September 11, 2024 • 17 mins
We continue with part two of the interview that Mike Scribner & John Crew had with Aledade CCO / CPO Sean Cavanaugh. Where they will wrap up their discussion about value-based care: where it is going, how organizations like Aledade can help, and what this ultimately means for patient care.
Sean can be found:
Twitter @dc_cavanaugh
Learn more about Aledade:
Twitter @AledadeACO
The transcript of our conversation can be found on our website.
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Production Assistance & Editing: Nyla Wiebe
Scripting by: Aaron C Higgins
Show Notes & Transcription: Aaron C Higgins
Social Media Management: Jeremy Miller
News Co-Hosts: Aaron C Higgins & Jason Crosby
Interview co-hosts: Mike Scribner & John Crew
Show Producers: Mike Scribner & John Crew
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Aaron Higgins (00:00):
Welcome to Beyond the Stethoscope Vital
Conversations with SHP.
As we take a summer break toprepare for Season 5, we're
revisiting some of our mostinsightful episodes to keep you
informed and engaged with thelatest in healthcare.
This episode Part 2 from ourinterview with Sean Cavanaugh,
john Crew and Mike Scribner sitdown with Sean to explore the
evolving landscape of MedicareAdvantage or MA, and value-based
(00:23):
care.
The evolving landscape ofMedicare Advantage or MA, and
value-based care.
Sean provides us an in-depthlook at the differences between
traditional Medicare and MA, theunique challenges and
opportunities posed by startupsin the Medicare space, and how
value-based care is shaping thefuture of healthcare, with a
(00:43):
special focus this time onMedicaid transitions and the
critical role of primary care.
Sean offers valuable insightsinto the complexities of
managing patient care acrossdiverse populations.
So, whether you're a healthcareprovider navigating these
changes or just curious aboutthe future of healthcare in
America, this episode offers athoughtful and engaging
discussion that remains highlyrelevant, even today.
If you find this episodeinsightful, please rate and
(01:06):
share this podcast in yourfavorite podcast app.
It really helps the show.
Thank you for tuning in.
Let's dive back into this vitalconversation with Sean
Cavanaugh.
John Crew (01:17):
It seems like to me, and maybe you can touch on this,
there's a very distinctdifference between the
traditional Medicare patientthey're in white, blue and the
MA population, and what I meanby that is MA sort of varies
from state to state in terms ofhow it's covered, how maybe a
Part D is wrapped in Part B andothers.
(01:39):
Can you share just a little bitfrom your perspective the
difference in the two models andwhat, if anything, is different
for the physician to besuccessful in life science and
the MA side?
Sean Cavanaugh (01:52):
Yeah, as you said, ma is growing rapidly.
It's a competitive market.
You tend to have four or fivebig national companies and then
often a long tail of smallerplans locally.
Within a market you tend to seea convergence on the types of
benefits being offered, but theycan vary from market to market.
(02:13):
What we've told our practicesis working with Allidade.
You might have three or four MAvalue-based contracts, but the
STARS rating quality measuresare going to be the same across
all of them.
So you're trying to do the samequality care.
As you said, the populations canbe somewhat different.
You know what is attractiveabout MA.
(02:33):
Ma is good for people who needfinancial protection, who are
willing to work within a definednetwork of providers but don't
have a lot of money out ofpocket and specifically can't
afford a Medicare supplementalpolicy.
So you do see often lowerincome communities gravitating
toward that product.
(02:54):
But you know, as we approach 50percent of the Medicare
population and if it keeps goingnorth of that, the differences,
you know, will not be thatstark.
It'll be more like the Medicarepopulation as a whole.
But we do see that particularlyin certain regions of the
country.
John Crew (03:12):
You know you touched on something there that really
is a challenge for providers.
As we have talked to, youmentioned those that are coming
into the market, building the MAplatforms, and there seems to
be an awful lot of VC-fundedorganizations that are coming in
and, to your point, there'sthose that are known and that
there's a lot that's unknown.
The one thing that seems to bea prevailing model in terms of
(03:36):
exposure for physicians arethese that come in.
They're either looking to builda model and sell it to someone
else or they're looking to maybebuild it and go public.
Either way, there's thisnatural instinct from providers
thinking everything's ashort-term relationship.
Can you sort of talk to that aminute?
Sean Cavanaugh (03:58):
Yeah, I think what you're getting at is
because MA is growing so muchand because the big companies
are, you know, longstanding youknow legacy companies like
United and Aetna there's aperception that there's an
opportunity for smarter startupsto come in and beat them at
this business.
(04:18):
It's like a lot of businesses.
You see some really cool,interesting ones, and you see
some that you roll your eyes at,and I worry about the ones we
roll our eyes at because, as yousaid, medicare Advantage can be
so lucrative.
You know you could start abusiness, enroll a bunch of
people and just sell the companyand probably get rich.
You know, at Allidade, we'repretty wary about doing business
with them.
(04:40):
What you're also seeing, though,is some separation of the wheat
from the chaff, like those samecompanies that looked at United
and said look at that big, dumblegacy company are learning
that United is not so dumb andthere's a reason they got big.
Right, maybe we don't allsupport the reasons they got big
, but they know what they'redoing, and beating them at their
own game is harder than itlooks, but you do see some
(05:02):
promising ones.
One we've known for a while,for example, is a plan that's
small but growing called DevotedHealth and I think they have
the right values and are in itfor the long haul.
They could have sold probablythey could be rich by now if
they needed to but they seem tobe in it for the long haul.
They didn't suffer.
Last year a bunch of them thestartups that went public
(05:25):
suffered tremendously in thestock market.
So I think over time you'll see.
You know you'll be able toseparate the good from the bad
and there will be some good ones.
But we are very careful who wedo work with.
For that reason, like it's notgood for the patient if there's
churning through plans.
What they need, just like is along, stable relationship,
(05:48):
because the challenge with theseniors is managing multiple
chronic diseases over.
You know the course of theirlife and so hopefully the most
stable thing in their life istheir relationship with their
PCP.
John Crew (06:01):
Thank you so much.
To piggyback off of thatquestion, one of the things that
we're being exposed to forproviders that are in
value-based medicine andexcelling in value-based
medicine, we are now seeing someof these companies who are
beginning to come in regionallyand try to pick up the best of
the best in each of the areasthat they're located in and
build a new model.
(06:22):
That's.
You know, that is all withsuccessful value-based providers
using benchmarks from otherareas as a way to appeal to them
.
So you're beginning to have,instead of having a organization
that was built and sustainable,you're having those trying to
pick it apart, take the best outof it, build another one.
Sean Cavanaugh (06:47):
Do you see that as being a problem long-term?
Potentially, as I said, that'scertainly not the Allidade
approach.
Allidade approach is everybodywho wants to do better by their
patients can probably get better.
The other thing I would say isthe limitation of that approach
is the big plans aren't lookingfor narrow networks in MA
because that's not consistentwith growing their membership.
(07:09):
So narrow networks have beenpopular, like in some of the ACA
exchange marketplaces wherepeople are paying out of their
own pocket.
It's some niche markets likethat, not that that's so niche.
It has a lot of people.
But in MA, even though peopleare choosing the product
themselves, people are notlooking for narrow networks and
(07:32):
so I don't think that approachwill have a long life in MA
unless something changes that wehaven't seen yet.
But there are places for narrownetwork high performers, but it
often gets more talk thanreality.
Mike Scribner (07:48):
Sean, not to kind of cut a hard left in the
discussion, but I guess I wantto spend the last few minutes
kind of talking about, from aCMS perspective in general, what
do you think is the future ofvalue-based care from their
perspective, and where's theInnovation Institute going,
those kinds of things.
Can you talk a little bit aboutthat?
Sean Cavanaugh (08:08):
Yeah, I think this group at CMS and the
administration more broadly theyspent a good part of their
first year trying to put out aroadmap and a statement of
values, and I think theimportant things they said were
two things.
One, we believe in value-basedcare and we have a goal by 2030
(08:30):
of getting everybody in Medicareand value-based care of some
sort, and they were a littlevague on what that meant, but I
think what it means is get outof the traditional
fee-for-service world wherepeople are just paid to produce
services, and get them into arelationship with someone who
cares about the total experienceof care, both the cost and the
(08:50):
quality, mssps being the largestexample of that, but there's
some other CMS models that wouldmean.
So that was the first thingthey said.
Not really that new right.
The Obama administration saidthat.
The Trump administration saidthat, maybe not in the same
words, but said somethingsimilar.
The thing they said that wasdifferent, though and that's,
(09:11):
you know, gotten a lot ofattention across the country is
a greater emphasis on healthequity, so not leaving some
populations behind, whether it'sin value-based care or anything
, or an access to care, and so Ithink that's what you'll
consistently see in every actionthey do is how do we get more
people into these models and howdo we design these models so
(09:33):
providers sign up lower incomepeople, providers improve care
for lower income people or anycommunity that hasn't gotten the
highest quality of care in thepast.
I think both of those areincredibly laudable goals and we
support them.
They're also very difficultgoals.
One you know value based care,which we've dived into
(09:55):
wholeheartedly, but you knowit's been a voluntary program.
How far can you get involuntary programs?
We'll find out.
And in health equity first ofall, we will not make any
progress unless they wereshining a light on it, unless
they're designing new programsaround it.
So more power to them.
But we also know it's hard.
(10:15):
Allidade's been committed tothis.
Over the past year We've beenfocusing on hypertension among
African-American patients,because our, our founder, farzad
Moshachari, says that's wherewe can save the most lives.
And so we've been and we'vemade some improvements.
But it's been hard and thephysicians love it, like they
(10:35):
love making a difference intheir communities.
But it is hard work.
So I think you'll see those twothemes in whatever form, you
know, whatever they're doing outof the administration, those
will be the themes, whetherthey're working in traditional
Medicare or MA, which are two,from a policy maker's
perspective, two very differentenvironments, but they'll be
(10:56):
pursuing the same goals.
John Crew (10:58):
I don't want to throw a curve here, so bear that in
mind as I ask this question.
So you know I appreciate thatyour expertise has been in the
Medicare side.
What we're experiencing in thevarious markets.
You're seeing the transition ofMedicaid going into value-based
models.
So have you guys experiencedany of the Medicaid transition
(11:20):
models going into value-basedand, if so, can you talk a
little bit about what thechallenges of Medicaid
value-based is versus Medicare?
Sean Cavanaugh (11:28):
Yeah, oh, I'm so glad you asked John, because we
have we've got, I think, 100,150,000 Medicaid lives and risk
contracts, value-based contracts.
And this came about because westarted working with federally
qualified health centers in acouple of markets in a big way
and we started working with themfor Medicare.
But they quickly said hey, youknow, we've got all these
(11:49):
Medicaid patients.
So we have a relationship witha couple plans where we're
taking risks for Medicaid.
We're really happy and proud tobe in the space, but it's a
learning experience.
But it's a learning experience.
One of the things you find isyou know, someone gets on
Medicare.
They're on Medicare for therest of their life.
(12:09):
So they may move throughfee-for-service, go into an MA
plan, but they're in Medicare,the Medicaid population, there's
much more churning, there'sless of a traditional attachment
to a provider.
So you know, medicare patientstend to have, if anything, too
many physicians, where in theMedicaid population many of them
don't have an usual source ofcare.
So you're trying to establishthat.
(12:30):
And then just the clinicaldifferences of, you know,
medicare population.
What they're dealing with are,you know, the management of
multiple chronic diseases over alongitudinal period of time,
where in Medicaid you're dealingwith a lot of moms, a lot of
kids, some single adults, youknow, and then the expansion
population, but just clinicallyit's.
(12:53):
The interventions are different, but the good news is, if you
take a step back, some of thestuff they need is the same
thing.
They need someone who's got a360 degree view of their health,
what's happening to them,someone who's looking at the
data, seeing when they're incrisis and reaching out to them
and wrapping them in the arms ofprimary care, someone who's
(13:14):
accountable for their experienceof care, their total cost of
care and the quality that theyreceive.
So the needs are the same.
The tools have to be adapted.
I'll give you an example.
Like we in Medicare, we targetwhat we call high priority
patients for annual wellnessvisits.
Well, deciding which seniorneeds to come in for an annual
(13:36):
wellness visit is very differentthan deciding which
six-year-old child needs to comein for a wellness visit.
So our clinicians, ourstatisticians, have been working
on that, and so theintelligence works its way into
our tools over time.
But it is a new space, john,you're right.
Like we don't see a lot ofother organizations rushing to
(13:57):
take Medicaid risk, we felt likeone.
We had to service our partnersor the federally qualified
health centers.
If this is important to them,it's important to us.
But also, you know, these folksneed value-based care too, so
we're going to be a provider ofit.
John Crew (14:14):
We're coming to an end.
I have one quick question sortof relates to that both the care
and the CAID models, statesvaried by or health insurers,
let me get that at least variedby what models they have.
For example, in Georgia we usedto have a lot of gatekeeper
models and we no longer havethat.
Is it more challenging cominginto a state where products are
sold that don't requiregatekeepers?
Sean Cavanaugh (14:37):
Yeah, we get that question a lot Like how are
you going to control costs?
There's no gatekeepers, and weremind people we've learned this
business in traditionalMedicare, which is the ultimate
PPO, right Like there's nogatekeeping at all.
What I remind people is therewas a backlash to the gatekeeper
models throughout the wholecountry and people gave up on
(14:57):
that for a while with goodreason, because it was used as a
pretty blunt instrument.
I think you can get a lot donewith, you know, with your PCP
being the gatekeeper, your PCPwho has your best interests in
mind, and it's not like aregulatory or contractual
gatekeeper, it's more of aquarterback.
I'm here to get the best thingfor you, and spending more money
(15:20):
isn't always the best thing.
So, yeah, get the best thingfor you, and spending more money
isn't always the best thing.
So, yeah, we're not worriedwhen there's no gatekeeper.
You know, that's where welearned our learned how to do
this.
Yeah, you can save some moneythat way, but you can get better
care another way through betterPCP, you know, better primary
care.
Mike Scribner (15:38):
Right, thank you, sean.
We really appreciate it thatwas great.
Aaron Higgins (15:56):
It was great talking to you guys.
It is produced and edited byNyla Weave.
Our social media contentproducers are Nyla Weave and
Jeremy Miller, and our executiveproducers are Mike Scribner and
John Kroop.
For more information about SHPand the services we offer,
including the back library ofepisodes, episode transcripts,
links to resources discussed andmuch, much more, please visit
(16:18):
our website at shplccom.
Thanks for listening.
Welcome to Beyond the Stethoscope Vital
Conversations with SHP.
As we take a summer break toprepare for Season 5, we're
revisiting some of our mostinsightful episodes to keep you
informed and engaged with thelatest in healthcare.
This episode Part 2 from ourinterview with Sean Cavanaugh,
john Crew and Mike Scribner sitdown with Sean to explore the
evolving landscape of MedicareAdvantage or MA, and value-based
(00:23):
care.
The evolving landscape ofMedicare Advantage or MA, and
value-based care.
Sean provides us an in-depthlook at the differences between
traditional Medicare and MA, theunique challenges and
opportunities posed by startupsin the Medicare space, and how
value-based care is shaping thefuture of healthcare, with a
(00:43):
special focus this time onMedicaid transitions and the
critical role of primary care.
Sean offers valuable insightsinto the complexities of
managing patient care acrossdiverse populations.
So, whether you're a healthcareprovider navigating these
changes or just curious aboutthe future of healthcare in
America, this episode offers athoughtful and engaging
discussion that remains highlyrelevant, even today.
If you find this episodeinsightful, please rate and
(01:06):
share this podcast in yourfavorite podcast app.
It really helps the show.
Thank you for tuning in.
Let's dive back into this vitalconversation with Sean
Cavanaugh.
John Crew (01:17):
It seems like to me, and maybe you can touch on this,
there's a very distinctdifference between the
traditional Medicare patientthey're in white, blue and the
MA population, and what I meanby that is MA sort of varies
from state to state in terms ofhow it's covered, how maybe a
Part D is wrapped in Part B andothers.
(01:39):
Can you share just a little bitfrom your perspective the
difference in the two models andwhat, if anything, is different
for the physician to besuccessful in life science and
the MA side?
Sean Cavanaugh (01:52):
Yeah, as you said, ma is growing rapidly.
It's a competitive market.
You tend to have four or fivebig national companies and then
often a long tail of smallerplans locally.
Within a market you tend to seea convergence on the types of
benefits being offered, but theycan vary from market to market.
(02:13):
What we've told our practicesis working with Allidade.
You might have three or four MAvalue-based contracts, but the
STARS rating quality measuresare going to be the same across
all of them.
So you're trying to do the samequality care.
As you said, the populations canbe somewhat different.
You know what is attractiveabout MA.
(02:33):
Ma is good for people who needfinancial protection, who are
willing to work within a definednetwork of providers but don't
have a lot of money out ofpocket and specifically can't
afford a Medicare supplementalpolicy.
So you do see often lowerincome communities gravitating
toward that product.
(02:54):
But you know, as we approach 50percent of the Medicare
population and if it keeps goingnorth of that, the differences,
you know, will not be thatstark.
It'll be more like the Medicarepopulation as a whole.
But we do see that particularlyin certain regions of the
country.
John Crew (03:12):
You know you touched on something there that really
is a challenge for providers.
As we have talked to, youmentioned those that are coming
into the market, building the MAplatforms, and there seems to
be an awful lot of VC-fundedorganizations that are coming in
and, to your point, there'sthose that are known and that
there's a lot that's unknown.
The one thing that seems to bea prevailing model in terms of
(03:36):
exposure for physicians arethese that come in.
They're either looking to builda model and sell it to someone
else or they're looking to maybebuild it and go public.
Either way, there's thisnatural instinct from providers
thinking everything's ashort-term relationship.
Can you sort of talk to that aminute?
Sean Cavanaugh (03:58):
Yeah, I think what you're getting at is
because MA is growing so muchand because the big companies
are, you know, longstanding youknow legacy companies like
United and Aetna there's aperception that there's an
opportunity for smarter startupsto come in and beat them at
this business.
(04:18):
It's like a lot of businesses.
You see some really cool,interesting ones, and you see
some that you roll your eyes at,and I worry about the ones we
roll our eyes at because, as yousaid, medicare Advantage can be
so lucrative.
You know you could start abusiness, enroll a bunch of
people and just sell the companyand probably get rich.
You know, at Allidade, we'repretty wary about doing business
with them.
(04:40):
What you're also seeing, though,is some separation of the wheat
from the chaff, like those samecompanies that looked at United
and said look at that big, dumblegacy company are learning
that United is not so dumb andthere's a reason they got big.
Right, maybe we don't allsupport the reasons they got big
, but they know what they'redoing, and beating them at their
own game is harder than itlooks, but you do see some
(05:02):
promising ones.
One we've known for a while,for example, is a plan that's
small but growing called DevotedHealth and I think they have
the right values and are in itfor the long haul.
They could have sold probablythey could be rich by now if
they needed to but they seem tobe in it for the long haul.
They didn't suffer.
Last year a bunch of them thestartups that went public
(05:25):
suffered tremendously in thestock market.
So I think over time you'll see.
You know you'll be able toseparate the good from the bad
and there will be some good ones.
But we are very careful who wedo work with.
For that reason, like it's notgood for the patient if there's
churning through plans.
What they need, just like is along, stable relationship,
(05:48):
because the challenge with theseniors is managing multiple
chronic diseases over.
You know the course of theirlife and so hopefully the most
stable thing in their life istheir relationship with their
PCP.
John Crew (06:01):
Thank you so much.
To piggyback off of thatquestion, one of the things that
we're being exposed to forproviders that are in
value-based medicine andexcelling in value-based
medicine, we are now seeing someof these companies who are
beginning to come in regionallyand try to pick up the best of
the best in each of the areasthat they're located in and
build a new model.
(06:22):
That's.
You know, that is all withsuccessful value-based providers
using benchmarks from otherareas as a way to appeal to them
.
So you're beginning to have,instead of having a organization
that was built and sustainable,you're having those trying to
pick it apart, take the best outof it, build another one.
Sean Cavanaugh (06:47):
Do you see that as being a problem long-term?
Potentially, as I said, that'scertainly not the Allidade
approach.
Allidade approach is everybodywho wants to do better by their
patients can probably get better.
The other thing I would say isthe limitation of that approach
is the big plans aren't lookingfor narrow networks in MA
because that's not consistentwith growing their membership.
(07:09):
So narrow networks have beenpopular, like in some of the ACA
exchange marketplaces wherepeople are paying out of their
own pocket.
It's some niche markets likethat, not that that's so niche.
It has a lot of people.
But in MA, even though peopleare choosing the product
themselves, people are notlooking for narrow networks and
(07:32):
so I don't think that approachwill have a long life in MA
unless something changes that wehaven't seen yet.
But there are places for narrownetwork high performers, but it
often gets more talk thanreality.
Mike Scribner (07:48):
Sean, not to kind of cut a hard left in the
discussion, but I guess I wantto spend the last few minutes
kind of talking about, from aCMS perspective in general, what
do you think is the future ofvalue-based care from their
perspective, and where's theInnovation Institute going,
those kinds of things.
Can you talk a little bit aboutthat?
Sean Cavanaugh (08:08):
Yeah, I think this group at CMS and the
administration more broadly theyspent a good part of their
first year trying to put out aroadmap and a statement of
values, and I think theimportant things they said were
two things.
One, we believe in value-basedcare and we have a goal by 2030
(08:30):
of getting everybody in Medicareand value-based care of some
sort, and they were a littlevague on what that meant, but I
think what it means is get outof the traditional
fee-for-service world wherepeople are just paid to produce
services, and get them into arelationship with someone who
cares about the total experienceof care, both the cost and the
(08:50):
quality, mssps being the largestexample of that, but there's
some other CMS models that wouldmean.
So that was the first thingthey said.
Not really that new right.
The Obama administration saidthat.
The Trump administration saidthat, maybe not in the same
words, but said somethingsimilar.
The thing they said that wasdifferent, though and that's,
(09:11):
you know, gotten a lot ofattention across the country is
a greater emphasis on healthequity, so not leaving some
populations behind, whether it'sin value-based care or anything
, or an access to care, and so Ithink that's what you'll
consistently see in every actionthey do is how do we get more
people into these models and howdo we design these models so
(09:33):
providers sign up lower incomepeople, providers improve care
for lower income people or anycommunity that hasn't gotten the
highest quality of care in thepast.
I think both of those areincredibly laudable goals and we
support them.
They're also very difficultgoals.
One you know value based care,which we've dived into
(09:55):
wholeheartedly, but you knowit's been a voluntary program.
How far can you get involuntary programs?
We'll find out.
And in health equity first ofall, we will not make any
progress unless they wereshining a light on it, unless
they're designing new programsaround it.
So more power to them.
But we also know it's hard.
(10:15):
Allidade's been committed tothis.
Over the past year We've beenfocusing on hypertension among
African-American patients,because our, our founder, farzad
Moshachari, says that's wherewe can save the most lives.
And so we've been and we'vemade some improvements.
But it's been hard and thephysicians love it, like they
(10:35):
love making a difference intheir communities.
But it is hard work.
So I think you'll see those twothemes in whatever form, you
know, whatever they're doing outof the administration, those
will be the themes, whetherthey're working in traditional
Medicare or MA, which are two,from a policy maker's
perspective, two very differentenvironments, but they'll be
(10:56):
pursuing the same goals.
John Crew (10:58):
I don't want to throw a curve here, so bear that in
mind as I ask this question.
So you know I appreciate thatyour expertise has been in the
Medicare side.
What we're experiencing in thevarious markets.
You're seeing the transition ofMedicaid going into value-based
models.
So have you guys experiencedany of the Medicaid transition
(11:20):
models going into value-basedand, if so, can you talk a
little bit about what thechallenges of Medicaid
value-based is versus Medicare?
Sean Cavanaugh (11:28):
Yeah, oh, I'm so glad you asked John, because we
have we've got, I think, 100,150,000 Medicaid lives and risk
contracts, value-based contracts.
And this came about because westarted working with federally
qualified health centers in acouple of markets in a big way
and we started working with themfor Medicare.
But they quickly said hey, youknow, we've got all these
(11:49):
Medicaid patients.
So we have a relationship witha couple plans where we're
taking risks for Medicaid.
We're really happy and proud tobe in the space, but it's a
learning experience.
But it's a learning experience.
One of the things you find isyou know, someone gets on
Medicare.
They're on Medicare for therest of their life.
(12:09):
So they may move throughfee-for-service, go into an MA
plan, but they're in Medicare,the Medicaid population, there's
much more churning, there'sless of a traditional attachment
to a provider.
So you know, medicare patientstend to have, if anything, too
many physicians, where in theMedicaid population many of them
don't have an usual source ofcare.
So you're trying to establishthat.
(12:30):
And then just the clinicaldifferences of, you know,
medicare population.
What they're dealing with are,you know, the management of
multiple chronic diseases over alongitudinal period of time,
where in Medicaid you're dealingwith a lot of moms, a lot of
kids, some single adults, youknow, and then the expansion
population, but just clinicallyit's.
(12:53):
The interventions are different, but the good news is, if you
take a step back, some of thestuff they need is the same
thing.
They need someone who's got a360 degree view of their health,
what's happening to them,someone who's looking at the
data, seeing when they're incrisis and reaching out to them
and wrapping them in the arms ofprimary care, someone who's
(13:14):
accountable for their experienceof care, their total cost of
care and the quality that theyreceive.
So the needs are the same.
The tools have to be adapted.
I'll give you an example.
Like we in Medicare, we targetwhat we call high priority
patients for annual wellnessvisits.
Well, deciding which seniorneeds to come in for an annual
(13:36):
wellness visit is very differentthan deciding which
six-year-old child needs to comein for a wellness visit.
So our clinicians, ourstatisticians, have been working
on that, and so theintelligence works its way into
our tools over time.
But it is a new space, john,you're right.
Like we don't see a lot ofother organizations rushing to
(13:57):
take Medicaid risk, we felt likeone.
We had to service our partnersor the federally qualified
health centers.
If this is important to them,it's important to us.
But also, you know, these folksneed value-based care too, so
we're going to be a provider ofit.
John Crew (14:14):
We're coming to an end.
I have one quick question sortof relates to that both the care
and the CAID models, statesvaried by or health insurers,
let me get that at least variedby what models they have.
For example, in Georgia we usedto have a lot of gatekeeper
models and we no longer havethat.
Is it more challenging cominginto a state where products are
sold that don't requiregatekeepers?
Sean Cavanaugh (14:37):
Yeah, we get that question a lot Like how are
you going to control costs?
There's no gatekeepers, and weremind people we've learned this
business in traditionalMedicare, which is the ultimate
PPO, right Like there's nogatekeeping at all.
What I remind people is therewas a backlash to the gatekeeper
models throughout the wholecountry and people gave up on
(14:57):
that for a while with goodreason, because it was used as a
pretty blunt instrument.
I think you can get a lot donewith, you know, with your PCP
being the gatekeeper, your PCPwho has your best interests in
mind, and it's not like aregulatory or contractual
gatekeeper, it's more of aquarterback.
I'm here to get the best thingfor you, and spending more money
(15:20):
isn't always the best thing.
So, yeah, get the best thingfor you, and spending more money
isn't always the best thing.
So, yeah, we're not worriedwhen there's no gatekeeper.
You know, that's where welearned our learned how to do
this.
Yeah, you can save some moneythat way, but you can get better
care another way through betterPCP, you know, better primary
care.
Mike Scribner (15:38):
Right, thank you, sean.
We really appreciate it thatwas great.
Aaron Higgins (15:56):
It was great talking to you guys.
It is produced and edited byNyla Weave.
Our social media contentproducers are Nyla Weave and
Jeremy Miller, and our executiveproducers are Mike Scribner and
John Kroop.
For more information about SHPand the services we offer,
including the back library ofepisodes, episode transcripts,
links to resources discussed andmuch, much more, please visit
(16:18):
our website at shplccom.
Thanks for listening.
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