Lisa Farren (Host): Hello everyone 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. So, my name is Lisa Farren and I'm your host today.

I'm really excited to chat with today's guest, Dr. David Howlett, about his professional journey in medicine, specifically with regard to value-based care. David Howlett, MD, is a partner of East Granby Family Practice, an independent family medical group of nine physicians and four nurse practitioners, which was established in 1978. Dr. Howlett was project director for the early implementation of electronic medical records in 2005. And he directed the process to award East Granby Family Practice the designation of a Level 3 Patient-Centered Medical Home in 2011, one of the first to be certified in Connecticut.

Dr. Howlett's special interests in Family Medicine include Pediatrics, Office Surgery, and Sports Medicine. And in addition to his practice, he has served as Assistant Clinical Professor of Family Medicine at the UConn School of Medicine, as well as the Quinnipiac School of Medicine, teaching medical students in his office. He is a past president of the Connecticut Academy of Family Physicians and is a current board member. He is a recognized leader and advocate for value-based care, and he sits on the board of Southern New England Healthcare, which is a clinically integrated network focused on population health.

So with that, good morning, Dr. Howlett, and welcome.

Dr. David Howlett: Good morning, Lisa. Thanks for the introduction.

Host: It's a pleasure to have you here today. So, I'm really excited for our conversation. As a foundation for our conversation today about your professional journey in medicine, I think it makes sense that we start at the very beginning. So, can you share a bit about why did you choose a career in Medicine, particularly Family Medicine?

Dr. David Howlett: Well, the story goes that my grandmother said that at age five, I wanted to be doctor, a family doctor. So, I figured that when I was in high school around age 18, I better go see what it was all about. So, I started working as an orderly at Wyndham Community Memorial Hospital, Willimantic, Connecticut. And I was quite impressed by the positive impact physicians could have on patients, making a difference in their life.

Also, I like biology, I like science, I didn't like physics, so it sort of fit. And I was taken under the wing of a number of physicians who worked there, who taught me many things about medicine. And eventually, I wanted to be more like them.

Host: That's a great story. So, your grandmother had a big impact on that. That's awesome.

Dr. David Howlett: Well, she did.

Host: At age five, too, nonetheless.

Dr. David Howlett: She kept pushing it.

Host: All right. That's great. Thanks for sharing that. So, let's dive into our discussion a little bit today. We're going to talk about your journey to value-based care. So in past episodes that we've recorded with other guests, value-based care has come up as a repeated theme. But I think many still may not really understand what that is. So, can you give sort of a man-on-the-street, if you will, explanation of what is value-based care?

Dr. David Howlett: Sure. So, in our healthcare system today, most physicians, or all of us, are really paid fee-for-service, which means that when the patient comes to the office, we do an office visit and we get paid for that service. With value-based care, we're getting paid for the value of the service that we give the patient, which means that if we are following guidelines for treatment of their chronic problems, following guidelines for treatment of their acute problems, and doing preventative services, we're actually doing a lot for that patient and giving a lot of value. So, it allows us more time to spend with our patients, more time to do prevention, more time to develop relationships with the patients and give better care, and actually have time to talk to the patients and make shared decisions about their health care. It gives us more time to record the data and transmit that to the insurance companies. Also, value-based care gives more access to the patients and gives us more access to them. So, the patient is also not charged for this extra time.

So, with contracting through SoNE, through our accountable care organization, we actually received more payments, bonus payments, so to speak, for doing quality care. And the quality care is determined by the insurers and by the data that is submitted to the insurance companies. So, we're able to get paid for value rather than just fee-for-service. And fee-for-service can be sometimes pretty broken up in that you might be seeing cardiologist for your heart, you might be seeing a dermatologist for your skin, you might be seeing a pulmonologist for your lungs, and that can be broken up services where everything can be done at the primary care office or the family practice office.

Host: Wow. Okay. So, one thing that sort of came to mind as you were explaining that is, and correct me if I'm wrong, but the more traditional model of fee-for-service is more transactional, whereas it sounds value-based care is more relational. Is that true? It allows you to foster a stronger bond and partnership with the patient.

Dr. David Howlett: Sure. You know, the roots in the general practice tradition, which was the norm in the United States, was actually developing relationships with families. And in the mid 20th century, medical specialization increased, and the role of the family doctor declined, and a lot of fragmentation of care, and also a deterioration of the patient-doctor relationship, because you're seeing multiple different doctors who don't really know you.

So actually, in 1969, family practice became actually a medical specialty, and this is a medical specialty with a holistic approach focusing on that person in the context of the family, of the community, and actually advocating for the patient, in the healthcare system. So with family practice, we have a specialty of flexibility, breadth, taking care of acute problems and preventative problems and actually spending more time with the patients.

However, even before the days of electronic medical records and patient-centered medical homes and accountable care organizations, even though we wanted to do all these things, we really didn't have a lot of time to do these things.

Host: So, it sounds as if family practice in particular is well-positioned for value-based care. But whether it's a practice that is a family practice or a more traditional practice, what are the challenges that physicians and providers face in really implementing value-based care in the practice?

Dr. David Howlett: Well, it certainly is a process, and it takes some time to do this. The challenges are, really, you have to have the ability to have time to do all of this. And time is the big factor in this. And we can get into that a little later. The other thing is that you really need to have an office practice culture, a culture of innovation. People in the practice who actually want to use electronic medical records, for instance, use data to help improve the care.

You also need to have a champion of this value-based care. You need either a physician or an office manager who's going to be really the leader to champion this and to bring it to the practice. Also, you need to change some of your office policies. You need to give more access to the patients to your practice and using your data and also using some of the guidelines that you get from something called patient-centered medical home to develop standard procedures and standing orders that the nurses can use.

So, there's a lot to this and then you need to be able to learn how to use your electronic medical records to send the data to the insurers. To say that, yes, we did do this care and we did do great care, because without doing that, you really don't get the payment that you need to support your staff. And we all have businesses to run and we have to pay our staff, so that is also a big challenge because if you're going to spend more time with patients, you're going to see fewer patients and therefore you're going to get fewer payments for fee-for-service.

Host: Okay. So, time is key here, it sounds. Time, data, recording the data in the electronic medical records. So, is there a patient story, a practical sort of example you could give on how this all came together or comes together?

Dr. David Howlett: Oh, sure. I can think of a couple of them. I certainly have two stories that come to mind, but the first one is really a particular patient. She had a high cholesterol profile. And with fee-for-service, many times that patient would see their doctor and they would say, "Okay, need to be on a statin medication." And the patient would leave and either take the statin medication or not take it because she didn't really want to take it. But with the value-based care and the extra time that we have with the patient, we can talk about what her desires are. And for her, she did not want to be on a statin. She wanted to do lifestyle changes, et cetera. But her cholesterol profile was quite high. And if you look at the guidelines, she should be on a statin. But we had a conversation and decided to do a CT coronary calcium score, which looks at the amount of calcium in the heart that can predict the amount of plaque. And her score was zero, which means, "Hey, you don't need to be on a statin." So, we did not give her a statin. She was very happy, but we said, "Hey, in a few years, we better repeat this just to make sure you're not putting plaque down." And she agreed. And so, when you have that extra time, you have the buy in from the patient. And they're going to trust you and do what you want.

Well, a few years later, we did do the calcium score again. Her score was again zero, but now she had a nodule on her lung. And so, we sent her to the pulmonologist. The nodule was a cancer, but it was caught very early. She's had treatment and she's done very well. So, sometimes without that extra time, without that time to build the trust and the relationship with the patient, you may do something by a guideline, but the patient may never follow through.

Host: So, taking the time, it's patient-centered, and it sounds like a partnership where the patient partners with you as the physician in their care journey.

Dr. David Howlett: That's correct. And there are many different examples of that. And certainly, doing preventative medicine really helps that too. And just a very quick story, I had another fellow who was going to get knee replacements and he didn't really want them. So, we talked about it and said, "You know what? If you can lose some weight, you may not need this." And we talked about many different ways of weight loss, whether he's going to do the Mediterranean diet, whether he's going to do intermittent fasting, et cetera. He left and he came back 30 pounds lighter, and it's eight years now since he has not had a knee replacement. So, I would say that's value-based care. The patient didn't need surgery, the healthcare system saved money, and the patient was very happy.

Host: Wow, two fantastic outcomes. And ultimately, as we all touch the healthcare system, that's what we were aiming for, right, is a positive outcome. So, that's fantastic. And I can say personally, I've experienced it, and I think most people have, seeing a particular provider and feeling rushed and/or not really heard. So, it's great to hear that story, because we all want to feel heard and seen. And like I said, feel like the doctor or our provider is our partner in our care and listening to our lifestyle and what's important to us. So, that's awesome.

Well, I really appreciate this. I would love to have you back again. Hopefully, we can continue the conversation in another episode and hear more from you, Dr. Howlett.

Dr. David Howlett: That'd be perfect.

Host: We'll definitely plan to have you back. It's a great conversation and I'd love to continue it. So, thank you so much, Dr. Howlett for joining us. And thank you everyone for listening and joining us. And remember, we all have a role to play in healthcare transformation, so please join us in crushing healthcare.