Podcast episode transcript: Value-based conundrum: How to measure complexity and value in primary care

With L. Gordon Moore, MD

Gordon Moore: Hello. This is Gordon Moore. I’m the host of 3M’s Inside Angle podcast. Welcome to today’s podcast. And with me today is Dr. Kyna Fong. Dr. Fong is the CEO and co-founder of Elation Health, the platform for independent primary care that strengthens the relationship between patients and physicians. Kyna’s expertise as a health economist and digital health leader has been featured in publications, including Forbes and Fast Company. And she is the recipient of several awards, including Fierce Healthcare’s 2021 Most Influential Minority Executives in Healthcare and the Top 100 Harvard Alumni in Technology of 2021. Welcome, Dr. Fong.

Kyna Fong: Thanks so much, Dr. Moore. Thank you for having me today.

Gordon Moore: Yeah. The premise of the conversation is that you and I both know a colleague and friend, Sara Pastoor who’s a family doc, and she was telling me about the amazing work that Elation is doing in terms of creating technology in an environment that helps independent primary care physicians survive, and that’s something that’s deeply interesting to me, especially because of the evidence that primary care, as a foundation, is essential, if we’re going to ever become a high-performing health system. And so I want to get into that, but I’m curious about what is Elation? Where did it come from? What do you do? And if you could tell me about that, that’d be terrific.

Kyna Fong: Yeah, absolutely. Happy to share that with you. So, Elation is a technology-first health care company. We’ve prided ourselves in having a clinical-first mindset in building technology, particularly for primary care. And so when you think about a primary care physician today, there’s a lot of pressure, not only to be able to see a significant load of patients, but also to do the increasing amount of administrative work that’s put especially on the primary care physician. And so that’s Elation in the nutshell. We’re there to solve that problem and help primary care really play the powerful role in health care that it should.

Gordon Moore: And so I got to live the experience of a solo independent primary care doc and actually filling out my forms by hand initially, because I didn’t realize my EMR would do that for me back in 2001. Was that the experience of what you saw in your father’s practice?

Kyna Fong: Yeah, absolutely. So let me tell you a little bit about the founding story of Elation. We started the company, my brother and I, after getting into health care, somewhat accidentally as children. So our dad is a primary care physician, a family doc, and he’s very passionate about patient care and really personalized whole-person primary care. And we actually had been born and raised in Canada, and one day he said, “Hey, I don’t think I can practice the type of medicine that I’d like to up here,” and so we actually moved down to the US. And he’s, as I mentioned, a pretty passionate physician. And so got down here, and my brother and I became responsible for helping him set up his practice and really help him understand and navigate the US health care system, which was many, many times more complicated than the single-payer system in Canada.

And that was really the introduction that we had to what it was like to be an independent primary care practice in the US. And that experience stuck with us as we progressed in our careers. I actually hired and managed all the staff and ran the back office of the practice for about 10 years. We’d gone forward in our careers professionally. I was an economics professor at Stanford. My brother was a management consultant doing health IT strategy and implementation work. And we just were sitting our dad’s practice. We’re like, “Hey, we need to put some sort of system into the clinic because that’s just what we need to do to be able to continue to be efficient in the practice and not really have paper everywhere.”

That led to a process which started very earnestly as just as a desire to put something in our dad’s practice and led to being pretty frustrated and disappointed that anything we saw, the EMRs or any practice management software we saw would lead to either having to hire additional staff or see fewer patients, neither of which made any sense to us. And so that was really the genesis of Elation and the observation that tools for independent clinics were really being focused on billing and administrative needs and not so much on clinical care, which is really the experience of a physician taking care of a patient.

Gordon Moore: It’s fascinating when you describe a clinical-first technology company, and yet you also touch on the economics of practice. Obviously, you know a ton about that. And I’m thinking 70 percent of practice revenue goes to overhead before a physician salary. That’s a huge nut and a problem to solve, and yet I’m seeing probably the same experience you had, which is that a lot of technology adds processes to the workday and adds a significant amount of work to the clinicians and the entire team within a practice as we start to use technology in a way that’s supposed to serve us. So how did you overcome that? And why is this clinical-first technology? What does that actually mean?

Kyna Fong: Very simply put, clinical-first technology just puts first and foremost the physician/patient relationship and really respecting the sanctity of that. And that technology is being invited into that and needs to support and enhance that as opposed to disrupt or change that. And I think it comes from our experience on the front lines of care, seeing our dad care for his patients and interacting with patients directly. I think a big takeaway for my brother and I was really health care, it’s a human relationship and it’s really built on foundations of trust. And so you could be the best doctor in the world, but if your patient doesn’t trust you enough to tell you really what’s going on with them and really what they’re experiencing, feeling, thinking, and not only that, but if you don’t get that and you don’t have that trust, then it’s going to be very hard to do your job as a physician. I mean, you’re a physician. So you know these things that I’m saying.

And then on the flip side, even if you do know what a patient needs to do, there’s a relationship and a trust there that’s needed for the patient to actually follow through, right? So physicians, a lot of times, there’s the language of orders that physicians provide to patients. But really, they’re not more than wishes, right? When you have a patient walking out the door and you send them with a bunch of things you wish that they will do, and I think it’s that trust and that relationship and that understanding of that patient as a human that helps those wishes be followed through upon and for the patient to get the follow up and ongoing treatment that they need.

Gordon Moore: I love that framing. I think about physician orders and it’s like, “Really, these are physician wishes.” You nailed it with that. That’s insightful. Thank you. So, wow. It almost threw out the other thought in my mind when I heard you say that.

Kyna Fong: Yeah. I mean, they walk out the door. They’re like, “I hope they go get that lab test.” It’s the simplest most common thing. “I hope they go get that medication,” and the patient can have every intent to do so. We know so much today about all the reasons that that doesn’t happen. That’s where all the social determinants work is so interesting.

Gordon Moore: Yeah. If I think about the trust, so I remember years ago, I was reading a study about the likelihood that somebody goes for a recommended colonoscopy. So an uncomfortable procedure, not something that naturally occurs to me as something to do if I’m not in health care, but a net good for a person. And it turned out that one of the predictors was waste and delays in office practice and trust in the physician, which in some deep interviews was identified as, “You don’t keep me waiting and you listen to me when I talk to you. So you don’t waste my time.” And so this is from the patient’s perspective. “And so if you demonstrate those behaviors, you are demonstrating respect for me, so therefore I respect you and I’m more likely to trust you and follow through in your recommendations.” So how is it that technology enables that relationship? What is it that you do that makes that work?

Kyna Fong: Fantastic question. I mean, it starts from the very simple things, and that’s a big part of where we started, which is when the patient and the physician are together, let them be together. Let them interact with one another and not be distracted by a computer that’s in front of them and really have the physician, or sorry, the patient feel like the physician is paying more attention to the computer than to the patient, right? So that’s this simple, straightforward thing that, at the same time, I would say a vast majority of health care is experiencing challenges with today. It’s just that human connection, despite being physically present together.

I think from there, I think technology can really lower the barriers to ongoing interaction and make it just a lot easier to do that. And when a patient hears from their physician or from their physician’s practice, their care team, it makes them feel cared for, right? It makes them feel like they matter to their practice and that builds trust as well. And so when you think about today, in our everyday lives, we can communicate with very low friction with anybody around the world. Just pick up our phone, send a text and the message.

And I think those abilities to have just much smaller touchpoints and express that the physician cares and make the patient feel connected to who’s taking care of their health, I think those are all fantastic ways to build trust. And it’s all a bunch of small things. And then from there, when the important times come up and bigger events are happening, I think that’s the foundation that you want to have to then really help guide the patient and support the patient and hopefully have prevented any more serious incidents for the patient.

Gordon Moore: I think about my personal experience, actually going back to the colonoscopy thing. I had to connect with a new GI doc because he retired, and going in for a reup of my colonoscopy. And they were communicating with me through a portal that obviously the practice is paying some company to do their portal. And I’ve done a bunch of portals and know technology. I could not get through that thing. It was miserable. So here’s channel of communication. “Hey, let’s communicate with patients and bring them closer. We have technology that does that,” and it was a complete face-plant, in my perspective. And I think that matters.

I mean, I probably still trust the practice, but boy, what a lot of friction. So I get the sense that technology can be an enabler or really get in the way, but the words they use in selling their stuff sound the same. If I were to walk down a vendor row in a big conference, probably all the signs say the same stuff. “We connect you with your patients. Our technology is going to make life better for everybody.” How do you differentiate?

Kyna Fong: Yeah. I mean, that’s the blessing in the curse of the innovation we’re seeing in health care today. I think it’s amazing how there’s so much talent and resource and investment into digital health and really trying to raise the bar on the technology and hence the experiences that can be built and offered in health care. But at the same time, it can be difficult to distinguish what is actually making a difference. I mean, I guess the first thing I would say is just being a product oriented person myself, what is delighting the end user, right? What types of products are creating that type of impact? And I think you follow that trail and you’ll get to your answers, whether you’re talking about net promoter scores or any type of measure of advocacy and fandom and excitement from the users.

I would also say that technology in and of itself is not a panacea. I think it’s a hugely important enabler of the next generation of care or the type of health care that we want to experience for our patients, ourselves, our children. But there’s also the big elephant in the room is the incentives surrounding health care. And getting back to the topic of primary care, I mean, the types of interactions and relationships that build trust really feel at odds with the fee for service transactional type incentive structure that prevails today in so much of primary care. And so when I think about technology and great user experiences, I think there’s a lot of potential for innovation there, but at the same time, we have to marry that with the right incentives, opportunity, and space for clinical innovation alongside that.

Gordon Moore: Oh, hear, hear. I mean, that was so much my experience back in the late ’90s in my own practice. I remember seeing a big consulting company saying that the more employees you have in your practice, the better able you are to draw down revenue and do all sorts of wonderful things. But I was looking at some other work that was looking at overhead in practice, and quoting that 70 percent number of revenue going to overhead beyond the physician’s salary. And that made me think, “If friction and wasted time using the lean concepts in primary care are the times spent not face-to-face with the clinician, and that non-physician time is also a lot of the overhead, then maybe I could downsize and spend more time in relationships.”

So I was lucky enough to get to prototype a practice that was just very, very small with an EMR, just me direct connection with patients. And that was a lot of fun, and it worked within fee-for-service, but only possibly because in Rochester, New York, the mix of payers and the primary care rates were okay. But we found out that that’s not true across the country, that there are many practices where you could be fantastic with your overhead, but still not successful financially. And so I completely agree. So where do you think we should go? What incentives should be in place to, again, enable terrific primary care?

Kyna Fong: There are a couple threads that you pulled on there that I would definitely love to dig into. But in terms of how we can enable terrific primary care, I think the starting point is one where the statistic I cite often that’s just so incredible that comes out of the Oregon Patient-Centered Medical Data shows that an incremental dollar spent on primary care can save 13 dollars in downstream medical spend. And that’s the type of ROI that you could only dream of in any industry, and in health care, nonetheless, where we have so much challenge with spiraling costs and inconsistent patient outcomes.

I think it behooves us to really think about, “How do we incentivize ourselves to realize that value?” And then you also put it against the facts that say that we spend about five to seven cents of our health care dollar on primary care, whereas much developed countries, OECD countries, are spending 12 to 14 cents on the dollar, and probably realizing much more of that ROI than we are. And I really think it starts from a place of primary care needs to be the primary way that care is experienced. When I think about in an effective health care system, I think a KPI that the US health care system could really benefit from is one where we’re simply measuring the number of people that have a primary care doctor they trust, and that they have a longitudinal relationship with.

And I think we enable that through really, first, incentivizing primary care led organizations, where I think we’re going in the right direction of saying, “Hey, how do we reimburse primary care, not just for the incremental minutes that they’re spending with their patients, but really the overall impact on their panel of patients, whether it’s in terms of total cost of care, and importantly, the quality of the care delivered, whether we’re talking specific, measurable patient outcomes, or even just simply patient satisfaction?” Which gets back to that notion of trust that I’ve been talking about. And I think that is really the paradigm that we need to get to and incentivize.

And I mentioned you pulled on a couple threads, I think one of the huge challenges in primary care is the fact that when you look at specialties by pay, that primary care just consistently sits at the bottom of that list. And so we’re really handicapping ourselves from getting the best and brightest into health care, sorry, into primary care, whereas primary care is where we can really use the best of our physicians. So it all comes back to, “How do we put primary care in the driver’s seat in terms of being accountable for panel in terms of cost and quality, and then how do we make it so that primary care physicians actually become the highest paid specialty?” And given the ROI of a dollar, primary care can save 13 dollars in downstream spend. There’s a lot of opportunity to reward primary care more financially. But even beyond that, it’s how do we do that so that we really get the best and the brightest into the specialty where we need it most?

Gordon Moore: I love that. The percent primary care spend, there’s some really interesting work. Chris Koller was the health insurance commissioner for the state of Rhode Island, and about 10 years ago, started working on the percent of primary care spend. He’s now with Millbank Memorial fund, and so he’s leading, along with the Peterson Foundation, a number of state Medicaids that are looking at measuring across all payers the percent primary care spend, expecting them to move from the five percent, as you mentioned, up to 10 percent, at least of dollars. This is not net new dollars. We have tons of money in health care right now. Let’s shift it, like you said, from unnecessary downstream care delivery from the potentially preventable things that are happening at very high dollar and shift it upstream where it’s going to work.

I think about measurements and the reasonable consideration that we should tie payment to quality, and I think about the different ways of measurement. The typical way, for instance, is a lot of process of care work that is very granular and frontline and creates a significant amount of work burden for a clinician and team, like for all your people with diabetes who have their A1C greater than nine, you’re doing X and Y and Z. I mean, that’s good. I don’t mean that’s a wrong thing, but boy, it creates a huge reporting burden. And then those factors are necessary and appropriate, but may not be sufficient to also achieve some impact on necessary health spending, like reducing unnecessary emergency room visits and the like. So we need measures at that level, and I wonder what do you think about those two different approaches, and how would you bring them to life in a technology environment, or is that the wrong venue?

Kyna Fong: It’s definitely the current value-based conundrum we find ourselves in, right? Because in order to reward based on value, we need to be able to measure value. The ways we know how to measure value are somewhat immature at best, right? And they don’t really encapsulate the complexity of what really high-performing primary care can drive. But it’s a process, right? And as players in that field, we need to accelerate and create the capabilities to help accelerate, and in the meantime, while it’s happening, minimize any negative impact on patients. So I think a couple ways to think about it. I think in the very near-term, it’s progress right direction, just to start thinking about value, and I think technology, like Elation’s, we try to reduce that administrative burden.

The last thing we want is for a physician to have more that they need to document or prove or explain about what they’re doing with their patient. So the more intelligent the technology can be to understand and anticipate what administrative documentation or coding is needed, the more we can help advance value-based care while reducing the burden on the physicians. So I think technology has a significant role to play there. I mean, I think as you play forward, I’m not confident that we’re going to get to a place where we can minutely measure every aspect of what high-performing primary care is.

I think that is a difficult endeavor. And I personally am more attracted to models where there’s shared accountability or even up to full accountability for a total cost of care and quality across a population by a group that’s helmed and led by primary care. I think that these models allow for the type of innovation and broader and more long-term perspective on their patients that gets them away from minute checking of boxes and delivery of codes that really hampers our health care system today. I mean, we haven’t talked explicitly about administrative cost. I mean, those are pushing 15 percent of spend, right? And so much of that is miscoordination or excess need for communication and documentation and coding that happens in health care.

Gordon Moore: When I think about the opportunities for payment aligning with quality, I like how you think about stepping away from the super-fine granularity. That makes a lot of sense to me. Some part of me thinks if I’m measuring hemoglobin A1C and I’m measuring percent of people with cholesterol who are achieving the right levels and hypertension, that’s all good work, but at some point tracking these detailed pieces for external reporting becomes burdensome, and I’ve reached my limit. And then I’ve only accomplished that for a handful of patients or a handful of conditions, but everything else is off the map. I can’t even look at it because I’m exhausted taking those first few things. Plus, as we put regulations and requirements around a handful of things, we can create bizarre behavior.

For instance, I remember reading somewhere about some hypertension management goal that you have to do X before you can do Y with certain patients had some PCP in the UK saying, “So you want me to get my little old ladies to fall down and pass out before I can choose the right med?” And of course, that’s not the intent. Nobody wants that to happen, but I hear that enough from colleagues that these granular, “We’re going to almost legislate exactly how you’re going to treat cholesterol in your practice,” it’s just too much. Let’s talk about the out outcomes. Let’s be less rigid about how we get there, although we need to use evidence. So that’s a fine line.

Kyna Fong: Yeah, absolutely. And it really also gets down to how much you see the physician as a partner, right? And organizations vary tremendously on this. We’re on the one end, you have independent primary care, physician-owned, independent physician-owned where physicians are the partners. They’re the owners. They’re really driving autonomy in their day-to-day up through large, much more employed arrangements where the metrics are used to manage the physicians. And I think health care is complex. Medicine is complex.

And I think physicians… There’s a lot in their expert ability to understand that complexity. And I think partnering with physicians to understand, “What does it make sense to measure? When does it make sense to measure, and what is the true value that comes out of measuring as it relates to outcomes?” At the end of the day outcomes, which are so well correlated with costs? But what is it that truly matters? And let’s measure those things. And once those don’t truly matter, let’s not measure them. And I think it’s that partnership with actual frontline practicing physicians that is a very, I think, powerful path forward as we think about measurement in health care.

Gordon Moore: So Dr. Fong, as we move towards wrapping up this conversation, I’d love to get your thoughts on if you had a magic wand, you could wave it and change some things in the near term, and then maybe in the long term, what comes to mind?

Kyna Fong: So on the technology front, interoperability, and true interoperability. I think it’d be so powerful to just allow data to flow and move. And there are so many reasons that’s hard, and totally understood. But I think getting some of the major repositories of information and some EHRs, I won’t name them by name, but some that hold a bunch of data that went unlocked can really deliver a lot of benefit to patients. And we’re making a ton of progress on this front. But if I could wave a magic wand and fast forward us to where we’re on track to get to in 10 years, I think that would be phenomenal.

I think the second thing, like I said… Right now, I feel like there’s this tremendous understanding, and sometimes I call what’s been happening over the last few years a renaissance for primary care, because I think there’s an understanding that primary care is one of the most powerful levers we have in building a sustainable health care system. And the things that get in the way of that really amount to the complexity of just getting from we have dollars we want to give to primary care, and on the other end, we have primary care providers who will take those dollars. But creating those win-wins are just so hard in our health care system, whether you’re talking about contracting and the complexity of the number of payers out there, whether you’re talking about some of the regulations that make it difficult to enter markets.

I think there is an appetite and a desire. Most payers that I talk to, they want to pay primary care more. They have incentive dollars and pots of money that they would like to pay primary care more. But the mechanisms to do that require innovation, and that’s a function of the complexity of the systems we’ve built so I think that’s what I would point at. But yeah, that’s a stumping question. I should ask myself that more often. 

Gordon Moore: We definitely need better interoperability and we need more payment going to primary care to help them do the right things in a facile system for understanding where there are opportunities to improve and where to direct effort.

Kyna Fong: And if I may add one thing, too, the overhead in health care is driving physicians into arrangements where they’re no longer autonomous and where the organizations are not led, especially by primary care. And whether we’re talking health systems, hospitals, et cetera, I do think primary care leading independently is a recipe for success for all the things I’ve talked about. And those reasons, whether it’s burnout from technology, difficulty of getting paid, lack of predictability in the evolving payment models, all these reasons that cause physicians to seek shelter and/or safety in arrangements that give them just less autonomy as physicians and don’t allow them to really take ownership of their patients and their panels as effectively, I think if we could get rid of all those things that prevent truly meaningful patient/physician relationships, I would do that, too, with a magic wand

Gordon Moore: And I would love to be there and I want that to happen so bad. So Dr. Kyna Fong, I want to thank you for your time and your insights today.

Kyna Fong: Thank you. I really enjoyed the conversation. Appreciate you having me on today, Dr. Moore.

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