August 04, 2020, 05:27 pm Scott Wilson – Risk, money, longitudinal care and … talking fish. If you tuned in for the National Conference of Family Medicine Residents and Medical Students' July 31 mainstage, you know what these matters have in common.
The event, a virtual sit-down featuring AAFP CEO/EVP Shawn Martin and Farzad Mostashari, M.D., M.P.H., CEO of value-based care network Aledade, was a more intimate keynote than usual: a pair of home offices, shown in split-screen. But the relative informality allowed a natural conversational rhythm to emerge, and the two packed a considerable amount of opinion and advice into their hour.
After Julia Wang, student chair of this year's National Conference, introduced the speakers, Mostashari started with those fish.
"What's your water?" he asked, starting a short allegory about sea denizens unaware just what their home is made of.
Mostashari offered the moral, then gave the morning's first piece of advice.
"We often can't see the very thing that's all around us, that shapes our world and defines the laws of physics we operate under," he said. "What I'm urging you to do is, don't let that happen to you. Be aware of what the environment is within which you're working and living.
"I refused for 20 years to ask about the financial incentives for the system, which creates everything that flows down and for decades has made it more profitable to treat strokes than to prevent them. The system creates moral injury. That's one of the things causing burnout."
For his own introductory remarks, Martin pointed out that the 55th anniversary of President Lyndon Johnson's signatures on Medicaid and Medicare had just passed -- epochal legislation with a legacy diminished by the systemic failures to which Mostashari had just alluded.
"Our national investment in primary care -- patient-centered, continuous, coordinated care that's not episodic or platform-based -- is simply unacceptable and has been for a long time," he said. "We need to say that more and say it louder. We have systemically undervalued primary care over a long period of time, searching for the brass ring of a quick fix while ignoring the real value in our longitudinal care."
The two then touched on a few broad questions, with Martin first asking Mostashari, "What's working right now, and what lessons have we learned in recent months?"
The answer was no less encouraging for its predictability.
"The rise in telehealth," Mostashari said. "The speed with which practices and policymakers, at multiple levels, have been able to adapt has been just jaw-dropping. Aledade supports about 550 primary care practices in about 28 states, and we went from 100 to 10,000 telehealth visits within 12 days.
"We can do big things fast. Things don't have to be the way they are. There can be a business model that doesn't depend entirely on ringing up transactions. Revolutions can happen. That's the most promising result of the pandemic."
Martin agreed: "We have the opportunity to reimagine and redesign primary care, not just payment models but the overall approach. None of the value-based practices seems to be on the closure path we're dealing with."
"You don't have to sell your practice to have integration and access to tools and expert policy advice and PPE," Mostashari added. "A fee schedule is not the only way to finance primary care. We're seeing more health plans accelerating the push to value while we ensure the survival of independent primary care.
"A lot of folks in training are not thinking of hanging up their shingle, like before. But I wonder if tech will make it easier to create a space for entrepreneurial doctors. They would get to set the culture, set the values. I'm excited about seeing what might come."
"We have an opportunity to re-emphasize community-based primary care," Martin agreed. "What does a person-based primary care look like and how do we get there? We could have a new paradigm of value to replace one where we created all the wrong measures, gauging activity and motion rather than outcomes."
"What is the value of good primary care?" asked Mostashari. "One way is to let other people define it. If the definition is productivity, what's the product if it's a fee per visit? Or we can say that preventing bad things from happening to people is the value we create. And then everyone is like, Hang on there. Should we give 30% to the doc who prevented the hospitalization? Well, a hundred office visits of value creation might prevent a hospitalization, and if you got paid for that, I bet you'd do it.
"What if we paid 20% for primary care? The economics would be mind-blowing. Then people thinking about career choice wouldn't have to choose between following their hearts and looking for financial incentive."
"What builds confidence in physicians toward making that leap?" Martin asked.
"Different personalities will embrace it," Mostashari said. "Early adopters, tinkerers come first. They love the chaos of it, the lack of definition. Then you get people who are pragmatic and have said they'll do it if you show that it works. That's where we are now. Later, the skeptics will have to see it as a safe choice. But we'll get there. More people will figure out what other countries have: You can pay for primary care, or you can pay for the failures of primary care."
"There's the high cost of inaction," Martin said. "We can document through research that the lack of investment in primary care has had real costs, such as more than 85% of our health care dollars treating chronic conditions. Give us 55 years of overinvestment and we'll see who wins."
"Not every primary care doc will agree that higher payment should be tied to proving better outcomes," Mostashari said. "We are not going to convince people unless we put ourselves on the line and take risks. Docs don't like the word risk, but I think there's freedom in taking more risks. That's how you get away from prior authorizations and documenting the 12 things you had to do to bill that code."
Next, Martin asked Mostashari to help the audience look toward the future.
"The people watching today are steeped in biomedical training," he said. "What else should they embrace?"
"At every career level, you need to ask: How am I building, in tech parlance, my stack?" Mostashari said. " Get really, really good at one layer of the stack and then immediately go to the adjacent areas up and down and work toward translating across the layers.
"Clinical medicine is the heart of the stack, your skill set. You have to be super competent in laying hands on patients and determining sickness. What's up and down from that? We often go down to the organism level, bacteriology and the science. But what if we go up the stack from clinical? What's higher on the stack from clinical are the systems that produce, in most cases, subpar results. Higher up still? Social drivers of why the systems are or are not feasible.
"My advice to you: Go up the stack. Pick a problem, measure it, improve it and think about the systems that will allow a better outcome."
That was a natural point for Martin to steer the talk to advocacy. Beyond the Academy's complex, D.C.-driven approach to seeking regulatory and legislative improvement, what can medical students and residents do where they are?
"There's nothing like the felt experiences of a human being to create change," Mostashari said. "Are you able to touch someone's heart and mind? You have to be able to marshal the facts and the data, but you have to be able to tell a story. That's a clinical skill, and you can use it to connect the dots from the 78-year-old you saw in clinic to the system.
"Also, trust your experts. The AAFP are experts at federal advocacy, with marrying what is right with what is practical in terms of getting there."
"Advocate from within," Martin added. "Within your social networks, your families, talk about the true value of family medicine. The best advocacy takes place in grocery store parking lots and chamber of commerce meetings.
"And membership matters. Organizations like the Academy are strengthened by numbers, and being empowered by the diversity of our membership allows broader collaborations. We can create alignments and collaborations."
Finally, Martin asked Mostashari to give the audience advice for their next professional steps.
"Back to the water," he said. "Big fish or small fish, be clear-eyed about the organizational financial incentives up front. Before you get yourself in a position that's frustrating as hell and feel like a cog in a machine, ask yourself what an organization's culture, values and financial incentives actually are."
"Think big and comprehensive about who you are and what you can bring to a community," Martin added. "Don't let someone push you into a narrow set of practice guidelines. Be as full-scope and aggressive as you want. We need you to do that.
"And never lose sight of the almost immeasurable positive impact you can have by being engaged with a community of patients. Treasure that."