Greater numbers of payers and employers are turning to advanced primary care (APC) to provide healthcare that reduces the total cost of care while driving improved health outcomes. But it can be a challenge to understand how APC aligns with your particular needs and goals.
To help payers and employers learn if APC is the right fit, we’ve launched a new APC guide. It’s an informative resource built with simplicity in mind, so readers can intuitively navigate APC’s benefits — whether they’re a payer, employer, patient, or provider.
Check out the video and full interview transcript of our conversation with Vera CEO and President Ryan Schmid to learn more about how APC differentiates itself from traditional healthcare models.
“The operational investment to be able to service multiple patient segments, even out of the same care center, has proven to be a big investment and a heavy operational lift, but I think it's set us apart and put us in a kind of space on our own.”
— Vera CEO and President Ryan Schmid
We hope the above video and APC guide help payers, employers, patients, and providers learn more about the proven benefits of APC.
Ryan:
The first thing to know about advanced primary care is that it fundamentally has to start with aligned financial incentives. So when we talk about what advanced primary care is, I always want to start there — because without aligned financial incentives, it is way too easy for interests to go in separate directions, which I think is what you see all the time if you have a service environment.
So by making sure that all stakeholders want the same thing financially, your odds of success go up infinitely — regardless of what the rest of the program looks like.
There are four pillars of advanced primary care.
The first pillar is a team-based approach. It’s really important that the care team works as a true team and sees and holds themselves responsible for an eligible population. Regardless of whether the members of that population have come into the care center or not, that team has to work together. The team typically includes physicians, nurse practitioners, medical assistants, and health coaches. Depending on the population, care teams include service providers as well.
The second pillar of advanced primary care is a rigorous informatic platform. At Vera, we ingest and aggregate as much data as we possibly can including clinical data, claims data, and lifestyle or social determinant data if we can get it. That gives care teams a very clear understanding of the full population as well as a clear understanding of specific and individual members they provide care for.
The third pillar of advanced primary care is a population health approach. Advanced primary care teams should ask themselves:
The care team should also have a full 360-degree view of each individual patient before that patient comes into a care center. And that's important because we want to be respectful of the patient's time. We also want to make sure that we're checking all the appropriate boxes during their appointment. Every one of us has forgotten when our last tetanus shot was, right? That’s one example.
If the care team already has all the information around a patient’s screenings, we can use that to better manage the appointment. That's really important.
The fourth pillar of advanced primary care is a care coordination approach. We recognize that a lot of the care patients receive is not through Vera; it is through a different community provider. Just because patients are not receiving care at a Vera care center, though, doesn't mean we're not responsible for them. So we take a lot of pride in essentially being the quarterback for the patient’s entire healthcare ecosystem and in helping all the moving parts work together.
If we make a referral, we have an internal-quality metric of a 100 percent referral closure. That means we're following up with the patient or following up with the receiving provider to confirm that the patient showed up. We ask:
And a lot of that is to support the patient and the provider, but some of it helps us make sure that a particular patient doesn't end up getting lost in “specialty land” receiving a bunch of unnecessary care that costs a lot of money that they otherwise maybe don't need at all, or receiving care that could be delivered through an advanced primary care environment.
Ryan:
Our model is adaptable mostly because of the people we hire. Our care teams are exceptional, and they come here because of the purpose-built nature of our advanced primary care model.
We're very intentional about hiring care teams that are excited about serving a broader patient population. And we build the clinical programs and give them the tools and data to leverage and understand different populations.
I do think, at the end of the day, it's a mentality that “no matter who my patient is or where they come from, if they're eligible to come into a Vera Whole Health care center, they're my responsibility.” And that unique mindset transcends any host of mistakes we could make organizationally because, at the end of the day, I have total confidence in our care teams to figure out how to manage that population. Our field support teams are a living, breathing system of constant change, but I'll put our team up against any team in the country. And I think they've done an amazing job.
Ryan:
Integration or interoperability are very buzzy words in healthcare right now and they are really important — but there is far more talk than action. Having said that, I do think that's an area where we've set ourselves apart. Some of the integrations that our teams have pulled off, and this may sound simple, but it is months and months of work connecting data warehouses for the robust flow of information. Those are big, gnarly lifts in systems that were initially not designed to talk. So it's hard to underscore enough how impressive our data integration is or to overstate what our teams have been able to pull off. We very much view ourselves as part of an ecosystem in each of the markets we serve — so we're always willing to come to the table to do that. And when we have a reciprocating provider, it does have a tremendous impact on both of our abilities to deliver value to who matters the most — and that's the patient.
Ryan:
We receive feedback from our stakeholders which include our patients, our care teams, our clients, and our customers. And we measure all that a bunch of different ways, but the subjective feedback and the objective data do point out that we stand apart, and that's something that we take a lot of pride in. And I think those stakeholders in Vera look at what we consider to be our ultimate value propositions, which are improved health. To us, improved health means a biopsychosocial health approach for reduced total cost of care. And across our business we're performing really well, and that gives us a lot of confidence.
Ryan:
There are a few things that make Vera's advanced primary care model unique. That the entire ecosystem is built around empathy is not to be understated. And I've gone back and forth over the years in my head even. Like how real is that? And I'm more convinced than ever today that it has been a huge differentiator in actually driving outcomes because at the end of the day, healthcare is a relationship business and that starts with trust and that is earned through empathy. So I think that makes a huge difference in the outcomes we've been able to generate.
I also think our unwavering commitment to embedding health coaching and behavior health counseling in our care centers has set us apart for the right reasons. The fact that we are only purpose-built to drive outcomes has resulted in all of our investment going into the operational and clinical programs to drive outcomes. We've never focused our investment in the next fancy technology because we thought it would help us sell more. We've always put our money where we thought we could improve outcomes. That has played itself out well.
We decided a long time ago that we did not want to define ourselves by who our patients were. Rather, we wanted to define ourselves as the best advanced primary care practice in the country that could serve multiple patient segments. And that has created a lot of opportunities for us and our clients who have a population base that isn't as narrow as perhaps some of our peers are going after. The operational investment to be able to service multiple patient segments, even out of the same care center, has proven to be a big investment and a heavy operational lift, but I think it's set us apart and put us in a kind of space of our own.
Ryan:
There’s been a movement towards value-based healthcare for a while. It's been slow, but it's really happening. I would say that COVID has significantly accelerated that move to value-based care models. When I say value-based care, we at Vera think of that as the quadruple aim that begins with higher-quality care (that’s more convenient for less money and is delivered by exceedingly satisfied care teams or clinicians). And at the core of that is aligned financial incentives.
What COVID exposed was the fatal flaw in fee-for-service models because when "elective care" just went away, you had the backbone of our entire healthcare system, which is primary care, essentially out of work for a significant amount of last year, which is a monumental loss. In a value-based arrangement (which is all of Vera’s arrangements), our care teams were able to keep as busy providing care to patients as they ever were. We had our best year in terms of overall quality, which we measure on a set of national metrics.
Even when patients weren't physically coming into the care center, our care teams were able to do outreach to them at the height of the pandemic. In April, 85 percent of all of our visits were virtual-based appointments. We remained the PCP or the primary care provider — the quarterback of the whole system — throughout the whole experience.
That's so relevant for a payer, as one key example, because Q1 through Q3 of 2020 saw very little claims activity. Medical loss ratios were extremely low, and there was a sense that payers were set for a financial windfall.
What you started to see in Q4 was pent-up demand, care avoidance, or understandable delay resulting in greater risk and higher acuity. Because of that avoidance, everything has gotten worse and you started to see that reflected in the claims in Q4 of 2020 — and it's only expected to increase going into 2021 and potentially 2022.
Had payers had more value-based contracts with advanced primary care providers like Vera in that COVID bubble, the overall trend would remain positive to the payer patient and customer as opposed to a downward spike and then an upward spike, which is what we're seeing.
And people would be healthier, frankly.
Beyond that for payers there's a very, very rapidly moving trend around that's called “the vertical integration,” basically where payers and providers have to and are quickly realizing they're better off working together around, again, "value-based contracts," which really just means aligned financial incentives. And most of those programs work best when they're built around advanced primary care models, because done well, advanced primary care is going to provide significantly higher quality care to the member, which is good for the patient. It's going to save the patient money.
But then they're also going to control the whole value stream when 80 to 90 percent of the care any working adult is ever going to need could and should be delivered through primary care, that reduces a ton of waste burdening the rest of the system, which is a huge win for anybody that's participating in that value-based arrangement. The winners include the hospital or the specialist because if it's the right kind of contract, everybody actually does better financially the higher the quality of care. That's why advanced primary care is valuable for payers.
Ryan:
You can think about the self-funded employer as the payer in this context, right? Whether it's because of the trend we're already seeing or because of COVID, employers lower their overall costs and see improved health outcomes from advanced primary care’s ability to provide high-quality care to members when they need it and where they need it (whether virtually or in-person which is really relevant in a COVID context) and to always be incentivized to do the right thing. For employers who pay for 50 to 60 percent of healthcare in this country, and at much higher rates than the rest of the ecosystem, being able to actually take control of that value stream is likely the number one reason for an employer to align with an advanced primary care provider.
Ryan:
The value proposition remains the same as for self-insured employers and with the same quadruple aim: higher quality care that's more convenient, costs less, and has wildly satisfied care teams.
Ryan:
Advanced primary care offers patients far superior quality and access whenever they want it, and they're going to save money themselves. Their outcomes are going to be better, they're going to have an esteeming experience and feel heard. And an advanced primary care model by definition should be a biopsychosocial clinical model.
So it's for the patient. It's not just addressing the symptom or physical disease or infirmity. It's making sure that somebody has the support and the resources to be mentally and socially well, which are usually drivers of physical health. So you have to truly build clinical programs to address the whole person, not just the sickness.
Ryan:
What's been constant through our journey has been empathy. Our entire organization is built around empathy. Our mission is to help people change behaviors by esteeming them through empathetic listening. It's in everything we do.
Next, we’ve retained a care team-based approach where our teams are purpose-built for specific populations. And third, health coaching has remained a constant. We've never wavered from clinically integrating coaches into our care teams. It's actually why we got into primary care — and it's been fundamental to all of our success.
Ryan:
I think the biggest surprise for me over the last eight years as we've been operating advanced primary care centers is the addiction that the whole system has to fee-for-service. To me it's been the most obvious thing in the world: Without aligned financial incentives, you're just never going to get better outcomes for less money. At some point along the way, I heard somebody say the system isn't broken — it works exactly the way it's designed to work. And that lack of transparency and the production-based payment models leads exactly where you would expect it to lead, which is a runaway freight train of costs for worsening outcomes.
The other surprise is the vast majority of individuals working in the system are really good people that actually want to change things, want to see outcomes improve, and would love to see costs come down. To say that it's like turning the Titanic is a gross understatement. It is a massive lift. And that dichotomy of intent vs impact is really hard to wrap your mind around. And it's easy to get lured in.
We've never wavered from our commitment to aligned incentives in every single deal we've done. And consequently, we've walked away from an awful lot of stuff, or we haven't been the right fit for a lot of stuff over the years, but nevertheless, I'm proud of how we've dug in there.
Finally, I've never heard a single person say they didn't believe that integrating behavioral health into primary care wasn't a no brainer. And yet it has been exceedingly slow to get people to pay for it. This is another area where I think COVID has accelerated positive change. You're starting to see more of that and that's a really good outcome from a really terrible thing. But it has been really surprising how hard it has been to get people to see and to pay for the value in embedding behavioral health.
Ryan:
A lot's changed since the beginning. Obviously we've added a lot of clinical programs over the years. We've moved from serving just employers to partnering with payers, serving in Medicare Advantage individual populations. But all that aside, I think the two things that come to mind with respect to our evolution are what we're able to do with data today to inform how we provide care and to whom we provide it. That has grown leaps and bounds compared to when we started.
The ability for our care teams and our patients to stay in a relationship and provide and receive care virtually has changed dramatically over the years. We think it's really important that our members be able to access our care teams when they want. And if digital tools can enable that to happen, then fantastic. I don't think virtual care is an end-all-be-all, but I do think it's a fantastic enabler for the team and the patient to stay connected.
Ryan:
I think APC is going to flourish in commercial populations, individual ACA-exchange populations, Medicare Advantage certainly, and likely even managed Medicaid.
I just don't see a way in which the system backtracks on what is now more obvious than ever, and that is if we have any hope of improving the health of our communities and curbing the tide of rising healthcare costs at all, it has to start and stop on the back of an advanced primary care platform across the country.
That is a massive change from where we're at today. But anytime you have such an out-of-whack supply and demand equation, in this case the demand being high with supply being low, I think it bodes extremely well for the future. I'm very optimistic. People around me call me chronically optimistic. So maybe don't take my word for it, but I'm excited.