[INTRODUCTION]
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[EPISODE]
Christopher Habig
Welcome to Healthcare Americana, your go-to podcast for all things related to direct primary care and the innovative world of healthcare.
I am your host Christopher Habig, CEO and co-founder of Freedom Healthworks. Each week we dive into the latest trends, share insightful stories, and interview industry leaders who are reshaping healthcare as we know it. Our mission is to inspire, educate, and empower you to take control of your healthcare journey.
Today we have a very special guest, and I know I say that after my introduction to every single episode, but it is always very, very true. Special guest, Katherine Evans, the president of Novocardia, a division of Cardiovascular Associates of America, the United States largest national private network of cardiologists. Katherine, welcome to the show. It's a pleasure to have you here on Healthcare Americana.
Dr. Katherine Evans
Thanks, I'm excited to be here.
Christopher Habig
Now I guess the first question right out of the gates, where have all the independent private practice cardiologists gone? Where are they?
Dr. Katherine Evans
Well, they have all gone to the health system. So about 20 years ago, we saw some shifts in reimbursement. And during that time, not just cardiology, but a lot of our healthcare providers and physicians in this country moved their private practice into the health system world. So sold the practice and became health system employed.
And what we are seeing today is really a shift in terms of those providers wanting to reunite their entrepreneurial spirit and join either large networks of practices and groups like Cardiovascular Associates of America remain independent. And even some of these employee cardiologists and other specialists and other primary care providers are looking to find ways to exit the employed space and really go back out on their own and become independent again.
Christopher Habig
Now my next question following up to that is, what was so enticing about joining hospital systems? Give us a quick brief history of this movement into what I'm going to consider employed practice of medicine with a specific lens on cardiology.
Dr. Katherine Evans
So the benefits of being employed, think probably the biggest one that made that attractive to cardiologists was not having to run their own business and having that capability of having someone else to do the payroll and make sure the lights are on, revenue cycle management, all the things that go into that day in and day out. Additionally, the reimbursement, a big shift was because the reimbursement was higher in the hospital setting. And that was a shift that CMS essentially led the way around.
Another piece in cardiology that makes it attractive is the opportunity, of course, to have those patients that are coming in the door being fed directly to you. So it makes your referral base pretty clear. So most cardiologists are getting their referrals from people who are hospitalized because they've had chest pain, they've had new onset atrial fibrillation, they've had some type of acute event that has led to them needing a cardiologist to follow them long-term. So having employment can make that a simpler process in terms of getting your referral process and that pipeline comes to you more readily versus being independent you have to do more hustle to sometimes make that happen.
Christopher Habig
Now with working at the nation's largest private network of cardiologists, you're in eight different states. You're based out of Atlanta, and then you kind of have this geographical reach that isn't really confined to one region of the United States. You've got states and practices all over the place. We don't see a lot of cardiologists in the direct care world. Talk a little bit more about your business model that is viable for these cardiologists to step out. Because as far as I know, correct me if I'm wrong, it's not all just cash or just membership. So, you I want to make sure I don't have tunnel vision in our daily lives here at Freedom Healthworks. So, you know, talk a little bit more about that business model that you are deploying for these physicians that join your organization.
Dr. Katherine Evans
Right. So for us, this is really the opportunity to transform cardiovascular care. We don't necessarily see this as let's have business as usual, as if these physicians are in a hospital model and employed model with the health system. We see this as the opportunity to make meaningful change and innovate in the practices. So we have, all of our practices are independent in terms of they are functioning under their own brand and their own name in a community. They are community doctors. They are going to the hospitals in their community, seeing patients there. Our practices are full-service cardiology practices. So we are seeing everything from coronary artery disease to if someone needs an electrophysiologist, we have those physicians available as well to specialize doctors that have heart failure training. So we really do have the gamut of whatever a patient would need within a given practice.
What we also have is the ability to provide innovative care that is not necessarily being seen in other areas. So value-based care is one piece, which is the area that I work in. It is a new opportunity in cardiology. We've seen a lot of shifts in terms of value-based care. It really started in the primary care space. It's now shifting into the specialty space. So having a network of independent doctors really gives us that ability to be nimble, innovative, and creative in new payment models and new care delivery models. So it's a real opportunity to make meaningful change in how patients are cared for, improve quality, and really see these patient populations more holistically and provide new ways of giving the best quality care.
Christopher Habig
I want to dive in to this concept of value-based care because I think most people have, when they hear that, they're like, yeah, this is a nice shift away from fee for service. And it's funny that fee for service has on the surface, kind of this, that sounds nice. Like I'm only going to pay for the services I need, but it's been totally perverted and totally corrupted. And it's led to a lot of misery and a lot of pain in healthcare from the financial side of it. So with value-based care, we hear that a lot. Again, being on the direct care side of it, we're a little insulated, we say, well, I kind of know what that means, but I think I have a lot of misconceptions and I just want to be okay voicing that.
When you talk about value-based care, what exactly does that mean from a dollars and cents transactional standpoint? When the people in your organization, your physicians, your providers actually care for somebody, how do they really get paid in a value-based care arrangement?
Dr. Katherine Evans
So when I think about value-based care at the highest level, right, to your point, when we have fee-for-service care, someone is getting paid for a service. So I see this patient, I saw them for 30 minutes, I get paid $50. Regardless of what that patient's outcome is. And if I made them better or worse, it doesn't matter, I still get paid $50.
In a value-based care arrangement, I get paid based upon how well that patient has an outcome. So if they have a great healthcare outcome, if their care quality is higher, then I get paid more versus if their quality of care is lower. So it's just a different way of thinking about how the incentives align.
Now, value-based care really sits on a continuum, right? So it's a big word. It encompasses a lot of things and it means a lot of different things to a lot of different people. So I think of it on that continuum. You can start at the one side of that continuum where you have things like bundled payment. So for example, if I'm taking care of a patient that needs a procedure, I'm going to get one bundled payment for that procedure. So if I manage that care well, I will make more money in that bundle versus if that patient has an infection, has a lot of complications, and then I run out of money out of that bundle, right? So that's one way of thinking of value-based care is a bundle payment.
Then you start getting into things like quality bonuses. So I do really well, all my patients get a colonoscopy, all my patients' blood pressures are controlled, they have great cholesterol levels, then I get a bonus payment from the payer to say, you did a great job, we still paid you fee for service, did extra work to get these patients under control, you get an additional incentive. So a bonus payment on top of your fee for service.
Then you move into what we think of as risk. So this is where you might take on what we call shared savings. So you get paid your fee for service, but at the end of the year, you can get additional money based upon how much money you saved in that population. And so if you do well, you look at a baseline to say, normally this patient costs a thousand dollars a month. You manage this patient for $800 a month. So Dr. Smith, you get a hundred dollars back and payer gets the other hundred dollars. So you share in that savings. And then as you go down the continuum, there might be what's called upside downside risk. So you get to keep some of the upside, but if you don't do well, you might owe some money back, so downside risk.
And then at the final end of that continuum is what you would think of as full risk. So you have a set of dollars that you're responsible for, and you have to manage that patient. You're responsible for everything that happens to that patient and all the dollars that go into that patient's care. And that's really the far end of the spectrum.
Christopher Habig
So about five different scenarios there that kind of boiled down to about three different ones. You got bundled payments and then at the end of it, it's basically you've got a hospital or a care organization acting almost as, okay, here's what we think it is. What happens? And I'm curious, because I'm big on incentives, right? And with bundled payments and you mentioned, well, if somebody gets sick or, you know, here's a hypothetical, a patient isn't compliant with their doctor's orders. I know that never happens, wink, wink. If that happens and whoever's foot in this bill says, hey, look, this person did not get better, you're out of bundle payments. What happens then? Because in my mind, it's created a perverse incentive to actually help that person out when they still need the care. Talk about incentives in these type of models, if you would.
Dr. Katherine Evans
So I think overarchingly, the incentives align to provide higher quality care versus a fee for service model. And all of these arrangements are designed in order to increase touch points with a patient so that you are more frequently seeing that person, you're making sure they're getting more proactive care. And you have very specific quality measures that you're trying to reach in all of these arrangements.
I think that the incentives for the most part align in favor of the patient and in favor of high-quality care. This is not capitation that we thought of in the 90s. It's a very different thinking. It's not that you're gonna get $1,000 and if the patient uses that $1,000, then they're out of money and they're not gonna get healthcare anymore. They'll still continue to get the care that they need in all of these models. So you have to think of it on a population level versus the patient right in front of you. And really high-quality value-based care is population health. So if you manage the entire population well, even those people that were really sick and required a lot of additional care and were a lot of additional cost, that evens out over the population because you did such a better job managing most of the people.
Christopher Habig
Yeah, and just to make sure I'm on the same page. And it's not just, the individual in front of me doesn't matter. It's we're going to look at if there's really sick people and we're going to kind of pool them. So it's kind of like what insurance should be doing. It's how insurance should kind of work to say, here's the general risk in this population and make sure that we've got our high-risk people and our low risk people kind of paying the bills for the high risk people over here. And there's just a lot of moving parts.
I am curious on the quality-of-care side of it, how do you guys measure, really define the word quality? Because again, that's a very nebulous term and I'm not trying to stick you on anything here, but we just have different definitions for the term quality of care. And I know every single doctor in the world does, every single nurse in the world does. When you talk about quality care from, value-based care and what you guys do specifically at Novocardia, how do you really say this is quality care…this is the highest quality care we can possibly deliver?
Dr. Katherine Evans
You're right, quality means something different to everybody in the same way that when you sit in front of every patient, they have different wants and needs and desires for their own healthcare. So that's even a piece of good value-based care is providing patient-centered care that is the care that that person wants versus the care that we want for that person. And that can certainly be challenging to do. It does require a lot more touch points.
I also really feel in cardiology, we have a huge opportunity to move care upstream. Meaning getting care out of the acute care setting, getting care into the offices, keeping people healthier on the given day so that they can have that opportunity to see their doctor quickly and get in to see their cardiologist fast. That is a big tenet of what we do is access. And that's something that really differentiates us from the health system.
We want to ensure that our patients can be seen when they pick up the phone, somebody answers, and they can get their needs met and that always leads to higher quality care because we are able to find those needs and meet them quickly. We have a heart failure program that really focuses on this very heavily and one of our patients said, “I am just so happy I know where to go to get care.” Because our patients really feel like they can't find someone and it's really shocking when you think about that in United States of America. Someone doesn't know where to go to get care all the time.
So when I have a patient saying to me, I am so grateful that I know where to call when I need help, I feel like that's a massive quality win right there. But really overarchingly, that's how I think about it.
Christopher Habig
I'm happy to hear you say that because I'm sitting here nodding my head behind my camera. I think that's a huge part where people have these misconceptions. And yeah, even in the United States, the most advanced country in civilization in the history of mankind, where people have all these like fear of, shoot, I don't have an insurance card in my wallet. I can't go see a doctor. No, wrong. I don't have, you know, I do have insurance, but I don't know what it's going to cost. That's a big problem right there.
Obviously that's what we're fighting to solve and we need great people such as yourselves and such as your organizations to say, no, I want to do what's better for the patient over here because I've been in conversations with hospital execs and I thought I'd ask them, I go, when you guys talk about bundled payments and you discharge somebody, what is your incentive to bring that person back in? Because according to my math here, you either want that person to get healthy, because you make a lot more money or you actually want that person to die because then you don't get penalized. And there's some interesting looks that start to happen when you say that in front of a group of people. It's like, did I just say the quiet part out loud? But to hear when you guys are talking about quality of care is let's make sure people are able to call in and answer the phone when they're having that to prevent something downstream.
I mean, that aligns to our audience and that aligns to everything that we're trying to do from this side. And I think that's the power of independent practitioners in healthcare. I really do. think that's from the independent side of it and the private network side of it that, like you said, we're all kind of in the same boat trying to fight and scratch and claw. When you are talking to physicians and saying, hey, I want to go into Illinois, or I asked earlier if you're in Indiana and you said, no, not yet. What is your value proposition to the physicians and the providers and the nurses and the care teams to say, let's get you out of the hospital. Let's get you into the private practice. Yeah, you got to wear a business owner hat, but there's a lot of great things that come from that.
Dr. Katherine Evans
Yeah, we actually have great business owner hats here at Cardiovascular Associates of America. Everybody gets one when they join in. So it's funny that you say that. We think of this value prop in several different ways. One is autonomy. And I think that's the biggest one. These physicians are very frustrated with having to answer to an administration, not able to control their own schedules, not having that capability to do the work that they want to do for their patient population. So I think that's a huge piece of it is having that autonomy.
The other is innovation. We really provide a space for the doctors to innovate, create new models of care, have that opportunity to have their own ambulatory surgery centers, have their own office-based labs so they can have their procedures happening in the way that they feel like that those labs and those procedures should run.
And then additionally, we have the value-based care proposition. So when you have a large network of private cardiologists, it opens up unique opportunities for value-based care contracting. We also provide a lot of support to the practices around the care model. So how we can help those doctors deliver the value-based care to those patient populations, we give them those tools and resources to do that as well.
Christopher Habig
What do you see, what's a typical care team? When you go into an area and say, great, we're going to work with this cardiologist, we're going to set up this clinic, what type of support team do you put in place?
Dr. Katherine Evans
So all of our practices are full service cardiology practices and it's really variable depending upon what the practice is looking to do and thinking about what a care team might need to be added. Some practices have a lot of great care teams already in place, but we think of it as certainly the cardiologists and having different cardiologists with different specialty expertise, as we talked about before, having electrophysiologists, general cardiologists, interventional cardiologists, cardiologists focused on heart failure. And then also having a group of advanced practice providers. So nurse practitioners and physician associates who are there to work with those physicians as interdisciplinary team members. These team members are really working closely and collaboratively with those doctors and really help us to provide access. As we all know, we have a shortage of physicians in this country. So having the capability to expand the team with advanced practice providers is critically important. So those are two pieces of the care team.
Of course, depending on the care model, adding registered nurses, obviously medical assistants are a huge part of this, as well as having the techs and the other people who can really focus on the testing, for example, stress testing, PET scanning, ECHOES, having all those care team members are critically important as well.
Christopher Habig
Do you run into any issues and…let me take a step back and again, I'm thrilled to hear you say, look, this is a team, we need physicians, we need nurses, we need techs, we need MAs all across there. I think right now there's a big debate going on in all 50 states of, I'm gonna draw a line and say, and this is mine and this is yours and whatever it is, depending on what letters you have at the end of your name. And I'm like, is that really in the best interest of the patient here? Let's get our best people out there and then let's get the best ways for patients to access care. Let's get those into place so that, like you said, when people are sick or having an accident or an incident, they can call somebody or they know where to go or what's gonna be able to happen and start that, not delay care and put that off there. So I'm thrilled to hear you say that, because I align very much with your sentiments there.
Curious on the staffing side of it. We hear a ton that healthcare staffing is expensive and it's hard and you know, we're, we have a lack of doctors, have a lack of nurses big time, we have a lack of MAs, we have lot of techs. How do you avoid really that kind of arms race against local hospitals that people think, well, they're going to be able to outbid us anyway for talent, for help. How do you guys, what is your really hiring strategy to get good people to come in and really invest themselves into these practices to help patients?
Dr. Katherine Evans
That's a great question and I wish I could say we were immune to all of the staffing issues that are plaguing our country right now. We are unfortunately not immune to that and we do have some strategies in place. I think that one of the pieces really is inherently the private practices can be more attractive to some of these staff members. They like the smaller family atmosphere, they really have also more autonomy and how they can be part of the care team and be more innovative within the care team. That's a big piece of it. We certainly have to be competitive,of course, with salaries and compensation and bonuses and all the things that everybody's looking at now. But I think it really comes back to creating an environment where people really love to work and are part of a team, to your point, where it's not about ownership, it's about doing the right thing for the patient right in front of you. And I think there's a lot of value in creating those environments that are welcoming and supportive and offer opportunities to really drive quality patient care and not feel necessarily like a cog in a large system.
Christopher Habig
We're talking and I should have said this earlier, we're talking with Katherine Evans, the president of Novocardia, a division of Cardiovascular Associates of America. And for those listening can probably understand that we're talking with one of the employees of one of the largest national private networks of cardiologists in the United States, hence the heavy slant on the independent practice of cardiology.
So Katherine, I'm curious here, as we wrap up our time together, where does not just the independent practice of cardiology, but where does the independent practice of medicine go from here? Are you seeing more people go private, less people, about the same? Misconceptions? What are you seeing out there?
Dr. Katherine Evans
I think we're definitely seeing a shift in physicians wanting to have more independence, autonomy, and the opportunity to innovate in healthcare, whether that's in cardiology, primary care, or other specialties. We are seeing that the employed model has stifled innovation for a lot of the cardiologists and other practitioners in this country. And we believe that we are seeing shifts that providers are wanting to be more independent and either start out in independent practice or potentially leave health system employment and create their own independent opportunities as well.
Christopher Habig
Are you guys looking at a direct care model at all?
Dr. Katherine Evans
So tell me what you mean by direct care model.
Christopher Habig
Cash. Cash and memberships. Not even dealing with insurance, know, and that's again, that's our world. And so that's why I'm like, my gosh, like cardiology is such a big need. And there's just not many docs out there who have gone, you know, direct care cardiology that just says, here's my prices, here's my programming, here's my packages, here's my membership. There's some out there, but they're few and far between. And so it's kind of…cardiology has been that one of that specialty that's like, man, we need that. We need it just so, you know, the practices who kind of opt out of the insurance world can refer and all this kind of stuff. And it's a big country out there. So just curious if you've even looked into that type of a model?
Dr. Katherine Evans
We haven't looked at purely direct care only. I think the challenge with that is you have a lot of people in cardiology that need procedures that are expensive and would be pretty big out of pocket cost for patients to bear.
We could potentially see that from the perspective of care model work and longitudinal care and chronic care management work. And that would be a potential opportunity there. I will say we have really been able to innovate in that chronic care management world in a way that I think patients have been very happy with having increased access and some of the things that go along with direct care and not having the insurance piece involved. We've been more creative in creating those models.
Christopher Habig
A lot of the direct care physicians out there will define quality care as how much time I was able to spend face-to-face with the patient or how accessible I was. So I think you're very close. You're a lot closer than you think. It's just like, okay, what's the dollars and cents, right? Let's use US dollars and US cents to be able to pay for care. But I hear you loud and clear. Katherine Evans, president of Novocardia. which is a division of Cardiovascular Associates of America. Katherine, I appreciate your time. Thanks for joining us here on Healthcare Americana. I truly enjoyed this conversation.
Dr. Katherine Evans
Thank you for having me, it was a lot of fun.
Christopher Habig
And to our listeners, thank you for joining us on this episode of Healthcare Americana. We hope you found today's discussion insightful and inspiring. If you enjoyed the show, leave us a rating and review on your favorite podcast platform. For more episodes and latest updates, visit our website at HealthcareAmericana.com.
Once again, I'm Christopher Habig reminding you to stay informed, stay healthy, and stay empowered. Until next time, thanks for listening and take care.
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