The Future of Primary Care: Quality, Access, and Costs

00:01

Welcome, everyone, and thank you so much for joining us this afternoon. I'm Sheree Crute, Director of Communications at the National Institute for Healthcare Management Foundation, NIHCM. Today, we have an extraordinary panel of experts who will explore policies and practices that may improve and strengthen primary care in the United States. Research confirms that primary care saves lives and lowers healthcare costs, yet nearly a third of Americans struggle to find a provider, and that number is growing. Several issues, including provider shortages, ineffective payment models, and underinvestment are contributing to these problems, according to a new report published this month by the Milbank Memorial Fund. Our panel will discuss emerging strategies and solutions to address these issues in primary care, as well as methods for improving, as well as methods for improving care and health outcomes, quality, and lowering costs. Before I introduce them, I want to take a moment to thank NIHCM's President and CEO, Avik Roy, and the NIHCM team for all of their help today with today's event. You will also be able to find biographical information for today's speakers, today's agenda, and our speaker slides on our website and in your chat. And if you have the time, join us online in the webinar conversation on social media at #primarycare2025. After our speakers have completed their presentations, we will have a brief Q&A if time permits. Please submit your questions through the Q&A panel on your screen. Now, I would like to introduce our first panelist, Amol Navathe, MD, PhD. Dr. Navathe is a Professor of Medicine, Health Policy, and Healthcare Management and Economics at the Perelman School of Medicine at the Wharton School of the University of Pennsylvania. He also serves as Vice Chairman of the Medicare Payment Advisory Commission, MedPAC, advising Congress on Medicare policy. He is going to talk about the current state of primary care and the potential positive impact of hybrid payment models. Dr. Navathe, thank you so much for joining us.

02:31

Thank you so much, Sheree. It's wonderful to be here. Thank you so much for that very generous and kind introduction. It's wonderful to have been invited to join this panel. Thank you so much, Sheree, Cait, Avik, and the entire NIHCM team. So what we're here to discuss today is just fundamentally important, primary care, the intersection of primary care, and the future of big important questions in health care around things like value-based payment. These are foundational, they're fundamental, they're important. But as you all know, they're also particularly challenging. So why are we here talking about these today? So primary care is kind of the bedrock in some sense of access to the health care system. Oftentimes, particularly in a high-functioning system, it is the first access point to all of health care. Ideally, we don't have most patients steering around primary care to go straight to the emergency room to get primary care or present to hospitals. Yet in the US, primary care lags relative to other countries, and other developed countries, particularly from the perspective of primary care supply, as well as the share of spending that actually is going to primary care. So the US, for example, and particularly in the Medicare program, a federal government program, is somewhere around 4% to 5%. That's similar across other players as well in the US. In other developed countries, particularly those with high-functioning health systems, that tends to be double or maybe even triple that on a percentage basis. So what we do know is that health systems at the national front that actually seem to produce better outcomes at lower costs, tend to feature primary care in a much more foundational way. Now, let's also take this question of value-based payment. So value-based payment has been around for a long time now. Certainly, it got a shot in its arm over the course of the decade of the 2010s, where we saw a number of different experiments for Medicare and other payers. Some of those experiments started a little bit before that decade. Yet fundamentally, value-based payment has, I would say, made progress, but with some fits and starts. It's also worth taking a step back and saying, so why is it that we care about value-based payment? Why is it that with primary care, value-based payment might be helpful? Now, value-based payments probably as a payment paradigm have the greatest promise to align the system with patients in a patient-centered way. And so what do I mean by that? So if we think about how patients want to receive care, they want to receive care where it makes the most sense when it makes the most sense, and by the clinician who makes the most sense, right? So if I'm going to present for a new chronic condition, then I might actually want to go into the office and see a clinician who will examine me and help get me on the initial set of medications or the right diagnosis and the right tests and so forth.

05:46

But if I'm just titrating a medication, maybe I've been on blood pressure medication for a long time, and what I need to do is just figure out what that next dose is to get myself in control. Maybe I don't really need to go to the physician, and that's something that could happen over the phone or through a telehealth visit. Or maybe I don't even need to see my primary care doctor, I could see a pharmacist and see kind of in a team-based model of care. So in our private and transactional fee-for-service system, it's very hard to get those codes right. CMS has made laudable efforts, being the Medicare program, have taken some laudable efforts to try to improve our coding system, but it's very hard to get these tiny codes that oftentimes take more expense to bill than they do generate revenue in the front door. It's very hard to get that system right. And so the reason we're so excited about value-based payments is maybe this is the way to really get the system to function well, and also give the clinicians the right incentive to invest in the types of infrastructure that allow access and quality in the way that we want to get there. Now, that being said, I started out saying, we're dealing with these foundational, really important questions, but hey, guess what? They are challenging, right? So value-based payments also are particularly challenging because they require change. And let's be very transparent and honest about it. It is very hard to get the exact incentives right. On one hand, we want clinicians to be, perhaps to some extent, aware of the resources that they're using, and be cost-conscious to some extent. At the same time, we want to ensure that we have access to really high-quality care, and that access should be unfettered, right? We want people to be able to get where they need to get, and so that's challenging. Now, I will tell you, that as I reflect upon both the opportunities and the challenges, I am incredibly optimistic. And the reason I'm optimistic is bethathere's now been an advent over the past several years of these models that are hybrid in nature, that are balancing population-based payments with some fee-for-service transactional payments. AnThiss sitting on top of a chassis of what we know of a set of clinicians in primary care, both physicians and advanced practitioners, nurses and otherwise, who have a lot of intrinsic motivation to care for the patients correctly. We also have a lot of innovation and testing that's happened over the years. And so, we have now emerged a payment paradigm that probably strikes at least getting closer to striking the right balance between transactional access-type incentives and population management, population-based payment-type incentives. We have a number of different federal initiatives, such as the comprehensive primary care program, and the comprehensive Primary Care Plus program that were led by CMS. We also have private-payer models.

08:50

I've been very fortunate to be a part of an initiative with the Blue Cross Blue Shield of Hawaii, otherwise known as HMSA or Hawaii Medical Services Association, where in 2015, we redesigned their whole primary care payment system to move in this hybrid way. And guess what? They adopted telehealth. They started to change practice patterns well in advance of the pandemic. So, when the pandemic hit, they were much better positioned because they were paid in a population-based payment system. They actually didn't hit any financial shocks. They were sustainably financed. And so, we got this benefit, right? There's no financial risk in some sense to the practices. There's a stable income. There's a stable cash flow coming in, just like practices get used to in that fee-for-service way of cash coming in the door. But the payments weren't super dependent, kind of partially, but not super dependent on visits and procedures. And so, what we were able to generate as part of that model, and there's good indicators, leading indicators from the other federal programs, that we could actually get a more cost-effective and patient-centered practice paradigm. So, better performance and quality metrics, some indications of decreased emergency room visits, and hospital use, greater use of telehealth, and a shift, kind of in from an infrastructure and investment perspective, to get there, and also reductions in low-value care. And so, those are reasons that I think we should be optimistic. Those are what I might call the promises of primary care, particularly when financed through this hybrid primary care population-based as well as transactional payment paradigm. And I think there is some evidence here that this can be sustainable. It can also improve the joy of practice. It can reduce burnout. It can maybe make primary care a really attractive specialty to join again, where increasingly, stepping back at a national level, we see more medical students picking non-primary care specialties in an increasing trend as opposed to in the other way. Now, before I close, I do want to, again, kind of give an honest picture of what are some of the challenges here. So, I talked to the promises. What are some of the pitfalls here that we might be facing that we really have to get right? Numbers one, two, and three in the primary care space relate to administrative burden. Any time we think about having a model that is paying in a prospective fashion, we tend to think of this notion of risk adjustment, which is how can we appropriately compensate clinicians and practices for caring for sicker patients? Seems fundamentally important because we want them to be appropriately compensated. We don't want it to be unattractive to care for the sickest patients because those are the ones that need the most help. We also need to measure quality. We want to make sure that as we shift to any kind of pyramid paradigm, there's not an incentive to shark care or to shift care towards certain types and not other types.

11:57

And that is challenging because that requires clinicians and practices to do a lot of data entry and reporting. And even if we might be shifting them partially away from billing, there's still a lot of administrative burden. And that is a number one factor when we use surveys and ask clinicians what's leading to burnout, it's really heavily coming down to administrative burden. So that is a challenge that we have to get right. I think some of our upcoming speakers are gonna address aspects of how they've been able to make this work. But I wanted to just flag that right up front that that's a work in progress. Another piece that I would flag is that there are new technologies that are coming out. There are now ways to do retinal screens, for example, for diabetic retinopathy in the primary care office, obviating the need for an elderly patient, maybe who has difficulty getting around to then have to separately go to an optometrist or ophthalmologist to get that screening. How do we pay for new technology in a paradigm again that has a population-based component? That is not trivial. So another thing I just wanna flag, these are elements that it would be good to get people's feedback and we need to figure out how to make that work as we think about a sustainable primary care payment system going forward. Overall, as I close here, I would say there's a lot to be excited about. There's certainly a lot of challenges. Hopefully, we can address some of these core issues with primary care supply. I wouldn't wanna just call out, that I'm a primary care physician by training and practice, but a lot of times it is my nurse practitioner, and advanced practitioner colleagues who are really stepping up and meeting a lot of the primary care needs that we have, whether it's in urban areas or rural areas. And I think we need to think about how we partner together across disciplines also to meet the needs of our overall population. But overall, again, very optimistic and very excited to hear thoughts from my fellow co-panelists who will come subsequently. Thank you so much.

13:55

Thank you, Dr. Navathe, for helping us understand some of the opportunities to improve the system and for a perfect segue to talking about how providers might work together and our next speaker, who is Priscilla Wang, MD, MPH. Dr. Wang is a primary care physician at Massachusetts General Hospital and serves as associate medical director for primary care health equity at Mass General in the office of the chief medical officer. She currently leads Mass General Brigham's efforts to close clinical disparities along lines of race, ethnicity, and language. Her work broadly seeks to address structural inequities in health care, particularly with regard to the care of patients with complex health and social needs. Dr. Wang will offer some analysis and strategies from a provider's perspective. Dr. Wang.

14:52

Thank you so much for that introduction, and it is such a pleasure to be here today, even virtually with so many people who care about primary care. That is very exciting to me. My talk today is titled, maybe somewhat provocatively, Can Primary Care Be Saved? Redesigning Primary Care for Quality, Sustainability, and Meaning. Next slide, please. I have no disclosures. Next slide, please. And so for today, in the time that we have together, I'd like to take a moment to highlight three areas in which primary care is in crisis in the United States, and three dimensions of that. And then I want to spend the most of our time, the bulk of our time, in discussing solutions that go beyond those really critical and important big-picture items that Dr. Navathe just introduced that are so helpful for us. I do think I suspect that many of you on this webinar may be similar to me in that we don't have the immediate power to make changes to, say, the entire structure of the US healthcare system, or even the structure of financing, although I hope there are some of you on this call who can. But for those of us who don't have those levers in the immediate moment, what are things that we can do from our spheres of influence in primary care or touching primary care that are relevant to these dimensions of quality, sustainability, and meaning? Next slide, please. So I'm going to start by preaching to the choir because I suspect that many of you are very aware that we have a really, really difficult situation right now in the United States regarding primary care. Next slide, please. And I really don't think, you know, I think the word crisis media can come across as alarmist, but I really mean that's the word for me as a practicing primary care physician, who works deeply with many colleagues in this field. I think crisis is absolutely the right word. And I want to highlight though that it's not just us or those of you here on the call who are from the United States, who are experiencing this, but this is actually a global problem. You can see headlines here from Canada. There is an analysis here from 2023 about the state of primary care in Europe. So we are fortunately or unfortunately not alone in this global primary care crisis. Next slide. Thank you. And so one of the first issues which I'm sure we all feel acutely is access. So it goes without saying that we are increasingly experiencing really challenging issues with getting in to see primary care. Let alone having a primary care doctor. There's a wonderful report that was referenced at the start of this talk. If you have not read it, I highly recommend you look this up, called the Health of Primary Care Scorecard. Literally last week, the third iteration of this report just came out, and it highlights some of the challenges that our country faces. So one challenge is that graph that we can see on the left, which demonstrates that over time, the number of primary care physicians per capita, relative to the number of individuals we have in the US, is going down.

18:09

At the same time, the share of all PCPs or those in primary care, and that includes MPs and PAs in this number two, is staying flat at a time when need more as opposed to less or even the same. Next slide, please. And then not only do we have a pipeline problem, we have a departure problem as well. I think this is a staggering statistic if you look at the 2022 global primary care crisis report from the Commonwealth Fund, they demonstrate that in countries similar to the US, at least one in three, and that means more in many countries, more than one in three primary care physicians and young ones under the age of 55 reported that they were burned out. Consistently in the US, primary care is among the top, the most burned-out burned-routes, probably not surprising. And then also, concerningly, among those who are older or experienced primary care physicians or providers, 45%, almost half in this study, plan to leave primary care immediately in the next three years. Next slide, please. So on top of the access problem, though, the work of primary care is hard and has only become more complex since the pandemic. This study that I referenced here at the bottom, this graph, basically shows that since the pandemic, the volume of messages went up, time spent in the electronic medical record went up, and it did not come down, even when COVID numbers came down. Next slide, please. And then on top of all those problems I raised, unfortunately, our primary care system is not doing such a great job in terms of delivering the quality and equitable health outcomes that we want for all of our patients. So in this 2024 report from the Kaiser Family Foundation, we can see the US is in green here, and we can see that unfortunately in the US, we have higher rates of premature death, so preventable death, and then in bread and butter conditions for primary care, like heart failure and diabetes, we have higher rates of hospital admissions as well. Next slide, please. And so with all that in mind, what are solutions that we can think about? Honestly, I sometimes get very depressed when I see these stats over and over because remember when I was a pre-med student in college, seeing basically the same stats, just different dates, and the same solutions proposed for, we need more money in primary care, we need to invest, that can feel incredibly discouraging. Next slide, please. But what I wanna pivot to today is to highlight that I do think there's actually a lot of work to be done that we all can be engaged in. And what I'm gonna argue first is that our solutions are not just supply, so yes, I would love to see an influx of providers in primary care, but that doesn't change the complexity of the work. Secondly, we critically need funding, new financing structures, and reimbursement structures, and yes, that's critically important, but we also need to think about the redesign and not just the funding piece.

21:14

And thirdly, technology, well, if there are any of my fellow PCPs on the call, I'm sure we can be the first to attest that sometimes technology can be part of the problem. And so my argument is actually, there's a lot of work to be done about the actual work of primary care, what we do every day, what our teams do every day, to take care of patients. And there's work to be done to think about that through the lens of quality, sustainability, and meaning. Next slide, please. And so the corollary assertion I'm going to make is that part of this problem, part of the reason I think that we have as a broader system not really coalesced around these areas is that I think we have not really explicitly mapped out what I'm calling continuums of care, and to do this in a way that's more routine and not just something that's done in the payer level or in certain systems. And this begins with the idea that when we say we want to give quality healthcare to patients and we want individuals to have high-quality outcomes, really the quality of care that someone needs depends on who they are and also where they are at a moment in time. So I'm going to share two of my patients here just to help illustrate part of this point. One is, I will call him Lenny, who I learned so much from. This is a gentleman who was struggling with high medical and high social complexity. So he's in the ED frequently, gets fluid-overloaded from heart failure, and almost has a heart attack. Unfortunately, he had to get an amputation for some of his toes. But on top of that, he had a lot of social challenges where he had no one in his life to help him. And he had on top of that an aphasia condition that makes it hard to speak. We could not communicate with him over the phone and he didn't know how to use our patient portal. But we had to use email, which you can imagine was less than ideal. In contrast, Nancy was a much younger patient who had many challenges related to social drivers of health, but actually from the medical standpoint was not that complex. So the needs of Lenny and Nancy were critically different. And it will be also different from the needs of someone with lower medical and social complexity, for instance. Next slide, please. And so I wanna share five brief points for us to consider. And so the first argument I'll make is that I think we need to collectively rethink and map this continuum. What care do we provide to whom and by whom and along three axes? So one is medical social complexity and those individually are different. The second is the length of intervention, the length of time that someone needs this intervention. Do they just need a phone call to get them back to primary care? Or are they like Lenny, is he gonna need probably years of support with a care manager? Thirdly is the site of care. So it's from the clinic to the community. And you can think about these continuums in holistic ways. You're thinking about patients holistically, you can think about it by condition, for example, a hypertension continuum of care. There are a lot of ways to do this.

24:15

And if you're interested in this idea, I'll direct you to our paper reframing value-based care management in JAMA. Next slide, please. Secondly, though, you know, we define the continuum, but I think we also need to define the baseline, the standard of care. You know, I think we have, you know, maybe in your region, if you have 200 hospitals, 200 clinics, I don't think we need 200 different hypertension management protocols, for example, or 200 different ways to follow up on thyroid nodules. I think there's a lot that we can do at the local and also the national societal level to better define really what are, what's the baseline of care everyone on the continuum should get. And all of those things, I think I saw a question in the chat about automation and AI, those things that are baseline and standard, there's real potential to automate those things, the decreased cognitive load. I would also say on the social side though, incredibly exciting, huge momentum in our country in the last five years to push systems to screen for social drivers of health. But I think those of you who work in direct care can attest, that this can be distressing if we are asking patients these things, getting these answers, you know, distressing for patients or distressing for staff, we don't do anything that causes what we call moral injury. And so what I would argue is that we need to pre-solve for these things. Yes, you know, primary care cannot fix all the ills of society, nor should we be expected to. But if you're going to ask about five domains, for instance, food insecurity or transportation access, housing, for instance, if you're going to ask it, let's make sure that for every domain we're going to get answers, we have determined a baseline standard of response. Maybe all we can do realistically is direct someone to your local county housing office or give them a tip sheet with a link to a food pantry. Maybe you have a community health worker that in certain cases, like domestic violence or intimate partner violence could meet with your patient, you know, directly, but let's pre-solve for those things that our providers and staff are not reinventing the wheel in really stressful and even distressing ways over and over. Next slide, please. Thirdly, going back to the continuum, let's map what we have to the continuum and use that to help us identify where we might be missing gaps, where we might be missing programming, and where we don't have a realistic or robust response. And so one example is, you know, here in my system, Mass General Brigham, one of our most popular programs was created more than a decade ago when our system recognized that we were systematically failing a particular group of patients, patients like Lenny with high medical, high social complexity and staff were overwhelmed, patients were suffering bad health outcomes or going to the ED frequently,

27:06

they were getting high co-pays and then also from a payment and a value-based care perspective, a lot of costs were being incurred. And so our program, the Integrated Care Management Program was created to basically help address this need and it embedded care coordinators, and care managers directly in primary care offices and then also used multidisciplinary roles. So for example, if a patient has substance use disorder or behavioral health needs, a social worker might head that team as care manager. If there's someone with social needs, it might be a community health worker, someone with more medical needs, it might be an RN, or another nurse role. And so this program has been well received and I think also has helped alleviate some of that, that horrible stress that you get in primary care when there are these frequent crises that you don't have the resources to address. Next slide, please. Fourthly, as Dr. Navathe referenced, we do, I think, have to be very practical. We have to think about sustainability and often that means financial sustainability as well. So yes, though most of us probably can't change how CMS or other payers reimburse for primary care. But what we can do, I think on our side, is think beyond the fee for service or routine reimbursement for primary care visits and look into reimbursement models for other role groups. So, nurses, clinical pharmacists who can prescribe diabetes medications, community health workers, and care management or chronic care management that now Medicare and Medicaid are seeking to reimburse. And let's maximize those opportunities and let's also align with value-based care. So when I got into the value-based care space, it was new to me. But I encourage those of you who are in systems to get to meet those folks who are doing the value-based care contracting because you may find that in those contracts, which are payment models that are negotiated with payers, you may find that you have common ground. Maybe some metrics could bring the system a lot of money that are directly related to primary care. Maybe some of that money could come back to primary care and be another means of it. Next slide, please. And finally, you know, and I want to be the first to admit, you know, coming from my system, we are actively struggling, you know, we're grappling with these challenges. So I do not want to come across as, you know, having that we've solved it all. We have not. But one thing I do want to put out as we close is that I strongly believe the cure cannot be worse than the disease. And I am wary of some of the consultant models or things that we've seen being proposed that seem to treat a patient like a collection of body parts. You know, the idea that somehow if someone becomes too complex or they develop, you know, heart failure, diabetes, and they need to go to a special, you know, heart failure clinic and have a heart failure PCP or provider.

29:51

I do believe strongly in continuums of care, but I also believe strongly that we have to be very careful that what we develop does not treat patients and providers like widgets or like parts of a whole. And so I'd encourage us, let's actively, proactively, not only try to solve problems, but let's try to design primary care to promote and protect what it means to be human and have these human and wonderful and funny and sometimes absurd and hard and sad, but also very joyful relationships in care and also what brings joy to our providers to work as well. Next slide, please. And so one more slide. Thanks. And so just quickly with five points and five takeaway points, map the continuum, define baselines of care, standardize and automate, identify gaps and build models to address this, identify opportunities for financial sustainability, and let's actively work to promote what makes primary care meaningful, joyful and dignified for all parties. Next slide, please. So that concludes my presentation. Thank you very much. And I look forward to hearing what the next speakers have to share.

30:59

Thank you so much, Dr. Wang. Sorry, I'm having a little trouble with my camera here for such a powerful presentation on the complexities of primary care and the challenges that are faced and met every day by providers. Our final speakers are Doctors Romilla Batra and Mia Wise. Romilla Batra, MD, is the Chief Medical Officer at Premera Blue Cross. She has accountability for the company's clinical strategy, focused on making healthcare work better for Premera members and improving the provider experience. She has oversight of teams focused on population health, quality, healthcare, performance, clinical programs, utilization management, and medical policy. Mia Wise, DO, is the Chief Medical Officer at Kenwell Medical Group. Dr. Wise is responsible for clinical programs, care management, and population health strategies, as well as strategic partnerships across the network and business operations. Most recently, Dr. Wise was a Medical Director with Premera's Healthcare Services, working with valued providers to improve healthcare. Together, Doctors Batra and Wise are going to share today the insights and solutions to improving primary care that are the result of a very successful Premera-Kenwell partnership. Doctors Batra and Wise?

32:27

Thanks, Sheree. I'll go ahead and kick it off first. First of all, amazing speakers so far. We heard and learned so much about what kind of changes need to happen in primary care and how to organize primary care to deliver the best for patients. Let me start by introducing you to the Premera Health Plan. It's a Washington-based health plan, so a regional not-for-profit organization that serves about 2.8 million members, multiple employees, and has been around the block for 90-plus years. So one and more times, just giving a little context of who we are at Premera Blue Cross. Let's go to the next slide. When we think about healthcare and we passionately believe in our vision, which is to make healthcare work better for our members, our clinical care strategy is grounded in the quintuple aim. I know all of us have progressed from triple aim to quadruple to quintuple. So we are truly looking at across the healthcare ecosystem and how do we improve clinical outcomes? How do we improve member experience? How do we reduce costs and make costs of care affordable for our members? In case you haven't paid attention, medical bankruptcy is the number one reason for bankruptcy in our country. How do we do it equitably? Because we understand populations that have different needs. And how do we practice alongside our providers, work alongside our providers to bring joy back in medicine, or bring joy back in healthcare for our provider systems? So when we think about this quintuple aim as a pair, as a regional not-for-profit pair, we believe that there is not one lever, one silver bullet. You heard from Amol, you heard from Priscilla about what other systems are doing. You heard what can be done in value-based care. So we look at the continuum of our providers and see where they are and how we can build capacity within a system for primary care. How can we build incentives in primary care so that primary care physicians can do and work and practice at the highest possible license? So to Dr. Wang's point, how can we pay for, let's say patient-centered medical home kind of concept? How can we pay for quality outcomes like readmissions? How do we pay for quality outcomes like screenings? So that there are dollars in the system that primary care providers can then invest in having that community health worker, having that behavioral health worker within the system. The second thing I would say is we also see ourselves playing a very strong role alongside our local regulators in proposing and advocating for primary care. And so with that in mind, we are participating with the local healthcare authority and multi-pair collaborative. How can pairs like us come together and not create seven different systems that add administrative burden to our primary care physicians but perhaps learn and adopt from models that are there from CMS like making care primary models and kind of paying for similar kinds of incentives to kind of build that infrastructure within primary care.

35:33

The third thing I would say is community investments. We don't live in silos. All of us know that social drivers of health play a big role in terms of what outcomes you will have. And it is our role as a local not-for-profit plan to build capacity within our community and to build a system within our communities. And so with that in mind, we have invested in the rural nursing health initiative. So folks who are trained nurses can stay within their communities. A lot of them are rural communities and can provide that care and that extension that we spoke about in the team-based model. Behavioral health also is a rising risk and has a bigger footprint and prevalence in our community. And so one more time, how do we support our primary care physician who perhaps wants to work at the top of their license? But there is dirt upon our psychiatrist and so has that struggle. And so collaborative care model is an evidence-based model that came out of the University of Washington. And so we have funded programs whereby primary care clinics can adopt this model, which gives them that extra resource to be able to manage depression, and anxiety, and integrate behavioral health with the physical health within their clinic. So community investments. Benefit designs, I'm a primary care physician. I'm completely biased, but I also know there's evidence that for every dollar you spend on primary care, there's $3 of return on investment on your cost and your value. So how do we make the right thing to do also, the cost-effective thing to do? So introducing $0 co-pays for our members so they can never have a barrier. A cost is not a barrier for them to see a primary care physician. Offering benefits like virtual care when you're working, when you're busy. How do we connect you to virtual care? And Mia is gonna talk about how Kinwell does that. Those are other benefit design ideas as we think about how we make people see primary care physicians a little bit more. In terms of population health, we believe in the power of integrating medical health alongside the physical, alongside the physical mental health, and physical health together. And so how do we reward those kinds of things? How do we fund those kinds of things? How do we create those models? That also remains core to us. Last but not least, building access is a very big thing. Accessing primary care physicians in our markets, I'm sure across the country, across many nations is super hard. As a not-for-profit organizational leader, we looked at it in our state of Washington and said, what can we do differently? Not only can we support them through incentives and working with the regulators and community investment, but we need to play a lead role here. And so with that in mind, a few years back, Premera Blue Cross decided to invest in starting its primary care access through Kinwell Clinics, which Dr. Wise is gonna talk about in a minute, to provide care, primary care in the community that's high-quality care within a drivable distance for some of our major communities, especially with a focus on some of our rural areas.

38:34

Next slide, please. I think the big thing we have also heard today is around not only do we have to have these models, but how do we take the administrative burdens away, how do we create a system and what role can a pair play? We feel like as a pair, we can play a big role in helping our primary care be able to deliver access, be able to have longer appointment times with care teams, how many times have we heard that the appointments are too short, and be able to offer virtual in-person visits and be able to incentivize the right thing. And that's where the Kinwell partnership plays a big role. So when we think about the system of Kinwell, a primary care medical group that has multiple clinics across the state of Washington, and Premeraa as a not-for-profit pair, that's where we see the two of us, the two of the organizations coming together, sharing that data seamlessly, identifying for problems like access, like mental health, and together coming up with solutions. On the pair end, we can design incentives. On the pair end, we also have actionable data, which a lot of primary care providers perhaps cannot have, and that's where this partnership becomes really real. Let's go to the next slide, please. So with that in mind and with the fact that primary care is not an individual sport, it's a team sport. We heard that from Dr. Wang. We'll hear that in a minute from Dr. Wise. We believe when we look within our data in order for us to deliver high-quality care with improved outcomes, with a focus on populations at large, we really need to have a system that looks at it and also does the right thing with the data that's available to them. And you can see all the different things that are being outlined here on whole-person care, right access at the right time, physicians, clinicians practicing at the top of their license, and actually having an embedded model with case managers working alongside the primary care physician groups in this particular model. Let's go to the next one. And so with that in mind, we have a joint partnership, and I would say I'm gonna pass it on to Dr. Wise, who will tell us how we are integrating and how we are creating this care model of the future alongside peer partners.

40:53

Thanks, Romilla. I might just take us back to slide three, if that's OK, Mikayla. And I'll just talk a little bit more deeply about some of the things that Dr. Batra shared. And I'll ask the team to keep in mind, we are, as Romilla was saying, a young endeavor for both of our organizations and a huge shift. So while we are young and learning and growing, I'll just speak to the fact that it's been a huge change management piece of work for both of our organizations. And it's a great endeavor. It's really exciting, but wow, there's been a lot of change for both of our organizations over the last few years. And it's a unique opportunity that we have in our partnership. The primary care team, it's really multiple systems running simultaneously, as both Dr. Navath and Wang have alluded to in their discussions. It's multiple service lines happening all at once around a patient's need, whether it's preventative care, population health, education, timely access to acute care, and robust team care for chronic condition management. These complex requirements are uniquely supported by the investment and by the shared goals of our organizations, by the health plan and the medical group. This alignment actually allows us to step off of the fee-by-for-service treadmill and move towards focusing on the shared outcomes and experience instead of focusing on transactions. So the essentials of our primary care model that you see on the slide here include time to connect with patient, bringing back some of the joy that we heard some of the other clinicians speak to today, bringing back some of the joy, hopefully being an antidote to some of the burnout that we've seen so much over the last few years, addressing patients' challenges holistically, really getting to a root cause, compensating clinicians for outcomes instead of RVUs, and encouraging clinicians than to stay curious in problem-solving for their patients and really develop their craft, get back to the why they went to medical school in the first place, and that idea of keeping more care in primary care. As chief medical officer, part of my work is to bring in the resources, whether that's a person, a program, or a consultant, to help us get smarter, right? How do we invest and try to stay ahead constantly into this, leaning into this top of license work? This is an environment that is truly supported by the top-of-licensee health plan. And it's a reflection of our dedication to the communities that we serve. And it's where capable, hardworking clinicians thrive. And like I said, I hope it's an antidote of sorts to the burnout that we've seen across the primary care systems. Next slide, please. So you all have probably heard the term advanced primary care. It takes on many different shapes and forms. The elements that are essential to our model that you see here include access, whole person team-based care, and an integrated data exchange system. So whole-person access first. Our origin story is actually all about access.

44:06

Our first doors opened specifically in order to solve some of the long wait times in primary care. Patients were waiting six to nine months as a new patient to get into primary care. You can imagine all of the transactions and fractures that happen to our patients who end up in urgent care or in emergency rooms. The second thing I'll call out is that Kinwell is distinct from other medical groups who dedicate access to a health plan partner because we don't require a specific plan or a specific product to have access to our clinics and our clinicians. So while this does bring with it some administrative challenges, we wanted the doors to be as wide open as possible to our clinics while staying aligned with our partner. And then we decided to build our first clinics in Eastern Washington and Central Washington. It's a part of the state that's been most impacted by consolidation in the market and with close proximity to the most rural parts of our state. And then we have a statewide virtual clinic. So this has two different purposes in our medical group. First, I'll point out that it's not a vendor or a white-label solution. They are colleagues and they're part of our integrated system. Patients can come to see a virtualist to be their PCP if they request or prefer for some reason, a virtual front door for their primary care home. And then we also use the statewide virtual care for access and overflow needs when a patient can't be seen by their PCP at home in their brick-and-mortar. The idea again, around all of these access strategies is really trying to meet the patient where the needs are highest and to remove some of the high-risk fractures where patients can fall into and lose traction in our ecosystem. And then the whole person care, chronic diseases, as Dr. Wang was saying, they're just not well addressed by just seeing one clinician every three to four months. It's a terrible way to manage things like diabetes and congestive heart failure, habits and changes, whether that's to a medication or a lifestyle, they're built over time, they're incremental. And so we invest and build in teams that help support that reality. We have complex care nurses who move forward care in between visits with the PCP, and behavioral health clinicians help address some of the psychosocial elements of these chronic conditions. Our shared medical appointments take patients through lifestyle medicine, as well as getting them some peer support. And then we leverage the pharmacy resources and care managers from our health plan partners as well. And then equally as important as how this care happens inside of Kinwell is how we take care of our patients when they need something outside of Kinwell. So we invest in referral coordinators and care advocates that help with health plan navigation.

47:06

And then most importantly, bring the patients back to us and back to the PCP home. And then data. The health plan is a wealth of data. It is their currency in many, many ways. And our electronic medical record really, first for the clinicians and the clinic teams, we wanna make sure that our EMR is as robust as possible. How do we stay connected with each other and with other regional care providers where our patients might be experiencing care? But the health plan data helps us really remove some of the blind spots that a medical group of our size would typically have, right? So population health data, pharmacy adherence data, rising risk analytics, values, and specialty care. This helps us understand our patients more holistically, the total cost of care, and emergency room utilization. Understanding our patients better, again, helps us build the teams and the resources that we need to deliver outcomes and experience. And to support the clinician teams who are at the front lines. Next slide. So in addition to the team-based, advanced primary care ethos, we also have an integrated model, primary care behavioral health. This specific model has medical clinicians working side by side with behavioral health clinicians. And there are a lot of benefits, not only for the patients but for the clinicians. They have clinicians who help them understand their patients through a different lens, allowing patients to hear from different clinical voices in service of moving or understanding a care plan forward. Sometimes this means there's a warm handoff, right? From a medical clinician to a behavioral health clinician. And sometimes it's a curbside between two clinicians trying to understand a patient better. Clinicians of different backgrounds, and different education, bring something different to the table and that helps really curate the voices and the tools that we bring to understanding our patients. The integrated model also allows us to remove barriers like access and stigma around receiving or looking for behavioral health because it's all now part of the patient's primary care home. We also have offered coping skill classes. These are things for more discrete topics like stress or work, stress at work, or grief. And then last year we started offering shared medical appointments. This is where a group of patients facing common challenges like diabetes or high blood pressure can learn from each other alongside a clinician and a lifestyle medicine coach, providing access to these different types of care. It's a big part of our model and it reflects the fact that we can build this environment with a partner who shares our goals and our values of experience and outcomes. And with that, next slide, Romel, I think this is yours to speak to.

50:15

Thanks, Mia. As you can see, the proof is always in the pudding. When you go into relationships like that, you're always looking at whether you are really meeting the two points that you set for yourself. And for us, it's around the quintuple aim. And it always starts with the member in the middle of rr4all our patients for Dr. Wise. When we look at our partnership with Kinwell, when we look at the members, Premera members, and the patients who are going to these clinics, you can see their net promoter score, which is the industry benchmark, is 85 versus 35 to 40. So people are not only going to the clinic and getting the access they need and services they need, they're actually really enjoying that experience. And there are multiple studies that have shown that when you have a good experience when you have a frustrated relationship, you're more likely to have an improvement in your chronic condition. So waiting to hear that as well. When we look at growth, as you look at the kind of models that we have built-in Kinwell, there has been 67% year-over-year patient growth. It's not only word of mouth, people are telling their friends and families and people are hearing about this one-stop shop where they can not only see a physician, but they can also learn about how to eat the right diet, have a mental health provider be right there, helping them in their journey and getting better. And as a pair being completely neutral and taking a step back and looking and comparing our total cost of care, what we have seen over the past year or so is it's 15% back in the market. What I mean by cost of care, is we all know the cost of care is related to not only utilization, like fewer year visits, fewer admissions, and fewer readmissions, which are wasteful and not value-add for our members, but also the right medications being prescribed at the right time. People are able to access urgently needed care or get a hold of their physician or their primary care team instead of showing up at the ER. We then took the specific quality measures because one more time you need to benchmark these kinds of endeavors alongside other physician groups within the same system. Consistently, Kinwell is outperforming on HEDIS measures around high blood pressure control, diabetes management, and antidepressant medication management, which is super hard, pre and postnatal care. And I would say most of the metrics that we are getting measured from a HEDIS performance perspective. So not only is it the right thing to do and not the member experience add, it is also the most cost-effective and business excellent thing to do. So one more time while it's not an easy endeavor for anyone to pull off, but to have those kinds of partnerships to be able to work together, to be able to see the same data together, create priorities together, be able to have referrals.

53:06

So when some of these folks show up in the ER, our case managers who are now embedded in primary care clinics at Kinwell are working alongside a Kinwell primary care physician, building and bringing to the forefront that team-based model that then prevents the next admission or the readmissions, make sure a patient has access to it. And since these case managers are trained in the benefits that a pair offers, more able to speak to those benefits as well. So one more time, it's an example of a great private pair provider relationship, which is creating value, not only I would say for our members in terms of cost and outcomes, but it's also creating value and bringing joy of medicine and back in healthcare for those providers that are working in Kinwell practice. And I believe that is our last slide.

53:56

Thank you, Drs. Batra and Wise. We have just a few seconds left, a few minutes left for some very quick questions. I would like all the panelists to please come back on screen. We've had many, many questions submitted, so I'm going to try to sort through. Dr. Novath, I would like to ask you the first question as you were our first speaker. What do you think are the most important adjustments that can be made to either the Medicare Shared Savings Program or Accountable Care Organization demonstrations that will fortify the nation's primary care infrastructure going forward?

54:33

Yeah, thanks for that very foundational question. So, you know, the Medicare Shared Savings Program has been one of the chassis of population-based payment type programs for Medicare. And as a linchpin program, I think other commercial payers have been able to build off of it. One of the challenges it has faced is while a lot of the care is provided at the primary care level in aggregate because it's a total medical expenditure model, a lot of the dollars are actually happening outside of primary care. And so, to some extent, that's created a challenge for ACO organizations and how they manage the model and manage the clinicians and the participants. More recently, as part of the ACO REACH program, and I think with some flexibility to extend to ACO programs, there was a program called ACO Primary Care Flex that was announced. That allows for a population-based primary care payment, so on a per beneficiary, per patient, per month basis, a payment to go to the ACOs. And those dollars are routed specifically to primary care. In fact, when we looked at the numbers, it was kind of an unprecedented amount of primary care investment that was being made, much larger than some of the programs that I mentioned as part of my talk, and then the other speakers also referenced comprehensive primary care, making primary care first, other CMS programs. And ACO PC Flex actually has a greater dollar number, basically, a dollar figure from a primary care investment perspective. So, I think there are ways in which these programs can really support primary care through financial elements as well as through programmatic design. And the last thing that I'll say is that they have largely been the testing grounds. What I think our aspiration is, is that those foundational pieces, like population-based primary care payment, hopefully can actually extend beyond just the innovation center-type demonstration projects to be something that disseminates across the Medicare program. And I think that's important because as Medicare is, in some sense, the largest payer nationwide, it allows commercial payers and other entities to then kind of piggyback on that momentum. And that makes it easier for primary care groups to actually participate in these models because it makes the alphabet soup of different, different things a little bit simpler. So, hopefully, we'll see some of that progress going forward.

57:30

We have just a couple of minutes, but in that vein, Dr. Wang, we had a question for you. What do you think might be the impact of some of the new federal administration policies on primary care, especially in terms of risk to insurance, the ACA, health equity, and other issues? I think that's probably on everyone's mind right now.

57:50

Yeah, I think we all have reason to be concerned. I think it's also a call to action for all of us here. You know, there's so much great work to be done in the redesign of primary care, but we can't do that if we don't have a functional health system. And for us to have a functional health system, that means that individuals have to be able to participate in health care in a way that's affordable, first of all, and accessible. And so I do think some of the things that we are seeing, just even beyond the specifics of primary care, so threats to Medicaid, for instance, threats to health care coverage, threats to the quality of health care if the Affordable Care Act is rolled back, threats to food and nutrition if SNAP is cut deeply. These all, you know, for us in primary care, we are the first line, and along with emergency rooms, often the last line. And with the current federal cuts, if any of you are from community health centers, you may be well aware that some community health centers were directly impacted by the freezing or the withholding of federal funds. So, unfortunately, I think there's a cause for concern. And I would say putting on my legislative advocacy hats, and my prior background, I would say we have huge power as the medical community. You know, I would hear from legislators, you'd be shocked how much the voice of someone working in health care, a few anecdotes can sometimes go a lot further than, you know, a page of statistics. So I would say I think we have great responsibility right now to help translate the impact of some of these policies into anecdotes, stories, and the human impact of what we're seeing in primary care. So I'd encourage everyone on this call, to find out who your legislator is. When you see things, don't be silent. Align with other advocacy organizations and get the word out there that I always say it's not about politics. It's about good policies and what's best for people. And I think we can all agree health is critical for people and primary care is critical for health. So I hope that all of us can work together on that even as the headwinds may be strong. Thank you.

59:49

Thank you, Dr. Wang. I think that is a great note for us to end on. Unfortunately, we are out of time today. I want to say a huge thank you to all of our panelists for helping us identify solutions and strategies for an improved landscape for primary care. And thank you to our audience members for sharing your afternoon with us. To our audience, your feedback is very important to us. So please take a moment to complete the brief survey that will pop up on your screen. It will also be shared in a follow-up window. Again, everybody have a great afternoon, and thank you for your time. Bye-bye.