Hi everybody, thanks for joining us for today's webinar. As folks are just now able to log in, we're going to wait about a minute or two for additional folks to be able to join the webinar before we begin. So sit tight, and we'll start the webinar in about two minutes. Thanks everybody for logging on and joining us for today's webinar. We're going to wait just about one more minute. We still see people trickling in as participants, so let's wait just one more minute for a couple others to join us, and then we'll begin. So thank you so much. All right, well I feel like the popping of the popcorn has slowed down enough where we can get going here. My name is Joe Sasson, I'm the Executive Vice President of MedAxiom Ventures, and happy to moderate today's webinar on how to make value-based care work inside of cardiology. Before we get started today, I want to just give a brief overview of your perspective from the Zoom webinar system. And so what you have is really two different functions right there on the screen. The first is a chat function. Inside of the chat, although you're not able to chat amongst each other and have dialogue in that box today, you will find a link to access and download the slides that are being presented today. So this whole presentation can be downloaded by going to the chat function. The second is the question and answer area. And so in the Q&A component, that's how you'll be able to interact with us and ask questions, and we will triage those questions either throughout the session, depending on what they are, if they're logistic or operational questions, we'll answer those immediately for you from our side. And if we need to bring the presenters into the conversation, we'll make that assessment. Otherwise, these are the questions that we will get to right towards the end of the session. And so just use that Q&A to communicate any of those questions with us, please. So with that, just introducing today's speakers, we have Dr. Jason Gunderson, who is the chief executive officer and the co-founder of Cardio One, and Jim Chokolos, who's a value-based care advisor with Cardio One. And so today, they're really going to get a wonderful overview of value-based care and the transition from volume to value, focusing on a variety of perspectives, including operations, analytics, clinical and care team management, and contracting. Because although value-based care means something different to everyone, if we can start to dial in on those specific elements that we can influence in really moving from volume to value, we get a much better picture of are we doing it and are we doing it well. And so to lead us in that discussion, I'm going to turn it over to Dr. Jason Gunderson to please take us away, and I will come on towards the end for Q&A. So Dr. Gunderson, thank you. Thank you, Joe. Thanks, everyone. Thanks for joining us. I'm really excited to be here. So as Joe pointed out, I'm Jason Gunderson, CEO here at Cardio One. We're a practice management company focused on supporting independent cardiologists and really interested in value-based care. So I've worked at a number of organizations, Team Health, NavVis, CareCentrics, and had really the pleasure of working in both fee-for-service environments and in full value-based care case rate capitated environments. And so I've managed both of those, and I've actually practiced in those. Very different experiences and very passionate about really moving more towards this value-based care world. And that definition means a lot of things to a lot of people, but I like to just view it simply as getting paid for outcomes, not just paid for volume. So really excited to be presenting alongside one of our trusted advisors, Jim Chokolos. I'm going to hand it over to Jim to introduce himself, and then we'll get going. Hi. Thanks, Jason. Hi, everybody. My name is Jim Chokolos, and working in an advisor capacity with Jason and the team at Cardio One. I'm really delighted to be doing so. They're doing some great stuff in the market. My experience really is working in value-based care for over probably 12 or 13 years with Evercore Healthcare, helping develop value-based care programs in a medical neighborhood concept in cardiology, orthopedics, and oncology. Also work with Fresenius Health Partners in a CMMI innovation project to help manage people with ESRD, with partner nephrologists, and had a spell with Village MD and Optum as well in value-based care programs. So really, again, happy and delighted to be here working with Jason and the team today, and appreciate everybody joining today. Excellent. So why are we having this conversation? Some of this feels a little bit kind of silly, talking to a bunch of cardiologists and those in the space. But let's be honest, cardiovascular disease, number one cause of death in the United States, one patient dies every 34 seconds from this disease. And when we look at it, our projected increase is only supposed to continue across all the different areas in CV disease. And so it's something that we have, as a nation, as a society, have to deal with, that it's a significant component of death and mortality and complications and a real challenge for patients. It's just going to continue to get worse. And we really need to find a way of helping to drive better outcomes for patients, at the same time, reward those physicians and clinicians that are helping to deliver on those outcomes. So when people talk about value-based care, I'm sure you've all heard it. And I'm sure if you asked 100 people, you'd probably get 300 different answers per person. And really, value-based care, as I look at it and mentioned it, I look at it as being paid for outcomes. But it's a continuum. It really starts with a whole range of programs. And it's not just one thing. And I think when people look at it, they think about it as well, whether it's capitation or a case rate or a pay for performance, really thinking about it as a continuum. And you're going to start off, kind of ease into it and work your way through the continuum. And just like you're managing the continuum for patients. It's really about payment for outcomes. And one thing is that you look at as the risk increases, so does the reward. But at that point, the ability to scale, the ability to bring in tools, have larger populations become more important, because you don't want one particular case to throw things off. So think of it as the continuum. Think of it as how we're going to move that transition. People ask me all the time about, well, why haven't we moved there? There is a lot of tension between health systems and the way our current payment model works, which rewards fee for service. And as you move to the pay for outcomes, people look at it like, well, I'm going to lose some of the revenue there. That's really the dance, and we'll talk about that as we move forward, as we kind of ease into this program. Kind of the agenda as we're talking about things, just so you have an idea of what we're laying out. We'll talk about kind of defining value-based care. Again, like, what does it mean? Really presence in value-based care. It's not new. And then we'll drive into some more of the mechanics around technology, care teams, contracting, and then really kind of Jim's got some great examples of kind of the real case studies of what he's been able to deliver within the space. I really like this slide a lot, not just because we put it on the PowerPoint, but I really think it kind of outlines the continuum. So if you look here, currently we live, most of us, the majority of the country lives lower left. We get paid for volume. We see more patients, we just get paid. And then you'll see as you move kind of more sophistication, more scale to the right, also does your risk. You have some current volume-driven codes around transitional care, chronic care management, which are kind of paying for coordination. And then you move more into that, like I have paid for performance. So if I do really well at hitting metrics for my heart fire patients or my MI patients, I get a bonus. Then we move into like the whole idea of managing an event or a condition. And really this, the major model I think about in this is the bundle payment model, which is I have someone come in for a heart fire admission, I'm responsible for 90 days. I get paid for that episode. You move further down and you start getting into shared savings, which is when we reduce total cost of care, reduce some expense for the patient and drive outcomes, we get a bonus. You slide further out and you get the upside, more of the upside, but you also get the downside. And then you get into what people really look at as kind of that global payment and capitation that's super sophisticated. I think for the way we're going to see this move is we're going to see practices slowly slide to the right and you'll see fee-for-service start to come down slowly, value-based care start to increase slowly. It's not going to go from 100% fee-for-service to 100% capitation. We'll just move ourselves down that line. So just kind of, you know, why, why do this? We really want to reward clinicians for better outcomes because cardiovascular disease costs are substantially higher than many other chronic conditions, such as diabetes and Alzheimer's. And that is just going to predict it to continue to increase over the next several years. So we really have got to find a way to bend that cost curve and, you know, really by bending the cost curve, driving better outcomes for our patients. Risk-sharing models, you know, I think a lot of folks think about value-based care and people immediately think about Medicare Advantage, ACOs, primary care, right? That's where things have really gotten started and really been heavily pointed. And you'll see here, we kind of talk about high current adoption. So like where there's a lot of it, right? Primary care has already been there. Nephrology is pretty well advanced in this and started with some of the Medicare bundle payment programs, number of different components. And, you know, nephrology has a captive patient audience that go for dialysis. So the nephrologists tend to be more like the primary care docs. You're starting to see a lot more movement in oncology. Again, high cost drugs, a lot of movement into bundles, cost containment, driving better outcomes, orthopedics the same way. Cardiovascular disease, obviously driving this conversation because people are really looking at it. Again, number one cause of death, but not a lot of adoption in terms of the presence in value-based care. I know that a lot of the primary care docs are like pretty comfortable, you know, a little more comfortable with cardiovascular disease than dialysis and oncology medications. But we all know how really sick these patients can get and how complicated the disease is. The involvement of our cardiology partners is critical to driving these outcomes. And then I throw in there, behavioral health is starting to creep on to the radar. But again, another significant factor that really influences all these processes. Jim, I'll hand it over to Jim to kind of run through a little bit more on kind of the history of this. Thanks, Jason. Well, you know, value-based care has really garnered a lot of attention over the past several years. But, you know, it's rich when you go back 15 years, sort of 2008, with the launch of both MIPA and the Prometheus payment reform. You know, and then the launch of the Affordable Care Act in 2012 really helped propel the program of product development of fee-for-service to value-based care models. With the Pioneer ECO and the Comprehensive Primary Care, better known as the MSSP program, launched both in 2012, it's really a seminal program that's being part of this journey, this ongoing journey. You know, and I'm sure most of you, many of you noticed the focus of value-based care has been in the PCP space, as witnessed by many of the PCP-centric programs. Even as recently as last month with the launch and the initiation of the Making Primary Care program in June of 2023. However, as Jason just pointed out, specialists in specialty care and value-based care models have also been in existence for virtually the same amount of time. And what we are seeing, as Jason again mentioned, is a growing interest and incorporation of other specialties like oncology, nephrology, and cardiology in newer value-based care programs and models. Next slide. And value-based care models participation is expected to continue to grow. In fact, in December of 2021, CMS released a statement saying that its goal is to have 100% of traditional or fee-for-service patients and the vast majority of Medicaid patients in accountable care relationships by 2030. Said another way, CMS wants all their Medicare fee-for-service patients in a care relationship that has accountability for quality and total cost of care by 2030. Well, that in effect is value-based care, but it's not just Medicare fee-for-service patients. As this chart shows, there is expected growth across all lines of business with really the highest growth expected to be in the Medicare Advantage space. And perhaps it's not really surprising given the ongoing increased enrollment of membership from traditional Medicare to MA plans. This also shows that there's going to be similar growth expectancy for both commercial and affordable care patients. So, I think it's safe to say that the value-based care training is on the tracks and moving ahead, full speed ahead. Next slide. Sorry for the little flip around on the slides there, a little too quick with the mouse. My apologies. I'm trying to make you dizzy. So, obviously, this is one of those, you know, I just want to point out, like, the value-based care programs have a lot of benefits, right? Patients, better satisfaction, better outcomes, better quality of life. That's what we're all here to do. I know when I went to med school, that's what I wanted to drive towards. Lower cost for patients, not something we all think about every day, but as people have high deductible plans, co-pay, self-pay, like, really driving better outcomes at the lowest possible cost is really important. People don't really think about that, but it's really important. I know as a clinician myself, thinking about just burnout, care efficiency, the ability to make a little bit more money when not having to run on a treadmill, but really getting paid to drive outcomes. That's what, you know, when I went to medical school, I really wanted to, you know, take care of patients and see them get better and see them do well. Obviously, payers look at it as reduce unnecessary costs, reduce risk. It's a good thing for them. From the industry in general, I think people are frustrated with healthcare, especially as we compare it to other industries, just because some of those, you know, alignments aren't there, and there's some frustration with access and costs and kind of redundancy, but really trying to get that alignment. So the industry really is delivering what we need for our patients. And then finally, society, right? Reduce costs, better outcomes, reduce spending. You know, it's pretty, these I think are obvious to folks. And I think when we all focus on what the benefits are, I think it helps drive the energy as we need to get forward into some of these arrangements and to push through some of that tension around fee-for-service and some of the conflicts people say. Going to run into some thoughts on how to make value-based care work. Like, how do we do it? I'm sure there'll be questions, but, you know, we'll kind of run through some of the higher levels components here. First thing I say, the fundamentals are, you have to have a great practice from day one, even in the fee-for-service world. If your practice isn't really running well, and I talk about some of the basics, ability to get a patient in to be seen. I like to tell the story. So I, you know, had a little issue. I see a cardiologist. I'm new out here in the Denver market. I don't have a big network. I can't get an appointment until September, which is just a little crazy, right? You know, if you're having an issue and you want to get seen, a month, six weeks just doesn't work. So if you have a practice, you need to have patients have access. They need to have a way to interact. They need to have a way to reach out and get ahold of people. Because if patients can't get in and they can't get access to their cardiologist, they're going to go to the ER. And we all know when they go to the ER, they're going to get admitted and, you know, off we go. So really thinking about how do we get our practice running great today? And I would tell you that a great running practice today, even in the fee-for-service world, with, you know, great patient access, great patient experience, is going to drive your business in a good way, just even in growing your business on a fee-for-service side. We then move into identification analytics. You need to know who these patients are. You need to understand kind of what their risks are. How do we identify them? Are they in a program? What's their risk? How do we figure out what their risks are? Right? And so we know what to do. Then we get into interventions and care management. I will tell you that most people I talk to that want to get into value-based care immediately jump to number three. They think about, well, I need a care team. Just take a pause. You need to be able to have great access, everything else. Identify patients. And then know what to do with your care team. Right? So if you don't have the analytics to make an intervention, if you don't have the analytics and the issue, you're kind of don't know what to do with them. So I actually think we need to kind of like walk before we run. And that's where I think people kind of get a little ahead of themselves. And then finally, reporting and contracting. You have to be able to demonstrate your results or you're not able to move forward. So when I talk about this, I like to say, especially here, like with the Cardio One team, we build things, solve for today, build for tomorrow. We live in a predominantly fee-for-service world. How do we solve for today? Appointment availability. That helps solve for today, gets me revenue, helps my practice grow, patient engagement, patient caregiver education. How do we code and document? That's all critically important to even contemplating how to move into a value-based care arrangement because we have a better idea of like how sick our patients are and the rest. Coding and documentation, let's face it, is not fun for any of us. Like we didn't go to medical school to be typing in the EMR, but finding ways to consolidate that and getting that together is important to build, to know what your patients look like to move forward. And again, TCM, CCM programs are kind of opportunities today to start to drive the business forward and they're fee-for-service generating codes that do good things. And then when we talk about bill for tomorrow, things that will really help drive the outcome we're trying to do. Remote patient monitoring is something I'm particularly a fan of. So if we're trying to keep heart failure patients out of the ER, remote patient monitoring is a great tool. They step on the scale every day. We see the weight change. We can reach out, make interventions, and then you move into some of these care team development, high-performing networks. This is where I think cardiology really needs to be. If you're the high-performing cardiology practice and you reach out to some of these primary care groups or to folks and they say, hey, that cardiology group's high-performing, we know what to work with them. When I worked in our value-based care in the full capitation arrangement down in South Florida, when I was at Team Health, we had extraordinarily narrow networks of specific cardiologists that our docs worked with and we all worked as a team. They knew how to get a hold of folks, follow up, pathways, super important. And then you get into data analytics and pair contracting. This is where scale becomes an issue where, you know, working with another organization that helps you build that is really important as you move forward into those programs. Some of the mechanics of this, technology is great. I think technology is an integrated portion of what we need. I think it needs to be integrated. I'm sure none of you want another app or another login. And it needs to be coordinated. Like I always like to talk about, I think I have nine Epic MyChart logins for all the different systems I've had to go to. I like to think of myself as fairly healthy, but, you know, I've gone places. I have multiple logins. But again, technology is the core. It is there to help the program, not to do everything for it. So you've got technology integrates with data analytics to understand how to identify patients, know what you need to do, drive your outcomes. Contracts obviously need to be the vehicle by which you get paid. Care teams come into the mix around how you make those interventions. So all that comes together. What I like to tell folks to think about is, think about all the levers you have. So if you think about ways that I like to like reduce readmissions, like what are the levers we have? Well, we can use remote patient monitoring. We can get patients in within 24 hours of discharge. We do medication reconciliation, coaching. When we have those, we then get to a contract. We can say the contract says I'm responsible for readmissions. I can say, oh, I've got the levers. This is how I can move those. So all this kind of integrates technology to support and the data to support the care teams all driven around the contracts. Three major areas I like to think about how you build the infrastructure, identify, support, report. So you need to identify your patients like we talked about. So tools to identify patients by cohort risk and identify patients like, oh, they're in the urgent care and maybe I should call down there. And what can I do to make an intervention? And then how do I stratify those? Like those are we know patients are going to need more interventions and some are going to need less. So identify then drives to support. This is the part where us doctors really like to jump in and be like, hey, I've got the answer, which is, you know, the the the fix to it. The support is clinical decision, like how do I figure out what patients need to drive my care team and then how do I drive my outcomes, get to know your patients, what do they need, whether it's a social support system or a medication change. And then again, we go into reporting, reporting in two ways, reporting to the team to know how they're doing. One thing I like to say is you really want to stay ahead of your value based care payment models. And what I like to say is you all know when you send a bill to the insurance company, right, it's months before you get paid. Well, what you don't want to do is be working in a model where you're at risk for either for some incentive or some repayment or a bundle. You want to know the kind of day to day. Oh, I'm doing pretty well. Things are moving forward before the payment lags sometimes three or six months behind you. So that's the reporting. The reporting is current reporting. How am I doing today? And then finally, the other reporting is like, OK, this is how it actually came through on the claims data. What am I doing? How do I follow up on folks? And then technology. Favorite task for a lot of folks to talk about, technology needs to be integrated, having a platform that sits somewhere different than what you're working in every day and your practice management platform isn't going to work. One, it's too cumbersome. You want the alerts to be there. So I like to talk about a value based care technology platform needs to have everything from kind of your billing claims, authorization data, contracts, utilization management. Some of those things you're working in fee for service today. Some are more important as we move forward. Then you move into the kind of help with care coordination, patient activation, identification, risk adjustment, reporting care. All those components need to be integrated with the practice management platform so that you as clinicians, when you're seeing a patient, because one thing I think you will realize is you're going to have to see fee for service patients next to value based care patients and like how those alerts work and help you drive the outcome. So, you know, we've built a fully integrated platform where everything flows in one. So all the physicians and clinicians have one single solitary view of the world. I think that's going to be the key. We all don't want any more alert fatigue as we move forward. The importance of care teams, I won't read through all these, but obviously the care team is is really a team, right? It's medical assistants, nurses, physicians, social workers. Everybody's involved. The person answering the phone is involved. The person answering your phone doesn't know that, hey, we got to get this patient in and reach out and activate. It's not going to work. So you need to make these care team responsibilities responsibility of the whole team so that everybody's advocating for patients. Everybody knows the outcomes we're trying to drive. Everybody knows who to reach out to to solve problems. So I think as you look through some of these components, it's really important to kind of work through. And I think just some tips for a successful care team. It's really a team, right? It's whoever answers the phone, it's whoever sees the patient knows that, hey, I've got to get an outcome. Something's not right. I don't know the answer. Where do I go? Really try to work towards helping that. I like that term more than patient engagement, the term patient activation. So the patient feels involved in their own care and just work on the more communication, the better. Busy slide, I know you'll have some of the chance to look at these afterwards. This is really like the patient view, right? So if I'm a patient, I've been a patient, don't really like being a patient very much. I'd rather not. But really trying to think about how does a patient view this whole value based care thing, right? Because they don't really understand it as value based care. They just view it as, hey, I'm sick or I've got a problem. How am I going to get it fixed? So it starts with like, you know, this we've kind of drew a journey out here. It's like access. I have an issue. How do I get access? I go back to that point about whether it's electronic activation, telemedicine visits after our Caroline or the ability to get in to be seen right away. Super important. Then I move into, hey, someone took care of me. Like, how do I kind of work with that? You know, is it is the check in process seamless? Do I have an efficient visit with my provider? Are they staring at the computer screen, clicking the whole time or are they talking to me? Can I figure all that out? Do I have a portal post visit, which is I left who follows me up monitor? How do I make sure I'm actually getting better? Did I get my medications? Hey, I don't feel right. What do I do? And then just that circle runs around. Just look at it as a patient. They need to come in and we need to build the technology and the system to surround them as they go through access care, follow up monitoring and hopefully. Not continue around the path, but just then they move into chronic care as we go forward and hand it over to Jim, we'll talk a little bit more on the contracting part of it to see kind of how that all pulls together. Thanks, Jason. I'm sorry, there you go, OK, well, no, no worries at all in general, the overarching objective of any value-based care contract is to achieve the quadruple aim. What's the quadruple aim? In fact, I'm sure many of you on the call, if not all of you familiar with the triple aim, which was introduced in 2008, quadruple aim was introduced in 2014. So what are the elements? What are the goals of the quadruple aim? And they're pretty simple, but very, very important. It's to improve the health of populations. It's improve the patient experience of care. It's to reduce per capita cost of care or reduce total cost of care and improve the provider or care team well-being. And this last component was the one that made it from a triple to quadruple aim back in 2014. So, you know, as we think of quality of care and cost reduction within a within a quadruple aim framework, there are really very standard metrics and measures that are included in any one of these contracts. And those are some Jason mentioned already, but very, very important reduction in admissions, reduction in readmissions, reduction in ED utilization, appropriate testing and diagnostic utilization and also access and timeliness to care. An example of that would be somebody being discharged from the hospital, getting that patient back into the office within a reasonable time to see them. And there are national benchmarks to be used to track and report these these important measures. MIPS is one that I trust many of you familiar with. ECQMS are also is another benchmark to be used for tracking patient care and safety care coordination. HEDIS is important. HEDIS contains the HCC scoring measures, which helps generate something called a RAF score, RAF being the risk adjustment factor. And if you think about that, really it's just a patient identification or really what does it defines the acuity or sickness level of your population of patients. And that's important, too, because the the RAF score does impact the amount of dollars CMS gives to both the MA and the exchange plans. So as you continue through this journey, moving to value based care and population health, it is essential to have the infrastructure, tools and resources that Jason talked about to be able to report these measures and metrics appropriately and consistently. Next slide. Next slide, Jason, maybe it's coming up. It should be up. You guys seeing it? Not yet. There we go. So overall, value based care contracts are pretty standard with similar elements contained in each one of them. I'm just going to point out two or three this afternoon that are the most relevant or important. The first is attribution. There are different attribution methodologies that are used in value based contracting with prospective and retrospective being the most common. But whichever is used, understanding attribution is important for a few reasons. Number one, it defines the population. But that's also important, too, because it also identifies which provider is accountable for the individual's care many, many times. It also allows for accurate performance measurement of the population that you're managing or the membership. It also allows for appropriate resource utilization for the membership that you're managing. And I like this, too. It also identifies for targeted intervention opportunities, especially for members that have chronic or comorbid conditions. A second element is quality and performance benchmarks. And this part of a contract is key because it also it helps identify agreed to measures and metrics that you agree to with the payer and or if you're a subcontractor or subcap provider, Jason alluded to working with some at risk providers. So this is important. No, it really gets back to achieving these measures and metrics that will translate into maximizing your payment opportunity. And a third area is the reporting and data requirements section, because it's critical to really understand the types of that you'll need to for the for you need to furnish it in and then the deadlines for submitting it, et cetera. This also includes data sharing requirements and responsibilities of both parties. Next slide. It's up to you. Yep, got it. Yeah. Once the contract's put in place, it's pretty imperative to identify what's most important, what matters the most to the payers or whoever you're contracted with and put processing workflows in place to really address them all the time. Specifically, if the focus is on the payers and the subcontractors, it's really important to identify what's most important, what matters the most to the payers and the subcontractors, what matters the most to the payers and the subcontractors. Next slide, please. Again, it's up to you to identify what's most important, what matters the most to the payers and the subcontractors, what matters the most to the payers and the subcontractors, what matters the most to the payers and the subcontractors, and put processing workflows in place to really address them all the time. Specifically, if the focus on those measures and metrics that have been agreed to and establish processing workflows that begin to track these measures and then have the flexibility within this workflow to shift protocols and processes to make them more cost-effective, to improve performance, maximize quality care, and to mitigate unnecessary downstream costs. And on the right, we've really identified the top cardiology value-based care metrics by the size of the cost impact. And I think if you look at these, you see there's really no surprise that three of the top four cost drivers associated with a hospital setting, while the others are based on provider utilization and care management protocols. What type of costs are happening in a value-based care contract, it's very important that all these are identified early on and solid steps are taken to address and reduce them at all times. Next slide. So I'd like to talk a little bit now about present and future-based cardiology in a value-based care setting. Thank you, Jason. So I've had the good fortune of witnessing being part of cardiologists being rewarded for good clinical and financial performance in a value-based care and risk and population health initiatives. And they did this by doing a few things. And I think the most important one was to make a firm commitment to transition from a volume-based to a value-based mindset. They also took the time to fully understand the basics of the value-based contract, including, again, the quality metrics that they agreed to, and they could realistically achieve and continue to manage throughout. Also, they established, again, the processes that reduced unnecessary utilization of high-cost services and facilities. They also took the time to really understand the financial performance metrics and were sure that they were based on realistic thresholds. Additionally, what they did, they took the time to, it was critical they educated their staff and all the providers on principles of value-based care and population health. So as potentially practices out there that are looking to move toward a value-based care of population health mindset and journey, I mean, I think one thing you'll do is you'll start appreciating and understanding risk stratification, how important it is to be able to manage different patient cohorts within your practice as shown in the triangle here to the right. That's why it is very important to really have the right partner that can provide the necessary tools, technology, and infrastructure to help implement these changes within your practice. Next slide. I think we're very successful working with independent cardiologists in our program. So the first thing we do is whenever we went out and met our independent cardiology groups, I would ask them what their pain points are. I said, what can I do, what we do as our care team to make their lives easier? And virtually without exception, the number one thing they said was anything you do to help us when our patients hit the ED, that would be very beneficial and very welcome. And specifically told us that when a patient hits the ED, they get lost. The cardiology partners had no visibility to the patients. And as a result, many times patients would get admitted without their knowledge. The ED doc would get them, the hospitals would come on down, they'd admit them right in inpatient. And of course, there were leakage concerns. A lot of times there were leakage concerns when this happened. And also there was no insight when patients got discharged from the hospital. So this whole ED becomes many times became a black hole for cardiology partners. So really after analyzing our different options, and there are several out there, we land on the solution we took back to our cardiology partners, talked to them, vetted it out with them, and really wanted to talk to them about confirming their adoption, which they did. And ultimately we landed on a solution we called the ED Optimization Program. ED Optimization essentially was partnered with a third party to deliver real-time alerts into the cardiology practices at any site of service within our market. We're focused on the ED, but this particular technology also allowed for alerts to the happen at, for example, let's say down at a post-acute care center, at a SNF or an LTAC or home health. These alerts would come into the cardiology practice in various ways, email, through patient portal, via text, or any or all of the above. The practice had their choice. Concurrent to that, as we were setting this up, and we're very close with our cardiology practice partners to make sure that they provided the infrastructure via care teams, or one individual, or sometimes even more care team that would accept the alerts. So when the alerts, we launched this, the alerts began happening, there was somebody or some folks within the practice that would accept these alerts, take that alert, and provide it to the appropriate caregiver within the practice. That could have been that patient's doctor. It could have been the doctor on call that day. It could have been a mid-level, whoever it was. It was then the responsibility of that individual in the practice to contact the ED, contact the ED physician, contact the ED nurse, and formulate a patient disposition. Why was my patient there? Let's face it, the cardiology practice knows their patients better than any ED doctor or hospitalist, that's for sure. And the best thing was that they were able then to determine the best course of action for his or her patient. Well, the end result was that this real-time intervention led to significant things. It led to significant ED production spend, admits, and even if admissions happened, what we found is by having the cardiologists intervene, oftentimes they would go to a lower acuity setting, low observation, versus a full-fledged inpatient admission. We were able to reduce remissions, and also, I think critically, we were able to provide our cardiology partners visibility and control of their patients, and ultimately the treatment plan. A side note, too, these alerts also provided our cardiology partners alerts when the patients got discharged. So back to visibility upon post-discharge, they were able then to proactively reach out upon these alerts, grab their patients, and have them come back into the office very expediently. From a cost standpoint, from a financial economic standpoint, generally a heart failure admissions around $11,800. So by virtue of this ED avoidance or optimizing the ED experience, we're able to avoid that heart failure admission and save $11,800. Generally, in a shared savings agreement, a 50-50 shared savings split, that would put about $5,900 straight into the shared savings pool for cardiology partners. Additionally, from a quality perspective, there's an ED avoidance, there's improved patient experience, and again, any out-of-pocket costs were mitigated by having this in place. So very successful and worthwhile experience. Next slide. Thanks, Chase. Another real-world example which had huge impact in quality and utilization was, as we started engaging with cardiology partners, we took a deep dive into data, all types of data, where they're doing things, how they're doing things, utilization, facilities, everything involved in a cardiology practice. And one thing we saw all the time universally was that there was a high incidence of catheterizations being done, not preceding cardiac intervention. Let me say this another way. These were caths that were performed without any subsequent coronary interventions. So our methodology was, we took a six-month look back. We'd look at patients that had caths done, take a six-month look back. And what we found was that 66%, or two-thirds of these patients, did not have a coronary intervention post-cath. And by that, they didn't have a PCI or a stent, a bypass, a TAVR, or mitral valve clip. And this data, our findings were actually supported by a Truven study that was done between 2015 and 2018 in a commercial population that found similar results that these cath percentage rates was consistently above 60% as well. You know, we discussed these results with our cardiology partners, and we had some long and hard conversations about this. And what we ended up deciding on, agreeing to, was to utilize coronary computed tomographic angiography, better known as CCTA, as a first-line diagnostic gatekeeper procedures for patients that had stable chest pain and low to medium risk of coronary artery disease, CAD. Our decision was actually supported by a pretty seminal study called the CONSERVE trial, and also at the time by newer national guidelines that lists CCTA as a class one recommendation for the evaluation of stable chest pain patients in patients with intermediate to high risk. So similarly, once our cardiology partners agreed, then we worked with our partners to make sure we implemented this from an operations perspective, made sure we identified the appropriate patients that were cath patients. We then got full buy-in from all the providers within the practice to make sure that there was willingness to support CCTA as the low-cost front-line or first-line option for these patients. But ultimately we decided that the decision point was we allowed our cardiologists, of course, to make that decision. After CCTA was done, it was up to cardiologists to decide if they wanted to proceed with the cath or not. But the results actually were unique and I think very exciting because we find that there's a sizable amount of our patient cases that did not result in cath procedures after CCTA was done. The result, again, from a financial standpoint, was generally a cardiac cath costs about $8,600. CCTA is 500 bucks. That's a saving of $8,100. Again, if we take that same example of a shared savings agreement, 50-50 split, that's a little over $4,000 that got banked right into the shared savings pool for the cardiologist. From a patient standpoint, it reduced the unnecessary invasive procedure. It improved the overall patient experience and we had a basically similar outcome with much less patient disruption. Next slide. Thanks, Jim. So here's the one question people often ask me about, like, well, how do I work with the PCPs? And I think this is really one of the key components. And one of the things that frustrates me a little bit about medicine is that we don't, like, we could collaborate a little bit better. The systems aren't particularly great and let's face it, you know, reading progress notes doesn't really cut it. So I like to talk about these five bars of like how do we collaborate with PCPs. So number one, communicate. The fastest way to solve things in healthcare is to communicate, you know, get on the phone, reach out via email. I think the phone's the best way. Collaborate, look at your ways that you can solve for issues that the PCPs are struggling with. And I think we really need, the PCPs need to see that, especially with how complicated some of our patients get. Cooperate, figure out ways to kind of work together. Non-compete. There's always a little bit of a touchy one, right? We're not there to compete with the PCPs. And I think too often in healthcare, we get caught up in what I call zero-sum competition, which is in order for me to win and you have to lose, we want competition as like our, you know, you as the cardiologist and your PCP partner are driving such great outcomes that you're both winning and patients are getting better. And then finally, you can actually build contracts. So I will tell you that I worked in South Florida. I built, I had a very large hospitalist program. We did 125,000 acute cases a year and 25,000 post-acute cases. And we did them all under flat case rates or capitation in partnership with a lot of full risk Humana centers, other big MA plans. You know, in that program, we had a deal where when patients got admitted, where we were a narrow network of, we had a narrow network of hospitalists that would go down and see them in the ED, talk to the patient. We would immediately call the PCPs and the PCPs would answer. And we would talk about the patient and we had a very robust program that we could send patients home and avoid admissions. We would send them directly to a nursing facility if they needed them. We had a narrow network of cardiologists that we were also partnered with all working together that we would get on the phone. So if a patient came in and was a heart failure patient, we'd call the PCP, call the cardiologist. We'd have a conversation. They'd say, oh, you know what? Send them right over. I can see them in the office today. I'll take care of it. That level of collaboration, patients were able to like, no one wants to be admitted. Patients had great outcomes. And it was all about this whole idea. We would talk to each other. We would collaborate. We would figure out what worked best, help each other out. We weren't competing. And we actually did have a contract that defined how much we all got paid for those. But those are ways you reach out to your PCPs. I was just talking to a cardiologist in the Philadelphia market. He's like, hey, can you come up and meet with this large IPA group of PCPs and we could talk about how we put something together? I live to do that. That's like the best thing to do. So I'm gonna hand it to Jim. He has this really great PCP care compact and then we'll wrap up. There you go, Jim. Thanks, Jason. Yeah, one thing Jason talked about is the necessity of working very, very closely with PCPs. So one thing we figured out pretty quickly in markets is who the strong PCPs, where those relationships exist. And we wanted to enhance those relationships. So we developed a care compact with the PCPs in the market. I mean, what's a care compact? It's essentially just an agreement between the PCPs and in this case, the cardiologists. And broadly speaking, what a care compact does, it really defines the referral protocols between the two practices. It helps defining the care transition expectations and the care management responsibilities. And we found there really four steps to a care compact. The first one being just identifying, talking to each other and identifying where the gaps and challenges are to collaboration. Where do they exist? Where do those gaps happen? And then how the care compact and the care compact language can help address and remedy those gaps in care or collaboration. Care compact also one of the steps to sit down and agree to both short and long-term goals and that how these goals can help enhance and highlight provider accountability. Critically is both entities need to educate staffs, train and educate staffs on the goals of the care compact along with their individual role and responsibilities. And then finally, after the care compact is executed to hold ongoing and regular meetings to assess performance, identify opportunities for improvement and refine the existing procedures and protocols as needed. So overall, the care compact really strengthened our relationships with the primary care physicians in the group, in the markets, and also provided really high quality care that addressed and met the needs of our individual shared patients. Thanks, Jim. So wrapping up and hopefully we'll have some questions to go through, some thoughts on this, right? As we summarize, this is a big task, right? So let's begin by building out testing small capabilities, try the care management programs, you wanna get prepared for where this is coming. We've been talking about value-based care for a long time. Some people don't believe it'll actually get here. I do believe it will actually get here. I think it needs to get here sooner, much, much sooner than the pace at which it's moving. Stabilize and optimize your current optimization, your current practice. Like remember, great practice today is gonna help you move into these programs in the future because you're gonna ease through those. Start thinking about technology care teams and contracts that kind of help you execute a report on quality metrics. Remember, value-based care, we talk about the payment of it, but the ultimate goal is you do the right thing for patients and you drive quality, but financial should follow you. That's not currently how our system is set up. Currently, we have great outcomes, but the more visits is how we get paid. What we're really trying to drive towards is the better we execute, the contract should follow. Ease into those value-based and performance-based contracts, right? Don't jump into a capitated arrangement because when people, I hear from people like, oh, I entered this program and I did terrible, I'm never doing it again. So think about how you ease into that continuum, pay for performance, episode, shared savings. Think about that graph. Be thoughtful with your primary care partners as we just talked about. And one thing I would say is you do need scale and leverage to really succeed in that. Scale and leverage in your own office by partnering with other programs to help build systems and scale and leverage by working with your colleagues, your PCPs, other specialists, radiologists, everybody needs to be on board to scale and move those forward. I'm gonna click it over to questions, but I'll put it out here. This is my direct cell phone, my virtual cell phone. I've had it out there forever. If you have any questions, please feel free to call me or email me. I hope you can tell I'm very passionate about this and love talking to folks about how we can drive this forward. But thanks for the attention today and hopefully we'll have some time for questions. Joe, I'll hand it back to you. Yeah, wonderful. We do have some questions that have come in, so we can jump right into those. Also at the bottom of your screen, as we started out with, I know some folks came on a little bit later, but at the bottom of your screen, there's a button to do Q&A. And if you submit questions through there, we will get to those at this time. They'll be put in the queue for us to answer. So please feel free to submit some more. One question that came across, and this can be for you, Dr. Gunderson or Jim, has to do with remote patient monitoring. And obviously, if that's a portion of what you do, whether you have an in-house platform or whether you've looked at some outside of your organization, and who do you recommend for cardiology for remote patient monitoring platforms? What have you found to be effective and what do you use? So we used an outsource integrated platform. So a couple of thoughts on remote patient monitoring. I'm a big fan of it. I do think you need to work, in order to get scale, you need to work, I really do believe it needs to be working with a larger vendor, right? Because patients are gonna get, you need to manage the device, all the billing, someone can handle that, that gets to the scale. One thing that you'll get that I don't want people to get is alert fatigue, right? So if you do it yourself and you don't have someone helping you out, anytime the blood pressure is one point over what is the upper threshold, it flags, you get an alert. So I like working with a company that has a scale of having a nurse that can look at those, figure out like what needs to be called, when that doesn't need to be called. And then, you know, we work with our docs to set what specific parameters like, hey, this is really important, I wanna hear about this. Some of my heart failure patients, weight goes up by two pounds, I need to hear about it. And so I think you set those parameters with the nurses is really important. And one thing about doing it yourself, I've talked to a lot of docs about this. There's a liability, I think, when you do it yourself. So if a patient puts their blood pressure cuff on at 11 o'clock at night and it's sky high and there's a problem and it comes into your system. So I think you need to have 24 seven capabilities. So that's why I like the scale of it. And I do like the integrative aspects. So we integrate our RPM platform directly into our EMR. So all the results come in, which is great so the docs can see them, but physicians can order the RPM from within the platform. So you don't have to log in separate. So I'm a fan of looking at some of the programs that are out there that will provide integration to your EMR, both for ordering and for results that have a strong clinical team that can help you figure out how to manage alert fatigue and a platform that does a great job using equipment that is cellular capable. When you have a one that's Bluetooth or Wi-Fi and the patient's not near that, it doesn't work as well. So those are a couple of the key points. Hopefully that's helpful. Thank you. If there's any follow-up questions to that, we're always able to filter those through the Q&A. Another one that's come through here is, do you think cardiovascular professionals should push health plans to use more registry-based quality outcome measures like NCDR? So should we, in practice, be pushing payers to use more of those quality-based registries? I think they're always a good thing to have a quality and a database of it. I think they can add value. I don't want them to become a barrier because I don't want it to become like a barrier on a reporting side where it doesn't do that. What I would say is that if the payers are using those databases and using quality outcomes, whether it's via the database, wherever they're doing it, to construct their contracts, I think that's where we need to move towards. Because you really want to be paid, like we'll go back to that. I just want to be a way to be paid for outcomes. Registries are great. There's a ton of them out there, right? They've had them in like, I know Jim went through a bunch of those. I think as long as they make sure that they use it as a, I want them to use it as a carrot, not the stick. How about that? Sure. Great question. Jim, anything to add? No, I'd agree with Jason. I think there's plenty of opportunity for what currently is in the system right now. I think adding those to the system adding those to the mix would be, I think a little bit, complicate matters. I understand the question, but I do think right now that there's plenty of opportunity now to report the metrics and measures in existence right now. Great, thanks to you both. We've got another one here. We'll just keep on going with the time we've got. The question is, I'd be interested to know if you're seeing much traction in cardiology groups taking sub-cap on different populations. So I guess capitated on a subset of the population, similar to how some point solutions would do with like chronic kidney disease, hypertension management, et cetera. So you do see people going at risk for certain measures. Are you doing that on a certain patient populations on a sub-cap basis? So I think there is an interest in doing sub-cap. I would say that the market is probably, the tendency is more towards, let me kind of phrase my question better. Yes, on the sub-cap, so moving risk down. The way that I think most of the larger at-risk PCP groups are looking at it are disease specific and they tend to like bundles or case rates rather than the full cap risk. That has been a little bit easier for folks to kind of figure out how to contract. I believe that's because the BBCI program was out and kind of established like an admission and a 90 day window. That's a framework to work behind. And if you asked me, I think most physicians that are not as comfortable in like a full capitated, like PMPM program, the idea of like I get paid $500 for a heart failure is easier to understand like where the levers are rather than the floor. So it's a little less scary for both sides and it's much more defined because we've had successful models of bundle payments. So I think they're doing sub-cap by diagnosis and we're seeing much more kind of case rate or bundling rather than a full PMPM. And the reason for that without getting too complicated on folks is some of that attribution starts to get a little wonky. It's easier to do it on a case or bundle. Yeah, I would add real quickly to Joe. I agree with Jason. I think one thing I've seen as well as cardiology groups, especially those high-performing narrow networks to certain markets taking risk and basically carving out certain elements of cardiology spend and taking risk basically for that uninsured savings. So bundles are one thing but I do see shared savings opportunities as well to take for the cardiology practices taking risk, especially sub-capping themselves under an at-risk PCP group. Yeah, I see that. I agree with you guys. I think that bundle payment space, whether it's around a TAVR or PCI or anything else is a really, really good way to get in there with less risk and have defined episodes. And that's a lot less scary to me than a PMPM if I was entering this space. And then I can focus my efforts on shifting care. So I think that's a great answer. And I think that's right for people transitioning into value-based care. We have very little time left. I'm gonna ask one more question. I'm gonna ask two more maybe. But with already tight margins that are out there, how can private practice cardiologists incorporate value-based care given how expensive some of those solutions really are? So the margins are already tight. How am I gonna go at risk? So I think, well, first I would say that goes back to ease into this. So don't go downside risk, go upside, right? Go for a shared savings program where I work on that. So I would say that's the easier way to look at it. Like look at it as I could make more, but I won't get hurt. And that's how you start to move into those. One and two, scalability. I can't stress that enough. Whether you work with an outside company, how do we get independent cardiologists to work in a network so you can kind of leverage scale so you can work with other folks? That's really key. So I would say one, ease into it. Go for like the episode upside only, where I make a bonus and then look at my current capabilities and look at what I need to work with other organizations or other independent cardiologists to come together to find a way to kind of get the scalability of some of those solutions like RPM or care coordination and the rest. And I'm talking fast. And so I know we wanna get one more in after this. I'm gonna get one more in. So thank you for that. What has your experience been with managing the subspecialty care such as hypertrophic cardiomyopathy or pulmonary hypertension or CHF or how do you reduce risk in those areas? And what's your experience been? So how do you reduce risk? So that's a big, long question for the, like I call that the hand on the doorknob question for us doctors when you put your hand to go to leave and the patient says, oh, I have chest pain. You're like, oh, that's a rough one. So disease specific, yes. I think the ones where folks are really focused on, I would say heart failure is probably the most attackable and needed intervention. And I think those start off with partnering with PCPs, looking at, I mean, I think heart failure is probably the number one, it's the number one cause of readmissions. And we have some markets with readmission rates, 27 to 30%. So those are how you go in and you can kind of look at those constructs and say, all right, this patient, heart failure patients, they're really struggling with readmission management. And so you can build a pathway to pull the levers to reduce the readmissions and drive forward. I think as you move into some of the other ones, hypertrophic cardiomyopathy, some of the other more complicated ones, the other thing I would say that makes those more challenging is the N is smaller. So start with the big N, like lots of patients with a big problem to attack, you have a lot more wiggle room to move forward. So I would say heart failure, some of the AFib programs, severe CAD, those are ones you really jump at because they're prevalent, they have big costs associated with it, so you can move a little needles and you move forward. I try to do that as the hand on the doorknob. Well, we are a minute over. I appreciate everybody hanging on for that extra minute. Any final comments, Dr. Gunderson or Jim? No, I would just say we're super excited about this and thank you, Joe and MedAxian team for inviting us to be a part of this and work with you and present on this. Looking forward to what we all can do together to drive cardiology into the forefront of value-based care. So again, reach out if you need me and Jim, I'll let you kind of close it out. Just want to say thank you as well. Thank you, Jason. Thank you, Cardio One team and Joe and MedAxian team for allowing me to be part of this as well. So it's been great. Thanks very much. Well, thanks to you both. This has been a wonderful webinar, extremely informative. That will conclude today's webinar and we will follow up with any additional questions and link to the recording. So thanks everybody and have a wonderful afternoon. Bye now.

value-based care

cardiology

transitioning

collaboration

practice foundation

patient access

data analytics

contracts

outcomes

implementation