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Join Michael Poku, a physician executive, as we delve into the challenges and solutions for transforming the U.S. health care system. Explore how the fee-for-service model perpetuates health inequities, the importance of value-based care, and the impact on patient outcomes. Discover how prioritizing patients and making strategic investments can lead to a more equitable and cost-effective health care model.

Michael Poku is a physician executive.

He discusses the KevinMD article, “How value-based care can address health inequities.”

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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 Michael Poku. He’s a physician executive. Today’s KevinMD article is “How value-based care can address health inequities.” Michael, welcome to the show.

Michael Poku: Thank you, nice to be with you, Kevin.

Kevin Pho: So we’ll talk about your article in a little bit. First off, briefly share your story and journey.

Michael Poku: Yeah. So currently chief clinical officer for Equality Health. I’m a practicing internist, I’m also board certified in clinical informatics.

At Equality Health we’re one of the national leaders in value based care, in that just terrific movement that your audience will know all too well. In that space, we’re really a value based care enabler with a Medicaid first approach, which is a bit unique, because we’re taking this idea of transforming the health care landscape and transforming the reimbursement landscape and doing it in a bit of a different manner, with the Medicaid first approach focusing on supporting mainly independent practices and primary care physicians to boot, with a combination of people and personnel armed with technology and data science, with a financial model, an incentive model, aimed to better sustain those practices.

Kevin Pho: All right, so before talking about your article, for those who aren’t familiar with how physicians generally are paid, maybe give a 30 second primer on the current fee for service system, define some of the acronyms that we’re going to be talking about, and then we’ll jump straight into your article. So give us a 30 second primer about the current landscape today.

Michael Poku: Yeah. So the current landscape, which again, it’s so exciting because we’re in a pretty rapid transition point right now, so things are in flux and changing pretty wildly.

But the traditional fee for service landscape, I would say, is a one-size-fits-all model where we’re paying providers and practices for discrete units of service. And the model there is essentially paying for specific services, and therefore, from an economic basis, practices and providers from a pure economic standpoint are incentivized to increase their throughput.

Now, thinking through what a value based care model, so-called VBC, it really takes that one-size-fits-all model and turns it on its head. And it focuses on people first and tries to push a so-called whole person care model, where we’re thinking about patients and families first and foremost, and what are their needs from a biopsychosocial perspective, and we’re paying more so for value and outcomes.

So it gives providers, practices, and other health and human services organizations, community based organizations, the flexibility for personalization, and to layer on additional measures and technology, and to make investments that from a societal perspective we need, and from a patient perspective has more person centricity, to be able to meet folks where they are and help guide them along their health and health care journey.

Kevin Pho: So can you elaborate, how does the current fee for service system, that payment model, how does that contribute to health inequities in our U.S. health care system?

Michael Poku: Yeah. So first and foremost, we have a pricing model that introduces pricing discrimination, to where, net net, all things being equal, commercial payers and folks living with commercial plans, they tend to reimburse on a, again, discrete unit of service basis, more richly than that of folks with Medicare insurance, more richly than that of folks with Medicaid insurance, and more richly than those that are self-paying, aren’t funded with respect to their health care delivery.

So what that essentially does, from again a pure economic perspective, it pushes practices to focus more time and attention on commercial versus Medicare versus Medicaid versus self-pay. And that contributes to inequities, because that then influences how access works, it influences how we sort of focus on communities and on patients and on individuals.

So what we really need to do is take some of that pricing discrimination out of the system, take out this economic incentive to think about throughput and to think about volume, and evolve and shift and transform the model so that we’re thinking about patients and people more holistically, and that we’re really economically incentivized to narrow and eliminate disparities and inequities and drive outcomes that are, again, much more person centered, and things that we all want as far as staying healthy and happy at home.

Kevin Pho: So I know that we’ve been trying to shift that fee for service model for who knows how long now, decades now. It’s almost like redirecting the Titanic, right? So in your ideal world, how would your payment model typically look like in a typical primary care practice?

Michael Poku: Yeah, and it’s an interesting question, right? Because again, the exciting thing is, we’re doing this at Equality Health, there’s many other organizations that are diving in in this particular space. There’s been a couple of interesting catalytic events I would say over the last several weeks to months where we’re really seeing a new inflection point of this.

And to answer your question more directly, I think the delivery system would be incentivized, and it would push the risk from payers and insurance companies into the delivery landscape. And again, just as we said before, the economic incentive would not be for volume. The economic incentive would be to take an impaneled set of patients living in a community and figure out what is the best way to take care of this pool of individuals in a true risk pool. And as many health plans should be doing, and are now doing, how do we plan for the health and the health care services for that population?

So by shifting the risk into the delivery system, and by making sure we’re investing in the appropriate technology, pulling in the appropriate human capital resources, and then importantly connecting with the community, connecting with other resources, and shifting from this historical view where we’re predominantly focusing on delivery of discrete medical services, to say more broadly, yes, medical services is a piece of it, but how do we think about prevention, how do we think about non-medical drivers of health and social determinants of health, and being able to have an incentive in an economic model to address that, such that we can get our patients on the appropriate medication, such that we can get the mammograms done, and some of the other pieces.

So thinking about things more broadly and holistically, and making sure that the reimbursement model and landscape is appropriately positioned to quite frankly force the delivery system to think with a wider aperture.

Kevin Pho: Now, how are you implementing your vision? Are you going practice by practice, are you offering an insurance model, are you engaging with employers? So how are you implementing this vision?

Michael Poku: Yeah, so the way that we’re implementing this vision at Equality Health, it’s a multi-prong approach.

So first and foremost, we’ve got heavy conviction that particularly supporting independent primary care practices is going to get us a lot of bang for the buck. So it’s that focus point of independent practices.

The next one, just as I mentioned before, is we’re helping in meeting patients where they are, in providing additional support services and that human capital investment piece that I mentioned. Whether it be chaplains, whether it be community health workers, folks that live and grow in the communities that we’re serving, to be able to support on some of the things that again, historically for a lot of practices, is a foreign concept, when we think about non-medical drivers of health and everything else.

So when you’ve got somebody and they should be on Lasix, but they’re not taking their Lasix and their water pill and their medications, because they are deciding between paying for medications or paying for food, or they’re experiencing homelessness, we’ve got the ability to have, again, a person centered model, leveraging technology and reaching out, embedded in the community, to be able to help.

And I mentioned the last piece there, which is the technology, data driven piece. So it’s investments in technology, investments in data driven insights, to be able to take all the disparate forms of data, put it into one system, convert that data into information to support the practices that are in our network.

Kevin Pho: So let’s give a practical example. Let’s say in a typical day of a primary care physician, can you contrast that day in a value based system that is facilitated by the technology tools that you mentioned, versus a traditional fee for service day?

Michael Poku: Yeah. So a traditional fee for service day, from an economic sustainability model, most know how many patients they need to get through the door to be able to be financially sustainable. So it’s dominated by that productivity model.

So what that essentially means is that you start the day and you’re probably double booked, and in some areas you’re triple booked, and you’re running at a pretty rapid and quick pace.

In a value based care model, we sort of turn that on its head, and we’re thinking about the triple aim, quadruple aim, and in that model of improving the experience of both the patients and families that are being served and the providers and the staff. We’re doing away with double and triple booking. We’re risk stratifying the population, because we’re moving away from a one-size-fits-all model where everybody gets a 10 or 15 minute appointment.

And we’re saying, you know what, in your panel of x amount of patients, there’s 5 percent that’s driving 50 percent of the cost. We’re going to show you that 5 percent, we’re going to preferentially get those folks in, and we’re going to help you with the last mile. So we’re going to minimize no-show rates by helping with things like child care, by helping with transportation, by addressing food insecurity, housing insecurity, getting folks in the door. And then also helping to figure out what are those value laden activities that we need to do that are going to give you the most bang for the buck at driving the best care for that particular patient in front of you.

So it really is about thinking broadly. And again, the nice thing is focusing on a risk stratified panel of patients, spending more time with those that need more time, and then for those folks that need more time, also providing wraparound services. So we’re not only thinking about folks when they’re within the four walls of the clinic, but we also have a model that we’re thinking about folks when they’re at home, we’re thinking about folks when they’re experiencing other interactions with other folks within the continuum.

Kevin Pho: So I know that since the Affordable Care Act was passed there’s been various initiatives to shift towards a more value based system. So how does what you’re describing contrast with what’s been going on on a more federal level?

Michael Poku: Yeah, so I would say I don’t think there is contrast. They’re very complementary.

And one thing that I’ve been pretty surprised about personally is the amount of dollars from a capital investment perspective, from capital allocators and the private sector interests here. So it’s terrific to see, because the federal government, and governments at all levels I would say, even down to the municipal point, sort of see the value of really supporting communities, see the value of thinking about folks more holistically, and they’re driving that from a policy lens. But then you’ve got private equity, venture capital investment, you’ve got the entire health care industry also pushing it.

So you get this synergistic effect that’s really catalyzing a pretty transformative view. To where, even in our value based care enablement model, we’ve seen almost a 200 percent increase in venture capital and private equity investment on a year-over-year basis from ’22 to ’23. And I think that’s just testament to, again, not only the public sector, CMS in particular, pushing this in the right direction, but the private sector also seeing the value that this has from a pure economics perspective, and the value this has from a broader societal perspective.

Kevin Pho: We’re talking to Michael Poku. He’s a physician executive. Today’s KevinMD article is “How value-based care can address health inequities.” Michael, let’s end with some of your take-home messages to the KevinMD audience.

Michael Poku: Yeah, so a couple of things that I’d say. One pretty significant take-home I’d say is that, particularly from a clinical perspective and a clinical audience, as I mentioned before, the landscape is changing so rapidly. But I think one thing that will always stay firm is this notion of people helping people.

So despite the rapid advances in technology, whether talking about AI more broadly or specific use cases like LLMs, large language models, ChatGPT, et cetera, there will always be a place and a space and a need, a critical need I would say, for people helping people.

So we need to increasingly think through, how do we leverage these technologies and these advances to support particularly folks in disinvested communities that have been historically marginalized from a health care access, economic development perspective? So thinking about supporting particularly in a Medicaid first plane, particularly on the plane of communities from that level, I think is of critical importance.

So again, that human capital investment piece is always going to be a critical one. And I think it’s the clinicians that are increasingly needing to lead on what that looks like, and how we use technology to augment all the great work that we’re trying to do.

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

Michael Poku: Thanks, happy to be with you.