What does the cure for scurvy have to do with the transition to population health? It shows that in healthcare, change — even change that's unequivocally good — takes time.
On the first episode of Decoding Healthcare, emergency room physician Kevin Ban, M.D., head of athenahealth's population health service, shares his journey from treating individuals to managing large groups of patients — and the mindsets that need to shift as healthcare embraces the future.
JOANNA WEISS: When you think about population health, what comes to mind? Utilization, network management, quality reporting? How about scurvy? That’s what Dr. Kevin Ban, the head of athenahealth’s Population Health Service, brings up when he talks about the transition from fee-for-service healthcare to a whole new way of looking at patients and doctors and healthcare systems.
So, scurvy, dread disease of the Middle Ages and beyond. It’s estimated to have killed up to two million sailors who took long journeys during the Age of Exploration and, it was a terrible way to go. First you get fatigued, then your muscles start to ache, your gums start to swell, you get pain in your joints and your bones, you develop a trembling fever, and you die. But it turns out scurvy had a surprisingly easy cure. I’ll let Kevin tell you.
KEVIN BAN: This wasn’t recognized until James Lind back in 1747 started doing some studies and realized that an orange—but, even easier, a teaspoon of citrus of any type—could prevent a group of sailors from dying. But it took him a while to even publish that treatise, but what is even more discouraging is it took nearly 50 years for the British Navy to adopt it into practice.
JOANNA: And this was Kevin’s point. Change in healthcare, even change that is obvious and unequivocally good, doesn’t always come easily, and sometimes for good reason.
KEVIN: In part because we’re careful about how we take care of patients. We don’t want to make big changes immediately, because there is plenty of snake oil out there, and we have to be sure that [the change] works. But even just changing the way we think about taking care of patients is a big deal, so we’re not going to see it overnight; it’s going to be a process, it’s going to be a journey. This will not be a singular event.
JOANNA: The transition Kevin just described is exactly what this podcast is going to be about. Kevin and I will meet people who are starting to see the differences, recognize the citrus, serve up the orange. We’ll get into the details of how to keep patients in network and how to shift doctors’ mindsets to evidence-based care. We’ll talk about some surprising innovations in care for the chronically ill, and we’ll take a deep dive into the future of payment reform. I’m Joanna Weiss and this is “Decoding Healthcare.”
Today we’re going to talk with Kevin about his journey from a swashbuckling ER doctor treating patients in crisis to someone who helps health systems think about managing the health of patients all the time, whether they are in front of a doctor or not. So let’s get started.
So, you started in a hospital system. You started with the classic American medical training.
KEVIN: My upbringing in healthcare was really in tertiary and quaternary care hospitals. That’s where I stayed all through medical school, through my residency. Even as an academic attending, I was at a teaching hospital in Boston, Beth Israel Deaconess Medical Center, and my worldview was very focused on the hospital, the complex care that we provided there. [I] didn’t think much about what happened to patients once we discharged them from the emergency department or the hospital. … Someone else would be on that. It wasn’t something that we thought too much about.
JOANNA: And then you went to Tuscany. How did you get that gig?
KEVIN: Tough life, right? It was around 2002, and Tuscany was struggling with some bad outcomes in the emergency department. They didn’t have formalized training in emergency medicine back then, and we got into a relationship—Harvard Medical [School] faculty physician, Harvard Medical International, with the Tuscan government to do education at the [universities] of Pisa, Siena, and Florence. And that was an eye-opener for me.
JOANNA: How was it? What did you see that was different from what you saw in the hospitals back home?
KEVIN: It’s almost embarrassing in some ways how, maybe, arrogant we were in terms of how convinced we were about how to provide care. We were deeply entrenched in a fee-for-service model at that point. There was no talk of value or value-based care. And we… would make fun at times of some of the stuff that they were doing, things that later we ended up doing ourselves.
JOANNA: Like what?
KEVIN: We would look at how they dealt with chest pain.
JOANNA: Okay. So someone comes into the ER …
KEVIN: Patient would arrive in the emergency department with chest pain, and what we would do is sort of get the ball rolling, admit them to the hospital. What they did in Tuscany was they would keep them for about 24 hours, do some essential testing.
JOANNA: Without admitting them, just keep them in the ER?
KEVIN: Yeah, what we would call “observation status” now. They would do that testing, make sure the patient was okay, didn’t need anything beyond the basic stuff that they were able to do there, and discharge them home. That is something that we looked at and said, “Wow, they’re creating a hospital within a hospital.” I mean I specifically remember that’s what we said about it. And now we do something exactly like that.
JOANNA: Give me some other examples of things they did in Italy that were mind-blowing to you at the time.
KEVIN: They would take recent graduates from medical school, people who were still waiting to start their residencies, and they would put them on ambulances, and when there was a call of shortness of breath—let’s say in a patient who had congestive heart failure—they would send these newly minted doctors, not yet residency trained, to evaluate these patients. It’s a really interesting concept. What they would do then is sometimes decide, “Well, you know what, if I just tweak their medications, maybe give them a little bit of a diuretic which helps the situation, the patient doesn’t need to go to the emergency department. In fact we’ll just have them follow up with their primary medical doctor.”
JOANNA: So how many years were you in Italy?
KEVIN: The program lasted about eight years overall.
JOANNA: And did you find that you were a different doctor by the time that was over? Had you bought into the system or changed the way you practice because of the system?
KEVIN: No, no. I’m not going to lie about that. I think I was exposed to a different way of providing care. I was primed in some way. I wouldn’t say, though, that I had really put it all together. So, it was really being exposed to this concept of value-based care and risk contracting that I started to reflect more on what happened in Italy and started to put the pieces together. It’s almost like if you’re on the dance floor and you’re doing a really good job of dancing, you’re tripping the light fantastic.
JOANNA: You’ve got the tango.
KEVIN: You’ve got it going on. You’re like, “I’m on this situation.” And then all of a sudden you take a break, you go up to the balcony, and you look down on the dance floor and you’re like, “Wow, there is so much more going on on that dance floor and … I’m just too focused in on this particular thing.” And I think that is the journey we’re on with value-based care. We’re kind of pulling back and saying, “Hey, what does this population look like? What are some strategies, what are some tactics that we can use to think about a bigger panel of people?”
JOANNA: So, let’s take a real-life scenario of a patient and how you might treat a patient differently. I will embarrass myself a little and bring up a personal situation.
KEVIN: Please do.
JOANNA: Yeah. A few months ago I broke my foot. It was a really dumb injury involving a dark staircase at 6:00 AM and a cat.
KEVIN: That is generally the formula.
JOANNA: That’s how it happens. So, fortunately for me and my cat, I didn’t need surgery, but let’s say I had hurt my knee, and I was a great runner, and it got to the point where this was the straw that broke the camel’s back and I needed surgery, and I was not in a fee-for-service contract, I was in a risk-based, bundled contract. How would my doctor be treating me differently?
KEVIN: Well, let’s say that you had repetitive injuries of that knee, and now you had this really arthritic knee and you needed to have a joint replacement.
JOANNA: I didn’t—you can’t blame my cat for that.
KEVIN: No, probably not. It would have to be a series of cats. It’s going to take time to do this. Yeah, so let’s say that you’re in a fee-for-service model, let’s start there.
KEVIN: The payer, whoever that is, pays for the procedure. They don’t necessarily pay for a good outcome. They just pay for the procedure to be done. Let’s say you’re in a value-based contract, and this is something I was involved with at the hospital. I guess a joint might cost, a knee replacement, let’s say about $30,000. I might not be dead on with that. If I say, as the payer, “We’re going to pay you $30,000 to do this procedure, [and] if you can do it for less, if you can do it for $27,000, $25,000, you can keep the difference, but we’re not paying you more than $30,000,” well, all of a sudden you have a completely different conversation that is happening internally, and that is an interesting moment. Now all of a sudden you’re gaining alignment among all of the different providers who touch that patient—the surgeon, rehabilitation, the folks who care for the patient in the hospital, maybe the hospitalist if it’s not the surgeons.
JOANNA: Who runs the conversation? Who facilitates?
KEVIN: That was one of the things that I did as a Chief Medical Officer is [I] got people together and said, “Hey, how can we think about care differently?” And so what happens then is you start to think about “What can we do to prep the patient beforehand that they’re going to go home, they’re going to go home with services instead of going to rehab?” Patients do better when they go home.
JOANNA: So you’re talking about changing doctors’ mindsets, but also changing patients’ mindsets, because I think a lot of them now go to the hospital or go to the doctor and say, “Give me my thing. Give me my surgery.”
KEVIN: Patients go into the hospital, and if they have the expectation that they’re going to go to rehab after, it’s almost impossible to get them off of that concept. They’re pretty fixated on “I’m going to rehab, I can’t go home.” So it really starts early on—before you are even in the hospital—in the way that the surgeon presents this to the patient and starts to create the expectation that in fact they will go home, they will do great with services at home, and that their outcomes will be better. So, all of a sudden you see a realignment in how we’re delivering care. And that needs to be carried … all the way through this episode of care, and when we do that, we find that we are able to do something very interesting, and that is provide really good care at decreased cost.
JOANNA: But you’re talking about shifting so many mindsets. In your experience how hard is it to convince patients that this is the standard of care, and then how hard is it to convince providers and doctors that this is the standard of care?
KEVIN: Patients tend to love this, especially those patients who have chronic medical problems. There are a lot of moving parts there, and to have a care manager who is kind of your trusted adviser, your friend at times who helps you navigate these really complicated waters—and these are complicated waters—is a really good thing, and the feedback from patients has been exceptionally positive.
JOANNA: So for doctors, then, I imagine it’s a little more complicated, because you’re not just talking about changing the delivery of care, you’re changing how they get paid. That’s a big deal.
KEVIN: It can be significantly more difficult. And I should mention that providers go to work every day taking care of patients and doing a really good job of it. The issue is they don’t think about all the patients who are in their panel, maybe patients who are in a risk contract, that they don’t know about. So, it’s hard for doctors to look at this and say, “Well, yeah, we need to totally change the system,” because their point of view is, “I’m doing a really good job of caring for my patients.” It’s not until you pull back and sort of see the whole population that you start to go, “Oh boy.”
JOANNA: So, as a Chief Medical Officer, as a physician leader, how do you pull them off the dance floor and get them to look at the dance floor? What steps can you take? What can you do?
KEVIN: For us it was a, it was a process. It was one probably characterized by stages of grief. You’ve got the denial, the anger, the deal making, and eventually you get to the acceptance. For us it was about really understanding our patient population. We had to get a window into the soul of what was happening, and that happened through data.
JOANNA: Let’s talk about that data. What is the most useful data that you could share with a physician to make him or her understand, “Hey this is the way we’ve got to go”?
KEVIN: Well, we started with claims data, adjudicated claims. That was really the foundation of what we needed to look at, but it really wasn’t enough, and so we pulled in stuff in the electronic health record like pharmacy, labs, other information. Nowadays we’re pulling in ADT, which is admission-discharge-transfer information—any data that you can pull in and really get a 360-degree look at the particular patient.
JOANNA: So you’re looking at one particular patient when he or she comes through the door with that bum knee and saying, “Here is where this patient is on the continuum. Here is what we should do right now”?
KEVIN: What we generally do is … aggregate all that data and normalize it. We make sure that we have a really good data set. The integrity is paramount. If you go to physicians with data that is questionable or not dead on, it’s a whole can of worms you do not want to open.
JOANNA: They know their numbers. They’re scientists, right?
KEVIN: The data has to be good. And once you have that data set put together … you run some analytics against it and try to get a sense of “where are we with quality, where are we with utilization? We’re spending a lot of money in some particular area. What is that area?” And you try to understand it. We also try to [learn whether patients are] staying inside of our network. What we found is that our patients are “cheating” on us for the most part, and I think we were surprised by how often our own patients would go outside the system—interestingly, sometimes referred by physicians in our system.
JOANNA: Was that a matter of just people [having] relationships? Were they shopping around in any way? How does that network leak?
KEVIN: Sometimes it’s the patient, right? They have a relationship already with a group maybe at a hospital that is not in system—a cardiologist, let’s say, a physician group, or a specialist group in a different system. Sometimes … it’s the physician who has a relationship, maybe the physician did residency with a friend, the friend is in a competing hospital, she knows that it’s a really good doctor and has been referring there for the last 20 years. In a fee-for-service model that’s okay, but now all of a sudden you’re in a risk contract, and it’s not as acceptable.
JOANNA: Right. You have to change not just the way doctors treat the patient but how doctors refer the patient, where doctors send the patient next.
KEVIN: Yeah, and patients don’t always like that. It’s referred to as a narrow network, and sometimes even physicians don’t like that. They don’t want to be constrained by finances. They’re just thinking about what they perceive to be the best course of care for their patient. And so there you have to come back and really look … the quality of care versus the cost, and you get at something called value, right?
JOANNA: And that is a new concept. That is something that as patients and, I think, as providers, people didn’t have to think about in medicine for a long time. Someone else was paying.
KEVIN: That’s right. And as soon as you start to spread risk, people start to say, “All right, well, what is the value?” Let’s just talk about an MRI for a second.
JOANNA: Let’s get specific.
KEVIN: Some meaty stuff here. So what happens if a patient needs an MRI, it’s indicated, [it] needs to happen. There are plenty of times when you don’t need it—and then we would call that overutilization—but let’s say you do, and at one hospital if you had it done in the hospital it might cost $1,600. Okay?
JOANNA: That’s a lot for one little procedure.
KEVIN: Absolutely. And then in another hospital, let’s say now a community-based hospital, it might be $1,000. Still a lot of money, but significantly less.
JOANNA: You save $600. You could do a lot with $600.
KEVIN: And if you were paying for that, it would be a no-brainer, especially if I told you that the quality was perfectly the same. And there might even be a third option, which is you could go to a Shields type of—
JOANNA: The MRI shop down the street.
KEVIN: Exactly right.
JOANNA: In the strip mall.
KEVIN: Now, it matters what the quality is, right? I don’t want to pay less and get less, but if I get the same amount of quality, what would you do?
JOANNA: Sure, you would pick the value, but as a patient you don’t always know that. You brought up trust before. I’m trusting my doctor to tell me where to get that MRI.
KEVIN: That’s right, and that is the mindset that you have to get people wrapped around or thinking about. You really have to point that out to people and say, “Do you realize that when you refer to this hospital it’s $1,600, when you refer to that hospital it’s $1,000, and when you refer to this place it’s 600 bucks?” I might be exaggerating here. And guess what, the quality of care is no different.
JOANNA: That’s got to be a big mindset shift, too. I’ve heard physicians say they don’t want to be thinking about price at that moment of care.
KEVIN: We tried very hard, and I think it’s smart to really focus in on what is just good clinical care and try not to overrotate too much on the financial piece, because you’ll turn people off. But over the course of time you start to have really interesting conversations that come from this new mindset, and eventually people really understand that it makes sense. Maybe it’s even more convenient for the patient. Something as simple as parking might be a big deal to a patient.
JOANNA: Access is incredibly important. It’s a lot easier to go to that strip mall than to deal with the hospital and the traffic …
KEVIN: And having to pay 20, 30, 40 bucks to park. A lot of people talk about this big leap, and I don’t think healthcare professionals and large hospital systems are interested in taking a big leap and having a lot of risk with that. This is something that we’re going to sort of incrementally move towards.
JOANNA: Now it feels like part of the complication, right, is that there are some risk-based contracts, but fee-for-service is still the lay of the land in most cases.
KEVIN: That’s right.
JOANNA: So how do you practice as a doctor with one foot in each world?
KEVIN: It’s really difficult. I think doctors just … want to think about taking care of patients. They don’t want to think about whether or not they’re in a risk-based contract or they’re fee-for-service. It’s just not the right way to do it. Interestingly, early on we would really focus our new care redesign and some of the services that were provided to just patients in risk contracts. That didn’t feel good. I’m hearing more and more that healthcare organizations want to think about how they’re delivering care to all patients and really transform the way they do care, not just for risk patients but really for all patients. That is an exciting direction to be moving in.
JOANNA: So, as a patient, I don’t want someone to look at me as I walk through the door and say, “Okay, because I know you’re risk contract I’m going to tell you to get the surgery, but [MBM1] I’m going to tell you to not get the surgery.”
KEVIN: That just doesn’t feel good from any perspective. No one wants to do that. But what is really happening is that we’re having new conversations. All of a sudden when you start thinking about a population and you start looking at different metrics, about “how are we doing with certain things,” now all of a sudden conversations are happening between providers, they’re happening between the providers and administrators, and even with patients, as we mentioned earlier, and that is really the beginning of transformative change.
JOANNA: Well, that’s as good a place as any to press pause, because that is what our upcoming podcast episodes are going to be about.
We will talk to health system leaders about building population health services from the ground up.
KEVIN: We’ll meet a community health leader who is focusing in on the social determinants of health.
JOANNA: We will talk to a healthcare executive who was present at the creation of the Affordable Care Act.
KEVIN: And importantly, we’ll take a look at the role data plays in driving better outcomes.
JOANNA: So, tune in for more conversations about how healthcare is changing from the inside out on “Decoding Healthcare,” and go to athenainsight.com for more stories and big ideas about healthcare in America today.
KEVIN: “Decoding Healthcare” is a production of athenahealth.
JOANNA: Our producer is Nikki Zais. Our engineer, composer, and all-around jack of all trades is Mike Moschetto.
KEVIN: You can rate and review us on Apple Podcasts, Stitcher, and Google Play, or wherever you get your podcasts.
JOANNA: And you can follow us on Twitter @athenahealth. I’m @JoannaWeiss.
KEVIN: And I’m @KevinBanMD. And hey, Joanna, remember, eat your oranges.
JOANNA: Every morning. Buh-bye.