Everyone. This is Jacob Emerson with the Becker's
Health Care podcast. Thrilled today to be joined
by a special guest. Doctor Ken Cohen is
executive director of translational research at Optum Health,
and he also leads the Optum Center for
Research and Innovation.
Doctor Cohen, thank you so much for taking
the time to be with us on the
podcast today.
Happy to be here, Jacob.
So, Ken, before we dive into everything we
wanna talk with you about, can you tell
us a little bit more about yourself, your
background in health care, and what it is
that you do today at Optum Health?
Yeah. I'm happy to do that. So I'm
an internist by training. I spent my first
ten years at one of the academic,
medical centers in Philadelphia.
And then the next twenty five years as
the chief medical officer of a large primary
care group in Denver, known as New West
Physicians.
And while at New West, I built a
care model that used level one and level
two evidence at the point of care
to drive improvements in patient outcomes as well
as the elimination of wasted and harmful care.
In 2,018,
Optum became interested in that model, and they
acquired our group, with the understanding that I
would take that model
and scale it across the rest of the
Optum health practices
nationally.
So today, I have two fundamental roles. One
is that role that I just described.
And then additionally,
I have a translational
research team,
and together, we do health outcomes research specifically
focused on value based care.
Fantastic. So decades at New West Physicians and
now helping lead research at Optum Health.
Ken, before we dive into your research that
you've done for Optum,
I wanted to level set for our audience
and get your perspective on on a term
that we, of course, hear often in the
health care industry, and that's value based care.
So we hear that from different stakeholders across
the health care spectrum, and I'm wondering if
you could,
put it in simple terms for us how
UnitedHealth Group and Optum specifically
define value based care today.
Certainly. So
value based care is where physicians
accept accountability
for the care outcomes.
And under value based care,
primary care providers engage with patients,
use high quality evidence based medicine combined with
shared decision making
to arrive at the decisions that align best
with patients' values and preferences.
There's a focus on prevention,
early
detection, and importantly,
management of chronic diseases.
And this approach emphasizes
a proactive
preventive care that looks at the patient's overall
health.
It increases the chances of early disease identification,
and it ensures that patients receive optimal, particularly
evidence based care.
Primary care physicians receive financial incentive, hence the
accountability,
for effectively improving both health outcomes and costs
by keeping their patients healthier and reducing their
total cost of care.
Wonderful. Appreciate that overview, Ken. And I wanted
to specifically talk with you today about some
of the research you've done into value based
care for Optum.
Actually, I wanna talk about two two of
your most recent research projects that you coauthored,
and that was in partnership with America's Physician
Groups.
And, ultimately, it validated the benefits of a
value based care model.
So your first study, it was peer reviewed
research published within the JAMA network open, and
that showed that Medicare Advantage members in value
based arrangements
receive better care compared to beneficiaries
in traditional
Medicare Advantage arrangements. So from from your perspective,
Ken, what were some of the most significant
takeaways
from the JAMA research
in terms of patient outcomes
under value based care models?
Importantly,
what it really focused on
is trying to isolate the impact
of different Medicare Advantage payment models.
So the study looked at 17 physician groups.
All of these groups were part of America's
Physician Groups, one of the large physician advocacy
organizations
that is really focused on,
developing skill sets around value based care.
In those 17 physician groups, we included over
15,000
primary care physicians,
and it included over 5,000,000 patient years of
data. So this was a very, very large
dataset.
And it compared two groups of Medicare Advantage
enrollees.
One was in value based care arrangements. So
these were either fully accountable two sided risk
arrangements
or at a minimum full professional risk.
And the other group that it compared to
were standard fee for service Medicare Advantage contracts.
And the unique feature of the study was
that all of the patients were cared for
by the same physicians and the same physician
groups.
So again, this allowed us to isolate and
highlight
the impact of the fully accountable value based
care model since the physicians caring for patients
were the same in both groups.
And the findings
highlight that Medicare Advantage
value based care arrangements,
which emphasize, as I mentioned, preventive screenings, integrated
medical and behavioral care,
care coordination,
population risk stratification,
embedded pharmacy services, so a whole range of
infrastructure associated with value based care.
But this model delivered higher
quality clinical care and better health outcomes
compared to the traditional
Medicare Advantage models that were paid fee for
service.
And these arrangements resulted in fewer hospitalizations,
fewer emergency visits, and safer medication use among
others.
Understood. So your study confirmed that these these
patients, these Medicare Advantage patients in value based
arrangements,
they're they're getting better clinical care, and overall,
they're seeing better health outcomes. It's it's, so
fascinating that that's the conclusion that you you
came to in your research.
Let's talk about another study that you published
in the American Journal of Managed Care recently,
which showed that Medicare fee for service patients
cared for by physician groups who also care
for patients under at risk payment arrangements with
Medicare Advantage Plans,
they experienced better health outcomes.
What that's that's fascinating, Ken. And what about
individuals that were not engaged
in value based care models? Can can you
explain for our listeners,
the spillover effect that that you highlighted
in that most recent paper for AGMC?
Yes. And and I agree with you, Jacob.
I think this is an an absolutely
fascinating finding, And I've been wanting to do
this study for a very long time, but
it wasn't until I had the data assets
available that I could really study this in
detail.
So we examined care
that was provided by nine large physician groups,
again, part of APG.
And in this case, these physician groups cared
for over one point four million traditional
Medicare patients.
And this study occurred with data between 02/2016
and 02/2019.
So again, these were APG physicians highly experienced
in value based care,
but now we're examining their traditional Medicare patients
who were not in value based care contracts.
So that was the intervention group. And the
control group is we compared outcomes
for those traditional Medicare patients
to the broader community of physicians caring for
traditional Medicare patients. So, again, the entire population
are traditional Medicare patients, but the intervention group
being those with experience and value based care
and the control group being the broader traditional
Medicare population.
And this study is the first to show
that the benefits of value based care,
including fewer hospitalizations for chronic illnesses, fewer emergency
visits, more wellness visits, and better medication adherence,
that these improvements in overall care quality and
efficiency
actually spill over from the Medicare Advantage patients
onto the Medicare recipients when their physicians are
skilled at value based care.
And this has just an absolutely enormous impact
on the traditional Medicare program.
So you can imagine what those benefits might
look like where the entire physician cohort taking
care of traditional Medicare patients
skilled in value based care arrangements.
And on average, about seventy percent of these
groups Medicare Advantage patients were under value based
care,
where the groups were responsible for the quality
and the cost of care.
And because these physician groups also treated many
traditional Medicare patients using the same advanced care
practices,
it was these advanced care practices that led
to the improved health outcomes,
not only for their MA patients,
but also meaningfully better care for their traditional
Medicare patients.
Wow. I mean, so just to confirm there,
because that's an amazing statement, Ken, in conclusion
from the study that that Medicare Advantage,
members and these value based care models for
physicians that participate in, that's spilling over to
also positively
impact
fee for service Medicare patients. Is that correct?
And that's correct. And and if you think
about it, it makes sense because what we're
talking about
is that when physicians
are skilled at a certain care model, so
for example, engaging in preventive services,
use of evidence based medicine,
careful selection of specialist cohorts, so you're referring
to the highest quality specialists,
Careful selection of hospitals and ambulatory surgery centers,
so you're using the highest quality and most
efficient sites of service.
All of these are not unique to a
Medicare Advantage population.
And once physicians learn that skill set and
see the positive impact that it has on
their MA population,
it's only natural that they would use that
same skill set when caring for their traditional
Medicare patient.
Absolutely. It makes complete sense. And and in
that vein, Ken, we we have a lot
of hospital and insurance leaders listening in right
now.
If we're considering both the pay papers that
you just gave us an overview of, what's
the most important point or takeaway that you
wanna make sure our listeners remember?
Well, let's talk about the JAMA network paper
first.
And recall that that paper examined two different
Medicare payment arrangements. One, a fully accountable two
sided risk and the other fee for service
MA.
And ultimately, the Medicare Advantage value based care
arrangements delivered exceptional results for their patients.
There's already a substantial literature showing that overall
MA patients receive care of higher quality and
efficiency compared to traditional Medicare.
However, it's important to recognize that MA plans
pay physicians differently and physician groups can either
be paid in a fully accountable model or
in a fee for service arrangement.
What was different about this study is that
it was one of the first and certainly
the largest and most comprehensive study to date
showing that within Medicare Advantage,
when physicians are paid in accountable care arrangements,
the care delivered to their patients is better
than when they are paid in fee for
service arrangements.
And some of those key results
included the patients in value based care arrangements
were twenty two percent less likely to be
admitted to the hospital for chronic chronic common
conditions like COPD or asthma.
They were fifteen percent less likely to use
high risk medications that can cause serious side
effects if used incorrectly.
And overall, there are nine percent less likely
to be admitted to the hospital
and nine percent less likely to visit hospital
emergency departments.
So so these studies then and then data
you just shared, Ken, they clearly validate the
impactful and the innovative work happening
at UnitedHealth and at Optum. If we were
looking ahead, how do we move the broader
transaction based health care
system to these value based care models that
you've been discussing with us today?
Ultimately,
how do we get these models moving forward,
so that
we're more proactive
with people's health and and we're keeping patients
and members healthy over the course of their
lifetimes.
I think that's the critical issue. And and
before I get there, let me spend a
little bit more time, just discussing the spillover
paper and looking at the specific impacts of
that paper.
And here, there was a clear indication that
the superior care outcomes achieved by physician groups
that are participating in accountable value based care
arrangements for quality and costs
spill over to the traditional Medicare patients, as
I just mentioned.
And the results of that paper further validate
that value based care models are improving health
outcomes across different populations,
including the traditional Medicare population.
And in that study,
what we showed is that the traditional Medicare
patients who were being cared for by these
physicians' skilled and value based care
were ten percent less likely to have acute
hospital admissions,
twelve percent less likely to be readmitted within
thirty days,
twenty one percent less likely to use emergency
departments,
and eighty two percent more likely to have
annual wellness visits.
They were nine to thirteen percent more likely
to adhere to medications for hypertension,
diabetes,
and hyperlipidemia,
and they were five percent less likely to
be prescribed high risk medications.
So putting these two papers together,
I think we can begin to answer the
question that you're asking.
And I think one point is that value
based care arrangements are working,
not only for Medicare Advantage patients, but across
traditional Medicare patients as well. And, frankly, although
we didn't study it, there's every reason to
expect
that these same skills would also spill over
into a commercial or a Medicaid population.
And the second critical point is that all
Medicare beneficiaries
are now benefiting from these advanced practices
that prioritize
whole person patient specific care.
So clearly, the benefits of these models are
are are known.
It's been validated by this research, Ken.
From your perspective, from where you're sitting at
Optum,
as a health care system,
where where is the rest of the the
the health care system on this journey of
broad adoption
of this model? Is it being widely accepted?
And where are you seeing some of the
hesitancies
out there?
Well, part of the problem is that
the definition
of value based care,
varies depending on who is looking at it.
So some folks will look at value based
care and they'll think that fee for service
with an upside bonus potential is value based
care, and I wish push back on that.
We've been studying this for a long period
of time now, and, ours aren't the only
studies that demonstrate this. But what moves the
needle
is that accountability
for costs and outcomes.
So, for example, there are studies that show
that in a Medicare Advantage model that, pays
physicians either by fee for service, fee for
service with upside bonus, or in two sided
risk fully accountable models.
That the needle on outcomes doesn't really improve
until you move to that accountable for two
sided outcomes model.
So it's really critical that we understand
what is the definition of value based care
that actually will drive
improvements in health outcomes.
And UnitedHealth Group through Optum and UnitedHealthcare
really aims to lead the shift towards a
health system
where the needs of all patients, care providers,
and payers are closely aligned
to deliver coordinated and seamless care in a
value based care model.
For example, home care can play a vital
role in this approach,
ensuring patient centered, equitable, and accessible care that
addresses complex conditions, medication adherence, social needs, and
behavioral health challenges
for patients that aren't able to reliably
reach the office for their care.
We have systems in place where patients' entire
health care journey,
takes place entirely in the home.
Another important point is that the Medicare
alternative payment models are also an important part
of the strategy,
driving value, improving quality, and lowering costs for
original Medicare beneficiaries,
again, with the caveat
that there should be a component of two
sided risk to them. So ACO reach, for
example, is an excellent example of that, and
MSSP
now has significant components of risk associated with
it as well. So the expectation is that
both of those models should also improve patient
outcomes,
reduce wasted and and harmful care, and overall
reduce total cost of care.
Certainly. Well, I know I speak for all
of us here at Becker's, Ken, when I
say that we look forward to your further
research into these important issues and and some
of those ones that you just mentioned. But
before we go, is there anything else that
we're missing? Any final thoughts or pieces of
advice you wanna offer our listeners today?
In closing, Jacob, the last point I'd like
to make is that our research and others
now have clearly shown that patients in value
based care arrangements
have better outcomes and overall efficiency of care
has improved.
For over two decades now, there has been
bipartisan agreement among healthcare experts and policy makers
that value based care outperforms fee for service
in terms of health outcomes, consumer experience, and
cost.
Most value based care arrangements are currently within
Medicare Advantage, but CMS is targeting one hundred
percent of Medicare members to be in VBC
arrangements by 02/1930.
Additionally, the number of individuals in commercial value
based plans has grown by nearly fifty percent
over the past two years, and many patients
are in Medicaid managed care as well.
We know that this is a better model.
The tipping point is almost upon us, but
we're not there yet, and it is time
to push fully accountable
value based care models over the finish line.
Absolutely. It's a great piece of advice for
us to leave things at today. Doctor. Cohen,
I want to thank you for taking the
time to sit down with us and for
sharing your insights with our listeners. We truly
appreciate it.
I was happy to have the opportunity to
speak with you, Jacob.
And if you'd like to listen to more
podcasts from Becker's HealthCare, you can visit beckershospitalreview.com.