Kathleen Wessel (Host): Proactive engagement within primary care has shown to result in a significant cost savings and improvement in quality outcomes.

Welcome to AHA Associates Bringing Value, a podcast from the American Hospital Association. In this series of podcasts, we speak with AHA associate program business partners, check in on their efforts and learn how they support AHA hospital and health system members. I'm Kathleen Wessel, Vice President of Business Management and Operations at the AHA, and today I'm joined by Dr. Jonathan Rubens, Chief Medical Officer for CVS Accountable Care. In this podcast episode, we'll explore the integration of technology to inform proactive primary care engagements and drive impact on quality care and medical costs. Welcome to the podcast.

Jonathan Rubens, MD: Thank you, Kathleen. Great to be with you today.

Host: Dr. Rubens, I love starting these podcasts just by giving the audience a little bit of feel for yourself. So you're a very well-known individual, but I'd love to hear a little bit more about your backstory and, and your journey to and with CVS Accountable Care.

Jonathan Rubens, MD: Sure, it'd be great to share that with you. So I'm originally a New York City kid and now live in the southeast part of the United States. I'm an emergency physician by training and by practice. So I, uh, trained in emergency medicine practice for 25 years in a variety of settings, including both academic and community emergency departments over those 25 years prior to joining CVS Health. I've also had many years of health system leadership, both at the medical staff and at the organizational levels.

So I kind of feel like I have the well-rounded view of the practice part of this. About 14 years ago, I joined some portion of what is now the entity of CVS Health. And I did that because I was seeking a little bit of professional change and growth. And also as an opportunity to use all the skills that I'd honed over the years in a different way.

In particular, being able to affect populations and their health in a broader scale. And the size and scope of all of the integrated assets of CVS Health really provide an opportunity to do that. And also give us, I think, kind of a unique opportunity in the marketplace to change, hopefully, positively influence the way healthcare is delivered. So that's how I ended up here.

Host: It's excellent. Thank you so much. Honestly, when you think about the, the evolution of healthcare and, and the landscape, that period of time, it's been significant. So being with one organization and kind of venturing through that is both impressive and it gives you a, a nice, clear scope of transition and the transformation of the field.

So I've teased at the beginning this, this idea of proactive primary care. Can you describe proactive primary care and what you see are the impacts on costs, patient care issues like readmissions?

Jonathan Rubens, MD: Sure. So the first thing I would ask everyone to sort of come along the journey with us here is to take as a basic tenant that primary care is important. It is foundational to healthcare of individuals and populations, and really foundational to the health system delivery, uh, in general. So you have to sort of take that as a basic foundation, as a place to start. But proactive primary care is really a part of any kind of patient-centered care model, and we've had a lot of those over the years.

Patient-centered medical homes and other things that we focused on with that sort of patient-centered piece at the center of it. And the key here really is focus on health improvement and wellbeing and the delayed onset, or if you can't delay it, the optimal management of chronic conditions. And why do you do this in proactive primary care?

You do it because it results in better health outcomes, better quality of care. It helps reduce what we call avoidable utilization in the healthcare system, but what might also be unnecessary utilization from some vantage points. And all of those things hopefully result in lower cost of care at the individual level and at the system level.

So that's the basic foundation of proactive primary care and why we think it's so foundational to value-based care um, in the current environment. When I talk about proactive primary care, it's really because we now are developing over time this evidence base that says if you do these things for these people and these people, these patients are of a certain level of complexity because we know there are patients on all end of the scale.

People who are well and staying well, and people who are critically ill and at, you know, sort of advanced illness an end-of-life. But there's a sweet spot in there, patients of certain level of complexity that when you see them regularly and when they're seen with a frequency and a cadence that's consistent.

So not just, you know, five times in January, never again. Right. It's sort of the consistent, the consistency through the year, if you will, and also being seen by the same primary care provider. The evidence base tells us that there is a significant improvement in their outcomes, and along with that comes a significant reduction in the cost of their care and the utilization that take place in the system.

These visits are specific, right? Proactive primary care has to include specific things, and those specific things are like regular health screenings. So think about your breast cancer screenings and your colon cancer screenings, that kind of thing. Health assessments to understand what's changing in a patient's health dynamic over time.

And really understanding where they are in terms of risk. And we talk about that in value-based care as risk stratification. It helps us look at an entire population of patients and sort of filter them into levels of, of risk. Why we do that is so that we can identify those who might require closer monitoring, who need more visits, those who don't need more visits. And also helps us target for those individuals who need a specific intervention.

So think of things like a care management intervention, for instance. Something that can go on between episodes of care with a provider. There is an important trend amongst this group of patients in this specific risk range, if you will. And there's a recent study in JAMA that showed this, that for those patient's of a certain risk, improvement continues with visit frequencies all the way up to seven to 10 times a year. And that sounds like a lot. And it is a lot both from the provider vantage point and from the patient vantage point. I mean, most people listening and most patient's would not think about seeing their primary care provider that often, but there's a reason. And this high cadence of visits is really associated with that reduction in risk and the reduction utilization I was talking about. So much so that when they looked at this frequency in a Medicare population; it was associated with 175% increase in the cost savings and a 53% reduction in risk adjusted hospitalizations over a three year period of time. So we know that if we do this at the right cadence for the right group of people, at the right level of risk, it really makes a difference. And people ask, well, what is that risk?

Well, there's something that we look at, particularly in Medicare populations called a RAF or Risk Adjustment Factor. It's kind of a risk score of patients if you'll. And the sweet spot really seems to be for those patients in that RAF score area between 1.3 and 3.1, where we can make the biggest difference by increasing this frequency with proactive primary care.

Host: I would guess, you know, just the value and coordination of care at that level is kind of adding to your success factors and, and what you're seeing is progress in these areas. So I'm thinking about the data, um, and analytics. You know, how do data analytics and technology support the prioritization of resources in proactive primary care?

Jonathan Rubens, MD: Again, to get to even understanding who's in that risk level, right? There's some data there. There's some analytics that are needed to parse out those portions of the population so that you understand who's in that specific risk corridor, and providers really need support for this because this is not what doctors and PAs and nurses do every day, right?

They are trying to see patients and work at the top of their license. So, it's incumbent upon us who support them in these value-based care arrangements and in their day-to-day work to provide that information in a way that's digestible and usable and what we call actionable information. So we started out last year specifically really trying to figure out how we can get those people we know that are high-risk within our ACOs seen for proactive primary care.

And we started, you know moderately. We said let's try to get them at least four times a year and see if we can make that happen. Um, and then sort of, you know, crank it up from there, if you'll. One of the things that we do in building the support around the providers is the data and analytics. And what this means is identifying the patients that fall into the specific risk category.

And so we know where there's benefit to be had. The second piece of that is, once you've done those analytics and you've identified that cohort is how, when and where do you communicate that information and to whom, so that those patients are reached out to so that the providers are aware and so that we're able to really close the loop in terms of the identification to the effectiveness of this particular intervention.

Our analytics platform is really key to how we support providers in these efforts. And through it, we present providers with clear actionable data and lists of those patients in that risk corridor where we think the opportunity is greatest. We provide that both at the point of care for some of our provider partners through our interoperability efforts.

But they can also see it within our analytics platforms themselves if they choose to sign in and access that information. And then finally, we work with both the providers as well as their office staff to ensure that these patients can be prioritized. And that's really key. Because once again, providers are trying to see patients, they're trying to practice medicine.

They have a staff of people who are focused on the other administrative tasks that are involved in successful, proactive primary care. And we need to include them in this loop of communication.

Host: You're starting to articulate some of the elements, but you know, maybe we could dive a little deeper, you know, given the challenges that you've just cited, you know, can you share how your organization supports providers to be successful in this, knowing that these challenges already exist and there's some real limitations to access to information?

Jonathan Rubens, MD: Oh, absolutely. Yeah. So we help support our partners in a number of ways. The first of which, you know, it's sort of in addition to the prioritization. So we can, we can tell them the who, and we can provide that list of patients. That's one piece of this. But then the next piece is really how do you help them either identify what they have today or design processes and workflows that will work within their practice.

And this is a really key point. You've seen one practice, you've seen one practice, you've seen one accountable care organization, you've seen one, right? Every healthcare environment is local to that environment for its specific set of reasons. And we as an enabler in this space, really have to be able to help our providers design the things that will work for them where they are.

And that's one of our strong suits is going in, having those conversations with them to understand where they are, where we're trying to get them to go, and what that roadmap is between those two places so that they can prioritize these patients. So our team comes in and it'll work with them on those workflows, but we can also work specifically in things like this scheduling software.

So they give us access to that. We can take on some of those tasks about how do we optimize that software or how do we optimize whatever scheduling capabilities they may have, so that we can make it easier for them to translate this list of targeted patients and a completed office visit with a provider, and really working with the office staff to ensure they understand what this list is and why people are on it.

And they know these patients better than we do. They see them. Why does Mrs. Jones need to come in more frequently? What do you, what is it that you understand is going on with her? That when she calls, we really want to make sure there's an opportunity for her to get in for this set of reasons. So the more we can communicate that kind of thing and make it personalized to them and their patient population, I think the more successful we'll be.

This year in 2025, we're really looking to some other tools to help us with that. We do a lot of our clinical work today in the Epic platform. We have interoperability across multiple EHRs within our ACOs and our value-based partnerships. Epic provides us something called the Book Anywhere tool, and we're working closely with them on how we can optimize use of that as well to get more engrained in the, so in the scheduling software that's available for our provider partners.

The tool will allow our care managers to assist in scheduling and to supplement the work of our partners office staff. Because we really look at these relationships we have with our providers as partnerships. They're doing their piece, we're doing our piecing together. You know, we're more than the sum of the parts, but it's how, how we help them make arrangements for these patients who are specifically identified, and there's some other strategies of things that we do, and we try to get practices to think about if they're appropriate for their environment.

Like call us first campaigns. You know, what is that? That's when you're having an issue, a problem, a concern, a pain, a new symptom. Call your primary care provider first. Don't think urgent care first. Don't think emergency department first. Think of your primary care provider, right? And it's the preferred site of care for any kind of unscheduled visit.

The flip side of that is the provider organizations have to have the ability to field those kind of requests from patients, right? So that's one thing. Going hand in hand with that is things like creating same days office visit space in their scheduling, making that part of how they schedule the provider's day, that there is X amount of time or X amount of visits during the day that are there just in case somebody needs a same-day appointment.

And then asking the providers themselves as well as their staff to really encourage engagement with care management. Why? Because care management for those patients for whom it's appropriate, can really kind of be the care that exists between the visits with the provider themselves. It can help bridge those times between visits, identify when there's something going on that would require a more urgent visit and keep people from falling through the cracks.

So, all of these are strategies that we employ as CVS Accountable Care to help wrap around and support our providers in this effort to improve proactive primary care.

Host: Can you share some insights into the value of proactive primary care? Let's think about this from a given population, like the senior population, for instance.

Jonathan Rubens, MD: Sure. So Medicare patients are like the rest of the population on that same scale I talked about earlier, right? There are well people you want to keep well, and there are ill people that you're trying to keep outta trouble. The older we get, the more complex our health gets, and the most complex patients in Medicare tend to have a lot of providers.

They've got an orthopedist, they've got a cardiologist, they've got a nephrologist, they've got an endocrinologist, they've got all these people in the mix, right? That in and of itself, we know tends to create a fractionated care environment. That's a dangerous environment in a lot of ways, when you don't have adequate communication between the providers because they don't know what's going on, no one's captaining the ship.

This gets back to my first comment, which is why I want everyone to align on the basic tenant of the need for primary care, because one of the things primary care doctors or providers do really well is captain the ship. They take in all that information from all of those disparate places. They align it to the person they know, and they're taking all of that expertise and they're saying, okay, this applies, this may not apply.

And you have someone looking at all of that complete set of information and making the the right choices alongside with the patient about what's right for them. So that in and of itself is a key value of this strategy. And we know that the more frequently they get in, the more that care is coordinated and we know that that helps their outcomes and it reduces the cost in the system.

So someone may order an MRI or say you call someone because you have back pain and they say, oh, you need an x-ray. Well your primary care doctor may say, no, this happened to Mrs. so and so before and I know she doesn't really need this. This is what she needs. Right? So there is some unnecessary utilization in the system.

Some estimate as high as 30% of what we spend in healthcare could be avoided, and primary care providers are the people who are really good about understanding that, identifying it, and being vigilant about it. And we know that that care with them just really avoids unnecessary hospitalizations. And this gets back to the safety comment, which is value from the patient standpoint, you know, is that they have someone who helps them navigate this very complex world of healthcare that we've created.

So, you know, it's an advocacy thing and it really helps in terms of safety so that someone is looking at all of the drugs that all of my specialists have prescribed and said, oh, these two don't go together. You shouldn't be on both of these things. Or I come out of the hospital and people in the hospital don't know I'm already taking this other medicine at home that I forgot to bring to the hospital with me, and then you have another problem or a safety issue.

So patient safety is something else in here that we really should emphasize as a benefit of proactive primary care.

Host: So many things resonating in my mind uh, with all of that, I've been nodding my head throughout, uh, your explanation. What are some impactful results, uh, that you're seeing across ACO providers in executing this proactive primary care?

Jonathan Rubens, MD: So I'll give you a couple examples. So one of the things we've seen is we looked across our ACO populations and we said, how are we doing with PCP visits? How often are, are our beneficiaries, our patients really getting seen? And the numbers were not where we wanted them to be. And certainly when we looked at this cohort in that risk part that we spoke about earlier, we thought there was opportunity for us to do better.

So we identified that and we went out to our provider partners and we said, you know, let's really try to make this a focus and get these folks in and see if we can improve just this metric of how frequently folks are being seen and just bringing that attention to our provider partners and to their office staff; we were ultimately able to really create a high percentage of them that were not only hadn't been seen in the year, or who were overdue for visits during the year to get those patients in and to get them seen. So just the awareness and just bringing the information alone created a significant uptick in proactive primary care amongst our patient populations.

So that's one. Another interesting result that we've seen is one of the things we'd love to do is share best practices amongst all of our ACOs and our providers. And they have this great best practice where the year before they try to front load PCP visits. So they look at the folks who are at-risk, and then October to December, they're calling those people to schedule their first appointments of the year or their appointments throughout the following year, which is really phenomenal because then you're not worried about schedules filling up, or it's not flu season or COVID season and people can't get in, and all those other vaugeries of scheduling, you know, you have prioritized a group of people and you've connected with them and you've got them on the schedule. So that's like the first step in making this happen.

So they were really good at this. One of the measures we have about proactive primary care, and one of the things that this allows our providers to do and facilitates is something called an annual wellness visit, which in Medicare is a key component of Medicare care for seniors. They're knocking out of the park in terms of accomplishing annual wellness visits for their population.

Why? Because they've already scheduled these folks. They already have the time, and their providers are socialized to understanding the value of this. So I think those are two great examples of how focusing on this can really start to yield results.

Host: We're kind of, uh, nearing the end of our discussion, and I want to close out this episode by asking kind of what some key takeaways are that you'd share when embarking on proactive primary care, and how are you introducing or expanding the focus in, in your practice?

Jonathan Rubens, MD: Well, first let me say thanks so much for giving me the time today and for inviting me to join you and talk about something that I'm a little passionate about that I think is an important lever in the work we do in across healthcare, but certainly in value-based care. I think the key takeaways that I really want people to know about this are, first of all, you gotta believe in primary care.

Second thing is, you know, understand the evidence-based, it's already out there. That is really starting to emerge in the medical literature about why this is valuable and for whom it's valuable and at what level of intensity. I think understanding how we can prove that this has value is important. The next piece is really internalizing amongst providers and evangelizing amongst your staff really the value that this brings to your patients and brings to the practice and use what you have, use your teams. Use a team-based approach. Make sure everyone has the opportunity to work at their top of their license so that your providers can focus on providing, your office staff can focus on administrative tasks. Your care managers can focus on that and enablers or partners like us can come and support those efforts where you need them. Next, I would say make sure you're using high quality data and analytics to understand your populations. Because you've gotta understand the who to know the what and when, and really work on instituting workflows or solutions.

Whether they're really basic paper processes, which lots of provider offices in our country still function on, or whether they're high tech solutions, to understand how you can prioritize those visits for those most at-risk and for those for whom the benefit may be the greatest. And then probably the last thing I would say is just remember, this is only one part of what we need to do as we transition our healthcare system from fee for service to value.

But it's a very impactful part and maybe it's a primary and foundational part. So believe in that and really look to partner with those who can support this work and support your efforts in this and the other things that we need to do to move our healthcare system forward in this way.

Host: Dr. Rubens, I really want to thank you so much for, for joining me in this discussion today. I thoroughly enjoyed kind of listening to some of the examples that you've shared and really your thinking about all of this and how to coordinate care better, um, just to improve outcomes overall. So this has been incredibly informative. Thank you so much for your time. Thank you for sharing your takeaways with AHA members.

For listeners, if you'd like to learn more about the AHA Associate program or anything you've heard on this podcast today, please visit sponsor.aha.org. This has been an AHA Associates Bringing Value Podcast, brought to you by the American Hospital Association. Thanks for listening.