Speaker 0: The payer provider relationship has never been simple, but what's happening now is something different. Value based models are maturing unevenly, prior authorization reform is reshaping workflows on both sides, and affordability pressure is intensifying. The organizations that figure out how to collaborate genuinely, not just contractually, are the ones that will set the terms for what comes next. Becker's fifth annual fall payer issues round table brings together more than 500 executive level attendees and 70 plus speakers for two days of focused senior level conversation on benefit design, network strategy, transparency, and the financial and regulatory dynamics that are redefining how care gets paid for. Join us November second and third at the Swiss Hotel Chicago.
For the agenda and event details, visit beckerspayer.com and click on the events tab in the upper right.
Speaker 1: Hi, everyone. My name is Elizabeth Cassello with the Becker's Payer Issues podcast. I'm thrilled today to be joined by doctor Ali Khan, Aetna Medicare chief medical officer. Doctor Khan, thank you so much for chatting with us today.
Speaker 2: It's such a pleasure to be here. Thanks for having me. Of course.
Speaker 1: So before we jump in, I would love for you to fill us in a bit more about your health care career backgrounds and your role at Aetna.
Speaker 2: Happy to. So, Elizabeth, I am coming to you from Becker's hometown of Chicago, Illinois, where I both live and practice still as a practicing primary care physician in the South And West Sides Of Chicago. I, you know, have the incredible good fortune to serve Aetna and CVS Health as the chief medical officer for our Medicare and, duly eligible members around the country. Really, you know, partnering closely with with our business partners and with everybody else in the Medicare team to try to drive, you know, superior clinical outcomes and fantastic population health for for folks who we're lucky enough to serve. I'm also really excited to talk to you today, in the context of value based care because I'm a bit of a one trick pony having spent almost my entire career in value based care delivery.
Prior to Aetna, I served, you know, six and a half years at Oak Street Health, the last three as chief medical officer, building that national network of value based care clinics for seniors and other Medicare enrollees. Prior to that, a number of years of CareMore Health Plan, part of Anthem, also focused as a health plan and as a clinical organization on the needs of highly vulnerable, complex seniors who are Medicare Advantage members with our health plan. And then before that, part of the early team at Iora Health, in their in what feels like the early days of value based care in the twenty teens, really trying to figure out how to build, you know, again, clinics that are driving phenomenal clinical outcomes and highly differentiated patient experiences for folks who really need that and work and deserve that kind of care. So the opportunity to come to talk today about value based care and what we see from the NETA landscape, particularly from a research standpoint, is just super exciting.
Speaker 1: We're looking forward to diving into this white paper that your team shared with me. So there are some new data points coming out regarding value based care and fee for service Medicare models. So can you give a high level overview of some of the key takeaways from those findings? And maybe even before you get into that, sometimes value based care can be kind of like an amorphous term. So what specifically are y'all referring to with this specific white paper?
Speaker 2: That's a great question. Good. That's the right frame. And I think look. When we talk about value based care in the country of this paper, we are talking about anything on the spectrum of arrangements that our network partners, providers around the country are partnering with us in any sort of fashion from, you know, quality bonus programs to shared savings programs, all the way through the full risk value based care arrangements, right, where those practices, those providers are taking on total responsibility for everything that happens to the patients under their care that are Aetna members.
And so we are looking at the entire spectrum of value based care arrangements, and there there's a lot of them. Right? To say, what happens once somebody's in these kinds of arrangements? Right? We've heard a lot about value based care in the past ten years and particularly last couple years.
Right? There's been a lot of questions about value based care. What does it do? Who is it good for? What kinds of outcomes is it is it driving?
Is it worth the hype? And what we have found in this paper, Elizabeth, is that the hype is actually deserved in the context of clinical outcomes and clinical quality, which at its core are where value based care has always, you know, positive to focus on in terms of what it's able to drive. So we looked at 2,000,000 members around the country in our both within Aetna value based care arrangements of any sort from, you know, shared savings all the way into full risk and against a cohort of our fee for service members around the country. And what we did was to look at those numbers and to say, hey. How do those numbers do on the elements of actual clinical outcomes?
Right? There are a lot of quality measures in in the Medicare Advantage world. We've got a lot of different things. But foundationally, the things that are hardest to influence are the things that are very clinical. Right?
And in our data, we saw the value our our members in value based care arrangements receive better care for their diabetes. Right? Forty three percent more members in our value based care arrangements got their hemoglobin a one c, their marker of diabetes management under control relative to our fee for service members. When it came to blood pressure control, not an easy thing for anyone, thirty four percent more members in our value based care arrangements, again, of any type, achieve blood pressure control relative to national standards versus our fee for service population. When it comes to prevention, our value based care members are much more likely, a ten percent or more more likely, actually, to get their recommended mammograms, their recommended colorectal cancer screenings, like colonoscopies and fit tests, or to be screened for diabetic, you know, kidney disease on at least an annual basis as is the recommendation.
Elizabeth, you and I both know that, like, the challenge in American medicine is not the amount of recommendations, the amount of things that we're supposed to do. It's about whether those things actually happen. Right? And our data really suggests that in our value based care partnerships, we are seeing the right things happen at a far greater frequency. And when those things come together, the payoff is in actually better care.
And we see this, again, when we're looking at this at the millions of members level, our members in value based care arrangements were admitted to the hospital 7% less often than those in fee for service arrangements. So and, like, that made that that's a huge number when we think about how many people we're talking about here. Right? That's potentially thousands of hospital admissions avoided because we did the right things up front. And I think that's the real the the real, you know, spotlight here is that when we get this right, we actually can fulfill the promise of what value based care is supposed to deliver.
Speaker 1: And can you fill us in on any sort of relevant context
Speaker 2: when
Speaker 1: it comes to value based care and the Medicare Advantage population and any big trends in terms of utilization and funding pressures? I know CMS also has some initiatives relating to value based care programs in this area. So what is it like operationalizing these arrangements when it comes to the Medicare Advantage population specifically?
Speaker 2: It's such a great question, Elizabeth. I think both from my own lived experience having, you know, run and operated these models and practice in these models for years, but also now from the vantage point of Aetna seeing the whole field. What we see over and over again is that it is the players who take the time to change how they are delivering care, to change the operations of what they're doing day in and day out so that they're not trying to run a 30 person fee for service schedule every ten minutes in one half of the clinic and then doing something else in the other half. But they've said, hey. We have the financial resources from value based care payment.
We have the incentive from, you know, the quality program and from the outcomes, that we run. And in many cases, we are assuming full risk or significant level of risk on these patients that we change the time. Right? We see patients for longer. We see them more frequently.
The average Medicare beneficiary sees a primary care physician 1.3 times a year for about seventeen minutes total. In these models, people are being seen upwards eight, twelve, fourteen, fifteen times a year, often for twenty, thirty, sixty minutes at a time. Right? They get resources. These teams are often larger staffed.
They have not just physicians and and nurse practitioners and PAs, but they also have, you know, medical assistants, nurses, behavioralists, podiatrists, pharmacists, social worker, and behavioralists, all coming together to support these patients. And then third, they get follow through. Right? Systems are designed as actually particularly from a technology perspective to ensure that members are being worked on proactively, engaged when when things could be getting worrisome, and that they don't fall through the cracks. Right?
That operationalization is very different than what we see in fee for service medicine because it's a matter of incentive alignment. And our paper bears that out in showing that the bulk of the value that we saw, in terms of those better clinical outcomes, those lower readmissions, the concentration was highest in our members who were in full those kinds of full risk arrangements. Right? Be those brick and mortar relationships like Oak Street Health, ChenMed, CenterWell, you know, and others, or our national partners who are working with independent practices across the country like Aladaid, Agilon, and others to support them in that journey of getting operations right, bringing in those resources, enabling that kind of time, and then getting that kind of execution. So I think when we think about this in the context of everything going on Medicare Advantage in the last few years, where there has been a renewed emphasis on what are we doing to manage total cost of care trends that continue to rise, And what is CMS signaling, the innovation center from other places in terms of from the Biden administration through the second Trump administration of emphasizing that not only is it the goal to get everybody in an accountable care arrangement, but that they are you know, as with this most recent position fee schedule notice in Medicare, that they're not gonna pay differentially for folks who are in an ACO in order to continue to incentivize that journey.
We are seeing real momentum around putting our dollars into the places that can fund this kind of reop re rejiggering of operations. And I think that's incredibly gratifying for where we're headed.
Speaker 1: So you mentioned Oak Street Health, and I do wanna follow-up a little bit on that, you know, given your background there. How is that relationship with Oak Street Health and between Aetna, shaping these findings, ultimately given how Oak Street Health focuses on value based primary care centers for older adults?
Speaker 2: It's a great question, Elizabeth. You know, Oak Street Health is obviously one of our eyes partners in the value based care space, one of our largest partners, but not the largest. Right? We work with value based care groups across the country, including many of Oak Street's competitors, ChenMed, CenterWell, Alidaide, Agiline, and, you know, many others. We work with also a number of specialty value based care partners around the country and, who are focusing on, you know, from the context of, you know, chronic kidney disease or cancer care or heart disease or other, you know, other sort of, you know, foci.
And so I would say that, like, in the in the context of Oak Street shaping these results, no one player is sort of driving any of these results or others. But I would say the what's been most obvious is that we also have a number of relationships around the country with large health systems and other provider groups and other, you know, small independent practices who may be earlier on that value based care or that risk journey. And so what we've realized is that, like, when we see that the results are so concentrated in terms of the the biggest benefits are happening in folks who are in full risk, then what we are saying is actually, it's we will always support the Oak Streets of the world, but we also need to be doing more to support everybody else as they are on that path towards, you know, that end state of of ideally more risk, more accountability, and whatever critical mass is needed to get to that that kind of substantive operational change.
Speaker 1: So I know the white paper talks a little bit about the one and two sided risk arrangements. Can you tell us in a bit more about what you're seeing with providers' risk appetites right now?
Speaker 2: Yeah. It's always a fun always a always a, a joy to dig into this question, because I think we see some providers who look at the last couple years, particularly in and around shifts in Medicare Advantage and and managed Medicaid enrollment. Right? Shifts in some of the how program design in some of those places with OB three and others, and where with more of an emphasis on needing to really drive key results on clinical quality, clinical outcomes, and therefore total cost of care. And they've said, hey.
We're not ready to do this. Right? Right? So we may be in a one-sided risk relationship right now, but we shouldn't do that. And, you know, glad that's disappointing to hear, but that's okay.
Right? Because then we we say, okay. You're not there yet. But then we need to figure out what to do to make sure that the patients who are seeing you are getting the support that they need. Right?
And what do we what do we offer as a health plan from our own care management, enablement and our own kinda set of programs? What are we doing to partner with you to make sure we can add layers of support, be that support from nurses coming at the nurses coming to the hospital to help with discharge planning and cross the t's and dot the i's to make sure people get home safely, not that they just get home quickly. Right? Whether it's or whether it's working on interoperability to make sure that we are presenting as many real time signals as possible for people to act on to do the right thing of heading off an ER visit or getting somebody enrolled in a hospital at home program or, you know, making sure that they transition from a skilled nursing facility back home in a safe manner. Those are the kinds of places where we all too often see so much room for error in American medicine.
Right, Elizabeth? And so we are saying no matter where anyone is on that journey, we have a suite of services that we're ready to deploy to try to drive more coordinated, higher quality, and ideally better outcome focused care. And if that's the, you know, connective tissue that we think will help give our partners no matter where they are on that risk journey, one-sided, two sided, or not not none, the confidence and the trust that they need to go down that path with us into taking on more risk. I think, you know, it's been a lot of ups and downs the last few years. And so we're hoping that with this kind of evidence in hand, we can really point to the fact of of a strong clinical North Star and then as and use that as justification for the investments that we're making to rebuild that trust and to advance, you know, better clinical care for everyone.
Speaker 1: And looking at the white paper, you know, if there was a critic in the room, what would they ask about your findings? I mean, what other room for inquiry is still left that you're hoping to explore?
Speaker 2: I mean, I think a critic who probably have a lot of things. Right? I'm not a health services researcher. I just like to pretend to be one on TV. So there's always that.
But I think that what folks would look at is that especially looking at our data, is that it's easy to sort of dismiss, like, oh, it's only 7% reduction in hospital admissions. And, again, I think the size of this study is really critical, Elizabeth, because at the millions of members level, this shows that it's that these are statistically significant results and it wasn't just by accident. It is not a sample bias question, right, or issue. This is real And critics will argue that it's not enough, that we have further to go, that there's far more left on the table. And we would agree with that.
I think all of us know that there is more that we can do substantively to drive better clinical outcomes, to drive a better patient experience, to reduce misery, and to ensure that everyone is getting the kind of care that we want for our parents and grandparents. And that's a long journey ahead. Right? And then at the dawn of the AI era that we're in right now, you know, my hope is that we will be able to use AgenTech technologies and others to be able to advance all those core points I just mentioned. But right now, you know, we may be focusing on other things in the AI world.
And so I think this kind of paper offers an opportunity to reset, to say, hey. Where are we supposed to be going? The and where have we been supposed to be going this whole time? To use this as validation to say, yes, we've been on the right path. And then hopefully take that as jet fuel to say, and as we think about what more we can do, here's what we now know about what's needed from an infrastructure perspective, what's needed from an operation standpoint, what's needed from a financing perspective, and what's needed from a, like, a just intangible support standpoint?
And how can we as payers come together with providers meaningfully to actually provide that, not just get lip service? I think that's the challenge ahead of us, and that's where I can imagine a lot of my critics heads would be as well.
Speaker 1: So with the white paper, what do you think is changing operationally at Aetna with these findings? Is this going to influence how y'all communicate with providers who might be on the fence with taking on more risk? What could that look like in practice?
Speaker 2: So I think very tactically, Elizabeth, what we're spending time on is, like, how are we giving people the tools they need to succeed? We think interoperability is a big part of this. Right? The best groups out there are relentless on pursuing real time data exchange, responding to ADT feeds like admission discharge and transfer notifications from hospitals and ERs in real time, and using claims based, you know, analytics to try to identify folks who they're who they should be worried about, who may be at risk of of a a new event, and then pushing forward. And so we are spending an enormous amount of resources in bringing interoperability into, like, as frontier of a capability as possible for us at Aetna to be able to use, you know, whether it's Epic payer platform, Athena, Care Connect, whatever, to make it easier for providers to really access and share more clinical data so that bidirectionally, they see what care gaps emerge, they see what opportunities emerge, and we and they can reach out for help or we reach out to them to offer support when we identify those kinds of opportunities together.
Right? I think that's that's job one. Job two is to also say, like, engagement is it's very sexy to talk about engagement in a digital and agentic form today, but engagement is also shoe leather and analog. Right? And so how do we use all the tools in our tool in our toolkit to get folks engaged with the providers who are taking care of them, who are their primary care physicians or their specialists?
So, you know, we our partnership with Signify, you know, another CVS Health cousin of ours, suggests when the mill the millions of members that get a Signify home visit, from us who are Aetna members every year, when we go into their homes when Signify goes into their homes rather and sees that this is a member who is eligible for an advanced care coordination or care management program through Aetna or when they see that this is a member who hasn't seen their primary care position in some time, We are able to flag then that number one concern for that member. And then in use, like, the Signify clinician working with the patient, taking the patient's phone from them, with permission, of course, dialing a number with a fifteen with a fifteen second pickup time, service level agreement with a clear requirement. And on the spot, get somebody enrolled in that care management program or get somebody engaged with that provider who they've been try who that provider has been trying to get a hold of them they haven't been able to. Right? We are doing the work not only at a digital level, but also at that shoe leather level of ensuring connectivity, making things simple when they're often all too complex, and trying to drive people into the kind of care that can be stabilizing and ultimately humanizing.
And so that's where we're really focused on, again, being that connective tissue and pushing as much as we can to be supportive but not abrasive in the journey towards better health.
Speaker 1: Well, doctor Khan, as we wrap up, do you have any sorts of final words of wisdom, advice for other Medicare leaders?
Speaker 2: I would say this. And, again, I'm very biased just given, you know, where I've spent my whole career. But we see this at Aetna as a very clear sign, Elizabeth, that value based care arrangements work. Right? When we create that kind of shared focus between health plans and providers and we get the rewards right, and then we see this obviously particularly in the two sided risk and full risk domains, We can actually fulfill the promise of value based care in delivering better quality, better value, and lower cost.
And so this isn't the first study to support this conclusion, but the size of this study and the the power it holds, I think, is a important reminder of where we where we need to be going from a North Star perspective as we head into this next era of innovation.
Speaker 1: Well, doctor Khan, thank you so much for taking the time to chat with us today.
Speaker 2: Elizabeth, it's such a pleasure, and, you know, always love interacting with the Becker's crew and looking forward to more.
Speaker 1: And to our listeners, if you'd like to hear more podcasts from Becker's Health Care, you can visit beckershospitalreview.com. Thank you.
For the agenda and event details, visit beckerspayer.com and click on the events tab in the upper right.
Speaker 1: Hi, everyone. My name is Elizabeth Cassello with the Becker's Payer Issues podcast. I'm thrilled today to be joined by doctor Ali Khan, Aetna Medicare chief medical officer. Doctor Khan, thank you so much for chatting with us today.
Speaker 2: It's such a pleasure to be here. Thanks for having me. Of course.
Speaker 1: So before we jump in, I would love for you to fill us in a bit more about your health care career backgrounds and your role at Aetna.
Speaker 2: Happy to. So, Elizabeth, I am coming to you from Becker's hometown of Chicago, Illinois, where I both live and practice still as a practicing primary care physician in the South And West Sides Of Chicago. I, you know, have the incredible good fortune to serve Aetna and CVS Health as the chief medical officer for our Medicare and, duly eligible members around the country. Really, you know, partnering closely with with our business partners and with everybody else in the Medicare team to try to drive, you know, superior clinical outcomes and fantastic population health for for folks who we're lucky enough to serve. I'm also really excited to talk to you today, in the context of value based care because I'm a bit of a one trick pony having spent almost my entire career in value based care delivery.
Prior to Aetna, I served, you know, six and a half years at Oak Street Health, the last three as chief medical officer, building that national network of value based care clinics for seniors and other Medicare enrollees. Prior to that, a number of years of CareMore Health Plan, part of Anthem, also focused as a health plan and as a clinical organization on the needs of highly vulnerable, complex seniors who are Medicare Advantage members with our health plan. And then before that, part of the early team at Iora Health, in their in what feels like the early days of value based care in the twenty teens, really trying to figure out how to build, you know, again, clinics that are driving phenomenal clinical outcomes and highly differentiated patient experiences for folks who really need that and work and deserve that kind of care. So the opportunity to come to talk today about value based care and what we see from the NETA landscape, particularly from a research standpoint, is just super exciting.
Speaker 1: We're looking forward to diving into this white paper that your team shared with me. So there are some new data points coming out regarding value based care and fee for service Medicare models. So can you give a high level overview of some of the key takeaways from those findings? And maybe even before you get into that, sometimes value based care can be kind of like an amorphous term. So what specifically are y'all referring to with this specific white paper?
Speaker 2: That's a great question. Good. That's the right frame. And I think look. When we talk about value based care in the country of this paper, we are talking about anything on the spectrum of arrangements that our network partners, providers around the country are partnering with us in any sort of fashion from, you know, quality bonus programs to shared savings programs, all the way through the full risk value based care arrangements, right, where those practices, those providers are taking on total responsibility for everything that happens to the patients under their care that are Aetna members.
And so we are looking at the entire spectrum of value based care arrangements, and there there's a lot of them. Right? To say, what happens once somebody's in these kinds of arrangements? Right? We've heard a lot about value based care in the past ten years and particularly last couple years.
Right? There's been a lot of questions about value based care. What does it do? Who is it good for? What kinds of outcomes is it is it driving?
Is it worth the hype? And what we have found in this paper, Elizabeth, is that the hype is actually deserved in the context of clinical outcomes and clinical quality, which at its core are where value based care has always, you know, positive to focus on in terms of what it's able to drive. So we looked at 2,000,000 members around the country in our both within Aetna value based care arrangements of any sort from, you know, shared savings all the way into full risk and against a cohort of our fee for service members around the country. And what we did was to look at those numbers and to say, hey. How do those numbers do on the elements of actual clinical outcomes?
Right? There are a lot of quality measures in in the Medicare Advantage world. We've got a lot of different things. But foundationally, the things that are hardest to influence are the things that are very clinical. Right?
And in our data, we saw the value our our members in value based care arrangements receive better care for their diabetes. Right? Forty three percent more members in our value based care arrangements got their hemoglobin a one c, their marker of diabetes management under control relative to our fee for service members. When it came to blood pressure control, not an easy thing for anyone, thirty four percent more members in our value based care arrangements, again, of any type, achieve blood pressure control relative to national standards versus our fee for service population. When it comes to prevention, our value based care members are much more likely, a ten percent or more more likely, actually, to get their recommended mammograms, their recommended colorectal cancer screenings, like colonoscopies and fit tests, or to be screened for diabetic, you know, kidney disease on at least an annual basis as is the recommendation.
Elizabeth, you and I both know that, like, the challenge in American medicine is not the amount of recommendations, the amount of things that we're supposed to do. It's about whether those things actually happen. Right? And our data really suggests that in our value based care partnerships, we are seeing the right things happen at a far greater frequency. And when those things come together, the payoff is in actually better care.
And we see this, again, when we're looking at this at the millions of members level, our members in value based care arrangements were admitted to the hospital 7% less often than those in fee for service arrangements. So and, like, that made that that's a huge number when we think about how many people we're talking about here. Right? That's potentially thousands of hospital admissions avoided because we did the right things up front. And I think that's the real the the real, you know, spotlight here is that when we get this right, we actually can fulfill the promise of what value based care is supposed to deliver.
Speaker 1: And can you fill us in on any sort of relevant context
Speaker 2: when
Speaker 1: it comes to value based care and the Medicare Advantage population and any big trends in terms of utilization and funding pressures? I know CMS also has some initiatives relating to value based care programs in this area. So what is it like operationalizing these arrangements when it comes to the Medicare Advantage population specifically?
Speaker 2: It's such a great question, Elizabeth. I think both from my own lived experience having, you know, run and operated these models and practice in these models for years, but also now from the vantage point of Aetna seeing the whole field. What we see over and over again is that it is the players who take the time to change how they are delivering care, to change the operations of what they're doing day in and day out so that they're not trying to run a 30 person fee for service schedule every ten minutes in one half of the clinic and then doing something else in the other half. But they've said, hey. We have the financial resources from value based care payment.
We have the incentive from, you know, the quality program and from the outcomes, that we run. And in many cases, we are assuming full risk or significant level of risk on these patients that we change the time. Right? We see patients for longer. We see them more frequently.
The average Medicare beneficiary sees a primary care physician 1.3 times a year for about seventeen minutes total. In these models, people are being seen upwards eight, twelve, fourteen, fifteen times a year, often for twenty, thirty, sixty minutes at a time. Right? They get resources. These teams are often larger staffed.
They have not just physicians and and nurse practitioners and PAs, but they also have, you know, medical assistants, nurses, behavioralists, podiatrists, pharmacists, social worker, and behavioralists, all coming together to support these patients. And then third, they get follow through. Right? Systems are designed as actually particularly from a technology perspective to ensure that members are being worked on proactively, engaged when when things could be getting worrisome, and that they don't fall through the cracks. Right?
That operationalization is very different than what we see in fee for service medicine because it's a matter of incentive alignment. And our paper bears that out in showing that the bulk of the value that we saw, in terms of those better clinical outcomes, those lower readmissions, the concentration was highest in our members who were in full those kinds of full risk arrangements. Right? Be those brick and mortar relationships like Oak Street Health, ChenMed, CenterWell, you know, and others, or our national partners who are working with independent practices across the country like Aladaid, Agilon, and others to support them in that journey of getting operations right, bringing in those resources, enabling that kind of time, and then getting that kind of execution. So I think when we think about this in the context of everything going on Medicare Advantage in the last few years, where there has been a renewed emphasis on what are we doing to manage total cost of care trends that continue to rise, And what is CMS signaling, the innovation center from other places in terms of from the Biden administration through the second Trump administration of emphasizing that not only is it the goal to get everybody in an accountable care arrangement, but that they are you know, as with this most recent position fee schedule notice in Medicare, that they're not gonna pay differentially for folks who are in an ACO in order to continue to incentivize that journey.
We are seeing real momentum around putting our dollars into the places that can fund this kind of reop re rejiggering of operations. And I think that's incredibly gratifying for where we're headed.
Speaker 1: So you mentioned Oak Street Health, and I do wanna follow-up a little bit on that, you know, given your background there. How is that relationship with Oak Street Health and between Aetna, shaping these findings, ultimately given how Oak Street Health focuses on value based primary care centers for older adults?
Speaker 2: It's a great question, Elizabeth. You know, Oak Street Health is obviously one of our eyes partners in the value based care space, one of our largest partners, but not the largest. Right? We work with value based care groups across the country, including many of Oak Street's competitors, ChenMed, CenterWell, Alidaide, Agiline, and, you know, many others. We work with also a number of specialty value based care partners around the country and, who are focusing on, you know, from the context of, you know, chronic kidney disease or cancer care or heart disease or other, you know, other sort of, you know, foci.
And so I would say that, like, in the in the context of Oak Street shaping these results, no one player is sort of driving any of these results or others. But I would say the what's been most obvious is that we also have a number of relationships around the country with large health systems and other provider groups and other, you know, small independent practices who may be earlier on that value based care or that risk journey. And so what we've realized is that, like, when we see that the results are so concentrated in terms of the the biggest benefits are happening in folks who are in full risk, then what we are saying is actually, it's we will always support the Oak Streets of the world, but we also need to be doing more to support everybody else as they are on that path towards, you know, that end state of of ideally more risk, more accountability, and whatever critical mass is needed to get to that that kind of substantive operational change.
Speaker 1: So I know the white paper talks a little bit about the one and two sided risk arrangements. Can you tell us in a bit more about what you're seeing with providers' risk appetites right now?
Speaker 2: Yeah. It's always a fun always a always a, a joy to dig into this question, because I think we see some providers who look at the last couple years, particularly in and around shifts in Medicare Advantage and and managed Medicaid enrollment. Right? Shifts in some of the how program design in some of those places with OB three and others, and where with more of an emphasis on needing to really drive key results on clinical quality, clinical outcomes, and therefore total cost of care. And they've said, hey.
We're not ready to do this. Right? Right? So we may be in a one-sided risk relationship right now, but we shouldn't do that. And, you know, glad that's disappointing to hear, but that's okay.
Right? Because then we we say, okay. You're not there yet. But then we need to figure out what to do to make sure that the patients who are seeing you are getting the support that they need. Right?
And what do we what do we offer as a health plan from our own care management, enablement and our own kinda set of programs? What are we doing to partner with you to make sure we can add layers of support, be that support from nurses coming at the nurses coming to the hospital to help with discharge planning and cross the t's and dot the i's to make sure people get home safely, not that they just get home quickly. Right? Whether it's or whether it's working on interoperability to make sure that we are presenting as many real time signals as possible for people to act on to do the right thing of heading off an ER visit or getting somebody enrolled in a hospital at home program or, you know, making sure that they transition from a skilled nursing facility back home in a safe manner. Those are the kinds of places where we all too often see so much room for error in American medicine.
Right, Elizabeth? And so we are saying no matter where anyone is on that journey, we have a suite of services that we're ready to deploy to try to drive more coordinated, higher quality, and ideally better outcome focused care. And if that's the, you know, connective tissue that we think will help give our partners no matter where they are on that risk journey, one-sided, two sided, or not not none, the confidence and the trust that they need to go down that path with us into taking on more risk. I think, you know, it's been a lot of ups and downs the last few years. And so we're hoping that with this kind of evidence in hand, we can really point to the fact of of a strong clinical North Star and then as and use that as justification for the investments that we're making to rebuild that trust and to advance, you know, better clinical care for everyone.
Speaker 1: And looking at the white paper, you know, if there was a critic in the room, what would they ask about your findings? I mean, what other room for inquiry is still left that you're hoping to explore?
Speaker 2: I mean, I think a critic who probably have a lot of things. Right? I'm not a health services researcher. I just like to pretend to be one on TV. So there's always that.
But I think that what folks would look at is that especially looking at our data, is that it's easy to sort of dismiss, like, oh, it's only 7% reduction in hospital admissions. And, again, I think the size of this study is really critical, Elizabeth, because at the millions of members level, this shows that it's that these are statistically significant results and it wasn't just by accident. It is not a sample bias question, right, or issue. This is real And critics will argue that it's not enough, that we have further to go, that there's far more left on the table. And we would agree with that.
I think all of us know that there is more that we can do substantively to drive better clinical outcomes, to drive a better patient experience, to reduce misery, and to ensure that everyone is getting the kind of care that we want for our parents and grandparents. And that's a long journey ahead. Right? And then at the dawn of the AI era that we're in right now, you know, my hope is that we will be able to use AgenTech technologies and others to be able to advance all those core points I just mentioned. But right now, you know, we may be focusing on other things in the AI world.
And so I think this kind of paper offers an opportunity to reset, to say, hey. Where are we supposed to be going? The and where have we been supposed to be going this whole time? To use this as validation to say, yes, we've been on the right path. And then hopefully take that as jet fuel to say, and as we think about what more we can do, here's what we now know about what's needed from an infrastructure perspective, what's needed from an operation standpoint, what's needed from a financing perspective, and what's needed from a, like, a just intangible support standpoint?
And how can we as payers come together with providers meaningfully to actually provide that, not just get lip service? I think that's the challenge ahead of us, and that's where I can imagine a lot of my critics heads would be as well.
Speaker 1: So with the white paper, what do you think is changing operationally at Aetna with these findings? Is this going to influence how y'all communicate with providers who might be on the fence with taking on more risk? What could that look like in practice?
Speaker 2: So I think very tactically, Elizabeth, what we're spending time on is, like, how are we giving people the tools they need to succeed? We think interoperability is a big part of this. Right? The best groups out there are relentless on pursuing real time data exchange, responding to ADT feeds like admission discharge and transfer notifications from hospitals and ERs in real time, and using claims based, you know, analytics to try to identify folks who they're who they should be worried about, who may be at risk of of a a new event, and then pushing forward. And so we are spending an enormous amount of resources in bringing interoperability into, like, as frontier of a capability as possible for us at Aetna to be able to use, you know, whether it's Epic payer platform, Athena, Care Connect, whatever, to make it easier for providers to really access and share more clinical data so that bidirectionally, they see what care gaps emerge, they see what opportunities emerge, and we and they can reach out for help or we reach out to them to offer support when we identify those kinds of opportunities together.
Right? I think that's that's job one. Job two is to also say, like, engagement is it's very sexy to talk about engagement in a digital and agentic form today, but engagement is also shoe leather and analog. Right? And so how do we use all the tools in our tool in our toolkit to get folks engaged with the providers who are taking care of them, who are their primary care physicians or their specialists?
So, you know, we our partnership with Signify, you know, another CVS Health cousin of ours, suggests when the mill the millions of members that get a Signify home visit, from us who are Aetna members every year, when we go into their homes when Signify goes into their homes rather and sees that this is a member who is eligible for an advanced care coordination or care management program through Aetna or when they see that this is a member who hasn't seen their primary care position in some time, We are able to flag then that number one concern for that member. And then in use, like, the Signify clinician working with the patient, taking the patient's phone from them, with permission, of course, dialing a number with a fifteen with a fifteen second pickup time, service level agreement with a clear requirement. And on the spot, get somebody enrolled in that care management program or get somebody engaged with that provider who they've been try who that provider has been trying to get a hold of them they haven't been able to. Right? We are doing the work not only at a digital level, but also at that shoe leather level of ensuring connectivity, making things simple when they're often all too complex, and trying to drive people into the kind of care that can be stabilizing and ultimately humanizing.
And so that's where we're really focused on, again, being that connective tissue and pushing as much as we can to be supportive but not abrasive in the journey towards better health.
Speaker 1: Well, doctor Khan, as we wrap up, do you have any sorts of final words of wisdom, advice for other Medicare leaders?
Speaker 2: I would say this. And, again, I'm very biased just given, you know, where I've spent my whole career. But we see this at Aetna as a very clear sign, Elizabeth, that value based care arrangements work. Right? When we create that kind of shared focus between health plans and providers and we get the rewards right, and then we see this obviously particularly in the two sided risk and full risk domains, We can actually fulfill the promise of value based care in delivering better quality, better value, and lower cost.
And so this isn't the first study to support this conclusion, but the size of this study and the the power it holds, I think, is a important reminder of where we where we need to be going from a North Star perspective as we head into this next era of innovation.
Speaker 1: Well, doctor Khan, thank you so much for taking the time to chat with us today.
Speaker 2: Elizabeth, it's such a pleasure, and, you know, always love interacting with the Becker's crew and looking forward to more.
Speaker 1: And to our listeners, if you'd like to hear more podcasts from Becker's Health Care, you can visit beckershospitalreview.com. Thank you.
