EP. 165: THE PROMISE OF VALUE-BASED MEDICINE

Mar 11

WITH FARZAD MOSTASHARI, MD, ScM

The former National Coordinator for Health IT explains how the electronic medical record has been distorted by the fee-for-service model — and makes the case for value-based care.

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Electronic Medical Records have transformed the way we practice health care, making patient data readily accessible to health care providers, facilitating collaboration within and across large medical teams, increasing transparency, and drastically improving the legibility of patient charts and prescriptions. But despite these benefits, many physicians cite the electronic medical record as a primary driver of burnout, pointing to the overwhelming volume of documentation it requires. In this episode, we explore how the launch of EMRs within the context of America’s predominantly fee-for-service health care system led to the technology falling short of its promise — and how transitioning to value-based care models might redeem the technology, revitalize physicians, and recenter public health.

Our guest on this episode is Farzad Mostashari, MD. After completing a degree in public health at Harvard, medical school at Yale, and residency at Massachusetts General Hospital, Dr. Mostashari spent over a decade working in public health: first for the CDC’s Epidemic Intelligence Service and then for the New York City Department of Health. From 2009 to 2011, he served as the National Coordinator for Health IT at the Department of Health and Human Services where he helped oversee the nationwide transition from paper to electronic medical records. In 2014, he founded Aledade, a company that helps primary care physicians form value-based care networks in the US.

Over the course of our conversation, Dr. Mostashari shares how his childhood in Iran pushed him towards public health, how his experience watching his father being cared for in the hospital drove him towards medicine, and how he has spent his career in the liminal space between public health and medicine. We discuss the rollout of EMRs, and how fee-for-service payment models led to EMRs being optimized for documentation rather than patient care. We explore how value-based care not only solves the problem of over-documentation, but also better aligns the goals of patients, physicians, and even insurance companies. Dr. Mostashari maps out the progress we have made toward this kind of model and the hurdles we have to clear before we have a system that incentivizes preventing stroke as much as treating stroke.

Farzad Mostashari, MD, is the co-founder and CEO of Aledade, a physician‑led, national leader in value‑based care whose mission is to deliver better health, better care and lower costs, creating a health care system that is good for patients, good for practices and good for society.
Previously, Mostashari served as the National Coordinator for Health IT at the U.S. Department of Health & Human Services (HHS). During his tenure, he oversaw the implementation of the HITECH Act and the "Meaningful Use" incentive program, managing over $13 billion in incentive payments and leading a dramatic increase in the adoption of electronic health records (EHRs) nationwide. He also championed consumer eHealth and established the “Blue Button” initiative to empower patients with access to their own health data.
Before joining the federal government, Mostashari served as assistant commissioner at the New York City Department of Health and Mental Hygiene. There, he designed and led the Primary Care Information Project, which equipped 1,500 physicians in under-resourced communities with EHRs and focused on using data for public health action. He also served as an epidemic intelligence service officer at the Centers for Disease Control and Prevention (CDC), where he was a lead investigator in the West Nile virus outbreak and anthrax attacks.
Mostashari currently serves as the chair of the board of directors for Resolve to Save Lives, a global health organization focused on accelerating action against the world's deadliest health threats. Mostashari frequently speaks on health policy and technology adoption to improve public health.
He earned a Bachelor of Arts in Biochemistry from Harvard University, a Master of Science in Population Sciences from the Harvard School of Public Health, and a Doctor of Medicine from the Yale School of Medicine.
In this episode, you’ll hear about:
3:35 - How Dr. Mostashari became drawn to the intersection between the intimate work of doctoring and the wide lens work of public health.
12:12 - Dr. Mostashari’s experiences modernizing health IT systems and learning to optimize for the number of lives saved rather than the number of technological solutions implemented.
16:05 - Dr. Mostashari’s assessment of the rollout of the electronic medical record in the US.
25:09 - How Aledade frees primary care physicians to prioritize patient outcomes and reduces the burden of EMR documentation.
38:57 - What the US can learn from international health care systems.
41:00 - Challenges in transitioning to outcome-based models of primary care.
50:30 - How Dr. Mostashari’s medical training has shaped his career in public health.
Henry Bair: [00:00:01] Hi, I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine, we will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Tyler Johnson: [00:01:02] Electronic medical records have transformed the way we practice healthcare, making patient data readily accessible to healthcare providers, facilitating collaboration within and across large medical teams, increasing transparency, and, yes, drastically improving the legibility of patient charts and prescriptions. But despite these benefits, many physicians cite the electronic medical record as a primary driver of burnout, often pointing to the overwhelming volume of documentation it requires. In this episode, we explore how the launch of Emr's, within the context of America's predominantly fee for service healthcare system, led to the technology falling short of its promise and how transitioning to value based care models might redeem the technology, revitalize physicians, and recenter public health. Our guest on this episode is Doctor Farzad Mostashari. After completing a degree in public health at Harvard Medical School at Yale, and residency at Massachusetts General Hospital. Doctor Mostashari spent over a decade working in public health, first for the CDC's epidemiological intelligence and then for the New York City Department of Health.

Tyler Johnson: [00:02:16] From 2009 to 2011, he served as the National Coordinator for health IT at the Department of Health and Human Services, where he helped oversee the nationwide transition from paper to electronic medical records. In 2014, he founded Alidade, a company that helps primary care physicians form value based care networks in the US. Over the course of our conversation, Doctor Mostashari shares how his childhood in Iran pushed him towards public health, how his experience watching his father being cared for in the hospital pulled him towards medicine, and how he has spent his career in the liminal space between public health and medicine. We discussed the rollout of EMRs and how fee for service payment models led to EMRs being optimized for documentation rather than patient care. We explore how value based care could not only solve the problem of over documentation, but also how paying for quality of health outcomes might better align the goals of patients, physicians, and even insurance companies. Doctor Mostashari maps out the progress we have made toward this kind of model in the US, and the hurdles we have to clear before we have a system that incentivizes preventing stroke as much as treating stroke. Doctor Mostashari, thanks so much for being here and welcome to the show.

Dr. Farzad Mostashari: [00:03:36] Really looking forward to the conversation.

Henry Bair: [00:03:38] So there's so much we can talk about. I mean, your career spans from clinical care to leading a national health policy. And then, you know, now you have this company that you lead. So I think we will spend some time on a little bit of all of those and hopefully find a common theme or themes that ties it all together. But to start us off, I'm wondering if we could have you share what initially drew you to medicine at all in the first place?

Dr. Farzad Mostashari: [00:04:05] Yeah, I've always been a bit of an insider outsider, I guess I would say. I know a lot of people feel that way, but kind of living in between medicine and public health. So I had wanted to work in international public health when I was in undergrad, and I did grad school at the School of Public Health. But then my dad got sick, and there was something so powerful about what I saw in the hospital, the laying on of hands compared to what seemed a bit remote, the, you know, international global health work when you're sitting in Boston. And I went to med school, but I knew I wanted to do after residency, I wanted to go back to public health. And so I was the kind of annoying med student who was in the ER learning about how to do whatever bronchodilator therapy for someone having an asthma attack, but also wondering and asking the question like why? Why this person? Why from this zip code? Why today kind of the questions around really epidemiology. Right. Like what is it. This disease is not randomly sorted through people and geographies and time and like why but then kept bouncing back and forth. When I was with the CDC's Epidemic Intelligence Service, I was saying, well, why isn't healthcare contributing more to public health? So I feel like my career, yes, it has been, you know, everything from from working at a city health department for ten years to working on national health technology policy to being an entrepreneur. But it's really been defined by kind of that liminal space between medicine, the laying on of hands, and public health. Answering the question, how do we save the most lives?

Henry Bair: [00:05:54] Okay. You mentioned that you had a very early interest in in global public health, but why at all, though, were there any experiences early in life or things or stories you came across that really pushed you to that?

Dr. Farzad Mostashari: [00:06:07] I grew up in Iran. I was born in the States, but went back to Iran with my parents. And it's hard not to feel your privilege weighing on you when you're seeing so many people who don't have, you know, going back to my my dad's little town, uh, with the, you know, dusty streets where he grew up and wondering, like, why are the kids on the street barefoot and running after the big suburban we're driving? That's what kind of the sense of giving back and service that came from my parents was kind of the motivation on the public health side.

Henry Bair: [00:06:45] I see, so you go to medical school, you do residency training, and then what did your career look like immediately after? After medical training.

Dr. Farzad Mostashari: [00:06:54] I did a fellowship at the CDC's Epidemic Intelligence Service, and it is an awesome training program, which I would recommend to anyone who's interested in public health. I think it got class, got dodged, but I think hopefully it'll be back. But it's an incredible training program and you either go deep on one, you know, mosquito borne diseases and travel all over the world studying that. Or you pick a locale and you do anything and any disease outbreak that happens in that locale. And I, I went to New York City and it was awesome being, you know, city of 10 million, the proximity, you know, you can you're a subway ride away from any outbreak that's happening in the city. And there's just, you know, it's listeria one day and, and anthrax and West Nile virus and Vibrio vulnificus the next day. It was it was a phenomenal training ground.

Henry Bair: [00:07:53] I read somewhere, correct me if I'm wrong, but I believe you were there at around the same time that doctor Tom Frieden was there. Is that correct?

Dr. Farzad Mostashari: [00:08:01] Yeah. Tom has had a huge influence on on my career. He he hired me in New York City and he was the one who asked the question. I was I was kind of a techie doctor, you know, uh, public health guy. And I was this is back in the early 2000, late 90s, where if you just said, like, oh, can we use a computer for this?

Henry Bair: [00:08:25] Yeah. I was about to say, what does being a techie mean at that time? Yeah, I just I don't know. I mean, I'm currently still in medical training, but I went to medical school in the I started medical school in the late 20 tens. And my really bulk of my medical training is in like early 2020s. And I cannot imagine medicine without the technology that we do today. So kind of interested to hear what what being a techie in public health and in medicine meant 20, 20 plus years ago.

Dr. Farzad Mostashari: [00:08:55] It was literally when you walked into the health department, there were rooms with paper stacked waist high, which were the the communicable disease reports, and you had people who were data entry clerks taking the handwritten pieces of paper and typing them into a database. That was public health. And I asked the question, my first week in training. I said, does anyone use like, computational methods for detecting outbreaks? And it pinged around CDC and they were like, well, the salmonella group has something. But no, the answer is no. And so that was my first kind of foray was, well, let's let's use computers to do outbreak detection. So developed a whole bunch of computational methods and so forth. But my point is that was like looking at a hammer and saying like, what can I pound on? What are all the nails in the world? How can we use computers to look at trends in illness or whatever? And Tom Frieden was the one who said to me, Farzad, that's not the question. The question isn't, what can you use technology for? The question is, how do we save the most lives? And it just it shook me to think about that question seriously. And it turned out that we did a lit review and there were no papers that answered the question. Let me put it precisely. What can medicine do to save the most lives of all of the guidelines and evidence base and Uspstf and all the hundreds of quality measures out there, which quality measure, which evidence based intervention, if we did it as well as the best institutions do, it would save the most lives, would prevent the most premature deaths. Do you have an idea?

Henry Bair: [00:10:46] I don't have the answer. I have some ideas, but I don't have an answer.

Dr. Farzad Mostashari: [00:10:50] What do you think? How would you think about it?

Henry Bair: [00:10:52] Specifically, in this country, I would assume the noncommunicable diseases. Yes, I would assume metabolic health. That's just a guess. Throwing it out there.

Dr. Farzad Mostashari: [00:11:00] And what should we do? Like what? From a clinical point of view, which clinical quality measure matters most?

Henry Bair: [00:11:06] I would assume, again, something along the lines of preventative health.

Dr. Farzad Mostashari: [00:11:09] Yeah. It's blood pressure control.

Henry Bair: [00:11:11] Mm.

Dr. Farzad Mostashari: [00:11:11] So we didn't know the answer to that 20 years ago. And it's still blood pressure control 20 years later. And then it's like well why why isn't the American health care system controlling blood pressure more than 65% of the time? That's shameful. We're spending trillions of dollars. And the thing that could save the most lives we're not doing. And we said, well, it's payment systems, it's workflows. And it's also you need the data and technology. And so I was back to can you use a computer for that. And that was the next ten years of my life was getting electronic health records with prevention, baked in with registry functions and decision support and measurement of blood pressure and all that. And at the end of that journey, I was US National Coordinator for health. It it was my dream job. I was in charge of policy for the country and the rollout of electronic health records, $2 billion of grants, $30 billion of payments to doctors and hospitals. We went from 10% of hospitals to 90% of hospitals having electronic health records and blood pressure control didn't change.

Henry Bair: [00:12:12] So yeah, we're let's get back to that. I'm going to put a bookmark in that because I want to talk about that. But but you've just covered a lot of ground. So we actually had a doctor on the show about a year ago. His career also spans many different work settings, and he's tackled so many issues. But I think to your point, I think if anyone were to listen to that conversation, what would be standing out would be just how mission driven he is to, like you said, save lives. I mean, making the title of this initiative Resolve to Save Lives. So okay, how did you learn how to work with it? Was that a part of your training or background?

Dr. Farzad Mostashari: [00:12:48] I was always that kid who, you know, was fooling around with computers. But yeah. And I don't regret all the time and effort we spent computerizing American Healthcare, although I'm sure some old timer docs questioned it at the time. But I think what drove home the message for me was that computers, any tool, any technology, works within the system and in particular within the financial incentives of the system. And so many people working in healthcare see that the system doesn't work in some ways. They they feel like frustrated or burnt out or disillusioned. And yet they're we're so part of the system that we can't even see the drivers of it. And so much of it has to do with fee for service incentives. And I say this with the jargon of fee for service. But if you just think about like we pay for strokes, like we pay a lot more, like there's no CPT code for didn't have a stroke. There's there's no, you know, rvu associated with prevented a stroke today. And so then we wonder like, well, why is the system the way it is? And, you know, one of the things that I, I tell med students is like, watch with fresh eyes what's happening around you and ask the question and try to think about what are the incentives in the system that are revealed by the behavior of the system.

Henry Bair: [00:14:26] Just a quick clarification for, for for those in the audience not embedded in direct clinical work. Cpt codes are what doctors enter into the medical record to officially document what the main problem addressed during a given visit was. And then reviews are sort of predefined reimbursement rates for specific interventions or things that were performed for a given patient. So I kind of want to talk a little bit about emr's EHRs, electronic medical records specifically, because that's so much of what you've done. And it is it has transformed American healthcare. Undeniable to listeners who, again, are not clinicians. I cannot imagine clinical work now without computers because it's everywhere. And, you know, we we spend so many hours in medical training, learning how to use these systems. We have, like we had whole days of just training sessions on how to document and how to navigate these health records. And I know that there's so much conversation amongst clinicians about how EMR EHRs are the bane of our existence and the leading drivers of burnout. Like I've heard those conversations and those arguments. What I will say is that so I work. I have worked in inpatient settings. I work in the emergency. I currently work in the emergency room setting as well and I work in clinics too. I pretty much spans the range of practice settings for physicians. There are moments in my hospital. There are times in my hospital when the Amr has to be taken offline for maintenance or update or whatever, and I have been stuck in moments when usually this happens for a few hours.

Henry Bair: [00:16:05] I have been stuck during er shifts, very busy er shifts when you have tens and tens and tens of patients waiting to be seen where that's when the IT department decides to take the EMR offline. And for those few hours, for those horrifying nightmare few hours, you have to do the same amount of work and see the same amount of patients without EMR. And what that means is that what are the things that I do for patients when they come to the emergency room? I have to document what's going on. I have to put in orders for anything, for diagnostics, for interventions. I have to consult specialists if necessary. All of that is supposed to be done through the EMR, and all of a sudden I have to do paper charts for all those things, and I'm lost. And in those moments, I understand the tremendous role and the importance of EMR in our system. And I do not want to go back to paper charts. That being said, I do want to ask you, and this is a huge question. You have witnessed the transformation of American healthcare from basically no one using EMR to now more than 90% of all hospitals in the country adopting it. And this is all again, this is this transformation occurred very recently within the last.

Dr. Farzad Mostashari: [00:17:18] Yeah, it was it was from 2009 to 2014.

Henry Bair: [00:17:21] Yeah. I mean that's incredible. I have attendings who completed training not too long ago, and they can tell me about when it was all paper charts. And it's still very striking to me that. Wait, that was just a few years ago. Well, how would you assess the way that EMR has have been implemented around this country. How would you assess the rollout? Are you happy with what it looks like now, and if not, what are the big things you want to highlight that should be done better?

Dr. Farzad Mostashari: [00:17:47] Yeah. So as I said, I was the person in charge of defining the programs and the policies around this transformation in American health care that was funded by the actually the American Recovery Act of 2009. And look, I think paper was terrible. Like I was in the hospital with my mom in 2008, one of the best hospitals in the country, and there was only one copy of her. Think about this. There was only one copy of her chart. It was bound in a in a gray binder, plastic binder, and there was only one. So if I'm reading it, you can't read it. If it's downstairs with her in radiology, like no one knows what's going on with the patient because they. When the attendings rounded and the chart wasn't there, they couldn't write their notes. They couldn't read. Like that's crazy. And then when literally she was having runs of ventricular tachycardia where the heart's beating so fast it's not pumping blood. And she was passing out, and I begged to see her chart. And it was uncomfortable because you're, you know, you're the patient. You're the patient's family. You're not you're not the physicians.

Dr. Farzad Mostashari: [00:19:00] The chart is meant for the physicians, right. And when I flipped open to the cardiology note from that day, I couldn't read the handwriting. Like, that's what we were dealing with. You couldn't read like, those orders were really easy back then because you would scrawl, like, CBC diff or whatever. But all too often the people on the other end of those orders couldn't read the order for what medication you ordered, what dose. It was madness, right? So I don't regret that we got off paper and handwriting, and there's only a single copy of the record. And now, you know, my mom was hospitalized again 20 years later, and we could log in to the portal and we could read the notes every day from. And everyone could read the notes. And the orders are all computerized. What I do think, though, is those became tools for billing and coding, more so than prioritizing prevention and and coordination. And so they do a really good job of capturing and forcing all the people, using them to put in all the information you need to maximally code and bill for those services.

Henry Bair: [00:20:17] Yes, I agree. And I know what you're talking about, but it can be a little abstract abstract for someone who's who's never used an EMR before. Can you illustrate with an example exactly what you mean by a system optimized for billing at the expense of, say, patient care or effective doctoring.

Dr. Farzad Mostashari: [00:20:35] Yeah. So if you have a system where doctors and systems and practices and hospitals. Someone said, we're not paid for delivering care, we're paid for documenting that we delivered care. And so if you want to get paid at a certain level, there are certain rules about what qualifies for this level of payment or this code that pays more than that code. And there are thousands of page books and criteria that have to be met. It used to be in the old days, you know, you have five levels of a doctor visit in an outpatient doctor visit that would get reimbursed. And, you know, if you wanted to go from a level three to a level four, which was more money, you had to document, you know, six elements of history, of present illness and for review of systems and three Complexity of medical decision making. And you just have to document document, document document. And so we ended up, you know, with these templates and checkboxes and clickers and to say how many did you document. What did you did you check this off so that you can qualify for this higher level of payment. And it's just madness because that's not what doctors want. That's not what patients want. Right? It's like the whole thing got taken over. Like the billing department is running the hospital.

Henry Bair: [00:22:03] So, you know, it's easy for now to look at what system we have now and sort of point to why this happened. It's electronic medical records. The market is basically dominated by 2 or 3 for profit companies. And I understand the financial drive. Obviously hospitals have to make money. I mean, they have to keep the lights. Someone has to sort of keep the operation running. And that takes a lot of money. I understand that. So it's not hard to understand the drivers of the system we have today, and in some ways it makes sense. Yamahas are designed by by companies that have employees they need. They need to improve the system and they need to return value for their shareholders and whatnot. That's generally true for for the vast majority of medical technology that we have. How would we, in your estimation, as you look at how developed, how could we have moved the trajectory as this thing was being unrolled, unfolded? What are some things we could have done or we can do now to course correct?

Dr. Farzad Mostashari: [00:23:02] Yeah. And this is where I think it's time to take a step back and say, well, what did I do in the past 12 years since I left? Yeah. Uh, the that that job in charge of the electronic health records, because it was that frustration and trying to answer the question you just asked. And I think we just need a new business model that the heart of it is what you said is, is like it's not that EMR companies that are for profit. It's that they're responding to their customers, and their customers are saying for me to, you know, make money. I need to document. And so give me a tool that documents better. And that is the heart of the problem is we're paying for strokes. We're paying to document the stroke. Care we're not paying for did not have a stroke until 12 years ago. I saw this new payment model that was being discussed in Health and Human Services, where the discussion was, if we give primary care docs some of the savings, if they can prevent strokes, let's give them half of the savings and it's life altering. And we now that's what Alidade, which I founded, does. We help primary care docs keep their patients healthy out of the hospital. And it's not that you're getting paid for documenting that. You did three elements of review of systems and 12 of physical exam. It's that you get paid for keeping people actually healthy and not having strokes, not having heart attacks. And it turns out that it ends up doctors spend more time talking to patients. That's what you get is more time with the patient, fewer bad things happening to the patient. And that to me. And we now have systems that are not focused on billing. The technology then adapts. And the technology that we have built to enable that is all about coordinating the care better, not about documenting the care that needs to be built.

Henry Bair: [00:25:09] So you mentioned fee for service earlier on in this conversation. And that's where medicine is transactional, where a patient goes into the doctor for a very, very, very specific thing. Let's say they have like I don't know, like chest pain or something. And the doctor orders Specific things. They order imaging, they order diagnostics and labs, and then eventually they prescribe a specific medication. And in some ways it is extremely intuitive. It's so easy to understand, okay, so you get paid for the things that you actually did. You get paid for ordering this test. You get paid for prescribing this medication. You get paid for this time you spent talking to the patient. That that makes very intuitive sense for even someone who's not in healthcare. You're saying that it makes much more sense to be paid for, for example, something not happening? Yeah, that is a lot less intuitive even to me. Can you walk us through what that actually looks like in concrete terms?

Dr. Farzad Mostashari: [00:25:59] Yeah. So we get groups of primary care docs together. Uh, we now have over 20,000 primary care physicians in the country who are working with us across all 47 states. And we kind of come together and we say, okay, we collectively are taking care of, say, 100,000 Medicare patients in this in this state, those 100,000 Medicare patients, each one might be expected to have $10,000 of all of those charges that you mentioned, right? Doctor visits, procedures, hospitalizations. $10,000 each. So that's $1 billion of spending. And then the question is, that's what the CMS actuaries, the green Eyeshades folks, that's what you're expecting to pay for this population, given their age and their number of conditions and how sick they are and where they live. You come up with with a number, which is how much you're expected to spend. But if the primary care docs work together and they help control the patient's blood pressure, remember we said that's the number one thing to save the most lives. Right. Where I trained at Mass General, our blood pressure control rate was better than the national average. It was. It wasn't 65%. It was 75%. At Alidade, we're at 84%. Why does it make sense? We're not paid a dime for every time you control someone's blood pressure. Better. But we're motivated to actually keep people healthy and out of the hospital and not have strokes and not have heart attacks. And when you do that together, we're saving 2% the first year, then 4%, then 6%, eight, ten, 12. One of our groups of docs in Louisiana saved 16% against what would have been expected to be the cost of care. We get a share of that. The government keeps share of that, and we end the primary care practices split that. So that's the whole business is work to beat the trends in health care costs by giving patients more, not less. More conversation, more engagement. More information, more coordination, more prevention, more primary care.

Henry Bair: [00:28:15] So like I said earlier, it's easy to see what doctors get paid for. Like where the money, what the money is being tied to. If we're talking about like a specific service, a specific intervention diagnostic procedure in this model that you just described to us, what exactly is a payment tied to? Like what what are doctors being paid for? I understand the cost savings that makes sense to, um, like instead of spending extra money on extra care by making sure the patients don't need that at all. Of course there's a cost saving there, but even further upstream, like where is the payment coming from and where is it going to? What's it for?

Dr. Farzad Mostashari: [00:28:49] So one really easy example to think about is the emergency room, where you practice. How many of those patients, if they had a primary care doctor who really knew them well, and when they first started having that problem, if they could have gone to see that primary care doctor and gone in to see them, what percent of all the people that come into the emergency room maybe could have been prevented, that er visit could have been prevented 80%.

Henry Bair: [00:29:22] Wow. Right. I think I think I'm just guessing. But yes, most of them did not need to come to the emergency room. Right.

Dr. Farzad Mostashari: [00:29:30] But if you wait, and then you come to the emergency room and you're scrambling, trying to figure out what's going on with this person. You've never met him before. You don't know their history. You don't know their family history. You don't know their living conditions. You don't know their past drugs that have been tried or whatever. Right. Then oftentimes those people end up getting admitted. And then one out of every five seniors who gets admitted gets a complication during their hospitalization. And then there's the deconditioning, and they're weak and they fall, and they're there in the nursing home afterwards. And that whole cascade that that happens that could have been prevented if the primary care doctor did what many of our practices do, which is they hang up signs in the waiting room that say, call us first before you go to the emergency room. That's what we're talking about, is a system where it makes sense for a primary care doctor. Not to say next visit is four months from now. For an 86 year old with heart failure, who's having trouble breathing? Right. As opposed to saying, come in right away, I'll see you. I know you will increase your dose of Lasix a little bit. I'll listen to your lungs. I'll make sure nothing else is going on. That's serious. And I'll see you back. Right? That's the system we would want. And that system is not supported by you get paid for for piecework, not for the total health of the patient.

Henry Bair: [00:30:55] How do we get from the system we have now to the system that you just described?

Dr. Farzad Mostashari: [00:30:59] There is this program that is quietly working. We saved the government $1 billion last year, and our primary care practice is community based primary care practices. Working with Alidade are going to get $500 million dollars of extra payments this year. It's huge for a primary care doctor. They're expanding their services. They're expanding their hours. They're putting in more staff. They get to hire more people to care for more patients, and they're happier. The solution? If you're in primary care or thinking about going into into primary care, I think you do not want to work in a place where the only way to make ends meet is to do more and more patient visits in less and less time. We were talking with one of our practice owner docs, Doctor Christine Meyer, who said before she started working with us, they were seeing something like three and a half patient visits an hour, and now it's down to 2.3 visits an hour. They're spending more time with patients and they're more financially successful than than ever. So I think this is a program, this Medicare shared savings program is what it's called. Accountable care organizations is another name for it. But fundamentally outcome based medicine as opposed to kind of fee for service medicine. I think this is the way for anyone who's in primary care. For specialists, it's a little more complicated. Specialists make a lot of money doing things to people, procedures, you know, injections and and the scalpel and the infusion. Like, it's pretty hard to focus on saving money when so much of the cost is you. But I think that's the next frontier is how do we get the same sort of flip in the business model towards prevention versus treatment of complications and bad health to get that flip to happen for specialists?

Henry Bair: [00:33:03] Yeah, I bet there's also some degree of just sort of a habit of mind of a lot of clinicians about just as much as a system is flawed. I must imagine there are a lot of people who are just a little bit more comfortable with the idea of getting paid for exactly what I did. I document exactly what what things I performed, and I get paid for that. I think it's a little bit scarier, I imagine. Yeah, to leap into the system where you're maybe getting paid, for example, for outcomes for what actually the patient got. And I think that can be a lot of pressure in some ways, or the idea of selling a system or convincing a doctor to go into a system where you do less, you see fewer patients, but somehow they make more money at the end. That sounds sounds a little bit contradictory. Again, maybe just because we're so, so accustomed to fee for service. When you talk to doctors, let's say primary care doctors, for now, when you talk to them and discuss the system, what are some of the biggest concerns you hear about and how do you address them?

Dr. Farzad Mostashari: [00:34:00] I think there's one concern of, you know, I'm going to do this work. And then at the end of the year they're going to tally up the costs. And, you know, is this going to work to your point. And I think it's really helpful now to have a decade of experience and where we can say, look, trust the process. When we do these, these four things, we call it the core four, right? When patients have more access, when there's better transitions, when someone goes to the ER, your office gives them that phone call, right? When the patient shows up, you know, if they filled their prescription or didn't fill their prescription. If someone needs to have a conversation, there's there's additional resources for you to, to talk to patients about, for example, their end of life wishes. When we put this package together. Trust the process. It works. And we have a decade of results to show for it. I think that's really important is it's not an it's not an experiment anymore. There's literally thousands of other practices like yours who've gone through this process and, and can vouch for the results of it. I think that's that's really important. The other question we get a lot is I don't want to stint on care. Does this mean that I, you know, I shouldn't, like, give my order.

Dr. Farzad Mostashari: [00:35:17] Order. And, you know, a lab test for my patient, and I'm like, no, no, no. Primary care costs are a tiny fraction of the cost of care. The most expensive things in health care is that hospitalization. That's what we're after. We're after spending whatever you need to spend to keep the patient doing well so that they don't have to be hospitalized. That most expensive source of suffering in health care. That's what we're trying to prevent, is the patient needing to be hospitalized. So do all the work that you feel is necessary to keep them healthy. That's a second thing that we hear, which is such a credit, honestly, to primary care docs, is that their concern is, gosh, I don't want to make money if if it means that I stint on care for my patients, they don't want to do that and we would never ask them to do that. And then the third thing is just, gosh, this seems complicated and I need someone who understands the 160 pages of reg text to figure out how this works. But, you know, at the end of the day, it's not that complicated. It's due primary care. But be more accessible, be more informed, be more engaged in the things that are going to make your patient end up in the hospital.

Henry Bair: [00:36:31] You know, I think that being more present, be more accessible, be more engaged. I think those are things that all doctors want to want to do and be. I do think a lot of doctors feel like they how, you know, their doctors are already. So in this country. The American Medical Association publishes statistics on burnout rates like every year at this point. And I believe earlier this year, they triumphantly announced that burnout rates were at the lowest they'd been since Covid. And when you look at the report, it's still like 50%. Yeah, that actually scares me quite a bit, knowing the fact that half of all doctors are tired of the system that they work in Yeah. And they already feel so stretched, so thin.

Dr. Farzad Mostashari: [00:37:10] Yeah. Can I just comment on that?

Henry Bair: [00:37:13] Please do.

Dr. Farzad Mostashari: [00:37:14] I don't think it's hard work that makes people burned out. I think it's moral injury. When you feel like it doesn't make sense, that the work doesn't have meaning, that what's best for the patient is not what's best for the duty you owe your employer. I think those are the sources of moral injury. And one of the things that I think is really powerful is the independent practice, someone who works for themselves and other doctors, they're part of a partnership. They feel ownership. They have autonomy. The biggest source of burnout is some middle manager telling you you can't take Wednesday off. Not having clinical autonomy, not having personal autonomy, not having agency over your own life. That's what causes burnout, right? And I think there's a lot of burnt out primary care docs who are working, as you said, for a system that doesn't seem to care about them and doesn't value them and doesn't value their work, and I think they would be much happier if they were working as an independent, community based practice.

Henry Bair: [00:38:27] Thank you so much for highlighting that. So, okay, the importance of or the value of being an independent practitioner. By the same time, the group that you're working with, it is part of a network, right? Like for the best value of healthcare, you often have to work in a team. So simultaneously independent but also part of a broader team. Very integrated.

Dr. Farzad Mostashari: [00:38:46] That's right. To be able to take advantage of of scale and, you know, technology and power of numbers. Right. But but yet retain your your autonomy.

Henry Bair: [00:38:57] So talking about costs a little bit. You know, I think it's no secret that the United States spends a disproportionate amount of its money on healthcare and for not the best results out there. As you look at maybe, maybe this is a little bit of a controversial question or it's really pushing a little bit. But as you look around the world, who has it figured out in your view, which health system somehow has figured out a way, if any, to do the job that is closest to what you're proposing, who somehow manages to not spend that much money but have good outcomes? And what do you think? How do you think they pulled it off?

Dr. Farzad Mostashari: [00:39:31] I spent a lot of time as a federal policymaker thinking about questions like that, and I honestly don't think it's that helpful for us to try to say, well, here is a fully realized system that is enmeshed in in their regulations and their financing systems and their culture and all that, and say, what elements of that can like, could we become like that? It doesn't really work that way. We have to come up with the with a solution, with an American solution that can build on and depart from the system we are fully embedded in. So I could say, look, if you could completely change wave a magic wand and have, you know, a single point of accountability for, for healthcare costs and delivery of healthcare, maybe that would be good. But then people would say, well, no, it doesn't look like the VA is doing so great, right? I actually love the VA. I think the VA is a is an underappreciated gem in many ways despite their many challenges. But I think we have a probably a uniquely not just expensive but complicated system where we have said, well, this has got to be, you know, market driven in many ways, but but also regulated. It's got to be competitive. But also we have these monopolies. So it's a it's a very complicated system. And I don't see a simple way to transpose what does or doesn't seem to work in other systems for us.

Henry Bair: [00:41:02] I see. So. So as you work to make these changes in our current in our given system, what we have now, what are the biggest sources of resistance? Is it from the policy side? Is it from the from the hospitals? Is it from the clinicians themselves? What are the biggest pushbacks that you're experiencing?

Dr. Farzad Mostashari: [00:41:20] It's not policy and that's actually encouraging. Um, Winston Churchill said Americans always do the right thing after they've exhausted all other possibilities. And I think from a policy point of view, this kind of move towards outcome based payment models and care models is that like we've tried everything else, but finally we've arrived at the right answer, and it seems that it's one of the few things that, regardless of administration, there seems to be continued support for it, because patients are getting better care and doctors are getting paid more, and the system is saving substantial amounts of money from from it. So it's not policy. There's policy is is supportive. We have about a third of all Medicare patients now in in one of these models. It's but the question that policymakers ask is, well, why not all of them? Right. When my mom came from the hospital and a nurse from her primary care doctor's office called and checked in on her, which was super helpful. And I said, is this a new service? And they said, no, but your mom is now in the ACO. And I'm like, well, everyone should be in an ACO then, right? And that's kind of how policymakers view it. So what is stopping us from having everyone be in an ACO, as it, as it were? I think a lot of it is the fear of the unknown. And, you know, it's like the devil, you know, right? I hate the system. Primary care doc might say. But, you know, I'm afraid of what lies behind that door. And so we really have to make it easy. We have to have an easy button. And that's kind of what we spend all day thinking about is how do we how do we make it as easy as possible for primary care practice to embrace this model and with minimum pain?

Henry Bair: [00:43:08] So we've spent a lot of time talking about the health care system, the current one, and the one that you're moving us towards from the more from the clinician's perspective. I want to explore it a little bit from the patient's perspective. Let's say ten years from now, we have it better figured out. From payment models to the technology, everything works better, more seamlessly from the patient's perspective. Can you paint a picture of what then their experience looks like? Let's say let's say they have a problem. Or maybe, maybe, maybe they're just there for an annual exam or whatever. Um, like what? What does that look like from start to finish? They go see a doctor, and then maybe they need subspecialty care. Like, what does that process look like when everything is better figured out?

Dr. Farzad Mostashari: [00:43:47] Yeah. And I think we are, you know, the future is here. It's just not evenly distributed. And I do think that the care at some of our primary care practices is, is approaching that ideal for the patients. And I'll draw a contrast maybe. So the patient and this may be an this may or may not be my mom. Right. The patient's husband goes to the pharmacy to pick up the medication, which is a the great new medicine for their condition. And it and the pharmacy says, uh, that's $700 for the first fill. They walk out. They don't fill the prescription the next time they go to the doctor. The primary care doctor would know that you didn't fill the prescription, and they would talk to you about it, and they would figure out what to do about it instead of in the current system. No one knows no one. There's no coordination. When you go to see your primary care doctor, what they're seeing in their electronic medical record is what they typed into your electronic medical record. It's not taking advantage, actually, of the possibilities of getting your labs and pharmacy data and your other specialist notes and all that into one place. So the physician at the point of care can really focus on you as a person, and not on all the billing codes that they need to do to be paid a level four visit instead of a level three visit. So that's piece one. Piece two is if you do have trouble breathing because maybe you didn't take that medicine and you can get in to see your your primary care doc that day or the next day and you're not told go to the urgent care clinic because in the urgent care clinic, they're going to take one look at you and they're going to say, go to the E.R.

Dr. Farzad Mostashari: [00:45:42] and in the E.R. they don't know you either, right? And you may get admitted, or you may sit in the E.R. for 40 hours, which is what happened to us. 40 hours sitting in mostly in the hallway in the emergency room. That's not good for anybody. And then when you get home, your primary care docs practice. The nurse would call you and say, are you okay? How's everything going? And here's the other thing that we don't want to talk about as doctors, but patients do want to talk about is like, what's happening to me. And you have a patient maybe with a little bit of, uh, of impending dementia is creeping in, and they need someone to talk to. And, you know, it's too much for a primary care practice to go through with them about how are you going to handle your medications or your end of life choices, or your finances, or your driving or. Right. But having someone who can be part of a team, working with the primary care doc to talk through all that with the family and make a plan that honors the patient's wishes and preferences. So those are elements of of what a better primary care led healthcare system can look like.

Henry Bair: [00:46:58] Yeah. So I'm an ophthalmologist, so I am not going to be in primary care. I'm a subspecialist. I'm one of those people who I think our field needs to do a little bit better, because it's still very fee for service. There are elements. Probably the single biggest thing that ophthalmologists do is cataract surgery. And cataract surgery is the most commonly performed procedure across all medical specialties in America. And I think that in that respect, that thing we are still being paid for, for the search, for doing the surgery, but as a bundled payment. So it's how much a surgeon gets paid. It's sort of tied to the outcomes, right? Because what happens after the surgery is sort of on the surgeon. Like they get paid a fixed amount and they have to figure out how to get the best outcomes for a given amount of money that they get paid for. But then there are many, many other areas of ophthalmology, let's say injections in the eye for macular degeneration or for diabetes, which I believe some of these injections are literally like the top among the top five largest areas of drug expenditure for like for Medicare is one of these injections. They are directly reimbursed for how many injections they do, not for the outcomes.

Henry Bair: [00:48:07] So lots of problems here. But I see every day what you're talking about, where we have patients coming in for just loss of vision. That's the complaint. And I see them in the emergency room, and I see an eye that's clearly been ravaged by diabetes or high blood pressure for decades. And you're like, how did this happen? You know? Yeah. What happened to the primary care visits? What happened? Like, by the time they get to us, many, many things have gone wrong over many, many years. And the things that you're describing would address all those things. So it resonates with me, even though I'm one of the specialists, and I see the value there. With the last few minutes here, I want to go back to something you mentioned all the way up front. Well, actually two things now, now that we're talking and now that I'm thinking about the conversation we've had just to close the loop, you talked about high blood pressure. Management hasn't really changed that much. Can you just briefly close the loop there? Address that. Why is that the case? How do we do better?

Dr. Farzad Mostashari: [00:49:04] We need to focus on blood pressure. It needs to be not one of literally a hundred quality measures that a primary care practice is judged on. There needs to be like three. We need to cut down the number of ticky tack measures that we try to quote, hold docs accountable to, to the things that really matter most. And by any measure, blood pressure control matters most in terms of lives saved, eyes saved, limbs saved. Let's focus on that. And I do think having payment systems that pay you for no stroke versus pay you for stroke are the essential, the essential part of that. And as I said, I'm when I was at Health and Human Services in the government, I helped launch something called the Million Hearts Campaign, and this year, 90 of our practices were recognized as being champions for for blood pressure control. And that's something we're we're super, super proud of.

Henry Bair: [00:50:05] Thank you for for sharing that. You mentioned all the way back that despite all your interests, your lifelong interest in global health and in public health health policy, you knew you wanted to do medical school because of that element of laying hands on the patient. Correct. Correct me if I'm wrong, but you're not still practicing, are you?

Dr. Farzad Mostashari: [00:50:25] No, I'm. I found my highest purpose in helping serve those who serve.

Henry Bair: [00:50:32] Then my question is, how has that early interest in laying hands on people and that that very real experience, how have those experiences actually interacting with patients? How has that shaped your career and your mission? Like how does that change the way you lead your organization now? Like having that as a core driver very early on and having those actual having those experiences with real on the ground patient care.

Dr. Farzad Mostashari: [00:50:59] You know, there's something about patient care that the hands on ness of it, there's no hierarchy, you know, like when you're working. When I was working in the emergency room, I would I would feel I'm not saying that that it's like enjoyable, but I felt a certain pride when I took care of some homeless person's feet. You're the only one who's going to do that. Literally. You're the only person who's going to do that. You're going to treat the wounds of whoever, whoever comes in, and you're going to do it with respect for them. There's no higher calling of service than that. And, you know, you can be a, you know, fancy doctor, but in that moment, you are, you are serving. You are at the feet of the person who needs it. It's not just a job, right? It's not just a transaction. It's not just like a CPT code. Right? That's something that I think is is truly heroic. And we want to serve people who are who are dedicating their lives to that sort of service.

Henry Bair: [00:52:09] Well, with that, we want to thank you so much for your time for that, for taking the time to to share with us your insights, your stories, every single clinician and even just every person who's worked in healthcare, who works in healthcare in America, knows and feels what you've shared with us and are a part of the system that you have described, and hopefully that you will be that you will help bring about to listeners who are maybe, uh, not not in the clinical world, who are who are patients caregivers or who are pre-medical students. I can't emphasize enough how wide the implications are for the ideas that we've discussed today. So for all that, thank you very much for for illuminating all that for us and for the incredible work that you continue to do.

Dr. Farzad Mostashari: [00:52:55] Thank you.

Henry Bair: [00:52:59] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.

Tyler Johnson: [00:53:18] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.

Henry Bair: [00:53:32] I'm Henry Bair.

Tyler Johnson: [00:53:33] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.

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