Thanks to all of you for taking the time
to listen in on an important conversation
about payments
and the new business models
that are powering value based health care.
Tim Bensley,
the CFO of agilon, a total care platform
for seniors, and Jeff
Lin, managing director and co-head of J.P. Morgan's health
care payments practice.
Thanks to both of you for making the time.
I can say I've been looking forward to having this chat with you for for quite some time, so ready to dig in.
Thanks again.
So let's start with a little preamble.
The conversation about value
based health care isn't a new one.
It's been happening for quite a long time,
although it is very hard
to pinpoint
exactly when the conversation started.
A little known fact
when I was doing my own digging around
is that the American Academy
of Pediatrics claims
that it introduced
the concept way back in 1967,
when it introduced this idea
of coordinating data across providers
so that sick children delivered
or had better outcomes delivered to them.
So if we assume that that is
the unofficial official starting point.
Fast forward 50 plus years.
How much progress has been made
since then in using digital
to break down the information silos
that seem
to be very critical in delivering
this idea of value based care?
Tim, you want to start us off?
Look,
I've been in the health care industry
and working for Agilent
for about three years now, so I can't be
I can't speak to what happened
that's happened over the last 50 years.
But I can tell you that being successful
in value based care,
which is to be successful, is essentially,
you know, improving the outcome
for all the patients that are basically
been in the value based care environment
is all about how you leverage information.
And by
the way, you know, more
and more leveraging information means
leveraging disparate information
across from many different sources.
So, you know, your term
data silos is probably a good term.
And by the way, the information that comes
from each of those areas, be it
payers names, information from the NCOs
or HIPAA information
that we can access or EMR information
from the providers themselves.
You know, all of that
now is that none of that data is perfect
and you sort of have to be able to use
information from all of those sources
to be truly successful
in a value based care environment.
So that I can give you a great example
of how that works and how that's
probably much different today
than it used to be.
And by the way, at Agilent,
probably the the biggest area
that we invest in on a day in and day out
basis is in the technology to be able to
ingest condition and leverage information
to basically be able to drive outcomes.
So an example that I like
use is like almost too obvious,
but is one of the biggest drivers of how
you can be successful in value based care.
As it turns out,
as we've been able to mine this data
and it really does take information across
multiple sources to get to this answer,
we reach a conclusion which might
seem obvious
but now can be proven from data.
Is that the more one of the biggest
indicators of success and value
based care,
meaning one of the biggest indicators
that you're going to be improving
the health outcome of your patients
is the number of quality
touchpoints that you can have
with the primary care physician.
In the past,
the model was really disincentive.
Primary care physicians
have a bunch of touchpoints
because they weren't
getting reimbursed enough
to really even pay back their own time
or the resources that that
that the practice was investing in it
under value based care.
They actually have the opportunity
to actually make it economic for them.
It's important
for them to have multiple touchpoints.
Well, the problem is,
if you're a primary care physician
that's got literally hundreds
of Medicare Advantage patients
and probably hundreds
more of Medicare fee for service patients,
and then you probably have multiple
even hundreds more of that of commercial
patients on your panel.
How do you figure out how to do that?
And so one of the things
that we've been able
to do with multiple sources of data
coming through our technology
is really carefully outline
for the most complex,
most critical senior patients
that are going to get the most value
out of multiple touchpoints.
And so we can put in front of the PCP
through this technology.
You know, here's
exactly the subset of your population
that you really should be focusing on
instead of seeing once a year
for an annual wellness visit,
seeing four or five or six times a year.
And then as importantly, we can
then also track
how are those physicians
complying with that?
You know, how many times
are they seeing these patients?
And the last thing is now through the kind
of looking across
those different sources of data,
we can then actually track longitude,
really longitudinally.
How well are those patients
actually doing?
So are they actually are the outcomes
improving or are we actually generating
lower costs,
more health outcomes for those patients?
So it's just really
data is really at the center
of everything that we do to be able
to drive that value based care model.
Yeah, I mean, your model is interesting.
We'll get to that in a minute.
How you've also created incentives.
But but Jeff, I want to kick it to you.
The role of digital in breaking down these
these these data information in silos
so that, you know,
there is in the best interest
of the patient
the ability to deliver the right care.
Yeah. No.
And I echo a lot of things that Tim said.
But, you know, I think we're
still in the first inning for this.
You know, 50 years ago,
the concepts of mobile APIs, going
digital platforms, you name it, that's
that was a foreign concept back then.
So the fact that these data silos,
they were paper silos back then,
we still have those digital silos
that exist today.
And I think where, you know,
especially if I look at the employer space
where there's 150 members,
150 million covered lives tied to that,
where we're in the early stages of this,
even if I look at the commercial space,
only 12.7% of the spending
there in the commercial space
is actually value based care.
And you could contrast that with the 35.2%
in the Medicare Advantage space
where where we have a lot
to go to achieve the scale
and the benefits of this digital sharing
that has to exist in order for value
based
care to see those outcomes be fruitful.
I think, you know, the point
that you just made, Jeff and Tim too, is
that technology is an enabler,
but it's not the only thing.
And that sort of brings me to
the to the part of the conversation
where we get to incentives.
And if you go back to, as I've done again,
getting prepared to go back
to what people have written about this,
I mean, decades ago,
Harvard Business School professor
Michael Porter wrote something in 2006
where he talked about creating competition
in health care, which is kind of
a foreign concept, competing for patients
on the on the virtue of value for service,
where costs come down, patient
satisfaction goes up is is a great idea,
but it comes down to
how do you and sent the right behaviors
across the ecosystem.
And Tim what what what Agilent has done to
to do what you described, which is incent
providers to have more touchpoints
with those patients
instead of churning through patient
after patient day after day
in order to deliver financial
value for the practice
is something that you guys have cracked.
Tell us
a little bit more about the business model
and how the incentive structures work.
Yeah, absolutely.
Can you now that I mean,
the model was basically broken
and it still is broken in many areas
where the Medicare fee for service model,
where a primary care physician
is really disincentive to spend the time
that they need with the patient
to improve the helpfulness
and to improve the outcomes
for those patients.
In fact, they're incented
to cycle through as many Medicare patients
as quickly as they can.
And in many cases, you know,
they're obviously not going
to get the same quality of care
because they're not spending the time
to really understand
what the needs of the patient are.
So what we do is
we go into a market and enter that market
by going into a partnership with a skilled
primary care physician group
in that market and essentially form
a 20 year partnership with that group.
So the first part of the incentive is
we are tied together in this partnership
with the primary care
physician group for for 20 years, which is
a big commitment for everyone to make.
And essentially what we do is go in
and say for all of the at least
initially Medicare Advantage patients
that we can attribute to that, to those
to those primary care physicians in that
partnership for all of those patients,
we're going to go out
and essentially facilitate
contracts
with the with the payers in that market,
with all the payers in that market.
So therefore,
for all the Medicare Advantage patients
in that market,
for that primary care physician group
in partnership
with us to take full risk for them.
So we're going to go in and say,
Hey, payer a in that market, we'd like to
for you to give us 85% of the premium
that you're receiving for that
a plan for this patient
that is seeing our primary care physician
and we'll take that 85%
and we'll take the risk for all the costs.
What happens
then is we work with
we leverage our platform,
we leverage our unique processes,
we leverage the knowledge
and the strength of our network.
And of course, we leverage
all of the technology and information
that we have to work with that
with those primary care physicians
to actually then improve the outcome
for these for these patients.
They're incented to do that now
because instead of getting 100
and something bucks per visit for that
for that Medicare patient visit,
they're essentially going to get
the economic benefit of whatever surplus
they can generate from that premium
or receiving and those that are going out.
And the better the health outcome
they can generate for that patient,
the larger that surplus is going to be.
As we generate that surplus,
which we do pretty much in every market by
by year or two,
that we're in a market most,
many markets in year
one half of that surplus is going back
to the primary care physician and half of
it is coming to us.
So that that I think the physician,
the primary care
physician is already incented
by their choice to get into this business
to want to do the best thing
for their patients.
This actually aligns
the economics with the desire to do
what they already want to do,
which is practice, which is practice
medicine the right way. So
yeah, so I think that that new model
and all the resources that we bring
to make that model successful really turn
the turn the entire process
back on that on its head
and make it the way that it should be,
which is the primary care
physician as the quarterback for,
for the care of the patient
and the primary care physician
essentially driving improved outcomes
and driving unnecessary
utilization out and costs down.
But but it's not like it's more than just
seeing patients on a more regular basis.
It's more about the decisions
that they're making
with respect to the care
that they're recommending patients get.
Can you talk a little bit
about how that aligns with the right
incentive for quality of care,
but also the financial incentive for that?
Yeah, absolutely.
So the other thing that we can do
that would be difficult to do
and this is kind of the power
of the Avalon Network that now we have
partnerships with
33 different partners across the country.
And, you know, many states
now around the country with over 2700
physicians that are in that network,
26 payers with 96 payer contracts.
And it's a really big network now.
And one of the things that we can do with
that amount of scale is to start going
into creating clinical programs
that can also be adopted by each of these
by each of these provider groups that
they would not be able to do on their own.
They can also significantly help drive
positive outcome for their members.
A great example is you're
not surprisingly, there's a predominance
of various levels of diabetes illness
among seniors, and it's a pretty large
percentage of costs of care
for the senior population.
We have the scale to be able to go in
and partner
with some large national renal
care vendors that can help.
Now that and then we can use the data
and working with our providers
to understand who are the right patients
who should be enrolled in this program,
get them into the program
and actually use UC scale programs
that we can generate to improve the health
wholeness of these renal patients.
And it can be a matter of making sure
that they're
getting the right amount of treatment
on a more regular basis, affordably,
It can be making sure
that they're getting that treatment
in the right side of service
so they're not having to go into
a hospital or an emergency room when they
but they're actually getting it
in their home.
I mean, that's the kind of
clinical program that we can bring
an employee across our network
that has a significant impact on cost
because it has significant impact
on the on the actual health wellness
and how how the patient is being treated.
And also obviously on the
on the patient quality of life
in addition to the quality of care.
Jeff, I want to
I want to kick it over to you because
you know what Tim
and the Agile on platform are doing
is they're investing for the long term,
you know, long term
payback, a kind of a captive
group of providers and patients.
But in the employer
market, it's very different.
You talk about a critical mass,
150 million employees
who are part of a part of these programs.
But the tenure at employers
is not 20 years.
So how do you how do you manage the value
based care proposition in a
in a in an employer employee population
that's really quite transient.
Yeah.
And I think that's a unique thing.
And as I hear him speak about 20
plus 20 year contracts there,
you know, we talk about quality
affordability and outcomes
and it'd be great
if you could actually measure
the marginal value of health care
and the outcomes over 20 years.
But with departmental labor
outside that employee's
average tenure is 4.1 years.
So what kind of outcomes,
what kind of things can you do
to actually incent or drive the consumer,
the member, the patient?
They're all the same entity here
to actually drive these healthy behaviors
here.
And that's either in terms of
we've we've seen this done in the past
before, which is high deductible plans
many years ago, driving, putting more onus
and on the consumer
to choose their health care
as they're owning more of the cost.
That hasn't solved everything.
Accessibility and sharing telehealth
and other options
to access care beyond the
day to day.
That's important here, but I think
incentives are going to be more and more.
We see that becoming a bigger factor
for driving consumers.
And, you know,
we know that about 70% of employees,
employers
actually offer incentive programs.
And so as you kind of look for the long
term view of this, which is that's
not only for wellness checks
and so on or chronic disease management,
what else can you be doing to drive
those healthy incentive behaviors
about care management
or how are you managing medications?
Or how about actually how you're eating
and which are lifestyle
to generate
sort of those healthy behaviors.
You see more and more aspect of
this health care becomes an ever present,
omnipresent view of the life
of ensuring the healthy consumer
in order to really drive
the better outcomes are exciting outcomes
that we talked about earlier.
What are the practical tactical steps
and and where does the employee get
worried that the employer
is crossing the line a little bit,
get it getting a little bit
too much into sort of the the health care
side of the employee versus
the work side of the employee.
Yeah.
You know, I you know,
I think I think in many ways
a lot of employers are almost every
company is now a health care company.
And I think that that I think is
is the core crux in many companies.
You've seen the investments
and the spend on health and benefits,
even outweigh some of the other products
that they're that they're building.
Right.
And so I think if you look at the long
term success of a healthy
employee population, it's incumbent
upon a lot of those employers
to ensure they're doing the right thing
for the employer's employees as well.
So I do think here that is that
state of where
the employer has to look out for.
The employee exists today,
and it's going to be even more present
as we look toward the future.
Yeah, it's actually and by the way,
it's interesting, in most cases
it's not even us saying it to a provider.
It's providers that we already
have contracts with in of recruiting.
One of the best ways we have to expand
our network is by physician groups
that are thinking about and partnering
with us, talking
to physician groups
that have already partnered with us.
You know, success kind of breeds success.
But, you know, at the end of the day, it's
not that difficult of a conversation
when you think about the dynamics
in health care today, where
obviously the population is aging.
So a bigger and bigger
mix of our physicians panel is going to be
in seniors, the Medicare Advantage
or Medicare fee for service.
And we do have,
you know, about a third of our partners.
We participate with
about a third of our partners in the CMS,
CMI acreage program as well.
So it's not just May,
but with
more and more going in that direction
and where there are more and more pressure
on rates in the commercial side
of their of their business, it's
really important for them to think about
how can I turn an uneconomic
senior panel into something that's
actually going to be economic for me.
So it's a pretty
almost like the in the dynamics of health
care are driving them in this direction.
And then it's just a matter of, well,
how do you want to go about that?
And, you know, I think time and time again
it's been proven out
that the most successful way
to get into a value based care scenario,
if you can do it
and you have the capability to do
it, is to go to full risk.
And so we're one of those
you know, we're we're an organization
that actually partnered with
with a group to get them to full risk,
value based care for seniors.
So, you know,
the incentive is pretty straightforward
because they're going to get you know,
they're going to turn something
that was uneconomic into something.
We're actually get economics
out of that out of that panel,
and they're going to do it in a way that
drives better output, doing it
by driving better
outcome for the patients,
which is the whole reason they probably
got into medicine in the first place.
So it's not it's
not that difficult to sell.
What is the role
largely of insurers now in driving
these value based care care programs?
And I'm curious to get to your thoughts
and Jeff, yours as well on on that.
Yeah, I mean, it's interesting for us.
And so we're so the
you know, we have contracts
with 26 different payers
now, you know, around the country.
So all the big nationals and in each area
that we're in, all the regionals
because we do, you know, we're payer
agnostic when we go into a market.
So we essentially get contracts
with every payer in the market
that has that is,
you know, running and made plans that
that to patients
that are seeing our physicians.
So those those payers
are basically looking at us as, hey,
you know, we're basically representing
a scale player in this market.
If they want access
to that physician group, then
obviously they're going to want to do that
through the program that we're offering.
I think a lot of the big payers
are also looking at it as,
Hey, they need to diversify
how they're taking risk through their M.A.
program
and one of their sort of supply chains
for their May program
is to have a certain amount
of their of their policies
in these in these
for risk, you know some capitated
for risk in areas like they have with us.
So a lot of the big payers are saying hey,
you're a great part of our supply chain
and you know, we'd love
to have you continue to look for,
you know, we'd love you to go continue
to go
in other markets and partner with us there
so we don't start with payer.
You know,
we start with the physician group
and go in and get the contract
there first and then go.
But the pair has become
a very important partner in that.
You know, it's working for them.
They're obviously,
you know, getting their guaranteed
basically margin on the business.
They're getting
access to the to the patients in that
position grouping and kind of guaranteeing
or getting their fair shot at market
share in that market.
And, you know,
they're going to get it in a way that,
you know, they're going to make sure
that the revenue
that they're getting out of that contract
is going to be maximized
through the processes that we bring in.
So it's I think it's a pretty good
winning situation.
We have joint operating committees
with all of our payers in our markets
and work work really closely with them
to make sure that we're executing a way
that works for them and works for us
and our provider partners as well.
If your thoughts on on the role of
of payers
and and the ROI and around the value
based health care proposition.
Yeah.
You know, so as I was listening to him
speak, you know it's
this is so complex and health care
you have so many stakeholders
that are involved and getting consensus
to ensure that everyone is moving
in the same direction
and actually have a shared
vision of an outcome is really tough.
Right.
And so I do think here insurers, just like
the providers and
employers,
all need to play a key part in this.
And and we've seen this occurring
in the market there, right.
Which is you have these integrated
delivery nodes
where whereas providers, insurers,
health care systems all coming together
and actually kind of trying to create
a shared vision across the board,
cutting down the administrative costs,
making sure they're sharing data
better,
they better able to control reimbursement.
You have talking about health information
exchanges.
How do you share data
with all these parties here?
How do you how do you ensure that the data
that's being shared across
all the constituents is being done
in a holistic manner across the board?
So you're creating a truly,
truly a network or a platform
that could actually see the launch channel
to a view
of that particular patient
as they're getting care there.
And so so I do think here
insurers are a critical component of this
along with every other entity
that exists out there.
Jeff, you mentioned payments,
our favorite topic, care payments.
So so how in fact
does payments play a role
in the enablement of the incentives
and the other money movement
that that is crucial
to the delivery of value based care?
Yeah, You know,
you know, as I look at this,
the core construct here,
especially as you're paying,
is earnings on the network
is is the data that triggers that.
So upon data on these outcomes
that you're measuring and ensuring that
that delivers a payment to some entity
there
that is driving that value
or that outcome there.
And so if I look look through that is
it's a broad view in terms of that trust,
and I call it the ability
to deliver those payments across the board
especially takes
a mixed level of complexity
when you're dealing with
incentives to the consumer,
Right?
How do you trust that consumer?
Who is that?
And once the consumer actually
has a wallet or has money
to manage a balance
and you're actually paying that
that consumer,
how are you managing that balance?
What's the fund management
company tied to that?
How are we actually going to be able to
how is that consumer
going to be able to use
that as they're looking to to pay
and actually deliver that payment
payout perspective there?
So if you kind of look at this from a
from a Antwon perspective, the
it starts off with the data
that thinks about the healthy outcome
of of of that patient here
and then it results into money
that moves from one entity
to another, that exchange of value there.
And so I actually think about this
in terms of the money in the data
have to be connected
end to end,
and there has to be trust on both ends
in order to deliver the data
and the money together.
So so I think this is a
this as a cross insurers, health systems
providers, employers
if you think how complex that is
by itself in each silo we might be this
this this becomes exponentially
more difficult as you connect
all the different players in the market.
Are there other frictions
that we haven't talked about where you see
this combination of digital and payments
becoming a really important
unlock to something
that's getting in the way of of
of changing the dynamic between quantity
of care to quality of care.
Yeah.
I gather that I think data
at payments is critical here
and I'll kind of look at this from a
employer perspective, right
sometimes that the data, even
the medication that Tim was talking about,
if you switch every four years,
you have to go find a new PCP, if at all.
And and I can't kind of
look at that, that digital divide
that could occur every four years
is really difficult to look
at the locked in tune or view of that.
And so if I have a 20 year relationship
with a PCP,
it's much tougher if I'm changing that PCP
every four years as well.
And so, you know, as I look to this
is that I call it the the quarterback.
As Tim highlighted this, I kind of like
this is that can digital help
bridge that divide and be a quarterback
as well as you think through
the we've heard out in the industry
talking about what if the consumer
actually own their healthcare data
and as transportable
and they actually could actually take that
to the next PCP or to any provider.
So there is a holistic end to end view of
that particular consumer's
medical history as well.
And so you
you potentially have put the ownership
into the hands of the consumer
as you do that by doing that actually
allows that data to be shared across
all that it is across the board here.
We're not there yet,
but I think the noble ambition
of empowering the consumer to own that
and have that seamless exchange across
all that is is a powerful thing here.
And I think that that data
is going to be more so,
especially as we move toward
more digital needs across the board.
Tim and Jeff, thanks
so much for all the great insight
and I hope we can have another one
on this topic at some point very soon.
Thanks again
for your time. Thanks so much.
