Beyond Math: Making Value Work in Healthcare with Rob Fields, MD

Rob Fields 0:00

You know the reality is that humans are mostly the same between Western North Carolina and New York or Boston. Yeah, sure, there are cultural differences and certainly the healthcare environment is different structurally in a lot of ways. But the things that drive behavior change for individual patients or the psychology of health systems is there's actually more the same than there is different is what I found and to not be scared about scale in size like the same leadership lessons from, you know, early days are mostly the same.

Welcome to the Move to Value Podcast powered by CHESS Health Solutions. In this episode, Rob Fields, Executive Vice President and Chief Clinical Officer at Beth Israel Lahey in Boston and Rebecca Grandy, CHESS Director of Pharmacy explore the clash between mission and math—how doing right by patients often means fighting outdated systems. They dig into the shift from fee-for-service to value, what it really takes to handle downside risk, and why care delivery must evolve fast to meet rising demand.

Rebecca Grandy 0:08

Rob Fields, welcome to the move to Value podcast.

Rob Fields 0:10

Thanks for having me.

Rebecca Grandy 0:12

Yeah. And, you know, I've been in healthcare now for almost 20 years.

I've had the chance to work with a lot of leaders in healthcare and there are a handful of folks who really have made an impression or stood out to me, and you're one of those. So I'm really excited to have you on the podcast today. Yeah. So I'm actually gonna tell a story, just sort of kick us off about how I first met you, which you may or may not remember, but it really left a lasting impression.

It was about 15 years ago. We were both working for a health system in Western North Carolina. I was working for a medication assistance program and we were trying to, you know, in addition to get people their medicines, we wanted to do something to try to improve health literacy, really empower them to take care of their health. And a colleague of mine reached out to you and asked if you would come be part of some classes that we were doing. It was after hours, just a handful of people. And that particular session was talking about, you know, how do you get the most out of the visit with your doctor? How do you advocate for yourself? And you came just because we asked. There was you didn't get any credit for it. No titles, no spotlight. Really nothing. But you came and you sat and you listened and you talked with people about how to engage, you know, with their primary care and their other physicians, and really tried to help them feel empowered, you know, in a system that can feel very overwhelming.

Rob Fields 2:38

Yeah. Well, thank you for that. It, I remember that program well and it was still is.

I mean, hopefully it's still around, but it's a pretty amazing program. And you guys did a really amazing job as a great service to the community there.

Rebecca Grandy 2:50

Thank you. Well, you know, in that moment has really always stuck with me because you know, that's what this work is all about. Value based care, especially the more I get into it, the more complicated it is. Contracts, metrics, models. But at the end of the day, it's just about people and you know, people who care enough to sit and try to make things better. And so that's what I'm hoping to talk about today is some of the complexities, but also the people.

Rob Fields 3:14

Yeah. No. Yeah, I'm excited to to, to dive in. It is indeed complicated, but we'll we'll do our best.

Rebecca Grandy 3:20

Well, you know, I know you've worked in lots of different systems, healthcare systems, geographically pretty varied. Just how did you get involved in value based care and what keeps you interested?

Rob Fields 3:32

Yeah. No, thank you for that. And honestly, I feel like, you know, like I said, I spent some time in New York and now in Boston. But the work we were doing in Asheville back in the day was only pretty amazing and it was it was amazing in lots of ways, but it was incredibly forward thinking and creative. In some ways that you know, I spent the rest of my career in these big cities trying to replicate. I think the culture that we had there at the time, which I think was really unique and spectacular in lots of ways. So good for patients. But I got into value based care mostly by accident.

You know, I think you may or may not remember back then, but 22 years ago in Asheville, I started a primary care practice with a close friend from the MAHEC residency program. And we had played music together, actually, and decided to open a new practice because, you know, taking multiple months to get a new primary care appointment and. Although you know Rob Fields is not the most Puerto Rican name you've ever heard. I was actually born in San Juan. My mom's from Guam. I speak Spanish, and we own open a practice called Vista family Health with bilingual staff and bilingual docs and a big part of our practice was serving a Spanish speaking only population. And we, you know, I'm really proud of a lot of what we built over the seven years of being an independent practice in in Western North Carolina. Early with, you know, the electronic medical records patient portals, E- prescribing all that stuff really early before the hospital was doing it before the residency program was doing it. And we provided a really great service to the community. It unfortunately was a total financial disaster for us personally. And we learned some really hard lessons about the impact of medical economics and healthcare policy on actually caring for patients. And I think as physicians, we think, oh, we'll just work hard, see patients, everything else will work itself out and it just it just wasn't the case we worked really hard. And it didn't. It didn't work economically and so it got me curious about root cause and why we're in the mess that we're in.

rward a few years is probably: 2013

Through that process, was invited to move to New York from Ashville, North Carolina, I think in season Asheville at that point maybe had a 150,000 - 180,000 people in it and ended up working in Manhattan, which was crazy. I remember texting my wife one day and said, what do you think about New York?

l. I was just coming to it in: 2013

Rebecca Grandy 8:29

North Carolina, you know, that's part of the reason that brought me to West North Carolina, originally from western North Carolina, but a different part, went to Chapel Hill for school. But then I had heard about just the healthcare system in Western North Carolina. How progressive it was, how team based care it was, and so really wanted to be here and have been here since and really enjoyed a lot of the lessons that I've learned.

Rob Fields 8:53

Exactly. Yeah, no, I agree. It's a It was a pretty amazing culture.

ased colonoscopy in the early: 2000

Really unbelievable research and unbelievable innovation from a therapeutic standpoint. I think still very far behind on the value journey from a health services delivery standpoint, you know and and just separating those two things you can be very advanced in lots of ways. But I think how we deliver care is behind some of the areas that we're under to some degree I think more financial pressure back then because we had a higher rate of government insurers, the rates weren't as high in places like North Carolina compared to these large urban environments.

aders in Raleigh, you know in: 2015

Rebecca Grandy: 13:37

Well, and there's so much to unpack in what you said. But one of the things that I do want to dig into a little bit is culture. So I know that you've said that you know, culture and creativity are so important for value based care. And so what things have you been doing, you know, in your current position to get folks to embrace sort of value based care and that culture over volume over that fee for service over you know, we can make more money as a health system if we have it, you know them do a procedure in the hospital versus an outpatient setting. Like, how do you counterbalance that, counteract counterbalance that.

Rob Fields: 14:13

Yeah, I think some hard lessons of making a lot of dumb mistakes and a lot of failed conversations like probably the classic story of folks that have learned over their career, how you, know not to do dumb things and continue to do them. You do them once and hopefully not two or three times. But you know, I think the harder conversation in the beginning was to go to a CFO, a more classic, what we say, stereotypical health system CFO and say also sort of argue a moral argument to this. And folks that have heard me give talks before, certainly more so earlier in my career I used to always have a slide that said, if the moral argument were we're if the moral argument were enough, we would be doing it already. And it's just not enough, unfortunately, to just to say it's the right thing to do. That was really hard. I think that's hard for all of us as a if it's the right thing to do, we should just do it. Well, sorta. Except it's it ends up being more complicated than that, because there's there are questions of sustainability and all those things that come into play. And sometimes the way the system is set up, this is I think my one of my big lessons from Vista is that we were doing the right things and it just wasn't enough to actually still be around and. And so if we wanted to be around, we had to get to the right thing, probably slightly differently. And I think for health systems and CFOs trying to just argue on the moral side just didn't work and then started to think, OK, well, what makes more sense and then try to argue with data. And so to your question on how we start to move folks, there are a couple themes that I would say historically were true and are even more true now. So even the way I use my language is different now than it was even a few years ago. But the basic foundation is at that point we knew that a tsunami of Medicare patients was happening. You know, people call it the silver tsunami. Whatever you want to call it. At this point, it's 10,000 new Medicare beneficiaries per day. So, if I'm talking to a health system CFO like this is your largest growing demographic. So, you have a couple of options, and it's probably not, they're not mutually exclusive. So, one option is I could ignore that and continue to do what I'm doing today in fee for service. You're guaranteed most hospitals these days, especially post the pandemic, are nowhere near Medicare break even, so they lose money every time a Medicare patient enters the hospital. For the vast majority of services. You could continue to provision care in a fee for service basis and you have guaranteed loss. You're going to provide more of it. You will lose more guaranteed. Or you could take a risk and think about a delivery and economic model that at least provides some possibility that you're gonna generate a return. You can choose, right, there there's almost zero chance you're gonna have Medicare rates be enough to cover your cost, but at least you can figure out a way to lower the the cost of delivery of care, try to move to value, get some returns and fund a different model and see if that works. And I think there was some progress made on that front. If a CFO was really thoughtful enough and again creative enough to think outside of the normal way a CFO thinks, which is heads and beds, you know, admit everybody that walks in the door. These days I add a little more to it because what's happening now, especially post pandemic and after probably going into 22 into 23 where people are returning to utilize healthcare en mass. So the supply demand mismatch is is real. And you know, Medicare beneficiaries utilize hospital services roughly depending on the market three to four times out of a commercial insured patient. So as you grow Medicare patients, the demand on the hospitals is much, much higher. Unfortunately, at the same time, the workforce is shrinking rather dramatically. And the supply demand mismatch and the capacity constraints, it's not really a, to some degree it's some, you know, financial constraint, but it's really in my mind a capacity constraint, whether it's capital capacity, brick and mortar capacity but in particular a workforce capacity constraint. You have to solve for that somehow and you can't force more volume through a narrow funnel that is the delivery of healthcare that you know hasn't changed in over 100 years pretty much. For all the technology you still have to make an appointment. You still got to drive to a clinic. You still got to get a diagnosis and a therapeutic in the office. Wait a bazillion hours and then go home and you can't force more work into that narrow funnel from a capacity perspective. So I think creativity comes in you're going to have to deliver it differently. If we could still be around because the demand is coming. And so how do we think about that differently? And I think that's where technology comes into play. A remote patient monitoring, I think growing use of AI, growing use of team-based care members, clinical pharmacists and others. I think we have to think differently and more creative in order to solve the problem and then how the economics of a value-based environment at least provide some possibility for for a return. So that's the kind of language I've been using in the last few years as the constraints become more real.

Rebecca Grandy: 19:15

Well, and thinking about your conversations with the CFOs and just and then just thinking about my experience, you know at CHESS and with the clients and health systems we work with, you know, early on in value based care, most of it is shared savings and that feels pretty palatable for people. It's like, OK, you know, if I do well, I'll get some shared savings. As they move along that journey and value based care, and now we find ourselves, you know, in downside risk, I guess my my question for you would be, you know, how do you assess whether an organization is truly ready for downside risk? How do you sell that to them? Because you know when you think about the market and value based care, you know there are aggregators and companies that will essentially take on all the risk for the providers, right?

And then there are other health systems that are taking that on themselves.

So if you could just talk more about that move to risk and how do we know when we're ready for that?

Rob Fields: 20:11

Yeah. And I think it so a few things I there's probably not one benchmark for one kind of delivery system. They're all a little different. If you're a large group of primary care physicians, that's a different calculus than if you're a health system with a bunch of specialists and a large sort of brick and mortar overhead structure that you have to contend with. So I think just to say that explicitly, it's really different depending on what you look like from a system perspective, large or small. I think there are sort of fundamental things like how you think about stop loss and how do you, you know to some degree how you de-risk it. How do you take on risk by being by de-risking it to some degree? But I think more importantly and fundamentally is is really the delivery model structure in the health system and how evolved is it? Because I think one of the things about risk is that I don't think for a hospital based health system, you know we have hundreds of ambulatory sites. We have a exceedingly strong primary care platform here at Beth Israel Lahey, which is great and obviously makes me really happy as a family doc and in the chief clinical officer here, but we have a ton of specialists and other things here there. And so I think that you know if we take on full risk and have changed nothing about the flow of patients from primary care to specialty to hospital, or have thought about how we think about our ambulatory surgery strategy, for example, other side of service things where we're making intentional investments in areas that lower the cost of care. It's hard to imagine that we're fully ready to take on full risk without the appropriate infrastructure, and you can say, OK, well, it's it's chicken to the egg. Well, if you invested in the infrastructure, then you'll be ready. But if you wait forever, then you'll never be ready, and you're perpetually in this two world thing that people have been saying since I got into pop health. The whole on the dock, on the with one foot on the canoe kind of thing. If I hear that one more time in a pop health conference, I'll probably explode. But we've been doing that for over a decade, right? Talking about the same thing. That will perpetually be true, unless you've made intentional investments on how the delivery of care needs to be different. And so I think part of readiness is just doing a good self-assessment on what are the things I need to be doing from a delivery perspective to be successful and full risk. That usually means provision of care in a way that's less expensive than the normal way. And again, what's different now is we would talk about those investments really hard for your CFO to say. I'm gonna accept a much lower rate in an ambulatory surgical center than the inpatient side that you know that's a dramatic fee difference. Why would I accept that? So what's changing now is that so much care is already going outpatient? You have to invest, otherwise you're going to be cut out and so that I think again, the language is changing as the flow of care and the drivers of care are really flowing to other areas outside of the hospital for many reasons, capacity constraints, you know, payer relationships, the role of venture and private equity in healthcare, which is sort of a mixed bag and can be really problematic. But it you know if there is a silver lining, it has driven a lot of care in the outpatient setting in a way that's pushed health systems to think differently. So I I think about all those things in terms of readiness. You know, what really about the delivery model, more so than anything else. Yeah. And I think, you know, doing that intelligently. I don't, I'm not a fan. I think it's self-destructive to sort of, you know, pull the pin on the grenade if you will, and just jump into full risk because you based on some ideological feeling that that's gonna like change behavior. I just, I just don't think that's the way it works, and I think you're more likely to put a lot of care at risk if you go foolishly into it. I think being thoughtful, it makes more sense. For example, in Medicare makes a lot less sense in Medicaid where.

The premiums aren't high enough to cover the risk and the cover the care in many states. Really challenging in commercial just because commercial patients utilize differently. You know, if you're a healthy 30-year-old, you tend not to utilize a lot of healthcare unless something God awful happens. You know you had have some traumatic event or horrible diagnosis and then your costs go way high, but it's otherwise it's pretty low. And how do you plan for that? Because normally when you take risk, it's all about proactive management and avoiding the high cost care. That's really hard to do for a healthy 30-year-old because he can't predict it. So taking full risk in commercial, especially with small populations, which is often what we're being asked to do, not smart. So I think you know taking risk you know, requires a lot of self-awareness, a lot of infrastructure investment on a delivery, different delivery model, and a strategy that doesn't, you know, risk the whole the whole process and do more damage than than good by just going foolishly ahead for taking risk for for all payers.

Rebecca Grandy: 25:23

Well, I'm just thinking about payers, you know. I know, you know, at least from my experience, being in primary care and then the providers that I know you know when you have the patient in front of you, you want to treat them like any other patient, right? Regardless of payer, you want them to have the best care. I feel like sometimes behind the scenes the reality of value based care is very different, right? Like a Medicare Advantage plan is different than Medicare is different than commercial like you said and thinking about the risk and the nuances. So I'm curious in like in your experience, either now at Beth Israel Lahey or in the past, like how do you create the infrastructure in the systems where you're thinking through all these different payers and contracts, but then you're allowing the providers at the time of care to sort of not feel that, and it'd be more seamless if that makes sense?

Rob Fields: 26:12

Yeah, absolutely. That's always a criticism, right? Is that the physicians and staff at the down at the office level in particular, but even at the hospital level, don't want to think in insurance, they just don't tend to have organ rejection as the thought of I want to treat a Medicare patient different than, you know, a Blue Cross patient or whatever, and I don't blame them. So the key is to create models of care that work for both. And I get really excited about that. I mean, I think that the more we stop thinking about individual initiatives or individual contract-based interventions and think more about platforms of care that can be pointed in for lots of different strategies, the better off we are because then you can be more payer agnostic.

What do I mean by that? All right. So let's take the concept of digital care broadly, whether it's a virtual care environment or remote patient monitoring or anything.

The way I try to talk about it is that it works for all populations. Because it can work for a concierge practice so super rich, you know, well-resourced patient, but that's a, you know, corporate executive and wants a digital care environment because they're too busy to be, you know to wait three hours for us in the office, you know and so.

We have a digital care environment, whether that's a remote blood pressure cuff and in a pharmacist provisioning care and writing prescriptions in between doctor visits, that's very high service, high touch. Very responsive as a role. Works for commercial population. Turns out works really well and probably better for a super poor Medicaid insured patient with lots of chronic conditions. Because if anyone needs concierge care, it's a poor person in America, right? So and so if you can provision a digital intervention, cause a lot of those folks actually have smartphones available.

So if you can provide something that doesn't require their own Wi-Fi or their own data plan, but that you know it's built in. And you send them the same blood pressure cough and the pharmacist is providing the same advice and managing chronic disease, it works particularly well for them because the challenge of trying to get to a doctor appointment and wait three hours for us to get the same care is even more challenging for them because it's a luxury to be able to make an appointment and go and wait three hours and it's a luxury a lot of folks don't have for one reason the other. Either they lose wages or lose their job, or trying to find childcare etc etc.

Life gets complicated if you don't have means and so it turns out digital care works well for both. So we can launch that same model works for value based care.

It also works to grow our commercial strategy. We put a different label on it. It's the same stuff. And so then you don't have to think as much about we're only doing remote patient monitoring for the commercial population. We're only for Medicare for that matter, we think more of it as platforms rather than individual initiatives. And I think that that helps a lot.

Rebecca Grandy: 29:10

Well, and I love that. And then it also gets at the point like, how do we implement value based care in a way that doesn't increase disparities? So I just sort of love your example of how this works better for people. Even better. Well, the technology works even better for people who may have transportation issues or, you know, can't be at the doctor for three hours. Are there other things that you all have done to make sure that as we move to value based care, we're not increasing disparities?

Rob Fields: 29:38

That that's a good question. I mean we we measure is probably the best thing is that you know you can have all the good intention in the world but, you need to be able to measure your progress to make sure that you're not. Because I think no matter what, no matter what I say about intent, it kind of doesn't matter. You still have to measure and and know that you're not having unintended consequences. Because to your point, as soon as you section off a segment of the population to do something with you've messed with the ecosystem in some way, and it's gonna have consequences. Not all of them, that are ones that you can predict. And so I think we constantly look at overall control. You know, I think in the in the current environment it it's a little, it's even more challenging to sort of think about how we get to the equal outcomes across all populations. But I was on a panel recently where I encourage all of us to my colleagues across the Boston area, actually throughout the state was, let's not we're not victims here, you know, at least fully. You know we can still measure. We can still look in the goals of providing the best outcomes for everyone that we care for is not only the right one, but it's still something that we can measure and openly and openly do. And so that's what we look at is we're looking for equal outcomes for, for all folks and we have to measure that constantly to make sure we're achieving that goal, regardless of the other you know, the noise that’s out there. But I think that's the big thing is to hold us accountable by continuing to measure.