Lisa Farren (Host): Hello, and welcome to Crushing Healthcare, where we explore diverse perspectives regarding the state of healthcare today and gutsy visions for a more affordable, accessible, equitable, and sustainable healthcare model.

My name is Lisa Farren, and I'll be your host today. I'm pleased to introduce today's guest, George Beauregard, DO. Dr. Beauregard is the Chief Population Health Officer at Southern New England Healthcare Organization, also known as SoNE Health. SoNE Health is a clinically integrated network providing population health management support to its network providers. As the Chief Population Health Officer, Dr. Beauregard leads SoNE's extensive population health programs, as well as performance improvement, clinical integration, and health equity.

His clinical experience in Internal Medicine spanned more than 20 years in the Boston market. You can read more about his impressive credentials and more about SoNE Health at crushinghealthcare.com. So now, let's dive in and get started. Hello, Dr. Beauregard, and welcome.

George Beauregard, DO: Hello, Lisa. It's a pleasure to be here.

Host: Great. So, our theme for today's episode is what is value-based care and why should you care? We're all healthcare consumers and we have firsthand experiences interacting with health systems and providers. As consumers, we naturally want to feel good about what we receive in exchange for what we pay. Healthcare is no different. One could argue it's the most important thing because it's all about our health and the health and wellbeing of those we love. We want high value, high quality care, and this is where value-based care comes in. So, Dr. Beauregard, what is value-based care and why is it important for all healthcare consumers to understand what it is?

George Beauregard, DO: So generally, external to the healthcare industry, value is defined as the utility or worth of something from the perspective of its user, its benefits related to how much it costs. Historically, hospitals and physicians have been paid on what I'll describe as a per-click basis for services provided, irrespective of whether or not those services were really necessary. So, the old healthcare payment model predominantly was do something, get paid for it, do something else, get paid for that, pay-per-click; thus, the name fee-for-service. In a fee-for-service payment model, there are no additional funds available to assist physicians to have population health capabilities at their disposal. And I'll talk a little bit later about what those population health capabilities resemble.

An emerging alternative model of healthcare reimbursement has occurred over the past several years, and that's a value-based healthcare in which the healthcare delivery model has providers, including hospitals and physicians being paid based on actual patient health outcomes achieved rather than just on the volume of services provided. That value-based payment model does result in funds being available to have those population health management resources and tools available to physicians and, therefore, available to patients as well.

Achieving good patient health outcomes, the true measure of quality in healthcare is the foundational purpose of healthcare. Value for the patient is created by providers' combined efforts over the full cycle of care. At times, it can be episodic or it can be longitudinal, depending on what the patient's chronic illness is or their current medical situation. Value should be measured for defined patient groups who have similar needs. For example, patients with end-stage renal disease who are dialysis-dependent, people who have chronic lung disease, people who have heart failure or diabetes, or combinations of those common chronic medical conditions.

Value-based care is a model wherein physicians and hospitals are held clinically and financially accountable for a defined population of people. That could be a group of Medicare beneficiaries, people enrolled in a particular Medicare Advantage plan, people who have a commercial health insurer, so defined cohorts of people.

Recently, the Centers for Medicare and Medicaid Services has declared its ambition to have 100% of Medicare beneficiaries in an accountable care arrangement by 2030. Because through various payment model innovations that have occurred over the past 10 years or so, they're starting to see the value of improved health of those beneficiaries and, frankly, a reduction in the medical expenditures of those beneficiaries as well. Along with that, CMS has also said that it intends to have all Medicare providers paid via an accountable care arrangement by 2030 as well.

So, this is the path going forward. I don't think there's going to be any retreat from this, and I think physicians and hospitals are keenly aware of that and are making transformative efforts to perform well and/or prepare for it.

Host: Thank you, Dr. Beauregard. So clearly, value-based care is the way future is headed. What resonated most with me is obviously it's working on the national level if CMS is working toward an initiative to move by 2030, that's several years from now. So definitely, there's a trend toward this.

George Beauregard, DO: Yes.

Host: Can you share with us what is SoNE Health specifically doing to provide value-based care and advanced value in healthcare?

George Beauregard, DO: To illustrate what value-based care looks like, I thought I'd share a real life clinical scenario with today's audience. The patient in question, is a 57-year-old English-speaking Hispanic male with a past medical history of adult-onset diabetes that involves damage to his nerves in his feet. He has heart failure. He's morbidly obese. He has end-stage renal disease, meaning he's dialysis-dependent. He's had a pulmonary embolism, a blood clot to his lungs. He's also had a traumatic brain injury and subsequent to that, has generalized anxiety and depression.

Over the past few months, he's been hospitalized three times due to uncontrolled diabetes and his heart failure, and he also sustained a leg fracture. So, the combination of all of these hospitalizations, his multiple chronic conditions, resulted in him being referred to SoNE's complex high-risk care management program. The patient lived independently with his spouse who serves as his primary caregiver. The SoNE nurse case manager worked with the patient and the spouse over several months, reinforcing disease self-management, and fall risk prevention strategies and techniques. The care management effort was multidisciplinary, involving behavioral health, a social worker, a community health worker, and a pharmacist in collaboration with the patient's primary care physician. Due to a new finding of confusion, a neurology consult was obtained. Physical therapy was brought in to evaluate and treat the sequelae of his leg fracture. Ongoing outpatient social work sessions were scheduled and took place. The community health worker identified what are known as social influencers of health needs, things like do they live in a food desert, do they have transportation issues, what access do they have for healthcare, and facilitated enrollment in Medicaid as well as additional caregiver support through the Connecticut Community Care.

Over the ensuing months, the patient has had no repeat hospital admissions. His blood sugar control has improved. He has attended his hemodialysis sessions without fail. And he's also been going to the heart failure clinic, along with seeing his primary care physician on a more regular basis. The patient's confidence about his ability to self-manage his illnesses to the degree necessary has also improved. So, he's a more engaged and activated patient as a result of being involved in our care management program for several months. And that's just one story, you know, we have hundreds of these stories, of people even more complicated with this situation and then others, you know, with probably less complicated scenarios. But the point is they get the help that they need when they need it, and we try to meet the patient where they are.

Host: Wow. That's a great story. Thank you, Dr. Beauregard. It's wonderful to hear how SoNE is collaborating with the patient's PCP for a multidisciplinary approach to wrap around him addressing his various conditions and needs, connecting him to community resources to make sure that everything was addressed, obviously a positive outcome, which is wonderful to hear. And ultimately, isn't that the goal of value-based care, is to improve patient outcomes? So, great story and I appreciate that.

George Beauregard, DO: Thank you.

Host: Awesome. I think you did a great job explaining value-based care with us today. Thank you so much for explaining it and sharing particularly the patient story and how the SoNE Health Population team is really leading the charge in the race to value in Southern New England. I think we can all agree our healthcare system needs transforming. And you offer compelling insight into value-based care as the catalyst for such transformation. So, thank you again. And thank you everyone for joining us today. To learn more, remember, we all have a role to play in healthcare transformation, so please join us in Crushing Healthcare.