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We sit down with physician executive Christopher Crow to discuss the pressing issue of physician burnout and the need for transformative changes in the primary care model. Join us as we explore the history, causes, and potential solutions to this crisis, with insights from an experienced health care leader.

Christopher Crow is a physician executive.

He discusses the KevinMD article, “Returning the joy of medicine to our primary care physicians.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Christopher Crow. He is a physician executive. His KevinMD article is titled “Returning the joy of medicine to our primary care physicians.” Christopher, welcome to the show.

Christopher Crow: Hey, thanks for having me. Long-time follower of yours.

Kevin Pho: Oh, thank you so much for joining me. So first off, just briefly share your story and journey to where you are today.

Christopher Crow: I’m a small-town kid who grew up about an hour outside of Dallas, in a little community called Hillsboro that had three doctors in it, and they were kind of everything to the community. They were population health before that was a term, in the ’70s. They were the mayor, the head of the city council, the head of the school board, and the heads of the Methodist, the Baptist and the Presbyterian churches. So they were people to look up to, and they really helped the town in a holistic way. I didn’t realize it until my 30s, but that really left an impression on me. I decided to go to medical school because when I looked around, that was really the best thing I saw in the community to look up to. So I went to medical school and became a family physician, like they did.

Somewhere during my training in medical school, and this was in the ’90s, I started to feel that the way we cared for people didn’t make sense to me, given all the technology advances, all the consumerism that was happening in those times and the internet coming on board. It just felt very archaic, 100 years old, and I started asking the question, “Why do we do it this way?” I’m 52 now, and I still ask, “Why do we do it this way?” That’s been my passion ever since: How do we make things better, and leave it better than we found it? That ultimately led to our purpose, which has been here since we started Catalyst Health Group: helping communities thrive. Because that’s what those three doctors in Hillsboro were doing. They were helping our small community thrive in way more ways than just the exam room.

So I practiced for 12 years as a family physician and grew a group called Village Health Partners, which is still in existence today and is one of the largest independent groups in Texas. It’s got about 50 physicians now. It’s part of what we have in the Catalyst Health Network, which has close to a thousand primary care providers across North Texas, the Panhandle and a little bit of East Texas. We only do value-based care contracting, which is shared risk on all the government lives and a little bit of that on the commercial lives, as well as your typical ACO-type contracts. So that’s a really fast summary of how we got from there to here.

Kevin Pho: All right, and your KevinMD article is titled “Returning the joy of medicine to our primary care physicians.” I’m an internal medicine primary care physician myself, so I’m interested in hearing what you have to say about returning the joy of medicine. Tell us, how did your article come together?

Christopher Crow: Well, it’s an ongoing thing, like I mentioned, of how do we leave it better than we found it, and to keep asking why, over and over. I think, structurally, the fee-for-service model turns us into widgets. We have all our aspirations of being a doctor when we grow up and taking care of people, in medical school and residency, and then you get out in the real world and understand that you’d better code this as a 99214 and get to the next room, while your patients need more. That creates a moral dilemma on a daily basis about how you’re going to spend your time. At the end of the day, do I see another patient or make a few phone calls, or do I miss dinner with my family? Do I miss the soccer practice? Do I miss the ballet? Every day you have to make that choice, and it just starts to wear on you, on top of regulations and technology that is probably getting stale in your office, because we don’t generally have the type of infrastructure to invest in that unless we join a big system. And then that big system, whether it’s a carrier or a hospital, has a different priority than actually keeping your patients healthy. So you just have this dilemma on a daily basis that some people name moral injury, and to me it goes back to the financing system.

So the joy: I’m seeing it in our physicians who are getting to do full-risk government work, Medicare and Medicare Advantage. They’re still living with one foot in each canoe, so to speak, but at the same time they’re starting to see a vision we’ve been preaching for a while, that if we could get more of our commercial lives on a subscription model, there’s something there. You’ve heard it from the hinterlands, from the direct primary care physicians who have said, “To hell with the insurance. I’m just going to take monthly payments.” You hear about how happy they are. Unfortunately, seeing 500 patients is not going to solve our American health care system from a supply and demand standpoint. I’m a guy from Hillsboro, Texas, who’s trying to help our communities thrive as a whole. Certainly that model works for that physician and those 500 patients, but it creates a gap for us nationally.

So I’m still trying to push: How can we help these community physicians get to this payment model? Because through the DPC doctors who talk to us and chirp loudly, and through what we’re seeing early with the government work, there’s just a sense of, “Oh, what I meant to do is coming back. It’s coming back to me.” So that’s the biggest one. Physicians aren’t scared to work hard; it’s just that they want to be working on the things where they feel they’re making an impact. Man, they will go 12-hour days all day long if it’s impact after impact after impact. But if it feels like you’re relegated to a widget, and you’re making an impact about two out of every five minutes, that’s where it’s difficult. So that’s what we mean. That’s the major structural thing about how you bring the joy back to medicine. It’s not meditation and wellness and all these things that come around. We have to change it structurally, not iteratively.

Kevin Pho: So give us some of your suggestions. You did mention direct primary care. I’ve had a lot of direct primary care physicians on my podcast, and they’ve written on KevinMD, and like you said, I think it’s relatively niche, and their impact is a little bit limited. So what ideas do you have that can scale?

Christopher Crow: We feel like we’re doing that here at Catalyst. You do have to be able to move to a subscription model, I think, which is going to require you to have some type of scale and be able to take risk. Unfortunately, the individual physician office of America today, which grew up on “Little House on the Prairie,” is not going to be able to do that. The world has just changed in that way. We don’t pay by the minute for our long-distance calls anymore, because there’s now scale in national carriers that allows us to do this in a subscription way. There’s something to primary care like that as well, because primary care is about relationships with patients, not transactions. So we really have to push that, and the government has actually led the way.

So how do we get more of our physicians into some type of affiliation that’s aligned with that? Again, hospitals don’t do that very well. The insurance companies that are doing this, whether that’s Humana with CenterWell or Optum with some of its assets, are a little bit better aligned. If you’re part of the other broader rollups, like One Medical or VillageMD, those have a little bit different goals in mind. Then there’s the rest of these physicians, 30 or 40 percent of the country still, who are in this independent state, and I think they have to learn to play together, because they want the same thing. They need to get the synergies of coming together, like we have at Catalyst, to give us the breadth and concentration in a market to actually be able to co-invest in some of these tools and services that allow you to perform in risk. And man, you really, really can, but it means getting into that type of formation and taking on those types of risk contracts.

Then there’s the opportunity to ultimately start contracting directly with employers, because employers are fed up with the current system too. That really happened right during COVID. It slowed down a little because of the labor shortage, but now, boy, the appetite at the employer level is really there. However, if you’re just a single practice in a community of even 100,000 people, just having one location is not going to be enough for an employer. So again, it’s figuring out what’s common among us. We can all have our differences, but the differences that have divided us have allowed businesses like payers and hospitals to really take over at our expense. So there needs to be a coming together of physicians to actually heal ourselves and move forward.

Kevin Pho: So give us a success story of your vision in action. Tell us how these practices can come together, and when they do, how they can navigate their own course rather than be coerced by larger systems, payers and insurance companies.

Christopher Crow: I’ll give you a success story of our vision that has actually come to fruition. I have countless physicians who now tell me, “I was planning on retiring in the next couple of years. I now see a path. This gives me a breath of fresh air, to practice and to be able to see a panel of patients.” It’s not 35 a day; it may be a little less, but they’re ultimately feeling the impact they’re making, in a team-based care model, leveraging technology. “Now I don’t see retirement next year or the year after.” That, I think, is the ultimate outcome I would share with you and your listeners. That’s a shift in mindset. That means the burnout is down. That means the joy of medicine is back, and they’re having fun in their career again.

To coalesce together, you’re going to have to have some physician leadership, and that’s probably, unfortunately, one of the rarest things in American health care today. Physicians have their heads down doing their craft, whether they’re in primary care or specialty care. Their heads are down, and unfortunately that leaves a void that has been filled by a bunch of administrators, MBAs and private equity, who are coming in and running their own business models. So there is this trade-off that has to happen. It doesn’t have to happen with all physicians, but you have to have physician leadership in your community that can actually help pull this together and create a vision. It’s a team sport, so you have to be able to partner with the right people, and maybe there is a management company component to it, for sure, which is what we are as well. But it has to be in a way that’s in partnership with the physicians, not in ownership of the physicians.

Kevin Pho: Now, physicians in general don’t have the business acumen to do that, and that’s probably why some of them choose to partner with management organizations, right? There are so many areas of the country where those independent physicians’ voices have been silenced. They’ve been bought out, like you said, by large hospitals or by private equity. So for independent organizations that don’t have the benefit of management support, what can they do? How can they fight back against some of these entities that have already pervaded their area?

Christopher Crow: Honestly, I think it’s really, really hard, and I don’t want to sugarcoat that at all. I think smaller practices are going to have a really, really hard time remaining independent in the future. They will get squeezed out; it’ll get so hard they’ll just give up. So therefore, I do think they have to attach themselves to some type of alliance or coalition, and there are several models in America today. Obviously, Catalyst is one in this area of the country. We’re not everywhere, on purpose. We try to go deep in communities rather than a mile wide and an inch deep. But there are many others, especially in the Medicare world, that will help you get on that train.

I think you have to have your head up and really consider your options. I know everyone says, “We’re busy, we’re so busy,” but we’ve gotten into this mode because we’ve had our heads down for too long, and we haven’t been taking stock of what the options are. And there are options. I could name a bunch of them, but they’re out there, and they’re probably knocking on the door, and it’s probably worth listening to them to see what they have to offer and who some of their competitors are. I just think you’re going to have to connect to some of those enablers, and that may not be the final step; it may be your first step in learning. You’re right that physicians haven’t gone to business school, but man, they’re going to have to have a little more thoughtfulness about strategy, and a little better understanding of how the business of health care works, to help themselves in the future. Otherwise, yes, you just have to be a cog in somebody else’s wheel.

I think that’s the divergence, and by the way, that’s exactly what we’ve seen over the last 10 to 20 years. We’ve gone from 0 percent of physicians being owned by hospitals in 1995 to well over half now being in some type of private equity, hospital or payer employment market. There are just so many options for physicians now, and that’s actually the good thing. But if you want to keep doing it the way we’re doing it, you’re going to have to get some business acumen and the right type of partners.

Kevin Pho: So in your particular area, how big is your physician coalition?

Christopher Crow: We have close to a thousand PCPs, mostly across North Texas. Dallas-Fort Worth is obviously one of the biggest metro areas in the country, and the most expensive, which creates a lot of opportunity. We probably have close to 20 percent of the market here. Then we’re out in the Panhandle and in areas of East Texas, where we probably have a little over half of the markets, which really helps. When you have that density, it’s not only economies of scale but also the influence you then have, versus being a one-doctor practice in a town of 100,000 people, where there’s only so much influence you can have.

Kevin Pho: Now, contrast how you pay your physicians versus the typical fee-for-service model.

Christopher Crow: Well, we’re still in fee-for-service too, so I would say it’s an “and” model, not an “instead of” model, because most of our commercial contracts, with the Blues, still work that way. However, on all the government lives, it is a per-member-per-month subscription model that pays them nicely once a month, and by the way, boy, during COVID they especially loved it. It just comes in. Then there are opportunities every month, paid quarterly, around quality and other incentives, to make sure we’re taking the best care of those patients. And the way these full-risk contracts work, if you’ve saved money, then there’s a surplus share back at the end of the year.

That’s why a lot of physicians are telling me, “Hey, can we cancel my Blue Cross commercial contract? Can I not do that anymore? I just want to do these subscription, per-member-per-month ones.” It’s like anything else. When I explain fee-for-service versus subscription payment models to my teenage sons, they’re like, “Why would anybody build a system off fee-for-service?” They get it very quickly, but ironically, that’s the system we’ve been in for 50 years. Physicians are beginning to want more and more of the subscription model, because of the predictability and the way the incentives are aligned: Better health equals more dollars. Literally, better health equals more dollars, whereas in fee-for-service, better health does not equal more dollars; only more volume equals more dollars.

Kevin Pho: So contrast the day-to-day life of a primary care physician who, say, came from a standard, traditional employed practice into one of your practices. Contrast their lives.

Christopher Crow: I think in the first week, they really start to appreciate the care team that is there to help them. In a fee-for-service model, you try to keep your overhead as low as possible, and you have a medical assistant and maybe one other FTE who is helping you. But all of a sudden you get access to a care coordinator, a referral coordinator and case management, which is an RN for your highest-risk patients. We help show you who they are, patients you probably know, but we also give you lists of people we think could use help. Social work, and then probably the biggest is a pharmacist, having the pharmacy integrated virtually. So you have this virtual team surrounding you, helping you with your patients right off the bat. Your MA, who heretofore has played all those roles, who has been the social worker, the care coordinator, the referral manager and the case manager, now has a team that can really, really help. So either you get a little more productive, i.e. you see more patients, or you limit that 5 o’clock dilemma and, a little more often, you’re able to see all your patients and make it to dinner. So there’s a satisfaction that comes right off the bat.

Then you start to see the predictability of the financials that come in after six to 12 months, because now you’ve begun getting some subscription-based payments, and that starts to feel safer. And then you start to see your quality measures, which maybe aren’t that great compared to some of your peers who have been in the system longer, and you start to get a little competitive about that and start looking for ways to make them better. So then you get to year two, and all of a sudden you can take a lot of pride. You can prove that you’re actually providing better quality care. You’ve been in many rooms speaking to physicians, and one of my favorite tricks when I’m speaking to physicians is to ask them to raise their hand if they think they’re above average. The whole room raises their hand. Statistically, that shouldn’t be the case, unless I just draw that kind of crowd. So now you can actually show with confidence, versus your peers in the market, that you’re really providing quality care. You’ve got a better revenue stream from an income standpoint, and you’ve got more of a team and technology to better take care of your patients.

And guess who’s thanking you for that? Your patients. They come in and say, “Thank you so much for connecting me to Tony the pharmacist. Thank you so much for connecting me to Susie the social worker. It is so awesome that Carrie called me while I was in the hospital and had an appointment set up for me two days later.” We all have egos, and that strokes our ego, when our patients come back and tell us how our team has really impacted them. So what do we do? We do more of that. And what does that end up doing? It ends up creating a better opportunity to coordinate care for patients. It improves their health, it lowers the costs and we win on that from a financial standpoint.

Kevin Pho: We’re talking to Christopher Crow. He’s a physician executive. His KevinMD article is titled “Returning the joy of medicine to our primary care physicians.” Christopher, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Christopher Crow: Well, if you’re a primary care physician out there, I hope you have a little hope that there is a future, that you’re very much valued and needed in the ecosystem of health care in America today, and that there are models out there you can be a part of that can bring the joy back, allow you to take better care of your patients and be financially rewarded for that. If you’re not a primary care physician, and you’re a patient listening to this, make sure you get attached to a primary care physician. I realize that supply and demand is not great right now; that’s certainly something else to be working on. But we know that over time, if you’re with a primary care physician, you lower your costs, you improve your life expectancy and you have more good days than bad. That seems like a good vitamin we should all be taking on a regular basis.

Kevin Pho: Christopher, thank you so much for sharing your perspective, time, and insight, and thanks again for coming on the show.