EP 28: A Shift To Value-Based Care

On this week’s episode, we feature Dr. Dan McCarter, family physician and National Director of Primary Care Advancement at ChenMed, a leader in full risk value-based care. Dr. McCarter shares how this full risk, value-based healthcare model works, how it benefits patients, and fosters a rewarding patient-physician relationship. We discuss value-based care vs. fee-for-service and other healthcare delivery models in the primary care field.

[00:00:00] Dr. JB: Ever wish for a safe place to have conversations that need to be had? A place where you could say the things that need to be said? Well, welcome to Hope4Med.

[00:00:16] Hi everyone. Welcome back to another episode of the Hope4Med podcast, featuring me as your host, Dr. JB. Today’s guest is Dr. Dan McCarter. Dr. Dan McCarter is a family physician and national director of primary care advancement at ChenMed, a leader in full risk, value-based care for the disadvantaged elderly. Welcome, Dr. McCarter.

[00:00:38] Dr. McCarter: It’s great to be here with you. Thank you for inviting me.

[00:00:41] Dr. JB: So Dr. McCarter, please tell my listener a little bit about yourself.

[00:00:45] Dr. McCarter: Well, I grew up in Appalachia and I went to the University of Virginia and basically stayed for 40 years. I may be, some people would call me a slow learner. Now, I went undergrad, medical school residency, and I stayed there on faculty. And just really watching the changes that were happening in primary care, got very interested in population health while I was there and very interested in working with a leader in population health, and that was the reason I made the move to ChenMed about four years ago.

[00:01:15] Dr. JB: So if we take it back a little bit, before you became a family medicine doctor, what made you decide to become a physician in the first place and why family medicine?

[00:01:24] Dr. McCarter: Oh boy. Yeah, that’s, I always go back to my mom was a nurse. I grew up in a small town, my mom was an operating room nurse. My maternal grandmother, her mom, was diabetic and had been diabetic and on insulin for many years and her eyesight was getting worse and my mom needed somebody to basically be available to give my grandmother insulin injections when she wasn’t available. So she would draw up the insulin, then if she wasn’t available to give my grandmother her insulin injections, I would go do that. And it was just, it was a lot of responsibility for a 12, 13 year old but you really– it was different approaching somebody when they’re having problems like that. It’s just a very special almost, obviously a grandson-grandmother is a special relationship anyway, but being able to do that and help somebody just makes you feel very fulfilled in that situation. So I think that was probably the reason to go into medicine. And as far as going into family medicine, I originally thought I wanted to be a surgeon. Two of our family friends, one of our close family friends in the town I grew up in was a surgeon. And ironically enough, while I was on the surgery rotation as a medical student, he actually died by suicide in the hospital back home. And I really got to thinking, did I want to be working every other night like that? What did I want to be doing? And I was thinking I needed to do something that I could pace myself with, and I also ran into Louis Barnett who was the founding chair of family medicine at the University of Virginia, and he really is one of the founders of family medicine as a specialty. And I just, although I told him the first time I met him, that I was sure I wasn’t going to be a family doctor, later I wound up very much appreciative of his mentoring as a medical student and then as a resident and then for many years thereafter. So that was, that’s sort of the journey I took.

[00:03:26] Dr. JB: If you’ll allow me to just take a couple steps back in what you just mentioned, about that surgeon who died by suicide, how long ago was that?

[00:03:35] Dr. McCarter: Oh boy, that would have been 30 plus years ago, ‘ cause I would have been a third-year medical student. It’s interesting, of physicians that I have known closely, there was another physician in the town I grew up in who was the father, again, of some close friends, who died by suicide. That was a few years later, that was while I was a resident. And then there was another physician that I worked with, a friend from college and medical school, and worked together with at UVA, and then he died by suicide, and that was probably about 10 years ago. So it happens more than we like to think about. And if you, if you’re lucky enough to know a lot of physicians like I have been, we see more of that than we would like to see.

[00:04:22] Dr. JB: So this death by suicide that we’re seeing happening in physicians and other healthcare professionals, it’s not a new thing.

[00:04:30] Dr. McCarter: No, no, it doesn’t seem to be. I mean, it seems like depression, substance abuse have been part of the specialty, I mean part of the profession, for a long time now. So what I will tell you again, I grew up in Appalachia, suicide is not that uncommon there anyway, so I’ve known a lot of people that aren’t physicians that have died by suicide as well.

[00:04:51] Dr. JB: Wow. Wow. What kind of conversations did you have or do the people in your small town have around all of these incidences of suicide?

[00:05:01] Dr. McCarter: You know, I think the thing that has always, and having been to a number of the funerals when this happens, the thing that I think is always sort of stunning to the people there is, generally there’ve been– usually somebody has known that this individual had problems, but a lot of people have problems, but the feeling was, “if we had only known, we would have done something differently.” And I’ve seen the outpouring of emotions that come from that and I just wonder, if you think about all the people that were there at a funeral and if each of them had taken that hour out of their life and spread it out over a couple of years for that individual, would it have made a difference? Because obviously they were cared about, but it was hard for them to reach out and ask for help in those situations. And so, I think that has been, that is generally the feeling it is, but again, when you come from an area where it’s not that uncommon, it’s like other causes of death as well, it’s not like it’s a huge shock when it happens either.

[00:06:04] Dr. JB: And so you lived in that community for how many years?

[00:06:08] Dr. McCarter: Oh, I grew up there, so I basically lived there exclusively until I was 18. And then, that was still my permanent residence until I finished medical school. So that would have been, when I was 26 years old, 27, something like that.

[00:06:25] Dr. JB: Wow. So you experienced quite a lot. From birth until 26 years old growing up in that community.

[00:06:34] Dr. McCarter: Yeah, well you know, I think that’s one of the things that I like about your work, is working to help physicians. I mean, we’re, as a profession, we’re still blessed to help other people. The reason that I went into medicine to begin with was to be able to help other people and one of the things I love about working with ChenMed is our ability to foster close relationships between the doctor and the patients, and give the doctors enough time with the patients that they can actually develop that close relationship, because that really seems to be what it’s all about, is how do we get that personal reward from the profession? And I think a lot of people are under the mistaken idea that it’s because of all the sick patients is the reason doctors burnout and the reason maybe doctors are prone to dying by suicide. I think doctors, I think we like taking care of complicated patients, but we like having the time and the resources available so we feel like we can do it justice and we’re not trying to rush through it so quickly. So, that’s what I would love to see is, take primary care moving forward and help primary care physicians lead the way to developing a better healthcare system for our patients.

[00:07:50] Dr. JB: So along those lines, tell me a little bit more about your thought process that made you decide to transition from what you were doing, is it four years ago now?

[00:08:01] Dr. McCarter: A little bit over four years. Well, I had– I still have a lot of good friends at UVA, I very much enjoyed the work I did there. I got to start a practice right out of residency. I got to work on the practice plan with the leadership there and on the finance committee. I got to be the Associate Chief Medical Officer for the clinics, and then when UVA decided to start an ACO, I got to provide leadership with that. I guess like everyone else, we were learning our way forward in population health but it became pretty clear that in the fee for service model, it was going to be very difficult to make it in population health in the fee for service model because when you’re working in a model that depends on the number of hospital admissions and the number of OR procedures and the number of emergency room visits, but to do value-based care, well, you’re trying to keep patients healthy and out of the hospital. So I, ChenMed was a leader in that, I had kept an eye on them for a long time, and I just decided that I was, I’d had career of 27 years and a lot of people are thinking about retiring and I’m not ready to retire, but I wanted to see what else I could learn in population health. To get the opportunity to work with a leader in that was the reason that I made the move at that point in time.

[00:09:20] Dr. JB: And so, it sounds like there’s a lot of changes happening in the field of primary care, almost like a primary care revolution.

[00:09:29] Dr. McCarter: Absolutely. Absolutely.

[00:09:31] Dr. JB: Tell me more about that.

[00:09:33] Dr. McCarter: Well, I think that there is, I think we absolutely are in the midst of a primary care revolution and the primary care revolution is really, it’s going to be driven by value-based care. We have to produce better outcomes for our patients and for society because one in five dollars in the U.S. economy is being spent on healthcare, and about one in four of those dollars is being wasted. So, if we could save 1% of the waste in healthcare in the U.S., just 1% of the waste and not all of it, but just 1% of it, we would have enough resources to pay for preschool for every four year old in the country. So I mean, we owe that to society, but physicians are going to need to focus more on high complexity patients. You look at what CVS Aetna is doing with Minute Clinics, you look at what Walmart is doing with their health centers, I think the lower complexity illness is going to be cared for by people who can do it cheaper, and the physicians are going to need to buckle down and take care of the sick or more complex patients. It’s still going to be about relationships. That’s the problem with the fee for service model is there’s not a CPT code for a doctor patient relationship and there’s not a CPT code for keeping a patient out of the hospital, you get paid a pretty high level of a CPT code for doing admission workups, but you don’t really get paid if you help the patient stay out of the hospital.

[00:10:56] And then we really have to prioritize coaching for health versus consulting for sickness, meaning we’ve got to work with people that help wherever they are on the sickness and wellness continuum, we’ve got to help them move more towards wellness. And there’s work that we can all do, right? We can exercise more, we can eat better, we can take care of our mental health. And almost, I don’t know of anybody who’s doing it perfectly. Maybe there’s some world-class athletes are, but the rest of us, we all have room to continue working to be more healthy. And so I think that’s going to be the key for the primary care revolution going forward.

[00:11:32] Dr. JB: I mean, that’s true, that, as it stands right now in the fee for service model, you don’t get paid to take care of healthy patients. And that’s what we want, we want our patients to be healthy, right? We want them to stay well, but it’s kind of almost counter-intuitive because if they’re healthy, then they don’t come in and see us, and then we don’t get paid. And so this value-based model sounds very promising.

[00:11:56] Dr. McCarter: Absolutely. Absolutely. And it is, it aligns the incentives perfectly because we only do well if our patients do well. And you know, some people will say, and they remember the managed care or the early 1990s where you had the gatekeeper and the PCP could deny payment for an emergency room visit or a hospitalization, and it doesn’t work like that now. Every patient has their insurance card and so they basically have our credit card in their wallet. And so they can go to any emergency room that they want to, and it’s basically going to be taken out at our capitated payments that we have. So we’ve got to build the relationships with them so that they trust us and they seek us out first. And it would be counterintuitive for us to keep a patient out of the hospital that needs to go to the hospital anyway, right? So if we don’t admit a patient for pneumonia that needs to be admitted for pneumonia, and now they get sicker and they go to the ICU, since we’re paying the ICU bill, that really backfires in a big way.

[00:13:00] Dr. JB: So is there a lump sum that you’re given per year per patient, or how does that work?

[00:13:05] Dr. McCarter: Well, the Medicare advantage program, it’s risk adjusted based on the HCC codes and so, it’s based on the complexity of the illness of the patients, but yeah, it basically is you get more for taking care of sicker patients, but it is a lump sum per year.

[00:13:21] Dr. JB: And if this patient keeps coming or going in and out of the hospital and you go into the net negative, then it’s a net loss for you?

[00:13:30] Dr. McCarter: Yep, it is.

[00:13:33] Dr. JB: And the population that you guys focus on are the elderly, which tend to have a lot of co-morbidities and be on tons of medications.

[00:13:45] Dr. McCarter: Yeah, they are. And that’s that. So our average patient is 72 years old and has five or more chronic medical conditions. Also, our average patients get by on the average social security, $1,200 a month or less, so not only are our patients older, but they tend to be more impoverished than other groups of patients. So, it is important that we’re able to provide this care to them because the other thing that happens is for what we do in the Medicare advantage, we’re able to offer our patients that don’t have the money fee reductions on what we do, so we can waive copays and stuff based on their income levels. And so generally, these patients don’t have a copay between themselves and their primary care physician. So what we offer in our office, we can pay, they don’t have to go out of pocket over and above what they have for their responsibility to get their Medicare plan. But if they have to go to the hospital or they have to go see too many expensive specialists, they’re paying copays, the same if they start, somebody puts them on the really expensive medicines, then they hit the donut hole. And that is something, yeah, the expensive medicines cost us money, but more importantly, they cost the patient money. And when they hit that donut hole, then they have difficulty paying for all of their medicines, and if somebody’s making $1,200 a month and you’re giving them a drug that cost, when they hit the donut hole, costs $100 or $150 a month, now you’re very often asking them to make a decision between eating more fresh fruit and vegetables or whether or not they can make their rent payment this month. And so it really is important that help them manage their care as economically as possible.

[00:15:27] Dr. JB: And so I guess I’m having a little bit of a hard time wrapping my head around how this is profitable for you guys, ’cause it just seems like there’s a lot of expenses.

[00:15:38] Dr. McCarter: There are a lot of expenses. And our primary care model is obviously not cheap to operate because we cap the panels at 450 patients, but we see the patients. Our goal is to see everybody once a month, for the sicker patients, we see them more frequently. Also during COVID, we instituted what we call “love calls,” and we have the staff reaching out to call every patient once a week, just to check on them, to see how they’re doing. So the idea is if we can see them frequently enough and we can detect problems before they go downhill, then we can intervene and help them stay healthier. So, on the average, if you look at risk adjusted numbers, our patients are over 40%, spend 40% fewer days in the hospital. And if you don’t risk adjust, it’s still about a third fewer days in the hospital. So that’s what it takes to be successful.

[00:16:31] Dr. JB: And so for your staff to call these patients, so 450 patients once a week is the plan? In addition to seeing them?

[00:16:38] Dr. McCarter: Well, no, no, we don’t call the ones we’re seeing. So remember, we’re going to see every patient, we’re going to see one quarter of the patients every week in an office visit. And so, the goal is to call the 320 other patients, but we prioritize that. Do we get every patient called every week? No, but our goal is to do that.

[00:16:56] Dr. JB: And the patients are supposed to ideally get in touch with you before going to the hospital?

[00:17:02] Dr. McCarter: Yeah. Yeah, absolutely. Absolutely. And we give, every patient has the doctor’s cell phone number. And we’re not saying that the doctors can’t take time off or anything like that, but if they’re, if the PCP is available, then they talk to the patient and patients tend to be very respectful of our time. So it actually works very well because if the PCP is available when the patient calls, then it’s usually a, very often, it’s a fairly easy conversation to have. We know our patients so well that it’s like helping a family member who would call, and talking them through something until the next day. And again, because of the smaller panels, we have plenty of time to see people in the office so we can always fit somebody in the next business day.

[00:17:44] Dr. JB: Yeah, ’cause I know that’s something that a lot of physicians are concerned about, if giving up their personal phone number. ” Well, the patients call me every day, every hour.”

[00:17:55] Dr. McCarter: Well, actually the issue we have is actually convincing our patients to call us. And we give each PCP, a work cell phone, so it’s not saying that they can’t, you know, if they’re feeling like they need to take a break and they may, as long as they’re not on call, obviously. But if they feel like they need to take a break and they need to cut off their work cell phone number, they can. So we’re not, it’s not slave labor at this point, but yeah, the issue is convincing them to call us. You would think it would be the other way around, but it’s really not.

[00:18:23] Dr. JB: And then what about the families and extended families, do you find that they will call you or not really?

[00:18:29] Dr. McCarter: Yeah. Yeah, they will. They will. Yeah, the other night I had a patient who fell in her driveway and she, I was just very concerned about what was going on and she said her arm was hurting and she’s not terribly tech savvy, so as she had to get her son to text me some pictures, and it was pretty clear, there was a high probability of being a fracture. She really didn’t want to go to the emergency room because of COVID, but was able to arrange the next day for her to go to one of the orthopedic on-call centers here in the Richmond area and she went and sure enough, she had a fracture, but they were able to put the appropriate plan in place. And so, she got the right care in the right location. And her son was very appreciative that I was available and was talking to them through this. So, I mean, I didn’t tell them they couldn’t go to the emergency room, but she was so desperate not to, we made the arrangements to meet her where she would be comfortable with her care.

[00:19:23] Dr. JB: And that’s amazing because you actually saved them a step in that process. Because if she had gone to the emergency room, yes, we would have confirmed she had a fracture and we would’ve put her in a splint, and then we would have referred her to the orthopedic surgeons for them to take over.

[00:19:37] Dr. McCarter: Right. Right. And this way, we were able to make sure she was seeing an orthopedic surgeon in our network and the group that we work with. And so it worked out well for her. So, and the thing is, what I’ve said very often, what we do is pretty simple, but it’s not easy. A lot of it is common sense, but she had a classic story for a colles fracture, and x-ray, she had bruising in the middle of her forearm and I could see that clearly on the text photo that I got. So it was clear she needed x-rays and we have x-rays in our office, but I was actually thinking, she was old enough and her hand and wrist were swollen, I was like, there might be enough going on here that I’m not going to be able to handle it. And so rather than her coming to our office and getting an x-ray and us having to send her to the orthopedist, seemed like the right thing to do was get her to the orthopedist and save her a step. So we did that and she was very appreciative of that.

[00:20:33] Dr. JB: So along with what ChenMed is doing, there’s other things that are popping up, in terms of changes in primary care with concierge medicine, there’s direct pay, could you talk a little bit more about those and the differences between ChenMed and those other options?

[00:20:49] Dr. McCarter: Sure. Sure. Well, and I, we actually, we find in the direct primary care model kindred spirits. One of my former partners from practice at UVA is doing direct primary care. And so that is, to put it simplistically, maybe I consider direct primary care the Netflix model, it’s sort of an all you can eat primary care. It’s a membership model, you pay a set amount of month, and then when you go, your visit with the PCP is covered. Sometimes usually you still have to pay for labs and stuff like that, but it still gives you pretty ready access to the PCP. The concierge models, now again, we offer a concierge model, but we don’t charge the concierge fee. But concierge models typically are you’re paying a membership fee and they will usually include like an executive physical or something every year as part of that, and you’ll have access to your doctor all the time, but generally, whatever you, whatever services you go for, you pay in addition to, so it’s more– direct primary care is a more affordable model. It would appear to me that direct primary care for someone with a high deductible health plan and then pay a direct primary care membership is probably a good combination to have. And I think a lot of employers are seeing that the concierge model is more for paying for the convenience and the access to the primary care doctors. And certainly, the primary care doctors provide high quality care, but the concierge model, I mean, it can be priced all over the place and can get to be quite expensive that way. I think the difference in what we have and what they have is because we’re full risk, we get not only the medical record information, we get the financial information, and so we’re able to keep an eye on what’s going on on the patients from a number of different angles. And so we just have a much more robust data set when we’re taking care of the patients.

[00:22:43] Dr. JB: So when you say ChenMed is full risk, the other examples that we were just talking about, are those more hybrid or is hybrid value-based care different than those models?

[00:22:54] Dr. McCarter: When I’m thinking about hybrid, I’m really thinking more along the lines of the upside only ACOs or even the ACOs with some downside risk, because they’re not usually taking full risks, and so it’s very often the hybrid is still built on a fee for service model and you have the quality incentives that you have to meet. They’re measuring your cost, but you’re still getting paid on the fee for service. You’re doing the quality improvement activities, and then you’re doing all the meaningful use, or I think the new models are calling it “promoting interoperability,” but again, you’re still depending on the fee for service to fuel the business model. The full risk model is you’re getting that lump sum payment and if you can spend less than you get paid, you make money. And so it’s a little, it’s quite a bit simpler business model. Now that doesn’t mean that we don’t do the quality measures, we do, I mean, we do very well. We get taught decile , our performance and quality. We get taught decile performance, as far as the patient satisfaction as well.

[00:24:01] Dr. JB: So is your, reimbursement or the lump sum that you get once a year, patient satisfaction, does that affect it or does that affect that lump sum that you receive?

[00:24:11] Dr. McCarter: Well, to the extent that that goes into the star measures, it affects it somewhat. The big thing that keeping the patients– two things– one, if the patients are happy, then they’re more likely to call us before they go somewhere else, right? And so that is the big piece of it. And then, our business model depends on patients choosing us as their primary care physician, they’re not just attributed to us by some computer in the sky, they actually have to pick us. So, they’re a whole lot more likely to stay with us if they’re happy.

[00:24:43] Dr. JB: That’s very true. So earlier in the conversation, you mentioned that one out of every $5 spent in the U.S. is on healthcare and of that lump sum, one out of every $5 is wasted. Can you talk more about that?

[00:25:01] Dr. McCarter: Sure, sure. If you look at how we compare to healthcare in other countries, we have some of the most expensive healthcare in the developed world. And if you actually look at longevity or health outcomes, we actually get some of the just very middling. And that’s, that may even be overstating how good it is, results. So, part of it is we have a system where people have to pay for their primary care, whereas, you go to other countries, England, Australia, where primary care is provided as part of the national health systems they have. And I’ve always used the analogy that paying for primary care is analogous to us as a society, putting quarters on the dashboard of cars and making people pay to put their seatbelt on. I mean, it just wouldn’t make sense from an insurance standpoint because seatbelts saved so many lives, people who engage in primary care and take care of problems, take care of their blood pressure, their diabetes, and their cholesterol before they develop a heart attack or stroke are obviously a whole lot easier to care for. But yet we sort of– I’ve said many times, I could fall over here and have a heart attack right now and call 9 1 1, and they’re going to take me to a hospital. And if I need heart surgery, they’re going to do heart surgery, whether or not I can pay for it, nobody’s going to check. Now they’re going to give me a bill and I may be completely broke for the rest of my life is because of it, but nobody’s going to withhold that from me based on the ability to pay. And if that’s the case, then the state is probably going to have to pick that, part of that payment that up. But yet, if I can’t afford my blood pressure medicine or I can’t afford my cholesterol medicine, then nobody’s going to give me that. They’re going to let me go with that and let that heart disease develop. But yet you could treat, generic, statin drug, you can probably treat somebody for a year for less than a hundred dollars with a generic statin drug. And the same with the generic diabetic drugs and our blood pressure drugs. So I think that is a big part of that. The other thing is we were paying all the specialists to do, it’s a system that pays for transactions, not for outcomes. So, specialists don’t get paid unless they do things. And so that gets to be expensive.

[00:27:16] Dr. JB: Well, with the bundled payments, which kind of is not quite what the value-based, but with bundling, that’s kind of changing things a little bit in terms of holding specialists accountable for outcomes.

[00:27:28] Dr. McCarter: It is, but it’s holding them accountable for the bundle episode, right? So what it means is it’s going to hold the price for like a hip replacement and the post-op care, but still there’s going to be an incentive to do more hip replacements because the bundling isn’t going to attach unless you’re actually operating on that patient. Whereas if you capitated all the orthopedic services in an area, then they wouldn’t have that perverse incentive to operate. Even though we say maybe 85% of– and we actually have orthopedic surgeons who work for 10 minutes, we have a couple who help us work through these, and was talking to Dr. Scott Tromanhauser yesterday about this. So an example is that an orthopedic surgeon when they operate, 85% of the people get pain relief from that hip replacement overall, but then if you take your grandmother in, and she’s 82 years old and maybe has rheumatoid arthritis on top of the problems with the joint, and if you do her individual risk assessment, maybe there’s only a 50% chance she’s going to get better, and maybe there’s a 30% chance that she’s going to stay the same, and a 20% chance that it’s going to make her worse. Now is that going to be the slam dunk to do that procedure? But yet, right now our incentive systems don’t really pay to take the time to have this conversations with those patients.

[00:29:01] Dr. JB: Okay. That’s true. That’s true, but along those lines, I do think that in terms of the outcomes for the procedures, because if you do, we’ll say hip replacement surgery, and then the patient comes back and they have an infection or something like that, that affects your reimbursement. And so you would think that that would ensure that the surgeon, the orthopedic surgeon, thinks a little bit more closely about which cases they should take on versus not. And then also strategize and make improvements in terms of improving outcomes in these cases.

[00:29:42] Dr. McCarter: Yeah. And I think you’re absolutely right there. And so I shouldn’t sound like that I’m against bundles. I think bundles might be, I mean they’re certainly a step on the value-based care path. I think to get where we need to go, we eventually have to get to where there’s more accountability for the risk, for the overall risk, but you’re right, for the individual procedures, it does work better that way.

[00:30:05] Dr. JB: Yeah. I mean, it’s not the solution, but it is a step, moving in the right direction. So now that you’ve been working at ChenMed, and you talked about this at the beginning about the patient and physician relationship and how that is being affected by the amount of time we’re able to spend with our patients being truncated and we just have to rush, rush, rush through every interaction. In terms of your feelings of job satisfaction, how has that changed when you transitioned over to this value-based model?

[00:30:37] Dr. McCarter: Well, you know what, and it’s not that we have a long visit every time we see our patients, but we’re seeing them frequently, so you really get to know them. And I feel like my patients are my friends and I’ve gotten to know them pretty well. And you get to know them fairly well in a short period of time. So I think that that makes for a lot more satisfaction because it’s easier to see patients that you know, but it’s also easier to make a difference for them as well. It just, you get to know them on a whole different level. So that is, I like seeing that now. Honestly, what I spend a lot of time, I spend a lot of time working with our doctors on seeing patients and getting the privilege to go out and help teach residency programs and other physicians about value-based care. I love having that time to be able to work with other doctors to help them learn more about value-based care and to help them be successful in value-based care. When they– if they make the decision to work with us, we want to help them be successful because it is a mindset and a different skillset than it is in fee for service because it’s not about just doing the visit and documenting the note and getting paid, it’s really about thinking about what is the next thing to do? We don’t want to give a patient too many things to do because they won’t remember to do too many things, so we want to do what are the one or two next things we’ll need to do for each patient to make a difference for them and then see them back in two weeks or see them back in a month, and then what’s the next step from there? And it’s just a truly refreshing way to take care of patients.

[00:32:22] Dr. JB: Because you’re coaching them for health.

[00:32:24] Dr. McCarter: Yes.

[00:32:25] Dr. JB: And it sounds like because you’re able to see them so frequently and you get to know your patients, you get to understand what is important to them, truly important, and collaborate with them, in terms of improving their individual health and lifestyle.

[00:32:38] Dr. McCarter: Yeah. You know, it’s interesting, I mentioned Dr. Barnett earlier, he wrote a few books before he passed away and I was rereading one of them the other day, and he had a turn of phrase in there that he talked about working with patients, working to consensus rather than achieving compliance. And it really is about– I hear a lot of people talking about “the patient’s non-compliant, I prescribed the pill and they wouldn’t take it,” but I mean, it’s really, the patient has to make the decision. So we really have to figure out what their motivations are and work with them and present it to them and hopefully help them to make healthy choices, but they have to make the healthy choices, we don’t get to make the choices for them. That’s generally not what, I mean, occasionally you’ll see a patient that will do whatever the doctor tells them to do, but most of us make our own choices. And so, before coming to ChenMed, having had the privilege of having a number of physicians be patients, physicians sometimes are the hardest to convince. So every time I hear a physician talking about a patient being noncompliant, I wonder what it would be like to be your doctor. How would that work out?

[00:33:48] Dr. JB: That’s so true. But then, when we talk about full risk, value-based care, isn’t that a little bit concerning if you make recommendations for our patients and they, for whatever reason it is, decide, ” eh, no, I don’t think that’s really important right now,” but then their condition worsens.

[00:34:07] Dr. McCarter: Yeah. Yeah, it is. You’re absolutely right. So that means that we have to think about different ways to approach the patient. I mean, we don’t ever just have one conversation about the flu shot if they refuse to take the flu shots, right? You gotta walk the line between creating a riff between you and the patient, but you have to keep coming back at it and coming back at it from different ways and working to convince them to do what they know we need that what we need them to do to make the healthy choice for themselves, whether it be that, whether it be the COVID shot, whether it be the whether it be taking their statin, taking their diabetic drug. I mean, it can be any, or all of those things together. So you’re right. It is, it’s interesting. So we talk about accountability and I sometimes like to rephrase it “responsibility,” meaning the ability to respond. And I really heard Scott Conner, who is a physician leader, talk about that you can take a hundred percent responsibility for world hunger doesn’t mean that you can personally end world hunger. But if you want to, you can write a check of what you can afford every month to the local food bank. And so, you can respond to world hunger. So what I would tell one of our doctors is we need you to take 100% responsibility for your patients and their outcomes, but not 110% responsibility. Part of your 100% responsibility is helping them take their 100% responsibility for their own outcomes, and so how do you engage them to do that?

[00:35:41] Dr. JB: Yeah, and besides, I guess, the obvious health consequences for the patient in terms of their accountability, in this model are the patients also held accountable for anything or not really? Does that make sense, my question?

[00:35:56] Dr. McCarter: Well, I guess they’re sorta ultimately accountable, I mean, it’s their life, right? And so, are there any penalties? No, we don’t discharge patients because they won’t take their pills or because they’re non-compliant. You will come across somebody who is combative and not treating the staff appropriately, and I mean really egregiously not treating the staff appropriately. I don’t want people to think that we don’t discharge patients because they are not eating correctly or because they’re not taking their medicines. I mean, if they come in and threaten bodily harm or our attempt to injure somebody, well, yeah, then we will do what we need to do to protect the staff. But we continue to come back and work with people to engage them. Now, what sometimes what happens is because we really work on calling them and asking them to come in for their monthly visits, and sometimes people don’t like that if they don’t want to engage. But we don’t, again, we’re open to them and we meet them where they are.

[00:36:56] Dr. JB: So, what about if the patient doesn’t come for their monthly visits? Is there anything, or is there a certain amount of visits the patient needs to do over the year?

[00:37:06] Dr. McCarter: Well, we average ten visits a year with all of our patients and our goal is twelve visits, and obviously we see some patients more frequently. No, we don’t– again, there is no discharging a patient for non-compliance. So, we work on calling those patients, sending them letters, sending them texts, we do everything we can to engage with them to work with us. But some people, try as we might, don’t come in, but again, we don’t lose track of them. We keep a list of them and we keep calling them and we keep working with them to get them back in.

[00:37:40] Dr. JB: Do you guys do home visits or engage in telemedicine?

[00:37:44] Dr. McCarter: Well with COVID, everybody went to telemedicine, so we still do telemedicine and we stood that up pretty quickly. We do, physicians will occasionally do a home visit. I’ve certainly done home visits, but it’s not a thing that we offer as a service or schedule. We do have community case managers who can go do home visits when we need them. Once the patient becomes completely home bound and that they’re really not able to get out, we usually suggest that they then look to switching their care to somebody like visiting physicians or somebody like that, because that’s not a service that we offer as a company. But I think most of the doctors in the company that I know, on occasion, will go to all the visits for patients.

[00:38:27] Dr. JB: Got it. And then do you guys work closely with hospice?

[00:38:31] Dr. McCarter: Absolutely. Absolutely. And we really work to help patients choose what they do want and have those conversations about advanced care planning. So we really know what they want when it comes to that situation. But to the extent we have a few palliative care doctors in the companies that can help give us advice, and then in the appropriate circumstances, we certainly make the referrals to hospice.

[00:38:55] Dr. JB: Got it. And I know similar to like hospice, for instance, when a patient comes to the emergency department and we know they’re in hospice, we’ll oftentimes contact the hospice company to let them know that they’re in the emergency department. Does something similar happen when your patients present to the emergency department, are you guys notified some way? Does the patient call you in advance?

[00:39:13] Dr. McCarter: We are. Again, because we’re tied on the financial side, we actually have for the vast majority of our patients, as soon as their insurance card is entered into the system in the emergency room, our PCPs get a notification that their patients in the emergency room and where they are.

[00:39:30] Dr. JB: And so, because of that, do you guys play a role in terms of approving versus not approving services they receive, like for reimbursement for services they receive in wherever they present?

[00:39:39] Dr. McCarter: No, it’s handled by whatever their insurance plan approves, but that doesn’t mean we will not call the patient and see what’s going on with them and make sure that the emergency room is the appropriate place. And then check with the emergency room to see if they need any information from us, do they need a med list? What do they need? And to make sure they know that if the patient’s appropriate to go home, we can see them in the office the next day or two days later, whatever they think is needed. So, we want to make sure again, that the patient is getting the right care in the right location each time. Going back a few months, one of my patients had quit taking their psych meds and they wound up in emergency room and I called and the charge nurse said, “you know, thank goodness you called because they’re not talking to us.” They were completely nonverbal, and I was able to give them some history and give them a medication list. Now this patient didn’t need to be in the hospital, but at least they had a better idea of what was going on. And every time, it’s always amazing when you make that phone call, they’re always a little surprised that you know your patient’s there and you’re calling before they’re reaching out to us.

[00:40:44] Dr. JB: Well, what I can say as an emergency room physician is it’s so wonderful to have a service where the primary care physician is available and accessible, so that we could have conversations about this. ‘Cause there’s a lot of patients that are borderline, you don’t really need to stay, but I do want you to have close followup. Can I manage that to make that happen? Cause if you can’t, if I can’t guarantee, then you’re going to get admitted. But if I can actually speak to your doctor and explain things, and your doctor says, “yeah, I’ll take over it, I got it, I’ll see him tomorrow or in 48 hours,” then that will save so many admissions to the hospital.

[00:41:19] Dr. McCarter: Right. You’re absolutely right. And again, this is not rocket science. It’s just knowing who has the ball, when you’re making the handoff, who gets the handoff. So absolutely, we want to treat every one of our patients the way we would want our own family member treated. If one of your family members wound up in the emergency room, you’d be talking to the emergency room. And if they said, you know, if you live in the same area and they said, “will you check on them the next day?” Your answer would be, yes, you would check on them the next day. And that’s a service we offer to our patients.

[00:41:48] Dr. JB: Well, that sounds like a fantastic company and a fantastic business model. It’s definitely– there’s risk in a full risk value-based model like this, especially with the population demographics that you are focused on, because as it stands right now, most of the healthcare spending is spent at the end of life. And the end of life care, especially if you’re elderly and you are full code, can get quite expensive.

[00:42:18] Dr. McCarter: It can get very pricey, very quickly, you’re right. But, what is it? The majority of people, if you ask them, would say they would prefer to die at home, but yet only 25% of people die at home or something like that. So. I think there is the opportunity to work with them there, but when you talk about risk, Howard Marks is a, I think it’s Oak Mark Investments, I think he’s there CEO, but he quoted in one of his books is that ” risk means more things can happen than will happen.” So I really think physicians have to learn about risk and learn about managing risk because this is, it truly– the people who are managing the risks are the people who are the ones who are controlling the money. And would it be better for the physicians to be controlling the money or is it better for this money to go into the pockets of the insurance companies’ shareholders? I would argue this with the physicians, if we want to make the improvements in quality of care, we as physicians have to step up, learn how to manage that risk, and improve outcomes for the patients. And yes, some patients are going to get to be quite expensive, but if on average, you’re really staying on top of your patients and you group with a like-minded group of physicians doing that, on average, you’re going to do well.

[00:43:42] Dr. JB: And that’s true, especially with regards to what you said about where patients would like to die. What I find is sometimes the patient says, yes, I’d rather I prefer to die at home, but when that time nears, the family may say something different. And so having a relationship not only with the patient, but also with their family, will be very, very beneficial in making sure that the patient’s wishes are kept because as the emergency medicine physician, the patient’s in front of me and they’re are no longer able to make decisions, and now I have a healthcare proxy who’s speaking on behalf of the patient and saying, “no, we’ve changed our minds,” and as a physician, I have to abide by whatever they say.

[00:44:25] Dr. McCarter: Right. And so that’s the key and that’s the conversation that we will have with patients. It’s not just a conversation between you and your doctor. Are you going to have the conversation with your family? And I really, I am a big fan of the five wishes document. I think it sometimes get to be a little bit long, but even if you don’t fill it out, having the conversation with the person, who’s going to be making the decisions, so that they know what your wishes are and they know what decisions you would want to make, because you’re– I think we’ve all been there, you got the piece of paper, you’ve got the person who’s not able to make a decision, and then you’ve got the family member saying they want you to keep doing everything. So if you can figure out who’s going to be making the decisions when that arrives, if the conversation can occur in advance, I think that takes some of the heat off of the individual making that decision because they feel like they’re doing what the loved one wants. You obviously can’t force that, but as much as possible, you want to encourage that.

[00:45:26] Dr. JB: Yes, indeed. So I know we are nearing the end of our time together and this has been such a fruitful conversation about these different care models currently being created in the realm of primary care, which is such an important, and so often neglected, part of our healthcare system. So, to my listeners, do you have any words of wisdom that you would like to leave?

[00:45:50] Dr. McCarter: Words of wisdom. I think it is don’t be afraid to take a risk, whether it be the financial risks taking care of patients or making a career move that you think is the right thing for you. It is stressful going through it, but it truly is, there’s a lot to be learned out there, and trust yourself to make the decisions when the time comes to be doing this.

[00:46:22] Dr. JB: Who says a doc can’t rap? D O C T O R J B. The greatest doctor to ever touch the mic. The greatest podcast ever broadcasted or prerecorded. Come learn some. Each one, teach one. I’m done.


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