Scale Matters: Making Data Work in Value-Based Care with Rob Fields MD

Rob Fields: 00:00

The things that I think are most valuable are, right now, are really chronic condition outcome measures, blood pressure, diabetes control, things of that nature and functional measures that that help guide to interventions like missing your PCP or specialist appointment, right? That information and data is helpful because it's, it's an intervention that we could guide people to show up. And so it's a very clear line of action from data to intervention. So those are the kinds of things that I think are most valuable.

Narrator: 00:38

In this episode, Dr. Rob Fields and Rebecca Grandy continue their conversation and focus on data . What’s useful and what’s a waste of time? What data truly drives value and why do so many predictive tools fall flat? You’ll also hear practical strategies such as where to direct focus when resources are tight, how to build an ideal care team, and how to make your value-based programs sustainable—even in a broken fee-for-service world.

Rebecca Grandy: 01:07

Well, and I will say I have a love hate relationship with data, right? Like data-driven decisions are so important, but sometimes the data can just feel overwhelming. So I guess as you're thinking about, you know, measuring, you know things that you implement, the data that you're looking at like, what data do you think is most important as we go through value-based care? I know that's a really broad question, but just really curious because it is so overwhelming but so important at the same time.

Rob Fields: 01:37

Yeah, I think it's a great question because I think pop health and value-based care is often misled by data more often than lead in the appropriate direction, and I think we have a tendency, the collective industry, to over engineer solutions that are just make logical sense. Example. Well, let me answer the question first and then kind of go back. The things that I think are most valuable are, right now, are really chronic condition outcome measures, blood pressure, diabetes control, things of that nature and functional measures that that help guide to interventions like missing your PCP or specialist appointment, right? That information and data is helpful because it's, it's an intervention that we could guide people to show up. And so it's a very clear line of action from data to intervention. So those are the kinds of things that I think are most valuable. I think the things that are way overhyped in our in every pop health conference that I go to a million vendors trying to sell you the best tool for predictive analytics on who's going to end up in the hospital. And I've done, I’ve made this mistake before. Lots of times, unfortunately. Back to trying not to do dumb things, but you know, vendors will sell you the newest, greatest AI based predictive model on who's going to have the complication, who's going to end up in the hospital, who's going to cost more and what I've learned over my career in pop health is that it's too dynamic to really do that well. And often the insights you get from that data are not helpful operationally. So, you know, there was a time earlier in my career we worked with a vendor that was really excited about that combined claims data with publicly available data that you can purchase that helped us give some context around social determinants at the person level. So it might tell you a risk of being unemployed or, you know, being have housing instability, etc, along with claims because we thought logically, the social care gaps that we might have are more important than the clinical care gaps we might have. Therefore, it should add to the predictably predictability of the model. Well, few things. One it didn't. Claims do a pretty good job and actually age and gender does a pretty good job of predicting, especially relative to the cost you pay for some of these models. So doesn't add that much, interestingly enough. Second is that OK I could predict with a high degree of certainty who might end up in the hospital in the next 30 days. What was I gonna do with that information alone without some actionable insight? So, what happened is our care managers would call and they would say, what are you going to say? My computer says you might end up in the hospital the next 30 days and you're driving, you know, to the grocery store and like, what? Who are you first of all? Like, why are you calling me? It didn't make practical sense, right? So, it is like duh, right? We didn't think it through all the way. Yeah, that's great the statistics are phenomenal. Turned out not to be that helpful right from an intervention standpoint. So we had to marry it with other actionable insights like missing appointments. And then so I think that's the other piece. And then the, the next piece that I think is from a data standpoint that I think is way overhyped is really the well, there are a few things, but one is we tend to look at the top of the pyramid of risk. You know who are my highest cost patients? My most complicated? And everyone's eyes goes to that first right? Everyone that enters pop health makes the same mistake over and over again, and inevitably what happens is that they're not terribly impactable A. These are patients that are super sick. Unfortunately, so far down the road that outside of palliative care and Hospice, there's often very little you can do to actually lower that cost. That's first problem. Second problem is that they're never the same. The dynamics of who's going to be your high cost population is actually not a static number. It's not the same patient. Some of them are the same year over year, but many of them change. They had a terrible year, super high cost and then they go back to being normal, right? There's that regression to the mean concept that you know just the laws of nature have it such that when you take a large population of anything, it tends to regress to the mean. We tend to be average as a rule, and anything else is fighting against that pull, it’s like gravity fighting against that pull to be average. And so when you look at any snapshot in time who’s flagged as being high risk, they're not likely to be high risk later. And so you've wasted a lot of time, energy, and resources trying to prevent this outcome. In the meantime, somebody else took their place. And so, inevitably, what happens is that you fail to actually reduce total cost in your contract because you're busy chasing the high cost folks.

But it's so dynamic that it, unless you're providing care across a large enough segment or proportion of your population to actually move the curve, you're just chasing yourself all the time. And I've I've found that over and over and over again.

I'm actually partnering with our Center for Healthcare Delivery Science at Harvard through through Beth Israel here to actually study that we, I don't think there's any data to look at the churn rate by risk segment, but that's one of the things we're starting to look at is how dynamic is it year over year to help inform how we think about pop health differently? So going back to the beginning, why I think outcomes like blood pressure and diabetes matter because those are the things that hit double digit percentages of the population. So, if you can control hypertension at a rate that you know people talk about, if you're going to solve one public health problem, it's hypertension. If you can do that from the whole system, we're all going to care for hypertension patients differently with RPM, with pharmacist, team-based care. So now the vast majority of the population gets to a better outcome. Then you could,

actuarily, you can start to move the curve, because now you've you've taken on such a big chunk of the bell curve. That inevitably it moves. That's how I'm starting to think maybe just say it like one sort of sort of tagline, I guess is like scale matters when it comes to pop health stuff and anything else I used to work with somebody used to call things science projects if they were subscale, then everything else is just a science project.

Rebecca Grandy: 08:11

Well, and you know, I've never been an organization that said, we have all the resources in the world. We can do all the things and so thinking about sort of the biggest bang for your buck and some of these pieces that you were talking through, you know, maybe it's not the highest risk at the tip of the pyramid, right? Because maybe, you know, we should think upstream or think you know, people who are rising risk or less focused on hypertension. If you had to prioritize for people who have limited resources, which in my experience is everyone right? If you had to prioritize, let's say the top three practical things that folks could focus on for value-based care, thinking about those clinical initiatives, what would those be?

Rob Fields: 08:54

So thinking clinical initiative specifically, so I'm taking out risk adjustment and I'm taking out pride of service, which are the the two biggest things that probably have impact, right shifting people to outpatient and risk adjusting. But from a clinical perspective, I 100% think it's chronic disease management. You know, it's the thing that's most scalable. Because the other clinicians you work with outside of the pop health enterprise that you have built, which to your point is often under resourced.

So you can get clinicians to understand hypertension control or diabetes control. And so doing that at scale is probably the most important thing you can invest in.

Now what that implies, though, is that you're adding resources to the typical primary and specialty care delivery of care. So I have a high intensity bias towards clinical pharmacists because I think of what they can do for your Rebecca.

Rebecca Grandy: 09:49

Love that, by the way.

Rob Fields: 09:53

People know but it I assume that would that would resonate with you. But yeah, I I have a high degree of bias primarily because they are the most skilled on medication reconciliation, medication access, interactions, side effect, counseling, and guidance.

And then they can prescribe. And that last one is really powerful because you need potentially you could train others to do that, but the ability to prescribe and actually intervene in the moment in time when you're on the phone and engaging with the patient where the outcome isn't another inbox message to a very busy PCP or specialist. That is immense power in a system. So when I say hypertension and diabetes control, it's not about brow beating the primary care docs to do better about controlling their patients or more education, which I think is not terribly powerful or effective. It's really about systems of care that augment what the regular system can do and to increase overall management and control. And I I happen to think pharmacists are are a really important part of that strategy. It's not the only way to do it, but it's the way that I have found to be intensely successful and I think what is most powerful beyond Med adherence and Med management is the in between visit interaction with patients to make sure they're taking the medicines regularly because we don't know in the regular practice of medicine, actually, we do know that most people don't take the medicines as prescribed. So being able to have that conversation and engagement in between visits is immensely powerful, and that's that's what we've observed in the models. We're just getting started at Beth Israel Lahey, but certainly some of the models, clinical pharmacist models we built at Sinai showed pretty amazing results. And yeah, so that's my bias.

Rebecca Grandy: 11:47

Well, and I'm going to dream with you for a minute, and then we'll bring it back down to something practical. So if you were to make your care team dream team finances are not an issue. Reimbursements are not an issue. Love that you're going to have clinical pharmacist. Who else you have on the dream team?

Rob Fields: 12:04

Certainly nurses and social workers, no doubt I do, despite what I said earlier about the predictive model, I think thinking about social determinants or social cares, I like to call it as part of the operations feels really important. And so I think social workers are a big part of that. But I think as much of anything, I think roles of non-licensed professionals like care coordinators and pharmacy techs and others I think are are important. But so, it's it's some combination of a coordination slash coaching model, but in some combination of nurses, social workers and pharmacists and you know physicians, sure. Nurse practitioners, sure, but they're already there, and there aren't enough of them. So I'm really not counting on that part of the workforce to really build the foundation of my dream pop health enterprise. It's it's these other team members. And if I could dream even broader. I think it's also about paramedics and you know, as you know, we built, it wasn't my idea, but learned a lot and helped help scale the community paramedic program at Mission and and at Sinai and with some great forward-thinking leadership there at the time to design this thing. There's lots of power in these other non-physician non APP staff that are in some ways looking to do more, or not some ways I mean very directly looking to do more. In some cases, expanding careers, nursing staff or paramedics that were on the being on the floor in the field, in the traditional job is hard physically, but still can contribute a lot intellectually and from a patient care perspective, there's a lot of possibility here to expand and extend careers in a pop health enterprise with some of these clinicians.

Rebecca Grandy: 13:57

Well, and now I'm going to bring us back to Earth and I'm going to circle back to the CFO conversation, right? You know, most of these professions, you know, as a pharmacist, this is something we've been fighting a long time, is that in the fee for service world, we were not reimbursable in a lot of ways. I think there's some progress that's been made there, but as you're thinking about building this dream team and making the case to the CFO, what success have you all had, I guess as far as selling this vision and making it financially sustainable in the current environment?

Rob Fields: 14:29

That's where a lot of creativity comes in. There are a couple ways to do that. In remote patient monitoring, I think there are a couple ways. Certainly, there are procedural codes, so it's still fee for service, but you know pennies on the dollar compared to more expensive services we provide. So there are fee for service codes for remote patient monitoring that can help offset some of that cost. I think a lot of the patients that we serve even in a hypertension program are also on very expensive specialty meds. And things of that nature that are costly for patients, costly for plans, and many times for systems as well. So, thinking about, you know, our specialty care pharmacy can, if those patients got care internally, it's better for them because we can coordinate the care better. It's supported often by pharmacy revenue or other things that help offset that cost. These things rarely are enough to, you know, make a margin for a nonprofit health system. But they are often enough to help pay for the program. And so that's all it needs to do, right? Because you know your returns from a value perspective, as you know are delayed by a couple years. But if we can at least get the program to pay for itself and provide a good service for people in need, then it meets all the philosophical aspects of some of these you know, pharmacy programs. And also is what remote patient monitoring is supposed to do from a CPT and fee for service perspective. So, you can get creative with the revenue model. It doesn't, I think most CFO's are fairly burned out on the prospect of this is gonna pay for itself in the shared savings. Nobody wants to hear that 'cause every CFO has been fooled by saying, oh, you know, we're gonna lower total cost of care by 10%. We're gonna get millions of dollars back in our shared savings arrangement and say nonsense, right? Because they have learned the same lesson that I learned, which is most of these things are fairly sub scale and are not enough to create shared savings on the totality of the contract. You can prove it in a cohort, as I said before.

A cohort is dynamic and changes. So, you proved it here. In the meantime, somebody else took their place and you haven't saved anything for the population, and they've all learned that lesson because, they're looking at the numbers. And so, we try to support the programs we build by other sources of revenue in the short term, knowing that it adds value from a total cost perspective, total cost of care perspective but it doesn't matter if it's not scaled. So, my goal is, can we get it to pay for itself on known revenue? That's a lot more of a sure thing. Enough that we can grow it and scale it. And then if we're successful there, the value-based piece will take care of itself. But I think starting from a different revenue model works better.

I just I think we'll see if those don't want to hear anything else.

Rebecca Grandy: 17:14

I know in the specialty pharmacy space has been sort of a hot topic for a while now and how you can save money and make money there. Alright Rob, so, thank you for all the insights and the great conversation that we've already had. So now I have some quick rapid-fire questions for you.

Rob Fields: 17:32

OK.

I'm ready. Yeah.

Rebecca Grandy: 17:36

Ready. OK.

The biggest buzzword in value-based care that you wish would just go away.

Rob Fields: 17:40

Well, it’s a phrase, but I think predictive analytics.

Rebecca Grandy: 17:44

Interesting. OK.

One book or resource that every leader should read.

Rob Fields: 17:52

I think the book “Drive” by Daniel Pink is a it's a good for leadership in general, but I think it's helpful for behavior change and knowing people a little better.

Rebecca Grandy: 18:05

Writing that one down. Thank you.

Hardest leadership lesson that you've learned in this space.

Rob Fields: 18:14

At the risk of repeating myself, but. The moral argument is almost never enough.

Rebecca Grandy: 18:24

Yeah, unfortunately, right.

Rob Fields: 18:25

Unfortunately.

Rebecca Grandy: 18:27

And then what keeps you optimistic?

Rob Fields: 18:30

I think what keeps me optimistic, maybe ironically, is that Healthcare is kind of a disaster at the moment. And I think a lot of health systems are looking at a, you know, I think cautious if not grim outlook on supply and demand and how they're going to sustain themselves over the next 20 years. And I think that creates a ton of opportunity to think differently than we have in the last 20 years. And in particular, in the areas of value-based care and population health, that's what keeps me optimistic is that there are only a few paths to solve the supply demand mismatch problems and the economic mismatch problems of the industry today. And I think value based care is one of them. And so I'm optimistic that folks will, besides pop health leaders, I'm optimistic that more folks will pay attention because they will have to.

And so I think in the midst of crisis, you know the what's that cliche like, never waste a good crisis, or however it goes, I’m sure I’m butchering it. But it it feels a little like that at the moment. So just I think keep focused and keep thinking creatively. Adapt your language, right, because it's all about behavior change. How you're gonna convince people? Listen to what the feedback is and adapt. I think there's a path.

Rebecca Grandy: 19:55

Yeah, for sure.

Value based care. You know, I truly believe value-based care and team-based care are the future of healthcare. I think the nitty gritty and the nuances of how we do it, there's a lot to be figured out there still.

Rob Fields: 20:07

A lot to be figured out. There's a ton of opportunity in technology that makes me optimistic too. You know, a lot ways, a lot of ways that we can engage an individual patient into behavior change that doesn't require a, you know, 1000 costly phone calls from staff and new ways to engage. That keeps me optimistic too. I think we have opportunities.

Rebecca Grandy: 20:29

Well, thank you so much for spending time with us today.

Rob Fields: 20:30

Yeah. Thanks for having me.

Rebecca Grandy: 20:32

Yeah, it's good to see you again.

Rob Fields: 20:33

Likewise, likewise in hope things in North Carolina are going smoothly.