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What happens when you ask clinicians to hit dozens of quality metrics but never explain why those metrics matter or how to manage them? Kenneth Botelho, founding program director of the Doctor of Medical Science program at the College of St. Scholastica, joins to discuss his KevinMD article, “Value-based care workforce: Bridging the gap in clinical education,” and why medical education still trains you to treat one patient at a time in a world that demands population health thinking. He breaks down the disconnect between fee-for-service training and value-based care realities, from dashboard management and HCC coding to compensation tied to screening rates you were never taught to influence. You will hear why this knowledge gap fuels burnout and early career attrition, what PA and NP programs are starting to do about it, and how postgraduate training could give clinicians the framework they need to regain control over their day-to-day work. If you have ever felt graded on a system no one explained to you, this episode will change how you see your role in it.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Kenneth Botelho. He is the founding program director of the Doctor of Medical Science program at the College of St. Scholastica. Today’s KevinMD article is “Value-based care workforce: bridging the gap in medical education.” Kenneth, welcome to the show.

Kenneth Botelho: Thank you so much for having me back, Kevin. I am happy to be back.

Kevin Pho: All right, so what led you to write this article and share it on KevinMD? Talk about the article itself for those who didn’t get a chance to read it.

Kenneth Botelho: Absolutely. A quick background because it jumps right into why I wrote the article: my background is in primary care as a PA. Like many clinicians, I have seen and felt the shift towards value-based care that is happening around us, but without anybody really explaining how to function within the system. In addition to clinical practice, as you had said, I am the founding director here at the Doctor of Medical Science program, and we are focusing on workforce development. I am seeing it from an academic perspective, and then you are also seeing it from a direct clinical perspective, realizing that there is a gap in our knowledge base from both the academic and clinical sides.

We are asked as clinicians to impact quality, cost, and population health, but none of us were really trained directly on how to think that way from an operational, day-to-day workflow perspective. That disconnect is what led me to write this piece. The article comes from the frustration that I have seen amongst clinicians in all those spaces, and it is a common theme. That is what prompted the article itself.

Kevin Pho: Now value-based care can mean a lot of things. Give us your definition of value-based care and how that contrasts with the fee-for-service paradigm.

Kenneth Botelho: Yes, you are absolutely right. There are so many nuances to value-based care in terms of different plans, different measures, or what have you. Let’s talk somewhat generically. Per your mention of fee for service, that is more about volume over perhaps quality, simply because if we are seeing more patients, the amount of time and effort spent with each patient is going to be inherently less. Value-based care rewards outcomes and quality more than numbers of patient visits. So we can take care of the same number of patients, but it may not have the same level of burden in the clinic. And I don’t mean burden from a negative perspective, but just a time burden.

The understanding of value-based care is inherent to the outcome portion that we are already being somewhat graded on in terms of metrics. It requires needing to understand what we are being evaluated on, whether it is breast cancer screening, cervical cancer screenings, or HCC coding in terms of how much weight there is for folks that are more ill or at a higher risk than those that are healthy and younger. In medical education, we talk about patient care. There is some population health as well, but there is not as much focus on measures and how to manage large patient panels and affect those changes that we are being reimbursed for. Having that type of education is important.

Kevin Pho: You talk a little bit about the burden and some of the out-of-the-exam-room work that needs to be done when switching to a majority value-based care system. Give us a scenario or example of what additional work needs to be done in order to be an efficient value-based care practitioner.

Kenneth Botelho: There is a lot that needs to be done. I know that is very generic, but let’s go into more specific depth. I just mentioned value-based care dashboards. The dashboards for value-based care track not only the percentage of your patient panel that is getting their mammograms, cervical cancer screenings, or colonoscopies, but much more. Much of what we are taught as clinicians is how to take care of an individual patient in front of us presenting with a problem. Now we are being asked to ensure that the overall population health of an entire panel is navigated appropriately. We are not only being given metrics on that, but some of our compensation is based on that now.

It is a different type of learning structure that a lot of us aren’t necessarily privy to until we go out into the field and we are told what we basically have to be graded on. Bridging that is really important. There is no specific or definitive way that has been proven across the United States for how we deliver it and how clinicians learn, but it is clear there is a gap between the way we have structured the workforce and the way we are now going to structure the workforce. Closing that knowledge gap is important for us as clinicians to deliver the care and to have positive changes in our own careers so that we can manage that panel effectively.

Kevin Pho: As you know, in primary care, there is more onus not necessarily on the clinician themselves, but on their staff to really have these dashboards up to date because, like you said, there are bonuses. The amount of money the institution receives from Medicare and insurance companies is dependent on whether these metrics are met. It could be a percentage of patients under a certain A1C, or a percentage of patients that have their blood pressure controlled. There are literally dozens and dozens of metrics that clinicians have to monitor in their patient panel. You obviously are the program director at a clinician institution. How much training typically do these future clinicians get when it comes to these value-based care metrics?

Kenneth Botelho: I will be very transparent: very little. Very little, to the point where even in the workforce, we are being asked to deliver these numbers within our panels, but as most clinicians are trained to do, they are not exactly sure why. Really understanding the “why” as a clinician helps empower us to not only improve the health care delivery for our panel but perhaps even have more professional satisfaction from that.

But if we don’t fully understand the system that we are working in, if we are not taught that, or if we are not really given a pathway for growth within it, then it becomes more of a documentation burden rather than being seen as leading to better outcomes for our patients. This is really a bit of a PR change if you think about it. We are trying to do the right thing, and we need to make sure we bridge the gap in clinician understanding of the system that we are moving into, or that we are already in in some ways.

Kevin Pho: Specifically, what kind of skills are needed for a clinician to function in a predominantly value-based care system?

Kenneth Botelho: Great. First off, we need to understand what we are being measured on. To your point, Kevin, you had mentioned A1C management and colonoscopies, and ensuring that those are performed appropriately and the patient panel is aware. Folks that get these types of screenings done have better outcomes. They reduce their risk of hospitalization because we are trying to provide preventative care. In terms of how that translates, it can actually translate into our day-to-day explanations to patients about why these types of measures are so important for their health. But if we, as clinicians, don’t even fully understand the system that we are trying to work within, then that type of communication directly in exam rooms may not happen, or it might be dismissed, even though it is important both to the patient and to the system we work in.

While I am not going to tell you a specific A1C measure that you can improve across the board for your patient panel, something as simple as how you communicate to patients about the importance of getting certain things accomplished is, in itself, critical.

Kevin Pho: In normal circumstances, a lot of these clinicians have to learn a lot of this stuff just on the fly and through mistakes, errors, and feedback from the administration. Tell us your ideal world. If we were to implement this during training, what would that look like?

Kenneth Botelho: Great question. I would say the way medical education is structured right now, it doesn’t need a complete overhaul. We should continue to teach clinicians how to go about patient care in the same way, but we need to expand upon the systems thought process as to how to manage larger populations. A lot of what we are taught in school is essentially to manage a patient at a time, and that is appropriate, but the world we are moving into is more about population health. We need an understanding of why these certain tests or recommendations are given—because they benefit not just the clinician and the health system they work for, but they benefit the patient themselves.

Where to put that education, at least from my perspective, is important. First off, I know there are some residency programs for medical education, for MDs and DOs, where this is present and put into the residency program itself. I think that is an appropriate timeframe to do that. For PAs and nurse practitioners, it looks different because a lot of what they are being taught is in a shorter timeframe than that of a physician, and I understand that completely.

In an ideal world, a PA and NP would come out of their school, start within a health care system, and have ongoing training and development on how best to navigate using the skills they have already learned in school. So you are taking value-based care and the concepts that are introduced and adding that on, likely after they have been in practice for a bit of time so that they can get their feet wet practicing directly. Then, once those measures become more visible in their day-to-day practice, having a better understanding of the “why” and how to develop professionally is really important. Whether that is an onboarding program or some type of PA or NP fellowship, having that in the postgraduate spaces is highly valuable now.

Kevin Pho: One of the things that you mentioned in your article is that aligning some of these real-world realities with what they learn academically can help prevent burnout and early career attrition, right?

Kenneth Botelho: That is absolutely right, because at the end of the day, a lot of us are asked to do more and more in our day-to-day. When you ask us to do more without telling us why it is so important, it adds to burnout and moral injury. But if it becomes part of our professional identity, where we inhabit the panel of patients we are responsible for, and we can see that there is a direct impact between meeting these measures and the quality of the patient care we deliver, as well as the quality of our own professional trajectory, that can coexist cohesively. We just haven’t quite gotten there yet.

Kevin Pho: So what is happening in other PA and NP programs across the country? Are they taking initiatives, as you are, to hopefully integrate some of these value-based care skills into graduating clinicians?

Kenneth Botelho: There is an absolute appetite for it, to the point where my colleague has been doing a number of different value-based care discussions with clinical-year PAs. For those that are listening who aren’t sure what I mean, that is the second year of PA school, so to speak, where these folks are more clinically grounded but maybe don’t fully understand what it is to code, how to code, or why it is important. The problem is that it is likely too little information—just enough for them to understand some of what the terminology is, but not what their day-to-day would look like. That is where the gap comes into play. There is a recognition that the gap exists. I think there is a lack of understanding about exactly what to do about it.

Kevin Pho: We are talking to Kenneth Botelho. He is the founding program director of the Doctor of Medical Science program at the College of St. Scholastica. Today’s KevinMD article is “Value-based care workforce: bridging the gap in medical education.” Kenneth, as always, we will end with some take-home messages that you want to leave with the KevinMD audience.

Kenneth Botelho: Yeah, absolutely. I appreciate it. At the end of the day, clinicians are struggling not because they are incapable; they are struggling because we haven’t quite given them a full or complete framework to understand fully the system that they are working in. When you give clinicians that framework, something important will happen: they will regain a sense of control over their day-to-day to a degree. When that happens, the system doesn’t just function better. The clinician starts to shape the system that they are working within, and that is really where true advocacy comes from. It is not just for clinicians, but it is also for patients. If we want a value-based care system to fully succeed, we can’t just change how we measure care. We have to change how we prepare the people that are delivering the care.

Kevin Pho: Kenneth, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Kenneth Botelho: Greatly appreciated. Thank you so much, Kevin.