Today we wrap up our conversation with Dr Ehab Sharawy and Dr David Cook of OneHealth by discussing the differences of the “big v” and the “little v” in value-based care and the positive impact of direct collaboration between the individual, the primary care provider and the specialist.

Well good afternoon gentlemen and welcome to the Move to Value podcast. we're back for episode #3 this afternoon, it's good to have you. Well listen we've really not talked that much about value-based care in our time together, so I'd like to start this session off with a question framed around some of the things I've heard you all say over the last year or so and oftentimes when we talk about value and value based care I've heard you say there's value with the big V and value with a little V and doctor Sharawy you want to take that and tell us what you mean by that?

Dr. Sharawy: Sure, so I'm going to leave the big V little V to the expert over there across from me, Dr Cook. Nobody articulates it better than he does, but I'll just start I think with some kind of real life analogies, because the word value means something different to everybody and within healthcare I think it means something different. When you talk about value if you talk about from a health system lens it's something different than it is from a payer lens than it is from a physician provider lens from a consumer lens, you know those are the kind of things. So just think of an analogy of you know folks that are lucky enough to be able to afford going to let's say a with two star Michelin restaurant, you know where you're going to go in and know it's going to be costly. OK let's just say it's $300 a head to go there. But when you get in there and let's just say that's the best food I've ever eaten you know in my whole life I've never tasted something that and somebody said was that good value for you if you're going to say yeah it was fantastic great value because you were so happy with the quality and all that and the cost was not the factors mitigated by not mitigated but overcome by the fantastic experience that you had. Then if you flip it to the other side and you say listen you know I got a family of four and I'm on a fixed budget and you know I want to go out and have a nice meal so I'm going to go to a restaurant where the cost is very reasonable I can afford it and by the way the food was good you know it didn’t knock my socks off but it was good and we enjoyed ourselves have a good time. That would be defined as value and those are two different experiences but both of them have satisfaction. What I always think in Healthcare is for so many people that situation is just upside down and really when we talk about value in healthcare we got to figure out how to make it right for everybody so everybody gets value in that regard. I want to let David expound on that.

Dr. Cook: yeah completely agree with Dr. Sharawy I mean that what a great anecdotal or model to look at because it's very hard to understand value in healthcare. Except I would say this I heard Don Berwick say this one time a long time ago and I’ll start my conversation with big V and the little V with this is that there really is no value in healthcare delivery. There's only value in health. OK you're not thinking about hey I love taking my car to the shop and getting it worked all the time. No what you like is your car running really well for a long time right and so when we talk about the big V, Dr. Sharawy and I have always said this is what really matters. it's health it's longevity I'm going to say this again longevity it's the human experience, it's quality of life, enjoyment of life doing things you like to do, feeling safe in your healthcare journey. It’s really experiencing something that's unique in your healthcare journey. The third piece is reduce suffering and I'm going to use this term reduce suffering, both mentally and emotionally, physically and financially, OK That's big V OK that's value and it really to me is something that no one addresses head on and in modern primary care OneHealth, our modern particular specialty program really is going to hit that head on. The little V is what we've all got I believe side sidetracked on over the past decade, decade and a half. Since the ACA American the Affordable Care Act came out often referred to as Obamacare, it was really initially built to do the things I'm talking about. But by the time it reached the American public it was very very different. And so we had these little V components that we thought OK this is value let me play in the value world which is a delta between what things should cost and how much we spend, actually. OK now that's different than what I just said right? yeah that's very different but we've just spent billions of dollars for a decade and 1/2 on that one thing. What things should cost and how much we will spend on that. Now think about this what things should cost we're basing it on the Titanic. It is going down so we're moving those deck chairs around getting into that delta. Unfortunately, we've not done the things to build a different ship and so the little V which is value based contracts, Medicare Advantage being one of the most prominent you hear about, now Medicare with the reach program and others MSSP work, all with really good intentions but in an environment where the patient is not put in the middle of the room, the boardroom especially, with great science compassion the desire to reduce suffering and put around the patient and the ego and the wallet put outside things happen, right? And what's happened over the past let's say 15 years when it comes to the little V in value is we we've not moved the needle one bit OK? We're on a trajectory to spend what is it $7.1 trillion by 30 or $2 trillion by 30 uh 2031? That's huge. Yeah. 20% of Americans still don't have healthcare coverage and 40% of Americans I believe that's the number still suffer financially from healthcare delivery.

the leading cause of bankruptcies right?

Yes. No one speaks of this bankruptcy. So what happened over the past 15 years? Well venture capital came in and PE with a design set on not the big V, but the little V. And they were able to extract millions and millions and millions of dollars out of the system playing in the delta. OK between what things were costing and what they do cost what they should cost what they do cost and we can we can debate about what they should be cost and how we change that. Well what they did is instead of taking that money often and reinvesting it into a system of a different ship they took that money to Wall Street. Right. They took that money to individuals they aggregated that wealth. They took that money in places that really made no sense to the system to take the money, leaving the system very barren for resources to build upon itself. The other thing they did is they didn't integrate well with other players, right, with health systems with payers with corporations with government with big business with small business with the individual, and they left everybody very confused. Individual deductibles are up yeah individual copays are up businesses are spending more for healthcare every year. So when you play in that little V game there's a lot of winners and the one thing we learned for sure and it's been our mission at OneHealth is the for all mission was never ever front and center. OK millions of dollars are made on small numbers of Medicare lives. Right. OK not even enough Medicare lives to make a difference for all of the nation. A subset of Medicaid lives subsets of commercial lives we created industries around direct primary care around direct to employer that really extracted money but didn't produce longevity improve human experience or reduction in suffering or cost. So we've put forward this whole mission around the big V. And what we find is if we can be very steadfast with our pillars of what we believe we have to maintain and build a modern primary care around the big V, we're not only going to be sustainable we're going to be scalable and we're going to be solution for the country. Because primary care itself is not expensive, it's not the expensive component of health care, but when it's broken health care becomes very expensive.

OK thank you Dr. Cook that was a great answer and what I wanted to do was kind of build on that a little bit and say tell us a little bit Dr Sharawy, if you want to take this question, tell us about your relationship to Advocate and to CHESS and how you are utilizing sort of little V tools to create big V for your patients and to create provider wellness and to drive this modern primary care platform, which I think we all agree, is the way to ultimately create the big V value and drive down cost improve quality and create longevity?

Dr Sharawy: I appreciate that that question you know what was just described is in the industry of Healthcare is a lot of what I call tribalism, tribalism, and taking certain segments of populations in in making a business out of it. But again, has it translated into anything that's helped healthcare in this country, we haven't seen it. OK we haven't seen it. The other thing is to create what I think are always not the best way to do things, that is to create transactional relationships in the healthcare space. So if you think about provider to payer that's transactional, probably about the most example of a transactional relationship, oftentimes between health system and provider, health system and patient and other services that are outside, all of them are these transactional relationships where what we felt was extremely important was to partner, OK and I say it in a in a way that that that that I hope makes sense is that that that, everybody should part all collaborators in the healthcare space should partner together towards common purpose. And so when we were in a in a health system before in what we were doing and felt like look we needed the autonomy to come out to be able to do the all the things that we're talking about now, it had it never could be in a vacuum. It always had to be with developing a partnership so our partnership with Advocate is just that. It's really a true partnership. We've been able to build this partnership with the big giant health system. In fact, I think I don't want to misquote but they might be the 5th largest in the United States you know today. To be disruptive in that environment by the way welcomed by the big health system to have that disruption so that we can actually accomplish the things that Dr. Cook just described and talked about. We were lucky enough in this journey to get together with you guys, you know at CHESS who I would say if we looked at our mission statements I think they're pretty comparable.

Very comparable.

And actually look at the history of how CHESS was created you know we could spend time talking about that but we very common almost like parallel universes and paths. So already we were aligned right and so kind of the big V and the little V, the big V is the critical, it's the thing you have to do if we're going to take a model that we I think could say comfortably and we’re not the only one saying it is on an unsustainable path and course correct it. You know build the new ship you know plug the hole in the Titanic whatever analogy we want to use so that we can actually move forward. We do have to have aligned incentives and do the little V work the stuff that's necessary the nuts and the bolts and the things that are necessary to do that but all aligned and collaborated together towards common purpose and the common purpose at the end of the day we have to bring very high quality care we have to do that and I think there's a lot of way to measure that but to sustain healthcare in this country we have to reduce the total cost of care. We have to take it from a current 4 1/2 or whatever it is trillion it's calculating upwards by the day and we got to pull out 25-30% of that cost to do that. So those are the things that the little V should be focused on, not trying to take advantage of a delta in a segmented population right or those type of things like that. And that's the exciting work that we have ahead of us with a partnership with the fifth largest healthcare system in the country, a robust value-based care delivery company in CHESS and then we're going to bring others to bear okay that we'd love to talk about at some point too right to do that.

Well, if you're going to be successful in the big V and the little V arenas you're going to we've talked about provider wellness, you’re going to need providers who enjoy what they're doing enjoy interacting with their patients but you're also going to need patients who are informed engaged empowered to participate in their care. Talk to us a little bit about how you're addressing patient engagement, patient empowerment, however you would like to describe it and who wants to take that one Dr Cook?

Dr. Cook: I'll start and great question and it's something that has always been perplexing to me is how do I get my patients more engaged in their own care because there's so much we can bring to them that they have to then do themself and I think one of the things that we've not been good in American healthcare and a lot of people have moved away from western care is that it's all about you know a pill to cure to cut to cure and so many individuals are looking for something else. So what we need to do is meet individuals where they are and help them understand where they should be and one of those things I believe is that relationship that advocacy that trust. I've seen trust eroded in healthcare more than I've ever seen it before between individuals I like to use the term probably individual better than patient and their physician their provider. So how do we bring that back? Well that that that trust comes from being able to develop that authentic relationship that authentic connectivity to the individual to be able to be there for them not only on their acute events but on the longitudinal events and then giving them tools and resources that they can utilize that then makes them better at all things, longevity the experience they're living and reducing their cost. Most tools if they evolve from just the patient side they're great for patients, there's some wonderful tools, but often they're disconnected from the tools that that primary care the primary care doctor has. If the primary care doctor the specialist has a tool sometimes it's a tool that they just use in isolation. So, one of the things we're trying to do is several one is two educate our patients better to create cohorts where patients work and operate together that have the same illness so that they can learn and grow is three introduce more lifestyle medicine to patients diet exercise stress reduction etcetera I think the 4th is if there's going to be digital tools or home based tools like monitoring of blood pressure etc. do it in a way that there's guardrails around it and guidelines that really help them become better at doing it not afraid to do it right and then give them immediate feedback with their provider so that they're working together in that process and if things need to escalate the escalate. So, I think the very first thing to answer that question is you've got to look at that patient as someone who needs to have that given to them and I say that sort of off the cuff but there's a lot of individual physicians and providers who just aren't in that ilk to say hey the patient deserves to have their own advocacy. OK I see some doctors frustrated when someone brings a an Internet article in I usually love that because it no not only does it challenge me gives me an opportunity then to engage the patient where they are. Right. But I think if we have the time the ability the tools to do that and it comes from that primary care perspective it really will make a difference and we've got to listen to our patients and be willing to listen to them because they'll tell us more about themselves than will the chart.

Well I think you all are trying to get your providers off the treadmill as well, based on other conversations that we've had together and I think once they're off the treadmill of just having to crank out a certain number of people every day you get you get out of that I've got 10 minutes 15 minute mindset then you can um engage patients you can spend more time educating you can pick up the article and go oh that's interesting let's talk about this right I'm glad you brought this in because at least they're looking for answers and what better opportunity for you to begin to provide those answers rather than exactly Google search as a source of answers. So one other thing I wanted to go back to for just a moment is you you've as you've talked about modern primary care and how you manage the patients care journey sort of their experience is a traverse that's very complex and complicated health system that quite frankly you know I think about my mom is 82 and if she didn't have a son as a physician I don't know how she would navigate it. I mean I get constantly get pictures of EOB's and bills and should I pay this and do I not pay this and what about my medicine and there's just so many questions that I end up helping her answer and if you don't have a family member in healthcare, that's really challenging. But going back to your you must have or either are building you have or are building strong relationships with your referrals out to specialties. Be that orthopedics cardiology other areas where we know it's almost impossible to get patients in like rheumatology and endocrinology. Can you tell us a little bit about how you go about building those relationships so that are you trying to create like in office video consults or getting patients seen in person how were you addressing the need to have a tight relationship with your specialty partners?

Dr. Sharawy: So Dr. Lennon, I would say all of the above you know all of the above and I'll start by kind of leaning into what you said earlier about your mom's care, you know I would consider myself an educated person through healthcare and you know for many reasons I have to access healthcare more than most and I think to myself all the time, what if I was not didn't have the knowledge that I have, there's not a chance. OK there's not a chance that folks can navigate this confusing, so it's going to take a village OK to figure out how do we create simplicity but boy we should start. OK so one thing we do and we and we kind of break the what I would say is the traditional thoughts about the relationship between primary care and specialists. Specialist equal want to do the right thing of what primary care does. We interact with independent specialists with specialists within the advocate arena. All of them to a tee all of them say I want to figure out how to navigate the system better too to be able to do that, it's multi pronged. OK it's about education so bidirectional education so that referrals are the appropriate referrals. It's about what we talked about in earlier times about how do you drive the care of the patient starting from modern primary care and I call it sometimes the 80/20 rule or maybe in some fields of specialists 80% of the care could be taken care of through just a collaborative conversation opening up those avenues and then it's that real 20% it really needs to get into the hands of the of the specialist, well we should just be really good at that. We should figure out how to mitigate all the barriers that are there, so we do that every day. So every day our team and us we're engaging with specialists to break the barriers. The barriers are traditional barriers that believe it or not I...