Primary care is the foundation of a strong healthcare system, but it faces mounting challenges, from workforce shortages to reimbursement struggles.
Is advanced primary care the solution and what would that model look like?
In this episode of CareTalk, David E. Williams and John Driscoll sit down with Kate Goodrich, Chief Medical Officer of Humana, to explore the critical role of primary care and how it must evolve to meet the growing demands of patients, providers, and the healthcare system as a whole.
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Episode Transcript:
David E. Williams: Primary care is the cornerstone of a healthy healthcare system, yet it faces mounting challenges from workforce shortages to reimbursement struggles. What would an advanced primary care model look like and how could it work for patients?
Hi, everyone. I'm David Williams, president of Health Business Group. And I'm John Driscoll, chairman of Waystar. Today's guest, Dr. Kate Goodrich is chief medical officer of Humana and a strong proponent of primary care. But before we talk about primary care, let's talk about the month of December. Well, some people think that wrapping up in a blanket with a mug of hot chocolate or watching a movie with the family is the best way to spend the last month of the year.
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Make it a great season with BetterHelp. Visit BetterHelp. com slash CareTalk to get 10 percent off your first month. That's BetterHelp, H E L P dot com slash CareTalk. Dr. Goodrich, welcome to CareTalk. Thank you for having me. You know, you missed the part where I put John on the toboggan and send him down.
Whee!
John Driscoll: Oh, I was going to send, yeah, I was, I was going to build on that one. You got me there, you got there first.
David E. Williams: Yeah, well, okay. We're going to talk about primary care, John, not orthopedic care, so.
John Driscoll: Depends on where your tobogganing day. Yeah. Most of us actually look where we're going. Okay.
David E. Williams: All right, John, primary care, you care about that.
John Driscoll: I guess, I guess, Kate, what's exciting about Humana is you probably made the biggest investment in both building primary care as well as providing the infrastructures of the data so that the docs actually know what they're managing, but maybe you could talk a little bit about the advantages of primary care and particularly what Humana is doing to make kind of turn, turn primary care and that integration of data into care into sort of a, a superpower in the Medicare Advantage program.
And then obviously for the, the, the talk to us a little bit about the population you serve.
Kate Goodrich: Be very glad to do both. I'll start actually with the population, you know, at Humana, we've really leaned all in into Medicare Advantage. So that is the majority of our business. We also, I do want to say, have a growing Medicaid business and of course, we are one of the Tricare contractors.
So the military is very important. So we really focus on the actual business Government funded businesses, but we have you know, a little over 5M Medicare Advantage members and you're right. We are all in not just on primary care, but on what I call value-based primary care. So, really aligning the.
Financial incentives for the clinicians who provide the care with better, you know, health outcomes in a very meaningful on intensive kind of way. There's all kinds of evidence that primary care is good. And more of it is even better that we didn't have to go out and generate that evidence that's out there.
The problem is that our primary care system in this country is broken less than 5 percent of the health care dollar. For goes towards primary care, which I think maybe
John Driscoll: it may be Kate, sorry to interrupt, but maybe just describe what you mean by primary care for those of us who aren't, you know, healthcare wonks, like David, who use all kinds of phrases that no one can understand.
If you could just maybe start with how you think about what primary care means and then what the, and how the patient. And then, and then get into value-based, because I think it's, it all comes
Kate Goodrich: together. Well, primary care, really, at its simplest, is your family doctor, clinician, right, that you go to for you know, vaccinations and preventive care.
We tend to focus on seniors, and so we think about it as preventive care. First and foremost, but also really good management of chronic diseases like high blood pressure, diabetes asthma. Those are all things that primary care doctors do day in and day out. Importantly, they also get to know you as a person and incorporate.
the aspects of your sort of social environment into your, medical care, because we know that 80 percent of health outcomes are actually influenced by non-medical factors. So where you live, what your diet is, do you exercise, those kinds of things. So that's basic primary care.
David E. Williams: So why is primary care struggling?
If it's so important, it sounds good. And why is it only getting a nickel?
Kate Goodrich: Well, that's because the payment system is fundamentally broken for primary care in this country. I hate to say it Just does not invest it in primary care in the way that many other countries do Some states are doing better at that than others, but in general that is true Primary care is not reimbursed very well.
So our country values in a dollar sense primary care less than It's a long complex history behind that, but I won't go into, but at the end of the day, that's really the main problem. And so what you see is fewer and fewer medical school graduates and residency graduates going into primary care in And more and more specialization in fields that are better reimbursed.
But the primary care need hasn't gone down population grows. And so we need more primary care. And as I said, the evidence shows, especially for seniors, the more primary care you get. The fewer complications you have, the better your health outcomes and so as you see that workforce declining, but the need increasing you, what's happening is those who are still in the primary care workforce have way too many patients and so, and because they're reimbursed on a fee per service system, meaning they get paid every time they see a patient.
By the health insurer, whether it's Medicare or Humana or whoever they have to see more and more patients in order to make ends meet. What does that mean? Shorter and shorter appointment times with less time to be able to get to know your patient and meet all of
John Driscoll: their needs. I mean, just to, just so you can contextualize that, Kate, describe how much time the average primaries take.
Care doctor spends doing the overview of the updates with their with their patients. I mean, what is it like five to seven minutes?
Kate Goodrich: In some places it is that short. That is not an uncommon scenario. Probably what we see mostly is about a 10 minute visit And you know for an initial visit when you're first meeting the primary care doctor, they might Allow for a little more time, maybe 15 20 sometimes 30 minutes But in general, they're really short and think about a senior who has multiple chronic conditions is dealing with functional decline.
Maybe cognitive decline has a family member with them, accompanying them to the appointment. They need more time, and they don't get that time in our in our primary care system for the most part.
David E. Williams: You know, John was coming up with David, you're gonna need a lot of time. Well, John was coming up to the five to seven minutes, because actually his doctor only wants to see him for half the amount of time as the usual one.
My doctor doesn't want to see me at all. But let's talk about this workforce issue, because there's a couple things that have happened. You know, one is you're seeing fewer primary care doctors, and then they have more patients.
John Driscoll: But David, what do you mean by workforce? You guys got to explain it
David E. Williams: All right. They work. Yeah, exactly. Okay. I'm talking about the people doing the job. So what's one of the things that's happened with primary care and this happened with my primary care physician. I know with a lot of others, they went to concierge practice, which meant that rather than having 3000 patients take, they put it down to 300, which meant that all the patients, including me who didn't go with them are now dumped on, you know, on the existing people that are taking regular primary care.
You hinted at something before where we said physician, but then you're talking about. more broadly providers. So I'm talking about when I say workforce, I'm talking about doctors, but I'm also interested in your view on nurse practitioners, physician assistants, you know, any others that may be playing a role.
Kate Goodrich: Absolutely. So we think of primary care physicians as being mostly family practice doctors or internal medicine doctors or pediatricians, obviously, in the case of children. Those are primary care doctors. Increasingly, we're seeing more and more advanced nurse practitioners. So these are nurses who have advanced degrees and have more training and can be more independent in taking care of patients and also physician assistants who are who also have.
Not less training than positions, but have regular schooling. And then they have really what I think of as on-the-job training and what we, what I'm actually a big advocate of expanding the workforce for primary care to advance nurse practitioners and position assistance. And both in particular are.
Supervised by physicians and review some of their more complex cases with positions and there's state licensure requirements and everything, but it has been a way to expand the primary care workforce. And, you know, I used to think a lot about quality when I was back at CMS, I worked for Medicare for a long time.
And we know from our data that nurse practitioners and PAs can provide very, very good quality care, just as good as physicians in many instances. A more complex patient might really need a physician to be their primary care practitioner, but many, many patients do very well with nurse practitioners and PAs.
In fact, I've been seeing a nurse practitioner myself for many, many years, and I feel like I've gotten really great care.
John Driscoll: Kate, the, the, the thing that I remember early on, in, in, in care was, was hearing the phrase that, you know, your, your specialist knows nothing and does everything, and your primary care doctor knows everything and does nothing.
But maybe you could explain why it's so important. Dave, I was sort of thinking about you as a specialist.
David E. Williams: I, I, I think I, I know nothing and do nothing. Where does that fit?
John Driscoll: But maybe you could talk a little bit about what. The promise of care coordination in primary care, really, why that's so important.
Kate Goodrich: Yeah, you know, we talked a little bit. I'm going to go back for a second to answer this question about the lack of time and why that is so critical. It's not just that you don't get to know your patient. If I'm a primary care physician and I have five minutes with the patient, I'm not gonna be able to address everything and I'm not gonna be able to know that patient well.
And what happens in primary care because of the lack of time is that patients are that normally a primary care physician is trained to work up. So certain conditions they may come in with or certain symptoms they come in with. We're trained as internists and family practitioners to work up a lot of stuff and handle it ourselves.
But because of the lack of time, What ends up happening is patients often get referred to specialists, and we've seen the increase in specialty referral go up and up and up over the last 10, 15, 20 years because of this problem. And I don't want to say anything bad about specialists. I love specialists, but we're using them more than we need to.
And unfortunately, there's not always a very good handle or communication or coordination between the primary care doctor and the specialist. And that is really fundamentally because of the lack of time and infrastructure to be able to do that. Well, and we know that there actually is a type of primary care that does exist actually doesn't concierge care, but it also does in some other types of advanced primary care practices where.
The physicians do have more time and they are able to work up things themselves and less reliant on specialty care. But when they do need to refer for specialists, they have the infrastructure in place to be able to coordinate that care with those specialists. So, care coordination is a critical part of it, but at the end of the day, it comes down to the same basic problem, which is lack of reimbursement, which leads to higher volumes per clinician and no time to really do all the things that you need to do in a coordinated, seamless fashion.
David E. Williams: So it sounds like, you know, we're not just going to be able to have enough doctors to deal with it. We have other parts of the workforce physician assistants and nurse practitioners. There's data, there's care coordination, and there's other, other other sort of roles like for technology beyond that or other, you know, other approaches.
I guess a reimbursement is one of them, but this whole advanced primary care model, what does it look like when you put it all together?
Kate Goodrich: That's a really important point. So we actually have a care delivery arm in Humana called Center Well, and these are senior-focused primary care clinics. It's also home health and pharmacy, but I'll focus on primary care for this discussion.
So, in in our clinics, and there are others like us out there, I would consider us to be an advanced primary care, you know, care delivery model where the payment, the way that clinicians get paid. Is very, very different. Clinicians are paid usually a salary with significant bonuses for providing high-quality care as measured by a number of very standard metrics.
And so what it does is what I said early on, it aligns the payment with really doing the right thing. Now, this, this type of advanced primary care. Requires really transformation of how that care gets delivered and that requires upfront resources, upfront payments to be able to invest in technology to be able to invest in the data.
So that the clinicians have. Right at their fingertips, all the information they need about the patient in front of them, but also about their population of payments and how they're doing population of patients, excuse me, and how they're doing, you know, taking care of all of their diabetics, how they're doing it, keeping people out of the hospital and out of the emergency room.
It's really important to have those data and we do help. We provide those data. To our advanced primary care clinicians both in our contracted network conditions, our positions on the Humana side, but also in our central well clinics. So I'm really glad you brought that up, because both of those things, I think, are absolutely foundational to advanced primary care to be able to actually know how you're doing and taking care of patients and how the patient in front of you is doing from a quality metric or care, you know, care gap perspective.
John Driscoll: And obviously Humana has invested a tremendous amount, billions of dollars in actually building primary care capacity uniquely, but to serve other, other groups as well. And you've spent probably hundreds of millions of dollars in terms of data infrastructure. You've made those investments. You're caring for millions of seniors.
What's the impact? How do you measure success or the gaps in your plan to close the gaps in care?
Kate Goodrich: Yeah, so I'm so glad you asked that question. One of the fun things I get to do with Humana is I lead our research group, and we've done a number of studies to look at exactly what you're asking. So we started off by looking at the impact on outcomes, like hospitalizations, readmissions, ER visits, you know, cancer screening, et cetera, et cetera.
For our members who see value-based care, advanced primary care providers. So those who are paid in this way aligns the incentives with better outcomes compared to traditional Medicare, right? And what we saw is that in Medicare Advantage, most of those outcomes actually are better. Just Medicare Advantage overall, even for our members.
John Driscoll: How do you measure when you think about outcomes again? What, what, how would you, from a patient-facing perspective, how do you describe that?
Kate Goodrich: So we, there are standardized national metrics around, for example, diabetes control, whether or not they're under control. So if they're hemoglobin A1c, which is a lab test that tells you how good your diabetes is doing or how badly it's doing, blood pressure control, cancer screening, vaccinations, patient experience.
And then you know, we really try to keep people out of the hospital, right? That's getting admitted to the hospital can often be avoidable. So we actually measure hospitalizations and ER visits that are avoidable. So it's those types of metrics that are frankly really meaningful to patients and to doctors.
So we look at, we know they're better in MA overall compared to traditional Medicare. We took that one step further. Within MA, we looked at outcomes for patients who see Physicians that we pay under fee for service compared to physicians that we pay under value-based care. So, paying for better outcomes, and we saw that all those same metrics are better in value-based care.
And then finally, we took it one last step and we published this recently in health affairs where we looked at those same outcome metrics for our members who go to these really advanced senior-focused primary care clinics, like center. Well, You may have heard of Oak Street or Chin Med. They're also similar types of clinics compared to other value-based care clinicians and fee-for-service clinicians and found actually again, even better outcomes just in that subset of senior-focused primary care clinics.
And interestingly. The outcomes were, the patient population that was most impacted by being able to see those senior-focused primary care clinicians, again, very advanced primary care, were those who were black and low-income. So, actually, it seems to have a disproportionately positive impact on some of our most historically disadvantaged members.
David E. Williams: So, Kate, you mentioned, you mentioned a couple names, even of others that are taking this kind of advanced primary care approach. I talked about concierge is another approach, which is obviously. Basically putting more dollars against something. So that's not a, that's not something that's going to work for everybody.
What else is out there? I hear about direct primary care. Is that something different than advanced primary care and how might it how might it fit into the overall equation?
Kate Goodrich: So I think when you say direct primary care, I think about that as the original sort of model that was proposed in during the first Trump administration that was really trying to get to.
Having Medicare pay for this advanced primary care really often, you know, concierge-type care. And I do want to say there actually are similarities in the way care is delivered between concierge care and advanced primary care. I'm not familiar with direct primary care being something different from that, but, you know, really, honestly, the secret ingredient beyond the financial structure for both of those is having more time with patients.
Right. In our clinics, we have 30 to 40 minutes per patient. Right. And, and so I, if direct primary care is kind of the same thing, I think the model is probably very similar in, to, to what I've already talked about.
John Driscoll: So Medicare-managed care has come under a lot of a lot of pressure and criticism.
There's it comes at that sort of, is it, there's an overlay of criticism about managed care, which obviously this. Horrible assassination of Brian Thompson is sort of crystallized and managed care, Medicare managed care in itself has had sort of a mixed reputation over the years. What's the state of Medicare-managed care right now?
And obviously the feds believe that they've been overpaying for subsidizing, if you will, the growth of it. We don't have to get into V28 and all the different reimbursement pieces, but certainly there's, there's economic pressure as the federal government. comes under just budgetary pressure for Medicare and Medicaid.
There's their Medicare-managed care comes in and out of favor. What's the state of Medicare-managed care right now? And if you were to argue the pro case for what you're doing, which I hopefully you'd be able to do as the expert what would that be?
Kate Goodrich: Approximately 52 percent of seniors right now are choosing Medicare Advantage and probably the reasons for that is that it's they actually pay less out of pocket and they have benefits that they don't have in traditional Medicare like.
Vision and dental and hearing benefits. So it is certainly growing in popularity for that reason. Right? And we, as I mentioned before, I think one of the biggest benefits of Medicare Advantage is the flexibility to actually innovate in how you pay. Clinicians so that they can actually deliver care in different ways that are better for seniors.
I think that's a major advantage. We have 70 percent of our Medicare members are seeing a value-based care or advanced primary care position and we think that is all to the good. I think what CMS and others are worried about is are we paying too much for it, right? And I do think that they're, that we are able to actually hold down costs within Medicare Advantage through these value-based care arrangements.
So we have less acute care through, you know, the very unpopular prior authorization process. And if you want to get into that, we can do that. Although I think that is really intended to reduce the amount of services that just aren't don't have evidence behind them and aren't really needed. We should not be denying services that are needed.
I want to say that very clearly. We should be really focused on the things that really don't have much value. And that is where we try to focus. So, I do think that the agency, CMS and potentially eventually Congress are going to need to look at the various policies that are going to look at the various policies associated with them.
A to learn from, you know, what, what we've been doing over the last several years and how we can make some of these policies better, whether it's through what CMS did with the 28 and risk adjustment, you know, I think actually what they were trying to do was really the right thing. They're trying to make sure that we are really.
Being incentivized to take care of sicker patients and be more accurate in how we and how we understand the illnesses of our patients and submit that to CMS. So I think that that was actually, you know, a rationalization of the risk adjustment model. I'm sure there's more of that to come. I think there's improvements that could be made in the quality program, for example.
So I'm sure it's certain that there's going to be changes that come to Medicare Advantage to really to try to continue to strengthen the program. And I think that's welcome. I think that we want to be at the table to talk through some of those and offer ideas, but I do think that that makes sense, especially given just the ongoing skyrocketing cost of care in this country.
David E. Williams: Kate, for the last question, I want to ask you a little bit about what it's like to be a primary care physician. You know, from what I can see, people aren't that happy. You see even primary care physicians unionizing, for example, which is something I wouldn't have imagined a few years ago. What's it like and is there hope for people that actually want to practice primary care that it could be rewarding and not something that you feel you need to, you know, to run and jump to collective bargaining for?
Right.
Kate Goodrich: People go into primary care because they want a career. That allows them to really get to know their patients. They don't just want to go in and like, do a surgery and leave. Not that there's anything wrong with that, but that's, that's not the kind of person that is attracted to primary care.
They want to really get to know their patients. They like the challenge of the complexity of medical care that is in front of them and being able to, you know, rise to that challenge. And, and really help their patients and keep them out of the hospital. They go into primary care for all the right reasons, but their day-to-day is really tough.
Often, they'll see 30 patients a day, again, 5 to 10 minutes each, and then they've got to do all the documentation and documentation is important. And there's a lot of reasons for good documentation. What ends up happening is they can't get it done at work. So they go home and get it done at home, usually after they put their kids to bed, and they spend two to four hours on the computer documenting.
They're notes for every patient they saw that day and then they go back the next morning and they do it again and through all of this, they're not really able to do the stop and think part of the job to really you know, work up a patient in a meaningful way that they really want to not that's not a never, but it is a big, a big complaint that I hear for primary care doctors.
Is there hope? There is definitely hope. We have models of care now that are expanding, that are demonstrating value to the patients in terms of the quality measures and outcomes I mentioned. And I didn't talk about the, the physician or clinician experience, but that's really important. It is a much more satisfying way to provide primary care.
Most of our physicians have come from the fee-for-service world and they they come to center. Well, because they want to do things differently. They want more time with their patients. Sure, there's still frustrations day to day, but we're doing things like we're using actually an AI tool to be able to allow the documentation to happen, you know, through ambient AI artificial intelligence that is already showing that it's reducing that pajama time at home that we talk about.
So I do think there's hope, but I think these models need to be supported and need to spread. And then my hope is that over time, if primary care payment changes the way it needs to, that we see more and more people coming into primary care.
David E. Williams: Well that's it for another episode of Care Talk. Our guest today has been Dr. Kate Goodrich, Chief Medical Officer of Humana. We've been talking about primary care, and especially for seniors. I'm David Williams, President of Health Business Group.
John Driscoll: And I'm John Driscoll, chairman of the Waystar Corporation. If you like what you heard or you didn't, we'd love you to subscribe on your favorite service and thank you for joining us, Dr.
Kate Goodrich: Thank you for having me. Appreciate it.
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CareTalk is the only healthcare podcast that tells it like it is. Join hosts John Driscoll (Senior Advisor, Walgreens Health) and David Williams (President, Health Business Group) as they provide an incisive, no B.S. view of the US healthcare industry.
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