Putting Primary Care First: A Blueprint for Community Health

00:00:00:04 - 00:00:20:02
Tom Haederle
Welcome to Advancing Health. Many people may think of primary care and a visit to the hospital as distinctly different paths for their care needs. But as we hear in this month's Leadership Dialog podcast, more hospitals and health systems are investing in preventive primary care to keep patients healthy.

00:00:20:04 - 00:00:39:26
Marc Boom, M.D.
Greetings, everybody, and thank you for joining me today. I'm Mark Boom. I'm the president and CEO of Houston Methodist, and I'm the board chair of the American Hospital Association. As we continue with these discussions, we're going to focus today's conversation on something really near and dear to me as a primary care physician myself, which is the rise of primary care as a key strategy for so many hospitals.

00:00:39:27 - 00:01:00:13
Marc Boom, M.D.
Some may obviously not immediately think of very acute care hospital or health system when thinking of primary care, but increasingly our hospital field is getting much more involved and for very, very good reasons. Because our core mission is to keep people healthy. And certainly that means providing very high quality care when a patient is sick and inside our organizations in the hospitals,

00:01:00:13 - 00:01:21:17
Marc Boom, M.D.
but even more so, it means helping patients access preventive services that keep them healthy and out of the hospital in the first place. There's tremendous value for everyone in ensuring that patients and communities have access to primary care clinicians and clinics for screenings, wellness care, as well as a trusted care team to help with chronic disease management and other drivers of health.

00:01:21:18 - 00:01:43:24
Marc Boom, M.D.
So investing in primary care prioritizes a patient's overall health and helps avoid costly or unnecessary emergency department visits. I'm joined today by a guest whose health system really understands these reasons of why investing in primary care is good for patients. David Banks is here today. He is the CEO of AdventHealth, an integrated health system that serves communities across nine states.

00:01:43:25 - 00:01:47:12
Marc Boom, M.D.
David, thank you so much for joining us. And let's get started.

00:01:47:15 - 00:01:50:09
David Banks
Yeah, thank you for having us. It's really an honor to be here.

00:01:50:10 - 00:02:05:20
Marc Boom, M.D.
Well, I'll start very broadly. I'd love to just...tell us very briefly about AdventHealth as a whole, and then talk to us about how AdventHealth thinks about primary care as a strategic priority and how you thereby support primary care and all of those communities that you serve.

00:02:05:22 - 00:02:43:08
David Banks
Yeah. So, AdventHealth, our roots go back to the late 1870s, the sanatorium movement, and actually John Harvey Kellogg. And so this notion of staying healthy has been at the core of our organization's founding. And so fast forward to today, AdventHealth serves over 10 million people in nine states, as you mentioned. Initially were a hospital centric company, but we decided in 2023 that we needed to fundamentally reset our primary care strategy. In order to have exactly what you open with the most pervasive community impact,

00:02:43:09 - 00:03:01:21
David Banks
we knew we needed to get outside the walls of the hospital and really create care relationships at a community level that could be longitudinal and help people really live at the top of their health care potential. And we think primary care is an essential component to get that done.

00:03:01:22 - 00:03:18:16
Marc Boom, M.D.
Well that's fantastic. So talk about a further role in terms of how primary care plays expansion to access. Talk about how you make decisions, about how you invest, because there's different ways and explain some of those different ways and where you invest in primary care.

00:03:18:19 - 00:04:07:09
David Banks
Yeah. So the key decision we made in 2023 was to really take apart what was our physician network, move it into its own operating division, not a hospital division, but an operating division that had as its focus primary care. And so for us that spans created better definition for four ways we seek to connect with our communities. And that ranges from virtual 24 hour access, primary care all the way up through really complex senior care models for older individuals that may have a variety of clinical conditions, that with the right level of primary care and turn in primary care, really allows them to manage the complexity of their chronic conditions in a way that

00:04:07:12 - 00:04:25:24
David Banks
keeps them out of the hospital, keeps them from bouncing between doctors and really having a coordinated experience. So we realize primary care is not one thing. For some folks it's same day access, don't need a longitudinal relationship. Just trying to solve a problem to more middle range, which is the primary care I like. I want to know my provider.

00:04:25:24 - 00:04:41:24
David Banks
I want a longitudinal relationship - up to that more chronic care, complicated levels of primary care that really require care coordination across multiple specialties to ensure peak health for folks that are dealing with a number of issues.

00:04:41:26 - 00:04:49:26
Marc Boom, M.D.
I'm curious, do you have people move from one of those different type of channels to another? Does that happen frequently?

00:04:50:01 - 00:05:15:04
David Banks
We do. In our traditional primary care offering, if you will, as they start to age into Medicare, we encourage them based on their clinical conditions, the support they need - they can either stay put or maybe they the senior care model really is a better model for them. There's just a lot of consumer choice that's built in in all of the models that that we have, and we realize that was essential.

00:05:15:04 - 00:05:45:26
David Banks
What was so interesting to us when we started is how few people really had a longitudinal relationship with their primary care doctor. And when we investigated that as to why it really came down to a question of value, we realized we needed to change our offering, support our clinicians better, and create more comprehensive clinical models that really allowed them to engage more fully with their patients and create more solutions for their patients in a way that the patients could find more value.

00:05:46:01 - 00:06:08:09
Marc Boom, M.D.
And I assume that the clinicians in those different kind of channels, I mean, they embrace the fact that there's differences. It's interesting you talking about so few having that longitudinal model. I still practice a tiny bit. And that's like the most valued thing for me, not to mention I think patients that I see is just known him for a quarter of a century or more many times, and it really helps with caring for them.

00:06:08:09 - 00:06:33:22
Marc Boom, M.D.
And I will say sometimes as people get older and very complicated, those senior type clinics can be a really much more logical place for somebody. So how do you navigate that sometimes? Does a clinician actually sometime raise his or her hand and say, you know, I love you, I've been taking care of you for 20 years, and I think you're going to actually be better over here because you're so complicated.

00:06:33:25 - 00:06:35:21
Marc Boom, M.D.
Does that get pretty fluid there?

00:06:35:27 - 00:07:00:01
David Banks
Yeah, we've actually had that exact case happen. And it takes a lot for the clinician to want to maybe give up that 25 year longitudinal relationship. But when the patient has, as you know, five specialists involved in their care, maybe some home based care, the senior clinics with the wraparound services from social work and other in-home support, some of the remote monitoring, it just makes more sense.

00:07:00:01 - 00:07:21:18
David Banks
And usually the families are so appreciative because it takes a lot of the burden off of that adult child, if you will. And we've all been in that situation of really having to be a clinical quarterback between a primary care provider and five specialists and trying to keep med rec straight and all those sorts of things, they really need to be in a more intensive setting when that happens.

00:07:21:18 - 00:07:26:15
David Banks
And the benefits are so clear that usually that transition is not a difficult thing.

00:07:26:18 - 00:07:39:27
Marc Boom, M.D.
Fascinating discussion. Give us an idea of scale and scope across AdventHealth. How many primary care physicians? And I'm sure you have nurse practitioners and physician assistants and others in that realm as well. But how many are we talking about?

00:07:40:00 - 00:08:13:18
David Banks
Yeah. So if we look at the state of Florida, for example, probably 700 employed providers in our model, majority of those physicians, although we have been really adding to our APP complement. We know they're really a great augmentation to care. Right levels of care from the right provider really allow reach. What we've really been able to do in our model in Florida is we've opened up since we started this, almost a quarter of a million more appointments for patients to be seen because access was such a major problem.

00:08:13:18 - 00:08:38:10
David Banks
And so by increasing the number of employed physicians we have up in that seven, really about 700 range actually relocated and redesigned our clinics. We again, I don't think we're atypical in this, but in our health system, we ended up with 100 doctors in 100 sites. And so we really built primary care pavilions that allowed an aggregation of up to ten providers.

00:08:38:10 - 00:08:57:27
David Banks
That allows then the other support services to be aggregated there as well. And so that's really created about a quarter million visit gain in the last two years. Because if you can't get in to see your doctor, it doesn't really matter. You know, that's really the thing that matters most. We're taking this strategy now out into what we call our multi-state division.

00:08:57:27 - 00:09:24:28
David Banks
So Chicago, Dallas-Fort worth, Kansas City, Colorado, where we have, again, large, large employed. In Colorado, we probably have close to 500 employed primary care providers. And so we've made a big investment in this simply because I don't think, like I said, we can have the community impact if we just stay within the walls of the hospital. We have to be able to ideally get people under a care plan that allows them to optimize health.

00:09:25:00 - 00:09:40:10
David Banks
Our hospitals are there when you when you need that level of acute support. But most of our interactions happen away from the hospital, so those need to be clinically robust, consumer focused, you know high value opportunities for the patients we have.

00:09:40:12 - 00:10:01:20
Marc Boom, M.D.
So sometimes the economics can get in the way like how much of this is in a fee for service type of environment? How much of this is in more of a value based or global care or some version of financing? And then as you talk about the economic side of the benefits, and we're gonna come to the other more important clinical and others, you know, how does that mesh with all of that?

00:10:01:24 - 00:10:36:15
David Banks
Yeah. So two ways we think about it. I like the idea of value based care in that, giving additional resources to primary care physicians to provide more longitudinal support. So we're active participants. We have about 900,000 lives in some sort of government program. We've been very active participants in reach. We've done work with MA providers as well. We like those models because it puts more resources into the clinic, and it allows us to be able to help people stay at the right level of care to get what they need.

00:10:36:16 - 00:10:59:25
David Banks
Additionally, what we've done in our own employee base, because the real pressure point for this comes for the self-funded employers. We've created a very high value. It's actually a high actuarial value option for our employees that is really primary care centric. So we have traditional insurance, we have the high deductible plans. We created a mid-level plan that is really a primary care centric plan.

00:10:59:25 - 00:11:23:10
David Banks
First year we had 9000 enrollees of our employees. This year it grew to almost 18,000. And really trying to understand can we get better care and can we see better economics? Because the thesis is if you see your primary care doctor, you should have a less financial burden because your care is being managed. And so we're testing that inside of our own employee base.

00:11:23:10 - 00:11:39:26
David Banks
And we're seeing some very good results in terms of access to care and some of those early indicators, some of those, those health factors we want to see from early screenings, chronic care as well as inpatient hospital admission avoidance.

00:11:39:26 - 00:12:03:00
Marc Boom, M.D.
So, what do you see in terms of total cost of care at this point then? Are you seeing ER visits going down in that population? Are you seeing better and less frequent hospitalizations in a chronic disease management group? Are you managing, I imagine some of these senior clinics you're managing complex end of life issues. You're managing complex dimension and neurodegenerative disease issues.

00:12:03:00 - 00:12:04:20
Marc Boom, M.D.
What are you seeing in that realm?

00:12:04:25 - 00:12:28:00
David Banks
Yeah, probably the most compelling statistic to me - and this would be true in our Reach program with CMS, as well as what we see in our employees. For those of our patients that are stratified in that rising risk or high risk category, when they're under care management, they're avoiding about $6,200 of cost a year. So you think about the expense of those patients at the top of your pop health pyramid.

00:12:28:03 - 00:12:49:15
David Banks
You know, those often are 30 to $40,000 a year type expenditures. So getting $6,000 a year of expense off of that group is a material gain. On the front end, we saw a 90% utilization rate of primary care in our employee base that are in that high value plan, and so we think that's going to pay dividends long term.

00:12:49:15 - 00:13:11:10
David Banks
And as I mentioned with our care management program, we put into our ERs. This year we've already diverted 511 admissions. And the way we were able to do that is we knew their providers, we knew their plan of care, and it allowed us to say, look, clinically, this is a this is safe to send this person back to this level of care.

00:13:11:10 - 00:13:31:06
David Banks
They don't need to be admitted. As you know, hospital admissions carry their own benefit and risks. And so we've seen those benefits across the board and we've seen those CMS benchmarks we've been able to come underneath them at 2%, you know. So those benchmarks are at 13,000 per member per year. So we're starting to see some early numbers.

00:13:31:06 - 00:13:35:15
David Banks
But we have a lot more to go, I think, to really prove out the case.

00:13:35:18 - 00:13:57:04
Marc Boom, M.D.
Well, I want to end with one last question of, you know, you've got many others watching this saying, you know, we need to go there. We haven't gone there. We're a very legacy like hospital system and different types of economic models and environments and things. What are the lessons learned? What would what advice would you give to somebody like that who leads a system and says, I think we need to go embark on a journey similar to this?

00:13:57:08 - 00:14:25:27
David Banks
I think we've learned two things. One is maybe it was unique to us, but we were losing subsidizing about $225,000 per primary care doc pre this this model. We've been able to cut that in half. So just the financial burden or expense if you will. We've been able to become more efficient through again redesigning the model, putting primary care out front, optimizing the way our practices flow, supporting with different resources.

00:14:25:27 - 00:14:49:27
David Banks
Our subsidy costs actually been cut in half, not to zero yet, but in half. Additionally, we've seen more access for that investment. And like I mentioned, we're starting to see some of those early pop health indicators coming. So it's the better organization just created a better expense management structure. And we're seeing patients use primary care at a rate they weren't using it before.

00:14:49:27 - 00:15:10:02
David Banks
I think the real lesson is give it its own leadership and focus. Tucking it up under a hospital. You and I both know a hospital just sucks all the air out of the room. And there's when you think about community based care, it's just hard for them to compete for the time, attention and resources. It's worth creating the special focus so they can thrive.

00:15:10:02 - 00:15:19:22
David Banks
And it's really one of the best decisions we've made, giving them their own focus. And I'm excited to see what this will produce for us in the coming 2 or 3 years.

00:15:19:25 - 00:15:41:12
Marc Boom, M.D.
Really fascinating discussion. Like I said, near and dear to my heart. Love seeing this impact that you've made. I mean, think about all the wins there, most importantly for your community in terms of access, in terms of coordination of care, all those different things. And things like lower subsidies, which of course enable the sustainability of health care and the affordability of health care for everybody.

00:15:41:12 - 00:15:48:27
Marc Boom, M.D.
And I would imagine you've got some pretty darn happy primary care physicians in that, in that model as well when you're building that structure around them.

00:15:49:02 - 00:16:16:04
David Banks
They definitely feel more seen and heard and valued. And they are. Listen, hospitals are great at rescue care. The longitudinal impacts, though are going to be outside the walls of the hospital. And to me, we believe it's built on a robust primary care. They're scientists, they're clinicians, they're compassionate. They care about their patients. That's just such a powerful model for community health that we just fully believe in.

00:16:16:07 - 00:16:34:20
Marc Boom, M.D.
David, thank you very, very much for your time today. This is fascinating conversation. I know a lot of valuable insights for our listeners. And you may be getting some calls for some, some help from some out there who want to go this way. So to all of our viewers, thank you for listening. And I'll be back next month for another one of our Leadership Dialog conversations.

00:16:34:20 - 00:16:36:26
Marc Boom, M.D.
Thanks, everybody for listening.

00:16:36:28 - 00:16:45:22
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.