Dr. Griffin Myers Chief Medical Officer at Oak Street Health. The organization provides fully-capitated care to patients covered under Medicare and Medicaid, so Oak Street is incentivized to provide efficient care with limited resources. Dr. Myers talks about this example of value-based care and how they’ve been able to reduce hospitalizations by over 40%, the mission of Oak Street health (personal, equitable, accountable care), and what new physicians entering the system need to know.
Give us an overview of Oak Street Health and the problem it’s solving
Oak Street Health is a network of 25 and soon to be 37 fully value-based primary care practices. [They are] very intentionally located in medically underserved communities. And we focus specifically on patients with Medicare and Medicaid.
When we got started five years ago, we had a pretty simple mission. It was to rebuild healthcare as it should be, and we think it should be three things: Number one, we think it should be personal. So for clinicians that’s our shortened jargon for ‘evidence-based.’ The second thing is we think it should be equitable, so this idea that people may have different abilities to pay is fine, but it shouldn’t determine the quality of your access to care that you receive. And the third part is that we believe providers should be accountable. If 20 percent of our economy is in healthcare, we should have some ability to know that what we pay for works. We don’t traditionally have that. We have a fee for service, a fee for volume model and we don’t believe that holds people accountable.
How does this work in practice?
We essentially act as a globally capitated primary care practice. [T]he easiest way to think about it is in the Medicare Advantage program, though there are others.
We take a globally capitated payment for each person who is attributed to us. Then we’re totally responsible for all of the costs of their care. If they go to the hospital, if they need a drug, if they need an emergency surgery, their primary care practice, [in this case] Oak Street Health, is going to pay those bills. It gives us a dramatic and powerful incentive, but not only that, it gives us the resources to invest in what our patients need. That means we invest in seeing our patients twice as long three times as often, providing transportation to and from the clinic for patients who need it.
What are the results of the capitated model?
What we’ve been able to do is reduced hospitalizations by over 40 percent, achieve five-star quality ratings [and] a 92 percent net promoter score. And obviously, those are things that are really hard to do if you’re trying to do short, fast visits with as many people as you can during the day.
Why isn’t everyone doing this?
I think a couple of things. Number one, it’s really hard. It involves so many different interfaces and providing great primary care was hard. Complementing that with behavioral health is hard. Providing a transportation service and doing care management and then all the back office health plan functions […] We’ve had to learn at Oak Street how to communicate with patients who may not have had previous access to primary care and explaining what primary care is and how it works, which is really a communications effort.
I think the second [thing is], once you’re entrenched in a fee for service business model, this [new approach] is so contrary to the way that works. I almost feel that large organizations who’ve been historically successful have disadvantages in making this transition. I would say it’s not an intellectual challenge, it’s a leadership challenge.
What about financial constraints within the system?
The challenge I think we have as a healthcare system is, and we found this at Oak Street, especially in the Medicare system, recognize there are enough resources to deliver high quality, equitable care to every beneficiary. And the challenge should lie on those of us in the delivery system to adjust the delivery system to be able to deliver that. [I]t’s possible, I think it’s just going to take a lot of creativity, a lot of innovation and a lot of leadership in the side of the delivery systems to do that in a way that is affordable to all patients.
What are you seeing from the new rules coming out of CMS?
I have heard a lot lately from partners around value-based insurance design work. I think that we’re recognizing that if we constrain people to spending those resources just on medicines, we’re going to get medicines. But if we’re freed that up to spend on what patients need […] it may end up helping people have access to healthy food, secure housing, transportation and other things.
I think rather like astrophysics, there’s no grand unified theory as of yet. And so if you want to participate and you want to be at the frontier of knowledge and innovate for patients, you’ve got to dig in and accept that complexity and recognize you can actually use that to your advantage. But I think more than anything if it seems like a moving target at CMS it’s not because they’re trying to distract us. It’s because we’re all learning this together. But if we can hold together those values that we want to deliver super high quality, equitable care to all of our beneficiaries in a way that holds the delivery system accountable, they’re trying to move us down that path. And from our experience in the system, we’re hearing people respond to that, especially lately.
How much of the Oak Street project was possible a decade ago and how much is made possible today by policy changes at CMS around value-based care?
Virtually all of what we do at Oak Street was possible 10 years ago. Nobody legislated the creation of our organization. No rules changed. Nobody invited us to build these centers in their neighborhoods. It really does come down to this idea of once you, as a practitioner, sign up to be held accountable to a price mechanism, you can practice in these value-based models. I don’t at all mean to suggest that it’s simple or easy. In fact, it’s very complicated. I think that’s part of the reason you don’t see a lot of people doing it.
At the same time, we take care of 43000 people at the moment. And that’s an incredible privilege, but there are 60,000,000 people in the Medicare program and the policymakers have to design programs for the other 59 point whatever million beneficiaries […] So while while Oak Street’s core business model was not the result of policy change, a lot of the policy changes we’re seeing are important and I think will bear fruit.