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What is value-based care? Interest in value-based care is at an all-time high. This episode gives an overview of this payment model and explores what's driving this growing interest in it and where the conversation about value-based care is headed in 2024. Our guest is Maria Ansari, MD, CEO and executive director at The Permanente Medical Group. Dr. Ansari also provides insights into barriers to adoption for value-based care and the culture an organization needs to maintain a long-term commitment to value-based care. AMA Chief Experience Officer Todd Unger hosts.
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- Maria Ansari, MD, CEO and executive director, The Permanente Medical Group
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're discussing value-based care and why more people than ever are talking about it. My guest today is Dr. Maria Ansari, CEO and executive director at the Permanente Medical Group in Oakland, California. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Ansari, welcome and congratulations on recently being named one of Modern Healthcare's 100 most influential people in health care.
Dr. Ansari: Thank you, Todd. It's great to be here.
Unger: Well, let's get into the topic of value-based care. Although the concept has obviously been around for quite some time, for those who may be less familiar with it, why don't we just set the stage with your own two-sentence summary of what we mean when we talk about value-based care?
Dr. Ansari: Yes, I'd love to tell you about that. So value-based care is really a care-delivery system that rewards for patient outcomes and quality of care, managing a population rather than transactional care. So it's more continuous care, population health and being rewarded for patients that live longer, healthier lives, as opposed to more siloed, transactional care that's more episodic.
Unger: And we're going to dig into that a little bit more. Last year was a big year for value-based care. The Biden-Harris administration continued to support it, and there was more mainstream news coverage about it. And believe it or not, online searches for value-based care reached an all-time high. It really feels like, in many regards, the topic's at a tipping point. What's your perspective on that?
Dr. Ansari: It's certainly at a tipping point. I would agree with that. You know, at Kaiser Permanente, we've been doing value-based care for 75 years. So for me, it feels tried and true. And I do think that the pandemic and changes in regulatory requirements for billing and also the advances in technology have allowed for value-based care to come back to the forefront of people's minds and where we want to go.
In part, I think during the pandemic, there was a loss of revenue in many of the fee-for-service medical groups and health care organizations that relied on bricks and mortar for people to come in and receive that care and get revenue. So when you lost revenue from that, that created an environment where things became unstable.
The other, I think, is the advances in technology. So right now, when you have value-based care, we really rely on a digital platform and a digital health record and use data analytics to help support managing a whole population. And so some of the advances, for example, in augmented intelligence or artificial intelligence have helped to catapult value-based care to the forefront. A quick example that I would share is during the pandemic, people did not come in for preventive care.
And so when the doors open back up and people came into care, there was a backlog and many of the preventive things, such as mammograms. And in a value-based care model, what we can do is use AI to predict who's most likely to go on to have cancer and pull those people in, trying to prioritize the patients who need that care the most.
So we did that with our mammograms. People who had normal mammograms who hadn't been seen in two years, we did proactive outreach to them, using AI, looking at their old, normal mammograms and using over 1,000 data points pulling from those images to predict, outside of normal, predictive models, who's going to go on to have cancer. And AI predicted better than traditional risk factors by 60%. So I think those types of things.
And finally, I would just say with the pandemic, I think we all saw that people started to get a lot of care at home remotely—televisits, remote patient monitoring and value-based care systems were set up for that at the get-go. They already had that infrastructure in place. And patients now want care when they want it, how they want it, where they want it. And value-based care supports that.
And there were regulatory changes during the pandemic that allowed the traditional fee-for-service folks to be able to get revenue for that. But value-based care had been doing that for a long time. So I think it's just a system that's set up for managing populations where they want to receive care.
Unger: Well, first of all, I love your first point, which is you've been doing it for 75 years. But then, what I'm really interested in is the, subsequently, about how technology is fueling additional advances in there.
It's interesting because when we think about adoption, there hasn't been widespread adoption yet. Maybe folks don't have—everybody have that access to the kind of technology that you do. But the bottom line, the facts show, at least according to an AMA survey, that over 86% of physicians are still using that fee-for-service payment model. Is it technology? What's holding people back from making the switch to value-based care?
Dr. Ansari: I think technology is part of the problem. I think the other is culture. With regards to technology, I think you do need to have that basic infrastructure because it helps enable you to manage that patient—predict who's going to have the next stroke, who's going to have the next heart attack. Focus on prevention, know who's due for their colonoscopy and be able to do a proactive outreach in management.
A lot of times people will say, Kaiser is like my mother. They're reaching out. It's not you coming in just for when you have a concern. It's long-term investment in prevention. And so having the technology and the data on our patients, and then also having the data analytics. So it's one thing to have the data, but it's also how to use that data to develop a system to care for an entire population and improve the lives of patients.
You know, I came to my job 20 years ago when there was a great study that showed that if you were a Kaiser Permanente member and you lived in Northern California, you were 30% less likely to die of a heart attack or stroke. And I'm a cardiologist, so I thought that sounds music to my ears.
But it's not because Kaiser Permanente has great cardiologists, which they do. I'm one of them. But it's because of the system. And it's being able to control hypertension and diabetes, and really doing that proactive outreach, and managing that population so that they never have that disease.
Unger: Interesting. Because you've brought up a number of different factors when we think about change of any kind. And you've outlined, for instance, the financial part, the operational part, but most of all, of course, when you've been doing it for 75 years, it's about the culture, which is very, very hard to support. And based on your experience, what kind of culture is necessary to keep that long-term commitment to value-based care?
Dr. Ansari: I think some of it is education about what exactly value-based care is, because I think there's some fear about it. But in general, I think, as a society, we're used to doing something and receiving a reward. It's a very transactional mindset. And you have to suspend your disbelief that if you are in a prepaid model that you can actually manage this patient, still generate revenue, and then if that patient never had a heart attack, never has a stroke, never has cancer, that you—that the system will still benefit, and your incentives are actually aligned.
And I think people are worried about perhaps a salaried model or not having that reward system that you do something and you get paid for it as opposed to preventing something and getting paid for it. And it's just a mindset shift. But it's very liberating because it allows you to put your care upstream and prevent the thing that that patient never wanted in the first place. As a cardiologist, if I'm in fee for service and my patient never has a heart attack, it's hard to make money. If my patient doesn't need a cath, it's hard to make money.
But my patient doesn't ever want to have a heart attack or stroke. And so if you can align your incentives with what the patient most wants and what we want for our patients, too, right? we all want the best for our patients. What if you have an entire system that actually rewards you for that patient to live a longer healthier life instead of rewarding on disease? We only pay when patients get sick in the traditional fee-for-service world.
Unger: So much of what you hear from everyone is that desire to focus on prevention as opposed to just treating an acute issue. I'm sure that's one of the reasons why that the value-based care discussion doesn't have any signs of slowing down this year. In fact, our own president, Dr. Jesse Ehrenfeld, just spoke about value-based care, believe it or not, at the consumer electronics show of all places. How do you think discussions about value-based care are going to evolve in 2024?
Dr. Ansari: I was actually with Dr. Ehrenfeld at that forum and was happy to be able to speak there as well. And I think what we're seeing is the largest provider—largest payer for insurance now is CMS or Medicare.
As the aging population gets older, sicker with more chronic diseases, I think we're going to see a bigger and bigger shift to government-funded insurance and a shift—I think Medicare is expecting that the beneficiaries really move into Medicare Advantage, which is a value-based platform, because they want to bring down the cost of care and improve the quality. And they've seen that if you have Medicare Advantage versus traditional fee-for-service Medicare, you have better control of chronic diseases and better screening for cancers. And so I think you're going to start to see more and more of a focus on value-based care, particularly Medicare Advantage, and a focus on what patients want—so drug-cost transparency, bringing down the cost of drugs.
And finally, I think we'll see in 2024 a bigger support for physicians to be involved in alternate payment models of care. Because I think the physician voice has been lost in many of the ways that health care has changed. Physicians want to focus on prevention. Physicians want to prevent disease. But we've been living in a system that rewards disease instead of rewards prevention. So I think part of the future is really trying to shift that mindset into doing the things that we set out to do as medical students, which is to really help patients live a healthy life.
Unger: Well, that'll be the ultimate objective is aligning those two things. Dr. Ansari, it's such a pleasure to talk to you today. I really appreciate your perspective. If you enjoyed this discussion, you can support more programming like it by becoming an AMA member at ama-assn.org/join.
That's it for today's episode and we'll be back with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.