar, this show is scrappy and self-funded.
If you wanna keep this podcast independentand laser focused on educating,
informing, and driving real changein our healthcare system, we invite
you to become a monthly sustainingmember of Relentless Health Value.
We have a few of you who have alreadytaken it upon themselves to do this
(06:44):
already, and we are deeply grateful.
Maybe in the future we willbe able to cook up some perks.
Could be mugs, Zoom meetups, and otherways to connect with like-minded listeners
who care about the same things you do.
So if you find value in whatwe do each week, head over to
relentlesshealthvalue.com/donateand donate to the Tip Jar.
Maybe become a sustaining member.
(07:04):
Or if you or your organizationwants to sponsor an episode
or two, we'd love to chat.
Thank you so much for listeningand being a part of the movement.
So again, the question ishow to sustain primary care
without falling into a paradox.
That is the hard questionthat I ask Dr. Tom X Lee.
Today, I asked Dr. Lee flat out whatit takes to stand up a standalone
(07:28):
entity doing primary care, and hesaid, enlightened leadership with
a value mindset combined with bigtime chops in service operations.
I of course asked what doesenlightened leadership and MAD
skills and service ops mean exactly.
And specifically, Dr. Lee broke this down.
Part of it he said is finding aneliminated hidden waste, which
(07:48):
according to Dr. Lee does existin primary care, although maybe
in a thinner layer than elsewhere.
And trust me, I asked Dr. Lee,what is this waste exactly, and
specifically of which he speaks.
Turns out a lot of it is cutting outbusy work, like clicking 90 times
to order a Tylenol or dumb paperworkor doctors doing stuff that a nurse
navigator could do in between visitsor the medical assistant could do,
(08:11):
or technology could just automate.
If you think about wasted time ascapital W waste, then yeah, there's a
hefty amount of waste that could be cut.
This also comes up in episode446 with Dr. Spencer Dorn.
Now you know me, you start talking aboutgetting rid of waste, and I am immediately
going to ask you how you define value.
(08:33):
How you define what you value,because when cutting waste, it's
really easy to cut more than waste.
Listen to the show with KateWolin or Rik Renard, or Dr. Will
Shrank for more on that one.
So I get into a proper grilling withDr. Lee on how he defines value.
Which leads us to talk about open accessas one component of delivering value.
(08:54):
But then of course I bring up,yeah, well access was Walmart and
Walgreens hypothesis giving patientsaccess to care and they will come
and that didn't work out so well.
The rebuttal there is access.
Sure.
But access to what?
And good point.
Clearly there was a disconnectbetween what patients thought good
primary care should be and what wason offer and around the wheel we go.
(09:18):
Because again, we're back tothe delta between the promise
of primary care and what oftenexists, again, with the paradox.
Okay, now just let's sum thisall up here because I really
wanna get to the interview.
The trick to doing a pure play PCPor indie PCP practice without falling
into the paradox of primary care isenlightened leadership with a value
(09:41):
mindset combined with service operationsto find the balance between human
centeredness, process and technology.
That's kind of the big wrap upof a many pronged conversation
that there is a balance here.
Dr. Lee puts it this way.
He's like, If you think about it as aparadox, you're kind of creating a binary.
What you want to find isthe productive middle.
(10:03):
Find the productive middle of primarycare, and you can get rid of the paradox.
Probably some of you are thinkingdirect primary care slash DPC is
a solution here, and yet for sure.
But to do DPC well you still have tohave enlightened leadership and do
a good job with service operations,especially if you're thinking you
want to work with employers or otherswho are going to measure outcomes.
(10:27):
Dr. Tom Lee, welcome toRelentless Health Value.
Thank you.
Thanks for having me.
I thought you would be the perfectperson to talk about something that
I'm wrestling with and I know thata lot of our listeners are wrestling
with, and this is what I'm startingto call the paradox of, primary care.
This is the idea that the promiseof primary care is through
evidence-based preventative careand by addressing issues early to
(10:50):
prevent or slow disease progression.
So specialist volume is therebyreduced and therefore one might assume
that specialty revenue is reduced.
However, one of the few, it seemssustainable ways to pay for primary care
is by vertically integrating primarycare into a consolidated stack and
(11:11):
then using the money from specialtycare to subsidize primary care.
So, I don't know, I'm starting tocall it a paradox like why would
a, a consolidated entity that knowswhere its bread is buttered, why are
they gonna do much, if anything, toempower primary care to cannibalize
its own major source of revenue?
Yeah, no, I get it.
Look, I think the world is slicedinto uneven slices, and when you
(11:34):
look at it from a variety of lenses,it looks odd or maybe paradoxical,
that the two should cooperate,certainly within one combined entity.
And so I understand that maybe thatmight be one lens to look at it.
Another lens to look at it is ifyou improve primary care by itself,
there's an opportunity set there.
But what's implied in the paradoxis that you can make primary
(11:56):
care work better on its own.
And you know, that was the wholepremise of starting up One Medical
was, can you start a pure play primarycare concept that's not dependent
on specialty revenue and otherwiseto self sustain itself and scale.
So there's an opportunity to do so byitself, but certainly when you combine
the two, then you need what I would callenlightened leadership to move off of
(12:19):
fee for service and more towards value.
But not all, all organizations cantraverse those waters at the same time.
So one of the things that yousaid there is that there is an
opportunity to start a pure playprimary care practice on its own.
Do you feel like that is ahypothesis that has been born out?
(12:39):
Well, let's just say this.
It's not easy, you know, uh,One Medical and Galileo are
somewhat exceptions to the rule.
But, it's possible.
The reason why it's hard to do isthe world has become increasingly
complicated and it's increasingly hardto run an independent primary care
practice without a lot of sophistication.
And so through unintended consequencesthrough the policies that we have,
(13:03):
you know, starting up de novospecialty practices is almost as
hard as primary care these days.
So, the hospital consolidation has beenhappening for a reason, and so yeah,
the, it is increasingly hard, but itis financially, theoretically feasible.
It's just it requires a differentmindset to care and service operations
that most folks don't have training in.
When you say a different mindset.
(13:24):
What exactly do you mean?
And, and you also use theterm enlightened leadership.
Maybe we start here.
What are the barriers Exactly.
And specifically, and I know alot of our listeners are like,
obviously fee for service for theRUC has destroyed primary care.
So you know, everybody's immediatelygonna be going, the incentive
payments are low with primary care.
What else?
Yeah, so the main thing to thinkthrough is a lot of the world is kind
(13:49):
of viewed as a zero sum or binarystate world, where it's either A or B,
meaning fee for service or value, andyou can't do both at the same time.
The reality is you cando both at the same time.
It just requires a bit morecreativity and innovation.
And the way you do that isfrankly to lower your unit costs.
(14:09):
If you can lower your unit costs, youcan make margin on fee for service, and
you can actually now increase your scopeand do more across value with the extra
infrastructure and enhanced resources.
So I think there's a lot of different waysyou can do both fee for service and value.
It just takes.
A slightly different mindsetto believe you can do both.
And I think so many leaders kindof have these binary talking points
(14:32):
about you can have your foot in twocanoes and a lot of that can be done.
It's just you kind of have tounlock yourselves from these
kind of binary modalities.
So it's interesting what you're sayingand we're talking about a pure play
primary care practice right now.
What I'm hearing you say, you can do thisif you have some value based contracts,
some of them, and you also have, youknow, if you have some value based,
(14:55):
you're gonna have some fee for service.
I was listening to, I think it was aRadio Advisory show where they basically
concurred with exactly what you're saying.
They're like, it's not a binary, there'sthese spots in the middle, where you've
got varying amounts of value-basedcontracts with fee for service, and
that's not gonna go away anytime soon.
It's not this kind of likemessy middle on the way to some
(15:17):
Shangri-La like it is the way it is.
So, what I'm hearing you say is you can doa pure play primary care if you have some
mix of value-based and fee for service andleadership is able to contend with having
value-based contracts as well as fee forservice contracts at the exact same time.
But then it also sounds likebecoming very efficient and lowering
(15:39):
costs is also part of this mix.
Did I get that right?
Close.
I mean, again, there's a lot ofsubtleties in kind of, uh, the terms.
When I say value it's not onlyabout value-based arrangements
and payment architectures.
Value is more about a mindset.
Can I do more for less?
Can I be more effective, more efficiently?
(16:00):
And so that mindset can exist ina hundred percent fee for service
architecture or a blended architecturewhere some of my payments are at risk.
So all I'm saying is within primarycare you can, what I call slim down
your overhead, run your practicemore effectively and efficiently
and be in a fee for service world.
And that's still a value focused mindsetbecause you're trying to do more for less.
(16:23):
And that's how we started off with OneMedical is trying to do more for less.
And then we realized that, oh wow, we canmake margin in primary care by itself.
And then, you know, scaled it from there.
And so again, it's a bit of the awarenessthat there is hidden waste everywhere,
across every layer of the ecosystem.
And granted, primary care is asmaller, thinner layer within the
(16:44):
healthcare ecosystem, but thereis still opportunities to innovate
within that layer by itself.
What are some examples of hiddenwaste in a primary care practice?
The easiest anecdote I would use ormaybe kind of shorthand is look at all
the people around any service model.
And for the most part, let's useknowledge based workers and ask
(17:05):
yourself what percent of their dayis their brain effectively utilized.
And if it's, you know, let's callit, uh, any reasonable percent.
That's an opportunity, and I wouldargue that most clinicians, most
administrative personnel would say, mybrain is not being effectively utilized.
My body and busy work is beingeffectively utilized, meaning
(17:28):
my busy work is very high.
But my effective work, the thing that I'mmost skilled at is being underutilized.
And so I think that's where inalmost all service models, we don't
recognize untapped talent, untappedpotential, and the lack of productivity
because people are just underutilizedand or the work is not organized.
(17:50):
To be most effective, and this istrue of all service organizations.
When we were starting up One Medical,I was looking at all different types of
service organizations and you just, youcan see organizations where workers are
engaged and workers are not engaged.
And we have a high percent ofunengaged workers, particularly
in, you know, office-based settingsbecause it's chaotic, right?
(18:11):
And that chaos dwarfs the ability toactually think and do productive work
. I could ask you like 40 questions right now.
So let me contain myself.
I love what you said about havinga value focused mindset, and
that doesn't just mean in a valuebased care payment architecture.
That one can have a value focusedmindset anytime including it, even if
(18:33):
it's pretty much all fee for service.
As I contemplate that, in order to have avalue focused mindset, you kind of really
have to think about what is value, whatare we trying to do, what are our goals?
And I've heard that there's onlyfour categories of goals really.
You know, you can have financialgoals, you can have patient reported
(18:55):
outcome kind of goals, PROMS.
You can have clinicianreported outcomes, right?
Like what is an outcome that a clinicianthinks is something to be proud of?
And then lastly, some kind ofperformance metric of some kind,
like patient satisfaction, et cetera.
So as I'm thinking about whatconstitutes this value focused mindset.
Probably part of it or the wholething is gonna have to begin
(19:18):
with what do we think value is?
Because if you try to be efficientwithout necessarily understanding
what good looks like, then you wind upcutting corners in ways that actually
diminish whatever you're trying toaccomplish beyond some financial metric.
Would you concur there orhow do you think about it?
Yeah, dimensionally I think thoseare reasonable ways to categorize
(19:42):
thoughts around quality or performance.
The reality is that the decisionmaking in any organization is
much more subtle than that.
You know, let's just kind of pick asimple dimension such as access or
service, which correlates with patientNet Promoter score, otherwise, right?
What's appropriate?
Same day appointments,next day appointments.
One week appointments.
One month appointments.
(20:02):
What's quality there?
Depends, right, on the clinicalsituation, the economic model,
the economic affordability.
So you can say all you want about thedimensions, but the judgments are still up
to the organization to determine what dothey value and what can they financially
and operationally achieve based on that.
And if we used access as a surrogatefor equality, which again, I'm
(20:25):
not saying that it should be,the industry's not doing great.
And so to me, you know, when I think aboutcare as a clinician, if a patient can't
reach me, I've lost the job in step one.
If they can't reach me, then how am Isupposed to be able to take care of them?
And, how can I give them great care?
To me, access is one of just thefirst steps to quality, and it
(20:45):
precedes quality at some level.
We do so poorly of thatacross the industry.
So to me, access is one dimensionof quality that we should start with
separate from all the clinical decisionmaking, separate from all the follow
through, separate from what are callthe experience and outcomes of care.
So you just take a simplemetric like access and say,
well, are we doing a great job?
(21:06):
You know, probably could be better.
So we're talking about thetwo dimensions that are super
important to be contemplative of.
One is access and convenience, andthen the other one is this, how
do you be perceived as an executeon a longitudinal patient journey?
And now I'm gonna go back to somethingthat you had talked about before,
which was also it definitely soundedlike making sure that amongst the
(21:31):
employees or those that are workingwithin the practice, there's a
lot of untapped talent potential.
And checking to see what percentage ofsomeone's day is effectively utilized
and how much of it is busy work, andthen getting rid of the busy work.
Another way to say this, which I don'tlike because it's become a euphemism
for all kinds of bad behavior, butthis idea of, um, working at the top
(21:52):
of your license, just making surethat everybody is cognitively able to
deliver at the level that they know thatthey can and not get bogged down into
just bureaucratic madness that burnspeople out and is often so frustrating
for really good people who understandwhat they could achieve and just the
latent potential that's kind of lost.
(22:13):
So like that's kind oflike one side of this.
But then the other side, I know you'vetalked at length about like the One
Medical app and other things that,that you've created on the technology
side and then processes also.
Is that kind of the sum of what you,you're thinking about as you think about
how do you efficiently and effectivelywithin the current kind of crappy
payment models for primary care actuallysucceed in a primary PCP or what am I
(22:38):
missing or what do you wanna dig into?
Yeah, I mean, I think some of thenuances on a service business are
challenging for a lot of quoteunquote traditional managers.
When you look at a service business,the human beings are the service,
and so you really have to think aboutthe dynamism of it, what it means
to be a caregiver, a team memberthat's interacting with a patient.
(23:00):
There's that human organic dimension,and then there's just the basics
of operations and finance onrunning a sustainable practice.
And those two sometimeswork against each other.
In some places you see humansdoing work that machines should
be doing as an assembly line, andyou know, that's not a great use.
And in other situations you have peoplethat are purely just ad-libbing and that's
(23:25):
not great from an economic perspective.
So you have to find thatright balance of operations.
And human centeredness to createthe best service organizations.
Otherwise, they feel like a machineand soulless, or they have too much
organic behavior and they feel chaotic.
So that middle ground is where the servicebusinesses, at least from my observation,
(23:47):
the best ones, tend to thrive, butyou gotta find that right balance.
And this is one of those things thatcapitalism and business school don't
do a great job at, which is kind offinding that gray middle where you get
a bit of both working well together.
And I think that's a lot of what makes,to me, services businesses, you know,
exciting and challenging and dynamic.
(24:09):
How do you start that?
If you were going to give somebodysome advice, who's sitting here
thinking, huh, I would like to checkand see how I'm doing with this.
What's step one to figure out wherethat sweet spot in the middle is?
Number one, and I don't know if thiscan be taught, but you kind of have
to give it, uh, I don't know if I cansay this, but you have to give a shit.
You really have to care about people.
(24:31):
If you don't, then you're, you're gonnabe losing that side of the equation.
And so you fundamentally have tobelieve in supporting your team
and supporting patients as humans.
That has to be an eight or at least veryhigh on the list of things you care about.
If you don't start there, then you'reactually working against yourself.
The second I would say is justunderstanding, you know, math and
(24:55):
operations and basic machinery, andthose are the two ends of the pole.
And then the beauty is using the toolsof math and science and whatever to
shape ecosystems that are more likelyto produce positive outcomes for your
team and the patients we care about.
And so that's kind of the nuance thatat least, you know, in most of the work
(25:17):
I've done have at least so far resultedin, you know, pretty positive ecosystems.
I definitely hear what you're sayingthat on one side of our axis here
we have, you have to give a shit andalso understand people and by people
we're including colleagues and beinga good manager and then also patients
(25:38):
and what good patient care looks like.
The healthcare is fundamentallya very human operation.
It will succeed if there's relationships,if there's trust and that has to happen
very much at a level where someone's EQis high enough to be able to do that.
I had a mentor one time that would sayrepeatedly, You can't legislate the heart.
(25:59):
And I think that mightbe what you mean by that.
On the other hand, it's alsounderstanding how operations works
and math and technology, what can beautomated and is there an API for that.
That side also becomes incrediblyimportant because if you have a human
doing something repeatedly, that's wherewe get ourselves in tons of trouble.
(26:19):
You know, it takes 90 clicks todo the right thing for a patient.
Even the most caring person inthe world could be undermined.
So finding that middle ground is certainlynot something that's easy, but I can
see exactly what you're saying thatis really essential to be able to do.
Is there any other kind of summaryadvice that you might give to someone
who's now thinking to themselves?
(26:40):
Hmm, I, I gotta dig in here.
Yeah, I mean the only other thing wouldmaybe be, you know, especially coming
from a medical world where it's likeresearch, validate, and then do, a lot
of, you know, real world innovationhappens from trial and error, and I
think people tend to underestimate thatin service oriented clinical cultures.
And so you kind of have to alwaysbe tweaking and figuring things out.
(27:04):
It's a dynamic industry.
That is the challenge is, how do youcontinue to innovate and learn and change?
Given all the human machinery,it's easy to upgrade software.
You just upgrade thesoftware and it's there.
But how do you continuously upgradethe service operating platform?
A little bit more challenging.
especially at scale.
How do you put together thisenlightened leadership team
(27:25):
then that is able to do that?
Is there a certain compositionof who's leading is there, you
know, like they gotta work withpatients three times a day maybe.
What advice do you have to puttogether a leadership team that is
capable of finding that middle ground?
It's challenging.
I don't know if I'vegot the right playbook.
I've only done this now twice.
(27:46):
But with One Medical and Galileo,we've relied on different talent,
different pools of talent, differentequations, so I don't think there's
necessarily a one size fits all playbook.
I think it has to be adaptiveto the strategy, the operations
in kind of the people goals.
It's just like anybody who's beingthoughtful about architecting
their org, it's at some level,a bit more intuitive, I guess.
(28:11):
And imagining how things should workand what talent types you do need.
So it's a little bit like cooking.
It's like what ingredients do I need?
It varies depending on whatyou're trying to cook up.
So the ingredient mix, at least forme, has changed between One Medical and
Galileo, between Galileo early stage,and we're moving into middle stage of
(28:31):
the organization in terms of scale.
So, the types of people and thetypes of needs are different.
I guess maybe the only other corollary isI don't see a lot of talent you can hire
and suddenly you have a instant voila.
You know, there's just, theindustry is so immature from my
perspective that you can't justfind somebody and just bolt them in.
Very often it needs to be a skillset or amindset that's being added, and it needs
(28:56):
to be shaped within the org dynamically.
It's very rarely just plopped in.
It feels like what you're saying,it's super important to make sure
the leadership team is purpose builtto achieve the goals which are set
forth, which are clear because it'snot necessarily like, oh, this person
checks all the boxes relative toskills, so it's gonna work out here.
(29:18):
It's also, do theybelieve the same things?
Do they care in the same ways as well?
So it's definitely, it's gonnabe a special blend, depending,
I mean, even on what part of thecountry, healthcare is local, right?
So there, there also could be aconsideration relative to what the
needs of the local community are.
So, maybe
(29:38):
Yeah.
Fair enough.
I just wanna go back to this longitudinalpatient journey, thinking about, you
know, you've got the access part of theequation, which may in a way, if you
can figure out how to operationalizeit, be somewhat of the easy part.
The other part here is how do you payfor and have a sustainable business model
around this longitudinal patient journey,given just kind of this paradox here that
(29:59):
you may not necessarily get the help thatyou want from entities who are downstream
that in a way you're eating their cheese.
So if you're thinking about thislongitudinal patient journey, I was
talking to, um, Dr. John Lee the otherday, who was basically, he had gone
to some seminars, a summit, and theydiscovered that one of the best ways to
get heart failure patients to report theirblood pressure in between ER visits and,
(30:25):
and subsequent readmissions was to have anurse call them on the phone and ask them
what their blood pressure reading was.
But nobody was doing it, or they werehaving a great struggle figuring out how
to do this because it wasn't paid for.
I could certainly see that if we'rethinking about a longitudinal patient
journey, that examples just like thatwould come up day in and day out.
(30:47):
Because it requires outreach.
You know, the reason why a patienthas uncontrolled something or other
is because they're not controllingit and they're, you know, like the,
the patients that most need engagedare the ones who are not engaged.
How do you think about that, especiallyin light of what you were talking
about before, where a lot of thisworld is still fee for service.
Like if you can get avalue-based contract, great,
(31:08):
but if not, what do you do?
Yeah.
You know, a lot of the work we did atOne Medical and at Galileo is if you
can be efficient, wherever you can beefficient, you generate extra margin
where you can make incremental investmentsin quality that aren't paid for.
So a lot of quality based metrics,unless you're an ACO or value based
(31:28):
arrangements, don't really pay forthemselves, but they're important to do.
So a lot of times I'm investing in qualityprograms through the margin you can
generate through reimbursable services.
So that's why, you know, being leanallows you to do the quality based care
regardless of payment architecture.
But that level of investment variesdepending on how labor intensive the
(31:51):
quality investment is and or, you know,uh, the systems you have to support it.
All of that kind of needs to fit aspart of the thesis on what kind of
care system you're trying to build.
What I'm hearing you say is maybeyou find services you can get
paid for through fee for service.
You figure out how to do thosebillable things as absolutely
(32:13):
efficiently as possible.
Then you wind up with a couple ofbucks left over that you can throw
in the pot of, alright, we're gonnaoutreach our heart failure patients even
though we're not getting paid for it.
Correct.
Does margin at a certain point,start eating mission because I could
see if you've got private equity oryou have entities in the mix here
who are really, really into valueextraction, meaning getting, making
(32:33):
as much money as possible that theymay not be super happy with that plan.
Yeah, those are the trade offsof mission and trying to achieve
societal impact versus margin.
Whether it's third party capitalor your own home equity loan
to finance your practice.
It's all the same thing.
Financial incentives versus human andhuman factor dimensions, and those
(32:58):
always are at some level traded off.
It's just an issue of what's theright ratio at what timeframe, and can
you make more of it work than less.
But that's true of almost allbusinesses at one form or another.
How do you address that trade off?
Like if you are standing in frontof a board of directors who's
basically saying, make more money,do you have any lessons to share?
(33:24):
Yeah, I mean, I think as youngerinnovators and entrepreneurs, you just
have fewer degrees of freedom to makethat trade off on behalf of investors,
but as you get more experience.
And have credibility and,and frankly, you still need a
financial equation on everything.
You can at least have a coachingdialogue with investors, but that is
inherently the challenge and wheremore organically funded entities have
(33:47):
more degrees of freedom to do so.
I, I think that's just kind of the tradeoff on professional capital versus not.
Professional capital allowsyou to, you know, scale quickly
and, and grow an entity.
With One Medical we knew there wasinherently a trade off by taking
professional capital, but it allowedus to scale the concept more rapidly,
and that was the trade off we made.
(34:07):
And same thing with Galileo.
At some level you're always trying tofind that right balance and dialogue.
It's the power of capitalism, but alsothe downside of it, if it's unchecked.
And so we always need to, as humans,try to find that right balance,
whether you're on the investorside or on the operator side.
I think both sides need tofind that right balance.
Yeah.
It certainly sounds like, again, we've gota situation where it's no binary, right?
(34:32):
Like there's no right or wrong.
There's this gray area in the middle.
We've been talking about that earlier.
You have to have people that havesome level of autonomy and freedom,
but it can't be complete chaos.
Also, you can't tech your way out of aproblem caused by tech a lot of times.
So there's a lot of edge cases and...
Yeah it's where the productive middle is.
(34:53):
We tend to underestimate that productivemiddle is gray zone, but that's where I
think there's a lot of productive energy.
You know, and not to make it overlypolitical, but ideally the political
system would be a little bit moreactively engaged in the middle
as well to be more productive.
But, these kind of binary states ofthe world are just not productive
for solving our problems.
(35:14):
And so we just need to kind of figureout ways to find that right balance.
What's your message for payersand I'm thinking for example,
Medicaid and, and I know a lot ofyour current work with Galileo.
I do believe, I could be wrong,is with, um, Medicaid and
manage Medicaid, maybe Medicare.
But you know, a lot of the work thatyou're doing should, again, if we're
(35:35):
achieving the promise of primary care,reduce the total cost of care, but
there is kind of a shortsighted quarterby quarter thinking and then nobody's
gonna pay for the nurse to call upthe heart failure patient to keep 'em
outta the hospital next quarter, right?
What would be youroverarching message for them?
Yeah, so you know, we work withall program types, commercial ACA,
(35:55):
Medicare, Medicaid, and operate withinall the constraints on reimbursement.
I think I understand the challenges inthe sense that when you're running a
state-based Medicaid program, there's alimit to what you can really do in shape.
You're mostly controlling thereimbursement architectures, and
so whether through intent or not,a lot of the reimbursement on a fee
(36:16):
for service basis in most states isunsustainable for most practices to
achieve any basic form of margin.
So when you do that, you limit accessto the upstream outpatient medicine,
and then you have excessive utilizationand more downstream resources like ERs.
It's just, you know, everywherewe've under reimbursed the upstream
(36:38):
and the downstream is wheremost people end up showing up.
So the constraints are harder,frankly, in a lot of these Medicaid
programs, but we've been ableto kind of innovate into that.
When we started Galileo, the goal wasto service last small communities,
rural communities, Medicaid communities,because if we can do that sustainably
we knew we could take care ofeverybody else sustainably as well.
(37:00):
Because it was what wecall the thinnest air.
And so that's been ournorth star on innovation.
So if we can service a higher qualitymodel to all lives, including complex
Medicaid lives and rural lives, thenuh, everybody else serves to benefit.
So it's a harder challenge.
I wouldn't have donethat as my first company.
And doing One Medical was hard enough,but it allowed me the insight to
(37:21):
understand how to innovate into someof these more complex situations.
And what are the conversations that youthen have with these Medicaid plans who,
as you said, have these unsustainablepayment models for fee for service?
Obviously you've got some IP that's inthis space, so I don't wanna ask you
anything untoward, but how do you do that?
(37:42):
Like as you said, it's the thinnestair, the reimbursement levels a lot of
times, I mean, not in some states, butin others for sure, are incredibly thin.
Is this kind of going back to what we weretalking about before, this kind of people
process, finding that middle ground, oris there something else going on here?
No, it's the, it's the samemindset with more intensity.
(38:03):
How do we more effectively care forpopulations and individuals more
efficiently using tech and data?
We believe we have one of themost efficient care models that
can service lives across broaddemographics, across broad geos.
And then we have high intensityservices around high cost lives.
(38:23):
And so wherever we can get valuealignment or value arrangements, we do.
That allows us to scale up ouroperations, even in what we call complex
markets or low reimbursement markets.
So that's how we've generally operated.
It's still early innings in terms of howdo we validate this across every state.
But so far the early datapoints seem promising.
(38:45):
And what message would you have forlike CMMI or a policymaker who, who's
in this mix, who may be hearing aboutthese thin margins, but also kind of
stuck between a rock and a hard place?
A lot of times there's not enough moneyto go investing in infrastructure, paying
a lot for value-based care now to savemoney, you know, years down the line.
There's just not this bolus of cashthat's available right now, so it is
(39:09):
really hard, but maybe through yourexperience you have some sage wisdom.
I understand if you're at CMMI's position,it's hard to watch all the different
kind of machinations and translationsacross each state, particularly on
the Medicaid side, but there areoperators that are working within
the system to innovate on quality andaffordability as broadly as possible.
(39:31):
It does take time.
We should continue innovationgrants and other experiments.
But at the same time, allowenough stability in the
marketplace to continue to evolve.
A lot of these innovations just take time.
More importantly, it's just thelack of what I call operational
understanding and operational wisdomin the broader industry, that that's
(39:51):
where we need to, you know, evenconsider, uh, reinvesting our insights.
It's just a, it's a verychallenging business.
Hospital operations are complex.
Outpatient operations are complex.
Insurance operations are complex.
They all need to kind of work together.
Now, having gone down the rabbit holeand partnered with almost every type
of institution, you just have empathyfor all the different organizations
(40:14):
and how everybody wants to do the rightthing, but they're trapped in their
own economics and the architectures.
And sure, a radical reimbursement changeand policy might change things, but
politically that seems just untenable.
So we just have to figure out how tooperate, uh, within the system and, and
ideally figure out how to, you know,get more collaborative partnerships
(40:36):
in place so that organizations canreally validate what's possible.
We've been partnering with a variety ofdifferent types of entities to validate
this further so we can, uh, make surethat we all are working cooperatively
together from health plan to, you know,uh, we view ourselves as a provider
group to employers and hospital systems.
We're all key parts of the ecosystem.
I was just talking to Dr. Scott Conardand, and Pat Dunn from the AHA, and
(40:59):
they just did a study that showedif a patient has a advanced primary
care visit, and when I say advancedprimary care visit, there's a bunch of
specifications for what that ,. It tooktwo years for there to be any significant
impact in health and cost savings.
(41:19):
But after that two year mark, itwas statistically significant.
So it's just interesting that knowingthat you have to be working with
entities who can think in terms oftwo year timelines, and that's rough.
Some of those areas are challenging,obviously, 'cause the internal incentives
(41:40):
are misaligned, where there's clearpublic goods, where there's very little
economic interest for the entitiesthemselves, if there's a way to help
offset the costs of those types ofservices, I think that could go a long
way to kind of improving on the long-termquality and long-term health of society.
But again, even that alone might bechallenging to push through legislatively.
(42:03):
So you're, the point that you're makingthere is great that we know that, but
still you're gonna have to figure out howto operate within a context that values
the short term to a much greater degree.
So figure out how to do itwithin a fee for service model.
Yeah, that's our bias.
I mean, we're trying to do more withinthe ecosystem and it helps our providers
(42:24):
feel better about our organization.
The fact that we do focus on quality,even regardless of how it's paid, that's a
positive thing as a provider organizationto be focused on, especially in today's
world where you talk about, you know,the challenges of being a primary care
physician today, half it's the busy work,but half it's just the re realization that
you're not really doing high quality workbecause of the constraints of the system.
(42:49):
And I think that's what creates whatwe call moral fatigue or this kind
of challenge of purpose for a doc.
So many docs, you know, I just got backfrom my med school reunion and it's
just like we went into the professionwanting to care for patients, and this
kind of vision is increasingly erodedas just the operations have made the
practice not just kind of, you know,lifestyle and sustainable, but just
(43:12):
at some level morally unsustainable.
That's really interestingthat you say that.
And, okay, so now I'm connecting a dotback to what we were talking about at
the top of this conversation relativeto the people are really important.
Like you can't process your wayinto amazing people who really care.
So if you're trying to recruit andattract great doctors who really
care, which can solve for a lot justhaving people and colleagues who are
(43:38):
thinking about things in a reallyinnovative way and able to build these
patient relationships, et cetera.
So if you wanna attract a great staff,then doing some of this stuff may not be
in air quotes, financially immediatelyrewarding, but it could wind up in a
very significant way contributing togetting the right people who actually
(43:59):
do in a direct way, contribute to allthe stuff that we're talking about
that is going to make a primary carepractice a pure play, both financially
sustainable, but also in such a way thatdelivers on the promise of primary care.
Yep, exactly.
Do you have anything that you wanna sum uphere with any words of wisdom or advice,
(44:20):
just having done and been as successfulas you have been in the industry.
I do feel like a lot of people arepitching value in an easy to consume way,
and I, I would just be sanguine and waryabout anybody pitching, quote, unquote,
ROI, or cost savings in a turnkey fashion.
I just think it's much more complicatedand challenging to truly do.
(44:45):
We're all interested in long-termtotal cost of care reduction
while improving quality.
I think it's harder to achieve than mostpeople realize, and I think we should be
somewhat humble by the opportunity andalso the ability to get there quickly.
That being said, we're learning aton and we're starting to see the
needle moving on a lot of populationsfrom total cost of care and quality.
(45:07):
And so on the bright side, Ido think it's quite possible
for organizations to get there.
And I do think that the American societyhas the potential to get the, get there
in a reasonable timeframe, let's callit the next five to 10 years, to really
validate improving of the cost trendwhile improving quality and hopefully the
(45:28):
long-term livelihood of our population.
And so I do think that there is lightat the end of the tunnel, but we have
to be patient and somewhat committed toworking together on solving this thing.
But I do think it is solvable.
Great advice.
Is there anywhere that you woulddirect our listeners to learn
more about your work Dr. Tom Lee?
Uh, yeah.
I mean, outside of our website, Idon't have anything else point you
(45:50):
to, I tend to be kind of heads down.
So, if anything, this podcast and others,but that would be kind of a circular
loop if I had you referred back here.
So listen to the show.
Again and again and again.
Yeah.
Dr. Tom Lee, thank you so much forbeing on Relentless Health Value today.
Thanks Stacey.
This is Shawn Gremminger, presidentand CEO of the National Alliance
(46:11):
of Healthcare Purchaser Coalitions.
If you like this podcast, Istrongly recommend subscribing
and leaving a review.
"Take Two. What Does It Take For An IndiePrimary Care Practice to Survive Right
Now." Today I speak with Dr. Tom x Lee.
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
(00:23):
Relentlessly Seeking Value.
Let's take a second.
Listen to this interview with Dr. TomLee that originally aired last summer,
but listen to it this time withinthe context first of how primary care
can or should reduce ER visits andalso downstream specialty spend, et
cetera, which is one of the throughlines that I, along with you lot have
(00:47):
been exploring a lot this past year.
And much of this conversation isabout how primary care can survive
in these unfavorable times whereCMS and commercial carriers complain
about the rates that they have to payconsolidated entities with market power,
consolidated health systems, but thenthey actively underpay in the practices.
(01:08):
That is very illogical.
I'd say at a fundamentallevel, it's not tricky math.
Do not force out of business yourpotential best partners, and then
wonder why you have so few of them left.
Dan O'Neill was talkingabout this the other day.
I will link to it in the show notes.
So that is one context to kind oflisten to how does primary care survive,
but then also listen to this show inthe context of my latest tear which
(01:33):
is this mission versus margin tear.
Some of the same themes come up as inthe show with, for example, Dr. Ben
Schwartz from a couple of weeks ago.
How do you ensure that if you want toachieve scale, and you can only achieve
scale, when you take professionalcapital from private equity or VCs
or even a consolidated health systemwith a venture fund or an innovation
(01:55):
studio, how do you take their money,but not wind up with some board member
sitting at the conference room tabletalking about a mission like you
know, Jeff Bezos is where he said,my mission is other people's margin.
How do you tow that line?
Rushika Fernandopulle talked about thisa little bit too, that you need money to
(02:16):
scale, but once you get money, it's easyfor mission to get kicked off the bus.
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
This is my originalconversation with Dr. Tom x Lee.
Today I am talking with Tom X Lee, MD,who has a long history in primary care.
He founded One Medical and thenalso most recently Galileo.
(02:38):
Dr. Lee also was a founder atHippocrates tossing that in for context.
I wanted to talk with Dr. Lee becauseso many RHV, Relentless Health Value
listeners are trying to figure out howto sustain primary care as a standalone
entity when most primary care docs thesedays are employees of health systems.
(03:02):
And that makes sense because thesedays the most obvious and most common
way to make enough money in primarycare is to drive and maximize the
dollars from downstream volume ofhigh priced service lines, which
if you think about it underminesthe entire point of primary care.
But is also a really good motivation fora consolidated health system to purchase
(03:23):
all of the primary care docs in the area.
I'm starting to call this the Paradox ofPrimary Care because when you begin seeing
the promise of primary care have to erode.
If you're gonna stay in thebusiness of primary care, then
yeah, it's sort of a paradox.
Said another way, if you do primarycare really well and use evidence-based
preventative care to curb the need forexcess specialty care, i.e. you reduce
(03:47):
specialty revenue through primarycare, now you're asking specialty,
high profit health system servicelines that is, to not only make less
money, but use the remaining moneyto pay for primary care, which is the
entity that is reducing its revenue.
So again, I am hereby coining the term,the Paradox of Primary Care to express the
conundrum for why a consolidated entitythat knows where its bread is buttered,
(04:11):
is going to do much, if anything, toempower primary care with the technology
and the staff and the time which, ifit goes well, is going to cannibalize
its own major source of revenue.
Meanwhile, if you choose not toparticipate in this paradox within
the context of a consolidated entity,it's kind of hard to stand up a
(04:31):
pure play primary care practice.
And I've heard this so many times mostrecently from Dr. Paul Beahrens who said,
he wrote on LinkedIn, "My own primary careclinic lasted independent from 1946 to
2017, and when costs were rising fasterthan reimbursement with no alternatives
available, we sought out purchase byour hospital, giving up on trying to
(04:56):
stay independent. Consolidation is notdriven by bad actors, nor by quality,
nor volume savings, but by the bizarreeconomics of healthcare as a highly
regulated, but hardly rational market".
I just, I, I simply don't get, why knowingas much as we know about the importance
of primary care, CMS and others continueto follow RUC guidance on PCP rates.
(05:19):
How much power must be wielded bythe AMA or the AHA or who knows?
I don't know the half of it admittedly.
Listen to episode 437 with BrianKlepper for more on just the RUC.
Also despite, again, all of the lipservice about the importance of primary
care, our current cohort of payers seemsto have a thing going where they do
(05:39):
not offer value-based care contracts,VBC contracts to the primary care
folks who seem most likely to succeed.
Add to that the moving goalpostsfor ACOs and the lack of available
data to even know how you're doing.
And yeah, here we are.
Hi, this is Tom Nash, editorand producer of the RHV Podcast.
You've probably heard me say thispodcast is sponsored by Aventria
(06:02):
Health Group, and that's true,but there's more to the story.
Aventria is our day job, and the peoplethat make this show happen are Aventria
employees generously donating their timeand talent on top of everything else
they do to get each episode out the door.
So yes, Aventria underwrites theproduction, but in many ways, Relentless
Health runs like an unofficialnonprofit, a very, very nonprofit.
(06:22):
Aside from the occasional and deeplyappreciated episode sponsor and our
wonderful listeners who donate to the TipJar, this show is scrappy and self-funded.
If you wanna keep this podcast independentand laser focused on educating,
informing, and driving real changein our healthcare system, we invite
you to become a monthly sustainingmember of Relentless Health Value.
We have a few of you who have alreadytaken it upon themselves to do this
(06:44):
already, and we are deeply grateful.
Maybe in the future we willbe able to cook up some perks.
Could be mugs, Zoom meetups, and otherways to connect with like-minded listeners
who care about the same things you do.
So if you find value in whatwe do each week, head over to
relentlesshealthvalue.com/donateand donate to the Tip Jar.
Maybe become a sustaining member.
(07:04):
Or if you or your organizationwants to sponsor an episode
or two, we'd love to chat.
Thank you so much for listeningand being a part of the movement.
So again, the question ishow to sustain primary care
without falling into a paradox.
That is the hard questionthat I ask Dr. Tom X Lee.
Today, I asked Dr. Lee flat out whatit takes to stand up a standalone
(07:28):
entity doing primary care, and hesaid, enlightened leadership with
a value mindset combined with bigtime chops in service operations.
I of course asked what doesenlightened leadership and MAD
skills and service ops mean exactly.
And specifically, Dr. Lee broke this down.
Part of it he said is finding aneliminated hidden waste, which
(07:48):
according to Dr. Lee does existin primary care, although maybe
in a thinner layer than elsewhere.
And trust me, I asked Dr. Lee,what is this waste exactly, and
specifically of which he speaks.
Turns out a lot of it is cutting outbusy work, like clicking 90 times
to order a Tylenol or dumb paperworkor doctors doing stuff that a nurse
navigator could do in between visitsor the medical assistant could do,
(08:11):
or technology could just automate.
If you think about wasted time ascapital W waste, then yeah, there's a
hefty amount of waste that could be cut.
This also comes up in episode446 with Dr. Spencer Dorn.
Now you know me, you start talking aboutgetting rid of waste, and I am immediately
going to ask you how you define value.
(08:33):
How you define what you value,because when cutting waste, it's
really easy to cut more than waste.
Listen to the show with KateWolin or Rik Renard, or Dr. Will
Shrank for more on that one.
So I get into a proper grilling withDr. Lee on how he defines value.
Which leads us to talk about open accessas one component of delivering value.
(08:54):
But then of course I bring up,yeah, well access was Walmart and
Walgreens hypothesis giving patientsaccess to care and they will come
and that didn't work out so well.
The rebuttal there is access.
Sure.
But access to what?
And good point.
Clearly there was a disconnectbetween what patients thought good
primary care should be and what wason offer and around the wheel we go.
(09:18):
Because again, we're back tothe delta between the promise
of primary care and what oftenexists, again, with the paradox.
Okay, now just let's sum thisall up here because I really
wanna get to the interview.
The trick to doing a pure play PCPor indie PCP practice without falling
into the paradox of primary care isenlightened leadership with a value
(09:41):
mindset combined with service operationsto find the balance between human
centeredness, process and technology.
That's kind of the big wrap upof a many pronged conversation
that there is a balance here.
Dr. Lee puts it this way.
He's like, If you think about it as aparadox, you're kind of creating a binary.
What you want to find isthe productive middle.
(10:03):
Find the productive middle of primarycare, and you can get rid of the paradox.
Probably some of you are thinkingdirect primary care slash DPC is
a solution here, and yet for sure.
But to do DPC well you still have tohave enlightened leadership and do
a good job with service operations,especially if you're thinking you
want to work with employers or otherswho are going to measure outcomes.
(10:27):
Dr. Tom Lee, welcome toRelentless Health Value.
Thank you.
Thanks for having me.
I thought you would be the perfectperson to talk about something that
I'm wrestling with and I know thata lot of our listeners are wrestling
with, and this is what I'm startingto call the paradox of, primary care.
This is the idea that the promiseof primary care is through
evidence-based preventative careand by addressing issues early to
(10:50):
prevent or slow disease progression.
So specialist volume is therebyreduced and therefore one might assume
that specialty revenue is reduced.
However, one of the few, it seemssustainable ways to pay for primary care
is by vertically integrating primarycare into a consolidated stack and
(11:11):
then using the money from specialtycare to subsidize primary care.
So, I don't know, I'm starting tocall it a paradox like why would
a, a consolidated entity that knowswhere its bread is buttered, why are
they gonna do much, if anything, toempower primary care to cannibalize
its own major source of revenue?
Yeah, no, I get it.
Look, I think the world is slicedinto uneven slices, and when you
(11:34):
look at it from a variety of lenses,it looks odd or maybe paradoxical,
that the two should cooperate,certainly within one combined entity.
And so I understand that maybe thatmight be one lens to look at it.
Another lens to look at it is ifyou improve primary care by itself,
there's an opportunity set there.
But what's implied in the paradoxis that you can make primary
(11:56):
care work better on its own.
And you know, that was the wholepremise of starting up One Medical
was, can you start a pure play primarycare concept that's not dependent
on specialty revenue and otherwiseto self sustain itself and scale.
So there's an opportunity to do so byitself, but certainly when you combine
the two, then you need what I would callenlightened leadership to move off of
(12:19):
fee for service and more towards value.
But not all, all organizations cantraverse those waters at the same time.
So one of the things that yousaid there is that there is an
opportunity to start a pure playprimary care practice on its own.
Do you feel like that is ahypothesis that has been born out?
(12:39):
Well, let's just say this.
It's not easy, you know, uh,One Medical and Galileo are
somewhat exceptions to the rule.
But, it's possible.
The reason why it's hard to do isthe world has become increasingly
complicated and it's increasingly hardto run an independent primary care
practice without a lot of sophistication.
And so through unintended consequencesthrough the policies that we have,
(13:03):
you know, starting up de novospecialty practices is almost as
hard as primary care these days.
So, the hospital consolidation has beenhappening for a reason, and so yeah,
the, it is increasingly hard, but itis financially, theoretically feasible.
It's just it requires a differentmindset to care and service operations
that most folks don't have training in.
When you say a different mindset.
(13:24):
What exactly do you mean?
And, and you also use theterm enlightened leadership.
Maybe we start here.
What are the barriers Exactly.
And specifically, and I know alot of our listeners are like,
obviously fee for service for theRUC has destroyed primary care.
So you know, everybody's immediatelygonna be going, the incentive
payments are low with primary care.
What else?
Yeah, so the main thing to thinkthrough is a lot of the world is kind
(13:49):
of viewed as a zero sum or binarystate world, where it's either A or B,
meaning fee for service or value, andyou can't do both at the same time.
The reality is you cando both at the same time.
It just requires a bit morecreativity and innovation.
And the way you do that isfrankly to lower your unit costs.
(14:09):
If you can lower your unit costs, youcan make margin on fee for service, and
you can actually now increase your scopeand do more across value with the extra
infrastructure and enhanced resources.
So I think there's a lot of different waysyou can do both fee for service and value.
It just takes.
A slightly different mindsetto believe you can do both.
And I think so many leaders kindof have these binary talking points
(14:32):
about you can have your foot in twocanoes and a lot of that can be done.
It's just you kind of have tounlock yourselves from these
kind of binary modalities.
So it's interesting what you're sayingand we're talking about a pure play
primary care practice right now.
What I'm hearing you say, you can do thisif you have some value based contracts,
some of them, and you also have, youknow, if you have some value based,
(14:55):
you're gonna have some fee for service.
I was listening to, I think it was aRadio Advisory show where they basically
concurred with exactly what you're saying.
They're like, it's not a binary, there'sthese spots in the middle, where you've
got varying amounts of value-basedcontracts with fee for service, and
that's not gonna go away anytime soon.
It's not this kind of likemessy middle on the way to some
(15:17):
Shangri-La like it is the way it is.
So, what I'm hearing you say is you can doa pure play primary care if you have some
mix of value-based and fee for service andleadership is able to contend with having
value-based contracts as well as fee forservice contracts at the exact same time.
But then it also sounds likebecoming very efficient and lowering
(15:39):
costs is also part of this mix.
Did I get that right?
Close.
I mean, again, there's a lot ofsubtleties in kind of, uh, the terms.
When I say value it's not onlyabout value-based arrangements
and payment architectures.
Value is more about a mindset.
Can I do more for less?
Can I be more effective, more efficiently?
(16:00):
And so that mindset can exist ina hundred percent fee for service
architecture or a blended architecturewhere some of my payments are at risk.
So all I'm saying is within primarycare you can, what I call slim down
your overhead, run your practicemore effectively and efficiently
and be in a fee for service world.
And that's still a value focused mindsetbecause you're trying to do more for less.
(16:23):
And that's how we started off with OneMedical is trying to do more for less.
And then we realized that, oh wow, we canmake margin in primary care by itself.
And then, you know, scaled it from there.
And so again, it's a bit of the awarenessthat there is hidden waste everywhere,
across every layer of the ecosystem.
And granted, primary care is asmaller, thinner layer within the
(16:44):
healthcare ecosystem, but thereis still opportunities to innovate
within that layer by itself.
What are some examples of hiddenwaste in a primary care practice?
The easiest anecdote I would use ormaybe kind of shorthand is look at all
the people around any service model.
And for the most part, let's useknowledge based workers and ask
(17:05):
yourself what percent of their dayis their brain effectively utilized.
And if it's, you know, let's callit, uh, any reasonable percent.
That's an opportunity, and I wouldargue that most clinicians, most
administrative personnel would say, mybrain is not being effectively utilized.
My body and busy work is beingeffectively utilized, meaning
(17:28):
my busy work is very high.
But my effective work, the thing that I'mmost skilled at is being underutilized.
And so I think that's where inalmost all service models, we don't
recognize untapped talent, untappedpotential, and the lack of productivity
because people are just underutilizedand or the work is not organized.
(17:50):
To be most effective, and this istrue of all service organizations.
When we were starting up One Medical,I was looking at all different types of
service organizations and you just, youcan see organizations where workers are
engaged and workers are not engaged.
And we have a high percent ofunengaged workers, particularly
in, you know, office-based settingsbecause it's chaotic, right?
(18:11):
And that chaos dwarfs the ability toactually think and do productive work
. I could ask you like 40 questions right now.
So let me contain myself.
I love what you said about havinga value focused mindset, and
that doesn't just mean in a valuebased care payment architecture.
That one can have a value focusedmindset anytime including it, even if
(18:33):
it's pretty much all fee for service.
As I contemplate that, in order to have avalue focused mindset, you kind of really
have to think about what is value, whatare we trying to do, what are our goals?
And I've heard that there's onlyfour categories of goals really.
You know, you can have financialgoals, you can have patient reported
(18:55):
outcome kind of goals, PROMS.
You can have clinicianreported outcomes, right?
Like what is an outcome that a clinicianthinks is something to be proud of?
And then lastly, some kind ofperformance metric of some kind,
like patient satisfaction, et cetera.
So as I'm thinking about whatconstitutes this value focused mindset.
Probably part of it or the wholething is gonna have to begin
(19:18):
with what do we think value is?
Because if you try to be efficientwithout necessarily understanding
what good looks like, then you wind upcutting corners in ways that actually
diminish whatever you're trying toaccomplish beyond some financial metric.
Would you concur there orhow do you think about it?
Yeah, dimensionally I think thoseare reasonable ways to categorize
(19:42):
thoughts around quality or performance.
The reality is that the decisionmaking in any organization is
much more subtle than that.
You know, let's just kind of pick asimple dimension such as access or
service, which correlates with patientNet Promoter score, otherwise, right?
What's appropriate?
Same day appointments,next day appointments.
One week appointments.
One month appointments.
(20:02):
What's quality there?
Depends, right, on the clinicalsituation, the economic model,
the economic affordability.
So you can say all you want about thedimensions, but the judgments are still up
to the organization to determine what dothey value and what can they financially
and operationally achieve based on that.
And if we used access as a surrogatefor equality, which again, I'm
(20:25):
not saying that it should be,the industry's not doing great.
And so to me, you know, when I think aboutcare as a clinician, if a patient can't
reach me, I've lost the job in step one.
If they can't reach me, then how am Isupposed to be able to take care of them?
And, how can I give them great care?
To me, access is one of just thefirst steps to quality, and it
(20:45):
precedes quality at some level.
We do so poorly of thatacross the industry.
So to me, access is one dimensionof quality that we should start with
separate from all the clinical decisionmaking, separate from all the follow
through, separate from what are callthe experience and outcomes of care.
So you just take a simplemetric like access and say,
well, are we doing a great job?
(21:06):
You know, probably could be better.
So we're talking about thetwo dimensions that are super
important to be contemplative of.
One is access and convenience, andthen the other one is this, how
do you be perceived as an executeon a longitudinal patient journey?
And now I'm gonna go back to somethingthat you had talked about before,
which was also it definitely soundedlike making sure that amongst the
(21:31):
employees or those that are workingwithin the practice, there's a
lot of untapped talent potential.
And checking to see what percentage ofsomeone's day is effectively utilized
and how much of it is busy work, andthen getting rid of the busy work.
Another way to say this, which I don'tlike because it's become a euphemism
for all kinds of bad behavior, butthis idea of, um, working at the top
(21:52):
of your license, just making surethat everybody is cognitively able to
deliver at the level that they know thatthey can and not get bogged down into
just bureaucratic madness that burnspeople out and is often so frustrating
for really good people who understandwhat they could achieve and just the
latent potential that's kind of lost.
(22:13):
So like that's kind oflike one side of this.
But then the other side, I know you'vetalked at length about like the One
Medical app and other things that,that you've created on the technology
side and then processes also.
Is that kind of the sum of what you,you're thinking about as you think about
how do you efficiently and effectivelywithin the current kind of crappy
payment models for primary care actuallysucceed in a primary PCP or what am I
(22:38):
missing or what do you wanna dig into?
Yeah, I mean, I think some of thenuances on a service business are
challenging for a lot of quoteunquote traditional managers.
When you look at a service business,the human beings are the service,
and so you really have to think aboutthe dynamism of it, what it means
to be a caregiver, a team memberthat's interacting with a patient.
(23:00):
There's that human organic dimension,and then there's just the basics
of operations and finance onrunning a sustainable practice.
And those two sometimeswork against each other.
In some places you see humansdoing work that machines should
be doing as an assembly line, andyou know, that's not a great use.
And in other situations you have peoplethat are purely just ad-libbing and that's
(23:25):
not great from an economic perspective.
So you have to find thatright balance of operations.
And human centeredness to createthe best service organizations.
Otherwise, they feel like a machineand soulless, or they have too much
organic behavior and they feel chaotic.
So that middle ground is where the servicebusinesses, at least from my observation,
(23:47):
the best ones, tend to thrive, butyou gotta find that right balance.
And this is one of those things thatcapitalism and business school don't
do a great job at, which is kind offinding that gray middle where you get
a bit of both working well together.
And I think that's a lot of what makes,to me, services businesses, you know,
exciting and challenging and dynamic.
(24:09):
How do you start that?
If you were going to give somebodysome advice, who's sitting here
thinking, huh, I would like to checkand see how I'm doing with this.
What's step one to figure out wherethat sweet spot in the middle is?
Number one, and I don't know if thiscan be taught, but you kind of have
to give it, uh, I don't know if I cansay this, but you have to give a shit.
You really have to care about people.
(24:31):
If you don't, then you're, you're gonnabe losing that side of the equation.
And so you fundamentally have tobelieve in supporting your team
and supporting patients as humans.
That has to be an eight or at least veryhigh on the list of things you care about.
If you don't start there, then you'reactually working against yourself.
The second I would say is justunderstanding, you know, math and
(24:55):
operations and basic machinery, andthose are the two ends of the pole.
And then the beauty is using the toolsof math and science and whatever to
shape ecosystems that are more likelyto produce positive outcomes for your
team and the patients we care about.
And so that's kind of the nuance thatat least, you know, in most of the work
(25:17):
I've done have at least so far resultedin, you know, pretty positive ecosystems.
I definitely hear what you're sayingthat on one side of our axis here
we have, you have to give a shit andalso understand people and by people
we're including colleagues and beinga good manager and then also patients
(25:38):
and what good patient care looks like.
The healthcare is fundamentallya very human operation.
It will succeed if there's relationships,if there's trust and that has to happen
very much at a level where someone's EQis high enough to be able to do that.
I had a mentor one time that would sayrepeatedly, You can't legislate the heart.
(25:59):
And I think that mightbe what you mean by that.
On the other hand, it's alsounderstanding how operations works
and math and technology, what can beautomated and is there an API for that.
That side also becomes incrediblyimportant because if you have a human
doing something repeatedly, that's wherewe get ourselves in tons of trouble.
(26:19):
You know, it takes 90 clicks todo the right thing for a patient.
Even the most caring person inthe world could be undermined.
So finding that middle ground is certainlynot something that's easy, but I can
see exactly what you're saying thatis really essential to be able to do.
Is there any other kind of summaryadvice that you might give to someone
who's now thinking to themselves?
(26:40):
Hmm, I, I gotta dig in here.
Yeah, I mean the only other thing wouldmaybe be, you know, especially coming
from a medical world where it's likeresearch, validate, and then do, a lot
of, you know, real world innovationhappens from trial and error, and I
think people tend to underestimate thatin service oriented clinical cultures.
And so you kind of have to alwaysbe tweaking and figuring things out.
(27:04):
It's a dynamic industry.
That is the challenge is, how do youcontinue to innovate and learn and change?
Given all the human machinery,it's easy to upgrade software.
You just upgrade thesoftware and it's there.
But how do you continuously upgradethe service operating platform?
A little bit more challenging.
especially at scale.
How do you put together thisenlightened leadership team
(27:25):
then that is able to do that?
Is there a certain compositionof who's leading is there, you
know, like they gotta work withpatients three times a day maybe.
What advice do you have to puttogether a leadership team that is
capable of finding that middle ground?
It's challenging.
I don't know if I'vegot the right playbook.
I've only done this now twice.
(27:46):
But with One Medical and Galileo,we've relied on different talent,
different pools of talent, differentequations, so I don't think there's
necessarily a one size fits all playbook.
I think it has to be adaptiveto the strategy, the operations
in kind of the people goals.
It's just like anybody who's beingthoughtful about architecting
their org, it's at some level,a bit more intuitive, I guess.
(28:11):
And imagining how things should workand what talent types you do need.
So it's a little bit like cooking.
It's like what ingredients do I need?
It varies depending on whatyou're trying to cook up.
So the ingredient mix, at least forme, has changed between One Medical and
Galileo, between Galileo early stage,and we're moving into middle stage of
(28:31):
the organization in terms of scale.
So, the types of people and thetypes of needs are different.
I guess maybe the only other corollary isI don't see a lot of talent you can hire
and suddenly you have a instant voila.
You know, there's just, theindustry is so immature from my
perspective that you can't justfind somebody and just bolt them in.
Very often it needs to be a skillset or amindset that's being added, and it needs
(28:56):
to be shaped within the org dynamically.
It's very rarely just plopped in.
It feels like what you're saying,it's super important to make sure
the leadership team is purpose builtto achieve the goals which are set
forth, which are clear because it'snot necessarily like, oh, this person
checks all the boxes relative toskills, so it's gonna work out here.
(29:18):
It's also, do theybelieve the same things?
Do they care in the same ways as well?
So it's definitely, it's gonnabe a special blend, depending,
I mean, even on what part of thecountry, healthcare is local, right?
So there, there also could be aconsideration relative to what the
needs of the local community are.
So, maybe
(29:38):
Yeah.
Fair enough.
I just wanna go back to this longitudinalpatient journey, thinking about, you
know, you've got the access part of theequation, which may in a way, if you
can figure out how to operationalizeit, be somewhat of the easy part.
The other part here is how do you payfor and have a sustainable business model
around this longitudinal patient journey,given just kind of this paradox here that
(29:59):
you may not necessarily get the help thatyou want from entities who are downstream
that in a way you're eating their cheese.
So if you're thinking about thislongitudinal patient journey, I was
talking to, um, Dr. John Lee the otherday, who was basically, he had gone
to some seminars, a summit, and theydiscovered that one of the best ways to
get heart failure patients to report theirblood pressure in between ER visits and,
(30:25):
and subsequent readmissions was to have anurse call them on the phone and ask them
what their blood pressure reading was.
But nobody was doing it, or they werehaving a great struggle figuring out how
to do this because it wasn't paid for.
I could certainly see that if we'rethinking about a longitudinal patient
journey, that examples just like thatwould come up day in and day out.
(30:47):
Because it requires outreach.
You know, the reason why a patienthas uncontrolled something or other
is because they're not controllingit and they're, you know, like the,
the patients that most need engagedare the ones who are not engaged.
How do you think about that, especiallyin light of what you were talking
about before, where a lot of thisworld is still fee for service.
Like if you can get avalue-based contract, great,
(31:08):
but if not, what do you do?
Yeah.
You know, a lot of the work we did atOne Medical and at Galileo is if you
can be efficient, wherever you can beefficient, you generate extra margin
where you can make incremental investmentsin quality that aren't paid for.
So a lot of quality based metrics,unless you're an ACO or value based
(31:28):
arrangements, don't really pay forthemselves, but they're important to do.
So a lot of times I'm investing in qualityprograms through the margin you can
generate through reimbursable services.
So that's why, you know, being leanallows you to do the quality based care
regardless of payment architecture.
But that level of investment variesdepending on how labor intensive the
(31:51):
quality investment is and or, you know,uh, the systems you have to support it.
All of that kind of needs to fit aspart of the thesis on what kind of
care system you're trying to build.
What I'm hearing you say is maybeyou find services you can get
paid for through fee for service.
You figure out how to do thosebillable things as absolutely
(32:13):
efficiently as possible.
Then you wind up with a couple ofbucks left over that you can throw
in the pot of, alright, we're gonnaoutreach our heart failure patients even
though we're not getting paid for it.
Correct.
Does margin at a certain point,start eating mission because I could
see if you've got private equity oryou have entities in the mix here
who are really, really into valueextraction, meaning getting, making
(32:33):
as much money as possible that theymay not be super happy with that plan.
Yeah, those are the trade offsof mission and trying to achieve
societal impact versus margin.
Whether it's third party capitalor your own home equity loan
to finance your practice.
It's all the same thing.
Financial incentives versus human andhuman factor dimensions, and those
(32:58):
always are at some level traded off.
It's just an issue of what's theright ratio at what timeframe, and can
you make more of it work than less.
But that's true of almost allbusinesses at one form or another.
How do you address that trade off?
Like if you are standing in frontof a board of directors who's
basically saying, make more money,do you have any lessons to share?
(33:24):
Yeah, I mean, I think as youngerinnovators and entrepreneurs, you just
have fewer degrees of freedom to makethat trade off on behalf of investors,
but as you get more experience.
And have credibility and,and frankly, you still need a
financial equation on everything.
You can at least have a coachingdialogue with investors, but that is
inherently the challenge and wheremore organically funded entities have
(33:47):
more degrees of freedom to do so.
I, I think that's just kind of the tradeoff on professional capital versus not.
Professional capital allowsyou to, you know, scale quickly
and, and grow an entity.
With One Medical we knew there wasinherently a trade off by taking
professional capital, but it allowedus to scale the concept more rapidly,
and that was the trade off we made.
(34:07):
And same thing with Galileo.
At some level you're always trying tofind that right balance and dialogue.
It's the power of capitalism, but alsothe downside of it, if it's unchecked.
And so we always need to, as humans,try to find that right balance,
whether you're on the investorside or on the operator side.
I think both sides need tofind that right balance.
Yeah.
It certainly sounds like, again, we've gota situation where it's no binary, right?
(34:32):
Like there's no right or wrong.
There's this gray area in the middle.
We've been talking about that earlier.
You have to have people that havesome level of autonomy and freedom,
but it can't be complete chaos.
Also, you can't tech your way out of aproblem caused by tech a lot of times.
So there's a lot of edge cases and...
Yeah it's where the productive middle is.
(34:53):
We tend to underestimate that productivemiddle is gray zone, but that's where I
think there's a lot of productive energy.
You know, and not to make it overlypolitical, but ideally the political
system would be a little bit moreactively engaged in the middle
as well to be more productive.
But, these kind of binary states ofthe world are just not productive
for solving our problems.
(35:14):
And so we just need to kind of figureout ways to find that right balance.
What's your message for payersand I'm thinking for example,
Medicaid and, and I know a lot ofyour current work with Galileo.
I do believe, I could be wrong,is with, um, Medicaid and
manage Medicaid, maybe Medicare.
But you know, a lot of the work thatyou're doing should, again, if we're
(35:35):
achieving the promise of primary care,reduce the total cost of care, but
there is kind of a shortsighted quarterby quarter thinking and then nobody's
gonna pay for the nurse to call upthe heart failure patient to keep 'em
outta the hospital next quarter, right?
What would be youroverarching message for them?
Yeah, so you know, we work withall program types, commercial ACA,
(35:55):
Medicare, Medicaid, and operate withinall the constraints on reimbursement.
I think I understand the challenges inthe sense that when you're running a
state-based Medicaid program, there's alimit to what you can really do in shape.
You're mostly controlling thereimbursement architectures, and
so whether through intent or not,a lot of the reimbursement on a fee
(36:16):
for service basis in most states isunsustainable for most practices to
achieve any basic form of margin.
So when you do that, you limit accessto the upstream outpatient medicine,
and then you have excessive utilizationand more downstream resources like ERs.
It's just, you know, everywherewe've under reimbursed the upstream
(36:38):
and the downstream is wheremost people end up showing up.
So the constraints are harder,frankly, in a lot of these Medicaid
programs, but we've been ableto kind of innovate into that.
When we started Galileo, the goal wasto service last small communities,
rural communities, Medicaid communities,because if we can do that sustainably
we knew we could take care ofeverybody else sustainably as well.
(37:00):
Because it was what wecall the thinnest air.
And so that's been ournorth star on innovation.
So if we can service a higher qualitymodel to all lives, including complex
Medicaid lives and rural lives, thenuh, everybody else serves to benefit.
So it's a harder challenge.
I wouldn't have donethat as my first company.
And doing One Medical was hard enough,but it allowed me the insight to
(37:21):
understand how to innovate into someof these more complex situations.
And what are the conversations that youthen have with these Medicaid plans who,
as you said, have these unsustainablepayment models for fee for service?
Obviously you've got some IP that's inthis space, so I don't wanna ask you
anything untoward, but how do you do that?
(37:42):
Like as you said, it's the thinnestair, the reimbursement levels a lot of
times, I mean, not in some states, butin others for sure, are incredibly thin.
Is this kind of going back to what we weretalking about before, this kind of people
process, finding that middle ground, oris there something else going on here?
No, it's the, it's the samemindset with more intensity.
(38:03):
How do we more effectively care forpopulations and individuals more
efficiently using tech and data?
We believe we have one of themost efficient care models that
can service lives across broaddemographics, across broad geos.
And then we have high intensityservices around high cost lives.
(38:23):
And so wherever we can get valuealignment or value arrangements, we do.
That allows us to scale up ouroperations, even in what we call complex
markets or low reimbursement markets.
So that's how we've generally operated.
It's still early innings in terms of howdo we validate this across every state.
But so far the early datapoints seem promising.
(38:45):
And what message would you have forlike CMMI or a policymaker who, who's
in this mix, who may be hearing aboutthese thin margins, but also kind of
stuck between a rock and a hard place?
A lot of times there's not enough moneyto go investing in infrastructure, paying
a lot for value-based care now to savemoney, you know, years down the line.
There's just not this bolus of cashthat's available right now, so it is
(39:09):
really hard, but maybe through yourexperience you have some sage wisdom.
I understand if you're at CMMI's position,it's hard to watch all the different
kind of machinations and translationsacross each state, particularly on
the Medicaid side, but there areoperators that are working within
the system to innovate on quality andaffordability as broadly as possible.
(39:31):
It does take time.
We should continue innovationgrants and other experiments.
But at the same time, allowenough stability in the
marketplace to continue to evolve.
A lot of these innovations just take time.
More importantly, it's just thelack of what I call operational
understanding and operational wisdomin the broader industry, that that's
(39:51):
where we need to, you know, evenconsider, uh, reinvesting our insights.
It's just a, it's a verychallenging business.
Hospital operations are complex.
Outpatient operations are complex.
Insurance operations are complex.
They all need to kind of work together.
Now, having gone down the rabbit holeand partnered with almost every type
of institution, you just have empathyfor all the different organizations
(40:14):
and how everybody wants to do the rightthing, but they're trapped in their
own economics and the architectures.
And sure, a radical reimbursement changeand policy might change things, but
politically that seems just untenable.
So we just have to figure out how tooperate, uh, within the system and, and
ideally figure out how to, you know,get more collaborative partnerships
(40:36):
in place so that organizations canreally validate what's possible.
We've been partnering with a variety ofdifferent types of entities to validate
this further so we can, uh, make surethat we all are working cooperatively
together from health plan to, you know,uh, we view ourselves as a provider
group to employers and hospital systems.
We're all key parts of the ecosystem.
I was just talking to Dr. Scott Conardand, and Pat Dunn from the AHA, and
(40:59):
they just did a study that showedif a patient has a advanced primary
care visit, and when I say advancedprimary care visit, there's a bunch of
specifications for what that ,. It tooktwo years for there to be any significant
impact in health and cost savings.
(41:19):
But after that two year mark, itwas statistically significant.
So it's just interesting that knowingthat you have to be working with
entities who can think in terms oftwo year timelines, and that's rough.
Some of those areas are challenging,obviously, 'cause the internal incentives
(41:40):
are misaligned, where there's clearpublic goods, where there's very little
economic interest for the entitiesthemselves, if there's a way to help
offset the costs of those types ofservices, I think that could go a long
way to kind of improving on the long-termquality and long-term health of society.
But again, even that alone might bechallenging to push through legislatively.
(42:03):
So you're, the point that you're makingthere is great that we know that, but
still you're gonna have to figure out howto operate within a context that values
the short term to a much greater degree.
So figure out how to do itwithin a fee for service model.
Yeah, that's our bias.
I mean, we're trying to do more withinthe ecosystem and it helps our providers
(42:24):
feel better about our organization.
The fact that we do focus on quality,even regardless of how it's paid, that's a
positive thing as a provider organizationto be focused on, especially in today's
world where you talk about, you know,the challenges of being a primary care
physician today, half it's the busy work,but half it's just the re realization that
you're not really doing high quality workbecause of the constraints of the system.
(42:49):
And I think that's what creates whatwe call moral fatigue or this kind
of challenge of purpose for a doc.
So many docs, you know, I just got backfrom my med school reunion and it's
just like we went into the professionwanting to care for patients, and this
kind of vision is increasingly erodedas just the operations have made the
practice not just kind of, you know,lifestyle and sustainable, but just
(43:12):
at some level morally unsustainable.
That's really interestingthat you say that.
And, okay, so now I'm connecting a dotback to what we were talking about at
the top of this conversation relativeto the people are really important.
Like you can't process your wayinto amazing people who really care.
So if you're trying to recruit andattract great doctors who really
care, which can solve for a lot justhaving people and colleagues who are
(43:38):
thinking about things in a reallyinnovative way and able to build these
patient relationships, et cetera.
So if you wanna attract a great staff,then doing some of this stuff may not be
in air quotes, financially immediatelyrewarding, but it could wind up in a
very significant way contributing togetting the right people who actually
(43:59):
do in a direct way, contribute to allthe stuff that we're talking about
that is going to make a primary carepractice a pure play, both financially
sustainable, but also in such a way thatdelivers on the promise of primary care.
Yep, exactly.
Do you have anything that you wanna sum uphere with any words of wisdom or advice,
(44:20):
just having done and been as successfulas you have been in the industry.
I do feel like a lot of people arepitching value in an easy to consume way,
and I, I would just be sanguine and waryabout anybody pitching, quote, unquote,
ROI, or cost savings in a turnkey fashion.
I just think it's much more complicatedand challenging to truly do.
(44:45):
We're all interested in long-termtotal cost of care reduction
while improving quality.
I think it's harder to achieve than mostpeople realize, and I think we should be
somewhat humble by the opportunity andalso the ability to get there quickly.
That being said, we're learning aton and we're starting to see the
needle moving on a lot of populationsfrom total cost of care and quality.
(45:07):
And so on the bright side, Ido think it's quite possible
for organizations to get there.
And I do think that the American societyhas the potential to get the, get there
in a reasonable timeframe, let's callit the next five to 10 years, to really
validate improving of the cost trendwhile improving quality and hopefully the
(45:28):
long-term livelihood of our population.
And so I do think that there is lightat the end of the tunnel, but we have
to be patient and somewhat committed toworking together on solving this thing.
But I do think it is solvable.
Great advice.
Is there anywhere that you woulddirect our listeners to learn
more about your work Dr. Tom Lee?
Uh, yeah.
I mean, outside of our website, Idon't have anything else point you
(45:50):
to, I tend to be kind of heads down.
So, if anything, this podcast and others,but that would be kind of a circular
loop if I had you referred back here.
So listen to the show.
Again and again and again.
Yeah.
Dr. Tom Lee, thank you so much forbeing on Relentless Health Value today.
Thanks Stacey.
This is Shawn Gremminger, presidentand CEO of the National Alliance
(46:11):
of Healthcare Purchaser Coalitions.
If you like this podcast, Istrongly recommend subscribing
and leaving a review.
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