In this episode we hear part 2 of the conversation between, Josh Vire and JP Sharp, where they discuss the current and future state of value-based care including primary and specialty care and the recently released making care primary payment model.

You've recently in your career focused on integration of behavioral health with primary care. Can you speak to a little bit how critical important that is in on this path of transformation and alternative payment models and those challenges with access to behavioral health and the finances of behavioral health care?

Glad you bring that up. It is a trend and for a reason is that our thinking, I think it's caught on in this kind of evolution of behavioral health being much more central to healthcare not this silent thing and that's just a vestige of history is that we as a people in healthcare and in America just drew a line there and said here's physical healthcare over here and there is behavioral healthcare over there and they were siloed off and behavioral health care was often more stigmatized and so it got the short end of the stick when it came to attention and funding and innovation. And so, it it's only through a snowballing of research and public momentum and acceptance of this where stigma of behavioral health and treatment associated with it is being reduced.

It's absolutely still there, but just better understanding of it. And it's incorporation into physical health is twofold. It's both from just an evidentiary standpoint and clinical is that they are linked. So the behavioral health impact, if you have say depression, your physical health if you have say diabetes, those are related you know if not like directly in a physiological mechanism but rather if you're depression goes unchecked you're less likely to take care of your diabetes and your physical health, take your meds, see your doctor what have you, and those things it's a compounding exacerbating effect. And so, the thought now is that hey these are these things are so intertwined that evidence suggests treating behavioral health issues first and alongside primary care issues is going to result in better care.

And then kind of the other is just purely logical and from a patient perspective like you know, you had a human level like we don't separate these things. If you ask me how I'm doing, I'm not going to there just say Oh my knee hurts and like stop there. If you ask me how I'm doing I'm going to be like well, you know I'm a bit stressed out right now. I've got a lot of things going and you know maybe feeling a bit down from x, y, or z reason. And you know what like my knee hurts and I wish I could run a little bit further than I did last weekend. And so, you know it's like that's like what you know our life experience is, it's not siloed like we've kind of set up the healthcare system to do. So how can we kind of design the system to better appreciate all of these things at a you know patient experience level as well.

Right yeah, that's the question and an important one particularly. I appreciate you talking about the stigma and the importance of behavioral health, I know it's important area for you and I think an important one that we get right as we think about this transformation. It's critically important. So, I'm going to ask you to look into your crystal ball here a little bit. Where do you think in the next five years let's say, 5 to 10 years, where will the focus in value based care be in your opinion? Will it still be in the primary care space primarily or do you think it'll shift to, specialty is obviously one that's already beginning to talk about, but just your thoughts on where you think this transformation will be in the next few years?

Absolutely. So primary care is not going to go away. I think it's caught on enough people have realized that and that's going to be more about incorporating it into more and more corners of America and making sure that about what like what value based primary care actually means that that is for like actually entrenched and made accessible to as many corners of our country as it can be so that it goes from a system with a lot of resources and some groups that have aggregated you know folks like an alligator for like you guys with to say alright we've got tools we're going to help you get there. So that's the cutting edge of where you have you know innovative groups focused on this to how do we get it to like everywhere? So, I think that's really what's happening now and what's going to continue to be on the horizon is to have primary care change for the masses from what we’ve learned so far today.

The exciting new part is looking at the rest of healthcare. There was a bit of this and maybe it's a misconception that like we just solved like we apportion all the risk at the primary care level and the rest takes care of itself and people figure it all out and so that's not reality. It is you've got multiple parties, they're not all sitting under the same tent all the time, usually they're not and so you need to bring everybody under the tent so that you're not just aligning a payer and a primary care provider, you're aligning a payer, and a primary care provider, and the cardiologist, and you know the mental health professional, and whoever else you've got you know the list, and that they're all actually have the same have aligned incentives for cost and quality outcomes. And for the most part that's not the case right now so primary care providers may you know look at a list of people that are referring to in their network and they're going to try to find the best ones, but how they're doing that is still an evolving science but even when they do make that referral to somebody they know and trust as great cardiologist is that cardiologist how are they going to get paid? It's usually the vast majority of those cardiologists are still getting paid on a strict fee-for-service basis. And so that's really where we have to get to as how do you start to it’s more complex but how do you start to break open that kind of single distribution of risk and responsibility with primary care provider to say all right how do we open that up and have the cardiologist share with the primary care provider in a way that all parties are aligned and incentivized to do the work together towards the outcomes? And so, I think that’s, and then multiply that times number of specialties down the list, cardiology is a big one because of the costs associated with that and the number of people that will need that care but you know diabetes has been one kidney 's been a little bit out in front where there are a lot of new innovative kidney models that have been going for several years. So, I think maybe take that approach and say what have we done with kidney care are there other specialties like that or is there another way that it needs to happen that's somewhere in between. And so that's I think exploring all these different models and different ways to incorporate these really key specialties into the overall risk environment.

Well stated. It'll be a challenge, but it'll be a fun one as you stated at the beginning this is challenging work but fun work and that the challenge is part of the fun, so it would be interesting to see how we go about addressing and incorporating other specialties into this work going forward. JP, you mentioned about independent primary care and the focus there. As you're aware CMMI just announced a new model to begin next year called Making Care Primary that's really focusing on supporting those that are serving vulnerable populations, rural communities and they've begun to introduce some levers that will help adoption and help that speed of adoption. I know you've written about this before about how advanced primary care can be adopted and accelerated. What are your thoughts what are some of the things that you think are incentives that could be put into place for independent primary care to succeed in value?

So, I think there's a there's a couple parts which is that you’re alluding to is how to help primary care be good at this and do it. And then there's also because it's a CMMI model, what's going to generate the best results for the taxpayers and total cost and quality of care. So, both of those things need to go in parallel and that's where I think hopefully we'll learn more with this new model. In previous models CBC and CPC+ they were great tests. They increased funding to primary care providers, set out a bunch of targets and requirements and said here's additional funding, additional opportunity, shared savings opportunities, etc., I think. But they were all they were all upside and it was all new and additional things and what you saw was, it was providers overall improved on a number of quality metrics, not all of them across the board there may be too many metrics, that's another conversation in categories there, but I think you know like overall general like quality improvement, capability improvement and advancement of the space through the funding. However, the costs really weren't materially different and they may have even gone up a little bit, overall total cost. So I think agree that primary care is underfunded so primary care costs, we should see go up but the goal of that would be they have to come from somewhere else they have to be you know reduced uh through those other acute episodes, ER inpatient spending, what have you where we know there's preventable higher priced, higher cost things that we can avoid through better primary care.

So, that's the part that didn't quite you know hit in previous models, so I think that's really where it'll look is, can you really take this funding and direct it in the most useful way possible so that it results across the board you know at a population across organizations, across geographies way that generates results. There's certainly when you look at any of those previous programs, you're going to see a bunch of different spikes where these providers over here did great things, had interventions, saved a bunch of money, you know these over here didn't and you know and it all evened out to be kind of a push. So I think what we need is what kind of model and program and organization supports are going to like move the whole needle and not just have you know a few people you know with successes and a few kind of flipping a coin. So I think that's where the real innovation and you know horizon is in primary care is like alright like who's really good at this. And part of that is this will be you know I don't know maybe controversial some people maybe some people just don't like it but having the downside risk component is something we did learn through the CMMI process. Having downside risk actually is a better incentive for behavior change then pretty much anything else in in the models. And that's because if it's a one-sided model in perpetuity and you're not forced to think about you know your outcomes that you're generating swinging both ways then you can just do what you're doing before flip a coin maybe you get some bonus dollars at the end of the day maybe you don't. But it doesn't actually compel any of the changes that we want to see and so that's really one of the major takeaways from all of those years of programs.

yeah that's uh that's great thank you so much JP sharp! Thank you for joining us on the Move to Value Podcast

Thank you for having me. This is fun.