- The strategic agenda facing hospital and health system
- leaders right now is not a short list.
- Growth in a consolidating market, sustainable margins in
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- Eker's fourteenth annual CEO CFO roundtable brings together
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- Not in the abstract, but against the real
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- It's the kind of event you leave with
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- upper right.
- This is Laura Dirda with the Becker's Healthcare
- podcast.
- I'm thrilled today to be joined by doctor
- Surendra Kara, president of the Cleveland Clinic Florida
- Accountable Care Organization and vice chief for the
- Primary Care Institute for the Florida Market of
- Cleveland Clinic. Doctor Cara, it's a pleasure to
- have you on the podcast today.
- Hi, Laura. Nice to be here. Thanks for
- having me.
- Absolutely. Now I'm excited for our conversation. I
- think it'll be,
- a lot of fun just to learn about
- what you're doing at Cleveland Clinic Florida and
- how you're thinking about the future. But before
- we dive in, can you tell us just
- a little bit about yourself and your background?
- Sure. Sure. So a lot of my background,
- I,
- in short,
- trained in in India in med school, did
- my postgraduate training in England, and then
- in in The US was predominantly,
- in the first half of my career,
- on the inpatient side, immersed in inpatient
- quality, safety, chief quality officer. And then in
- the second,
- migrated
- slowly towards population health, value based care, and
- primary care.
- And so I've been with Cleveland Clinic, Cleveland
- Clinic Florida for the last four years,
- overseeing
- their primary care institute in Florida and also
- overseeing the ACO,
- the treatment clinic,
- what we call the treatment of Florida integrated
- health care ACO.
- I so I'm the president of that ACO.
- So my role is work overseeing the institute
- on the people, operations,
- processes point of view. And then
- as president of the ACU, I oversee the,
- the value based care
- and the care delivery structures and innovations that
- supports,
- supports that.
- That's great to hear. And, you know, it's
- such an important
- aspect of the,
- whole organization to oversee and look because I
- know, you know, ACO
- is so important and touches a variety of
- different aspects of the whole enterprise and then
- looking at, everything else that funnels into being
- able to provide care is so critical.
- Now could you give us just a a
- quick state of the union? What's going well
- this year, and what are you focused on
- for the rest of 2026?
- Yeah. No. Beautiful. So I think my
- my journey into
- primary care started with managing the complex patients
- and in trying to work my way through
- readmissions.
- And one of the things I realized
- during that time was
- the the difficulty and challenges that primary care
- faces with access.
- So pretty much the last four years and
- more so,
- almost the completion of that happened this year
- is the work that we have done on
- access redesign in primary care.
- And then we divided that that work,
- Lauren, into
- the just hiring of clinicians and expansion of
- primary care, across Florida.
- And, for example, we've now in my third
- third year
- sorry. Fourth year, we've now recruited over over
- a 100
- clinicians into the Prameka Institute across the region.
- That has led to an absolute opening of
- access,
- But then we've done a lot of work
- on access innovations.
- We for example, we have a team called
- the clinical access team that has now seen
- over 20,000 visits, and this team
- essentially manages same day access for patients when
- they need it, complex patients when they leave
- the hospital.
- They also see patients when physicians, primary care
- physicians, or or FMLA or leave,
- and then then they manage their patients during
- that time. So that team alone
- has, has significantly improved our access in addition
- to the recruitment and expansion of primary care
- that Cleveland Clinic has supported.
- We've continued to do innovations of primary care.
- In a couple of weeks, we will launch
- our first,
- what we call,
- primary care integrated model for care in the
- evening and weekends. So we'll have our first
- four primary care physicians who will work in
- the evening, and they will be like any
- other primary care physicians. They will have a
- panel of patients,
- but they will open access to our patients
- in the evening and on weekends.
- And they'll work in partnership with the data
- in primary care physicians.
- So it's innovations
- in access like that. We redesigned our templates.
- We've introduced
- for for clinician retention.
- We now have thirty minute templates that we
- offer to primary care physicians.
- As you know, primary care patients are very
- complex.
- So fifteen minute, twenty minutes
- doesn't do justice to them. So we now
- have well over 75 clinicians on the thirty
- minute template, and
- that has been a huge improvement, not just
- in in clinician well-being, but the time that
- they get to spend with the,
- with the patient.
- So if you if you add all of
- this up,
- I'll say the the big team for the
- last four years,
- which has almost reached
- its perfection this year, but not still a
- lot of work to do is is the
- work around access.
- So the net result is we've dropped new
- patient wait days by almost 75%.
- Two years ago, our patients were waiting months
- to find a primary care physician, and now
- that has dropped to under under, like, few
- days. You can find a primary care physician
- in some parts of the market.
- We have,
- you know, the
- the number of visits that you get with
- a primary care physician,
- from three years ago to now, that has
- doubled. So an average patient now gets double
- the number of visits that they would get
- three years ago with their primary care physician.
- We've completed over seventy five percent of of
- our patients who are eligible
- at the annual wellness visits completed now. That
- number was half a few years ago.
- The net result is not just better patient
- care, better access, but the second year in
- a row, our ACO has had
- a positive shared savings. So we are we
- are seeing the numbers improve in in metrics
- like appointments spent when, you know, when wanted.
- Our turnover rate for clinicians, which was in
- double digit, is now
- in the low, you know, under 5%. So
- we've we've and for the first time, as
- an example, with two of our submarkets, we
- have no openings in primary care, which we
- never thought we would see today.
- So we've recruited
- successfully. Our turnover has dropped. We've done access
- innovations.
- All of that has resulted in in
- in addressing those challenges of a very complex
- patient population in Florida. You know, they're older.
- About seven some markets, almost 72%
- of them are on Medicare and managed Medicare.
- So I think the
- extremely proud of the work that we have
- done around that, Laura.
- That's amazing to hear and and very impressive.
- And and, you know, love to to kind
- of hear how you're thinking about that as
- well.
- Yeah. No. And I I'll tell you, we
- we declared access not a scheduling issue.
- Access is a safety issue. You know, I
- came from the quality safety world.
- Lack of access is almost a I consider
- it a safety event.
- So we say access is no longer a
- scheduling problem. It's a health outcome strategy,
- and that is deeply tied to our value
- based agenda and our our the care that
- we provide to our patients.
- It's very proud of that workload.
- Absolutely. And that's amazing to hear. And, you
- know, when you think about that mindset shift
- of,
- having
- access be a health outcome strategy tied to
- quality, tied to everything else that you're looking
- at for the patients, you know, it seems
- like the team has been very innovative in
- improving that access and finding ways that, they
- can continue to, you know,
- be,
- innovative in,
- redesigning care delivery and that whole process.
- And I'm curious when you look at everything
- that's going on, what are some of the
- big headwinds that,
- you're seeing right now or or that you're
- facing as you're,
- redesigning care and having the success?
- How are you thinking about those headwinds in
- preparing for them going forward?
- Yeah. Oh, beautiful. So
- I can tell you,
- one of our biggest challenges is is a
- national challenge, and then some of it is
- very local to Florida.
- The national challenge, I mean, if you saw
- the study, for example, in JAMA a few
- few weeks ago on the number of messages
- that come to our primary care physicians.
- So in the last five years,
- the number of messages that come to primary
- care physicians through portals, like MyChart messages and
- and patient portals
- has gone up by a 153%.
- So that is if you see a primary
- care clinic, you see a physical clinic. You
- see primary care physicians.
- What what no one sees is what what
- I increasingly call the digital clinic. So running
- in parallel to the physical clinic
- is the digital messages that our patient has
- are sending us, and that has gone up
- by by a 153%.
- Five years ago, they used to send about
- point nine nine message or about one message
- per patient, and now it's about two and
- a half messages per patient.
- We have not accounted for that. So,
- nowhere,
- I mean, we have inbox ologists. Increasingly, Cleveland
- Clinic has ATPs who function as inboxologists in
- managing these messages,
- but we have not,
- collectively,
- strategically,
- by way of policy,
- payments, and measurements,
- looked at what's happening in this digital
- workload that has that has come out.
- So the net result, for example, in
- Cleveland Clinic primary care in Florida,
- for every hour that a primary care physician
- sees patients, they generate fifteen minutes of what
- we call work outside of work. So that's
- their task time,
- time outside of scheduled hours.
- So for every hour that they work, they
- take fifteen minutes of work home. So if
- you work a eight hour day, you've taken
- about an hour and a half, two hours
- of work home.
- That is unaccounted for work. That is work
- that primary care docs are doing on their
- own time, on a weekends.
- And if we don't find a solution to
- that,
- I think the the issues that primary care
- faces with this they just continue to get
- worse. I mean, we are projecting about an
- 87, 90,000
- primary care physician by 2037.
- A lot of that is coming from the
- burnout that they face, not just from the
- physical work that they do, but the work
- outside of work that they have to handle,
- what we call the digital
- work. So that is a real challenge, and
- and different ways to solve that including,
- treatment. So we have an inboxology
- structure that is someone
- sits and manages these in baskets for the
- for the primary care physicians.
- When they go on vacation, they come back
- to about 65, 70% of the in basket
- work done for them. So they're not sitting
- after their vacation and going through hundreds of
- messages.
- But that is not all. I think there's
- something I I I personally call a digital
- corridor. I feel we need to design something
- that runs in parallel
- and in real time to primary care practices,
- which I I I I just call it
- a digital corridor. And in that, there are
- inboxologists.
- There are nurses. There are APPs who do
- the work.
- There are APPs and maybe even physicians who
- do virtual visits so that the general sense
- of pressure
- that the clinics feel is shifted
- into this this corridor.
- So for example, in in our clinical access
- team that we have,
- which is
- which I had mentioned earlier is an access
- innovation.
- One of the APPs there is is always
- functioning as an in bask inboxologists,
- and they're managing the in basket work that
- comes out of the primary care practices.
- I feel you need to you need to
- expand that. I think we really need to
- address this problem seriously, and not just in
- care delivery redesigns, but also in policy. And
- how do we account for this? You know,
- we measure visits. We reimburse for visits. We
- measure our views. We reimburse for our views.
- But we we don't measure and we don't
- count the digital workflow. So I think that
- the policy changes need to be made and
- payment changes need to be made and how
- we do that.
- And whether that is shifting some to the
- patients or whether it is by the by
- the peer
- that needs to be determined. But but either
- way, the digital aspect of our work needs
- to be looked at seriously.
- The other thing in Florida, I think, is
- is this changing demographics.
- I think,
- we always knew Florida, I mean, was was
- was the place for people to retire.
- And now we anticipate
- by, for example, by 2037,
- the '20,
- the CBO estimates that by 2034,
- almost
- sixty three, sixty four percent of our Medicare
- patients would be on managed Medicare.
- So the combination of the pressure that a
- state like Florida fee feels,
- managed Medicare and and Medicare patients
- is a lot. So
- category redesigns that supports,
- these complex patients,
- needs to be made. And I think I
- don't think we have made enough practice optimization,
- and support structure has not really changed a
- whole lot in that direction.
- A lot of that needs to happen.
- We still function as a traditional primary care
- assuming a very different tier mix
- than a rising complexity
- aging populations,
- but I think we we need to very
- intentionally need to make investment in that direction.
- Those will be the two big that I
- see,
- you know, from the burnout prevention and then
- then care we redesign that supports
- the rising complexity and the demographic shifts in
- our patients.
- Absolutely. I think that makes a lot of
- sense, and I appreciate you laying that out
- so clearly for us because there's, you know,
- so much, that it it relies on primary
- care physicians being able to do what they
- do in a critical role within the health
- health care ecosystem. So to build that support
- system around that digital work they're doing,
- it's been great to see the start of
- that. And then to your point, you know,
- continuing to expand that and grow how you're
- supporting their work as well.
- And and as you've been going through this
- transformation,
- I'm curious
- how,
- easy or hard has it been to, you
- know, put put people into these new positions
- and roles,
- as the digital workload has been increasing? Has
- there it been well received, or or has
- it taken some time to get people,
- understanding how important this is and and what
- they need to do in order to, make
- sure the entire ecosystem works?
- Beautiful question. So both. In a way, it
- is it's
- it was quite heartening to see that there
- are people who want to do that work,
- that there were,
- there are,
- clinicians who are willing to
- be digital clinicians and managing basket and digital
- visits and and support the practices in that
- way. But on the other hand,
- that space is,
- as I said, the the structure there is
- not well designed. The return on investments there
- are not clear.
- So so if if if if they are
- doing work that has no tangible
- business model tied to it
- other than, you know,
- offloading the clinicians in the physical space
- and and retention,
- then I think it just makes it harder
- for them to understand the work and for
- us to expand that work from the from
- the business point of view.
- I think if anything has come in the
- way, of of of adoption of that, it
- is that that lack of clarity or or
- ambiguity that surrounds that space. But I think
- from the adoption point of view,
- I myself are quite pleasantly surprised on the
- number of people who are
- willing to embrace these kind of innovations in
- primary care. So whether it is being a
- digital,
- primary care clinician
- or a clinical access team member where you
- provide access without being a primary care physician
- or recruiting
- the evening primary care physicians, which I thought
- would be very hard, but we will manage
- to we manage to recruit all of them
- for the pilot to go live in two
- weeks' time. I'm quite impressed really on the
- willingness of the workforce and the people to
- embrace
- these schedule redesigns
- and their willingness to jump in and do
- it. So I'm very impressed there
- and quite satisfying. I think they having worked
- at the other side,
- these clinicians find it very satisfying to do
- the work that they know are helping their
- colleagues in the physical space. For example, an
- in basket,
- clinician
- or an APP
- feels extremely satisfied. You know, that seventy, seventy
- five percent of the work
- could be done when someone is on vacation
- and the primary care docs are coming back
- to a much lighter workload than they used
- to.
- So I think it's a combination of of
- very well embraced by
- the clinicians who are doing it,
- some ambiguity around
- the the business modeling of that and the
- expansion of that, and
- then and then some gratification
- in the work that they do in in
- eventually preventing burnout and re and improving retention
- in primary care.
- Does that make sense?
- Oh, absolutely. Yes. Thank you so much for
- digging a bit deeper in there. And I
- think, you know, that that's,
- it can be such a big,
- focus for a lot of the executive leadership
- teams in terms of just making sure they
- have everything set up in the right way
- and are delivering the right messages that are
- motivating the team and helping,
- everyone grow and transform in the same way.
- Now I'm curious. What is the next step
- for you over the next two or three
- years? Where do you see growth coming from,
- and and what comes next?
- Yeah. Beautiful. So I think the work on
- access will just continue, Laura. That work is
- our foundational work, but it is also the
- future. So the future growth
- will come from continuing to
- sharpen access
- both in the absolute sense of recruitment and
- expansion,
- but also innovations and access,
- digital access,
- and continuing to explore ways by which
- the patients are seen
- where they want to be seen and when
- they want to be seen. And they are
- not limited by the traditional designs of the
- 8AM to 4PM primary care or 5PM primary
- care.
- So I think that work around access, access
- innovation, digital access
- is a huge team. And then try to
- do that.
- I feel very excited about
- the prospect of AI and what that will
- do for primary care and
- whether it be in the space of
- ambient Scribes, which we are now using, you
- know, 90% of our primary care physicians are
- now using Ambient Scribe. It's been life changing.
- You know? We used to spend hours doing
- our notes, and now we have a tool
- that does that.
- But, also,
- what will be the next step in that
- tool?
- How will that aid us in our clinical
- documentation,
- in our billing,
- in subsegmenting
- our patients' risks? So we redesign the future
- care delivery. It could be redesigned
- around the complexity of the
- patient. So I run a complex care clinic.
- Could future
- AI delivery tools segment the population? So based
- on the design of the clinic,
- those patients, will be seen. So feel very
- excited about
- the work in AI, the so the predictive
- risk modelings of AI. Also,
- the ability of AI to to help primary
- care physicians just like the the scribe,
- and we inscribe the work that they can
- do in managing it in baskets. So there's
- a pilot in Cleveland Clinic right now on
- in basket responses,
- using AI. So feel very, very excited about
- how that'll
- almost like AI could redesign
- the entire flow of primary care and the
- future of primary care. You The role that
- that would take in our screenings, our annual
- wellness exams,
- our physicals,
- questionnaires that we send out. So,
- lots of spaces and areas where
- both Cleveland Clinic and nationally, there there's room
- for changes.
- So I think the future will be I
- feel very excited about the work on access,
- the work on digital access, the work on
- supporting primary care and making primary care,
- not just something you know, traditionally, there's a
- crisis in primary care, people leaving, but but
- to switch it back into where people feel
- engaged
- in in the work that they they feel
- traditionally, they feel very drawn to being primary
- care physicians.
- And I think a big portion of that
- will be the work and access and and
- then the role of AI.
- That's amazing to hear. And, you know, it's
- so incredible to think about what,
- technology and AI has
- allowed us to do in the health care
- industry,
- that wouldn't have even been imaginable a few
- years ago. So it's, cool to have that
- opportunity and then find those smart ways where,
- clinicians are leveraging the technology to superpower them
- and what they're doing for patients.
- Before we wrap up here, I'm curious, who
- do you admire as a leader, really, from
- any industry and why?
- Well, there are lots of people in the
- industry I admire,
- you know, and my my quality safety days,
- Don Berwick. I was I absolutely love doctor
- Berwick and the work and the the the
- simplicity with which she delivered the message on
- quality and safety.
- But as as a leader, since my high
- school days, Laura, I'm I'm a a big,
- big fan of of Gandhi, Mahatma Gandhi.
- And and coming from India, that's that's so
- and then I can safely say the more
- I read about Gandhi,
- the more I'm convinced is is
- if there's a leader in health care today
- that that someone needs to look at it,
- it is his teachings.
- And
- I think his idea of of
- of equity, his idea of finding solutions that
- works for everyone, not just for some,
- His idea of,
- of
- he had a phrase that he said commerce
- without conscience is a sin. I don't like
- to use the word sin, but he used
- it. He defined seven social sins, one of
- which was commerce without a conscience.
- Now we've seen a thousand percent increase
- in equity money flow into
- health care and primary care.
- What does this mean,
- for us? What does it mean for our
- patients? You know, I
- he said something very beautiful, Laura. He said
- there's there's enough in the world for all
- of us for what we need,
- but there'll never be enough for our greed.
- So so I I feel very drawn to
- the teachings of
- of of my middle school, high school learnings
- of Gandhi, and now I keep reading it.
- So
- health care, I have a lot of heroes,
- but but over time, I found the the
- teachings of
- of Gandhi very meaningful.
- This
- this call for tolerance,
- nonviolence,
- we need it more than ever.
- He remains my hero.
- Absolutely. What an inspiring
- person to look to and and truly,
- embody the things that,
- Mahatma Gandhi
- taught and lived out, during this time and,
- you know, incredible inspiration for health care and
- any industry in general. Thank you so much
- for joining us on the podcast today. This
- has been such a,
- great conversation, doctor Kiera, and I'm looking forward
- to speaking with you as well and seeing
- you in person at our,
- in November CEO, CFO roundtable. I think it's
- gonna be, an incredible opportunity for us to
- connect and and dig deeper into many of
- the themes you talked about, and we'll just
- look forward to seeing you there.
- Beautiful. I'm very excited for that. Thank you
- for this opportunity. Thank you for the November
- opportunity, and hope to see you there.