Lisa Farren (Host): Hello everyone. 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. I'm your host, Lisa Farren. Welcome, everyone. We have a returning guest today, Dr. David Howlett. Dr. Howlett joined us recently to talk about his journey in medicine, particularly with regard to value based care and what that looks like in his practice. So we wanted to expand on that discussion and welcome Dr. Howlett back. We'll pick up where we left off and keep the conversation going.

So, with that, allow me to reintroduce Dr. Howlett. David Howlett, M. D., is a partner of East Granby Family Practice, an independent family medical group of nine physicians and four nurse practitioners. It was established in 1978. Dr. Howlett was project director for the early implementation of electronic medical records in 2005. He also directed the process to award East Granby Family Practice the designation of a Level 3 patient centered medical home in 2011, which was one of the first to be certified in the state of Connecticut. Dr. Howlett's special interests in family medicine include pediatrics, office surgery, and sports medicine.

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 member of the Connecticut Academy of Family Physicians and is currently a board member. Dr. Howlett is a recognized leader and advocate for value based care and sits on the board of Southern New England Healthcare, also known as SoNE Health, a clinically integrated network focused on population health. All right. So with that, Dr. Howlett, hello and welcome back to Crushing Healthcare.

David Howlett, MD: Good morning. Thanks for having me.

Host: Absolutely. We're so thrilled to have you back. So last time we talked, you shared a bit about how you came to choose your career in medicine, particularly family medicine. I particularly liked how your grandmother was instrumental in that. You also talked a lot about value based care as a tool to truly engage with your patients in building a trusting relationship and partnership in their care for patient centered care,

including, in some cases, multi generations of the same family. So, I thought we would build on some of the themes that we talked a little bit about last time in more detail. You talked a lot about some of the key themes that support value based care in a practice as being the flexibility and ability to really spend time with the patients, to talk with them and understand them, as well as the electronic medical records, a team based approach, collaboration, support.

So with all that, can you just provide some examples of how each of these look in your practice and or what is like a typical day in your practice?

David Howlett, MD: So we talked about patient centered medical home, which is quality program. And to become a patient centered medical home, you actually go through a procedure where you develop protocols and procedures to give patient centered care. And so a couple of the aspects you want patient centered access and we have that 24/7 days a week access to our practice.

Team based care is imperative because you can't do it all yourself. And then you need some data to see actually how well you are treating patients. As a matter of fact, you need the data from EMR and all of us as physicians thinks we're doing great jobs taking care of patients. But, I have to say that even we, who thought we were doing a great job with our paper charts, when we converted the paper charts to the electronic medical records, we found that there were gaps in care that we could correct right then.

So the data from the EMR is very important. And then, you need a structure in your office where you can actually coordinate care for the patients and get them to where they need to go. And then, at the end, you want to be able to measure your performance. How well did you do in closing gaps in care, giving immunizations, getting colonoscopies done, doing mammograms, getting DEXAs done, making sure that patients who smoke, you give counseling for smoking cessation, that you get their ultrasound of the aorta, that you send them for low dose CT scans of the lungs.

So there's a lot to do. And so, to go to value based care, number one, you need the philosophy. And certainly, family medicine has that philosophy of taking care of the whole patient and taking care of families and the community. But you need tools, and the EMR gives you those tools. But you need structure.

So patient centered medical home gives you that structure that you can build upon and actually create office procedures and protocols that become the office handout for the practice. And then finally, you need time. And I think our accountable care organization, SoNE, gives us that time by allowing a different payment model so we don't have to see as many patients.

So what happens in our practice? Just quickly as a patient's in a medical home. Number one, we answer our phones. We have no menus. So patients can get in. We actually leave slots in our schedule so that we can get patients in the same day. So, we create the access. And then, how do we get all these things done?

Well, we do a lot through our patient portal. Patients can register. They can do a lot of their questionnaires, like their fall questionnaire, depression questionnaire, healthy living questionnaire, and they can actually communicate with us. So they have that access. And they also can receive the results from us.

And at sign in, we get their proper ID, their proper insurance, because if you don't send the right information and the right codes to the insurance companies, they're going to say you did not do those procedures that you actually did for value based care. Now, team based approach is very important, and our nursing department does a ton of work for us.

They'll update the social history of the patient and find out about smoking, alcohol, get their advanced directive. And then they have standing orders, standing orders that they do for all the patients. For instance, they'll get the vitals. via the most up to date guidelines on how to get a blood pressure.

Some people are still getting blood pressures while the patient is sitting on the exam table. That's not the way to do it. They'll ask about immunizations. Do you want your flu shot today? Do you want your COVID shot today? They'll get urines for patients who have hypertension and diabetes. They'll get that already so they can send it out for the microalbumin.

And the diabetic, they'll have the diabetic take their socks off, so when the doctor comes into the room, they know that they have to do a foot exam, and they do age specific cognitive screening right there. They draw blood, and if they're ordered, they do the EKGs, PFTs. And they'll get the last reports of the patient's mammogram, colonoscopies, DEXA scans, and consultations if they're not in the chart.

So they do a ton of things for us. So when the provider goes into the exam room, he already has a gestalt of that patient and what's been done. So the provider will now go in and address acute or chronic needs and prevention. And then he has enough time to do some shared decisions based on the up to date guidelines, and that's another part of patient-centered medical home is constant process improvement and improvement of your medical acumen, let's say. And then the patients will get information, handouts from our copier, from our EMR, and quick text letters, that will have a lot of information, like the Mediterranean diet, exercise, and the benefits of a weight loss, etc. Doc orders tests, orders the consults, and then the other part is our nurse coordinators.

Now, we're able to afford nurse coordinators in our own practice, given some of the benefits of SoNE and their contracting, which gives us some incentive payments, and those payments go to hire these nurse coordinators in our practice, who can coordinate, testing for the patient to give advice and send out the consultations.

Now, it comes back to the provider also to make sure that they do the proper billing at that time. So we need the time to make sure that we have the right codes in so that the insurers put enough money into the system to cover those patients. And that's another topic altogether. And also put codes in to say, yes, we've done the questionnaires.

Yes. They've had their mammograms, they've had their colonoscopy, etc. These are the CPT2 codes and they go to the insurance companies to say, okay, you have done this value based care, you have given the immunizations, so all that needs to go there. Otherwise, the data is not helpful in getting those type of payments that allow us to do this value based care.

And then finally, at the end of all this, we have to get back to the patients and tell them what the results were of the consultations, the imaging, and the blood tests. So, it's a big process. And one final process is at the back window when the patient, signs out. That patient is in our practice. We have put our arms around that patient and say, you are a part of this practice. So when you leave, make your follow up appointment. And if they don't make the follow up appointment, their name goes into a tickler file. And we'll call them and we'll keep them coming back so that we can give long term coordinated care to this patient.

Host: That is an incredible story. So comprehensive. In fact, that was one word that kept coming to mind is comprehensive, collaborative, when you're talking about value based care and an average day in your practice. The amount of care and time that you're taking with each patient and not just you, but the entire team.

Everyone kind of has their own role, if you will, to make sure that, as you said, that patient feels like the practice is wrapping around them to provide them with comprehensive care, listening to their needs, their concerns, and hearing a bit about, you mentioned the 24/7 access for your patients, that you answer the phone, you keep some open slots in the calendars for same day appointments, it sounds to me as if value based care is kind of similar to concierge medicine.

Can you speak to that?

David Howlett, MD: So what do patients want from their doctor? They want access to their doctor. When they call, they wanna see their doctor, right? They also wanna spend time with their doctor and they want their doctor to be up to date on medicine. So concierge model says, yes, you have access to me anytime you want, and I'm going to spend an hour or more with you, and you're going to pay a fee for that.

So the difference is that we give our patients access. We spend the time, but the patients do not pay an extra fee for that because we get our money through the value based care contracts, through incentive payments and through shared savings by doing a good job for these patients. So basically we do have a concierge philosophy and the payment is different and the patients don't have to even pay for that. So it works well.

Host: Yeah, it sounds as if value based care really benefits patients and the physicians and the providers. It's a win-win for everybody.

David Howlett, MD: That's correct.

Host: So last time you were here, you shared some actual patient stories, which I think everyone can relate to. Is there a patient story that you can share about the team based approach you just described?

David Howlett, MD: Sure. So we get a lot of benefits from SoNE, the Accountable Care Organization. And Family Medicine and Patients at a Medical Home and Accountable Care Organizations all have the same philosophy that we want to take care of patients, take care of populations, and do it in a cost effective way. So one of the procedures is something called a transitional care management that is coordinated through SoNE and our office, which means that when a patient is admitted to the hospital or to the emergency room, that when that patient is discharged, that we should see them quickly, and reconcile their medications and find out what happened so that that patient is not readmitted.

Well, I had this great elderly gentleman who kept going to the hospital for congestive heart failure. And in one of these transitional care management office visits, I had the time to sit down with him and really talk about diet and what was happening and why he kept going to the hospital. And guess what we found out?

He loved pickles, and every time, pickles, yes, and so he would eat three or four pickles at the same time and end up in the emergency room. Once we had the time to figure this out, he stopped eating pickles, he stopped going to the emergency room, and certainly he was much healthier at that point in time, and it did, again, save the health system quite a bit of money.

Host: Another great story. I didn't see where that was coming with the pickles, and also saving him and his family, I imagine, time and anxiety with all those hospital visits. And what a simple fix, which, you know, you found out because you were able to take the time and talk.

David Howlett, MD: I should have mentioned that pickles are high in salt, and that was really the problem.

Host: Okay. So you're seeing less patients spending more time with each, to really talk and understand them as a whole person. So ultimately you're seeing less patients each day or week in your practice with less patient volume. So how is it possible for the practice to remain financially viable when seeing fewer patients?

David Howlett, MD: A good part of it is the contracts that we have through SoNE and SoNE does contracting such that we are able to get per member per month, type of incentive payments to give good care from certain insurance companies. And then if we do good care, and certainly through Medicare Shared Savings, there is quote money left over from this money that Medicare put into the system to take care of that patient.

And so some of it goes back to Medicare, and some of it comes to the practice in terms of shared savings. So, if you're doing a good job, you actually get incentive payments in shared savings, and that actually compensates for not seeing as many patients. And it gives us the time to do the things we need to do, but we also need to do those things that are necessary to let the insurers know that we are taking good care of the patients.

So, definitely we can see 10 to 12 patients per provider a day, where other practices are seeing 25 to 30 patients a day, but we can give a lot more time to our patients to do all the things that we need to do for them.

Host: I'll say, definitely. And I said it before, but I'll say it again. So value based care really benefits the patients, the physicians and the providers, and really the overall healthcare system, because it sounds as if it's the preventative care. Catches patients upstream before a chronic illness could develop or certainly worsen, helping to eliminate hospital visits.

 It just sounds like it's really, beneficial for the entire healthcare system, which we know, we're all looking to find ways to, to improve our healthcare system. So that's great.

David Howlett, MD: Yeah, absolutely. And one of the other benefits we get from SoNE is, data about patients that despite our best efforts, do not get these things done. And so, for instance, they may not get their colonoscopy done or their Cologuard or their mammogram done. And so we get reports on patients who haven't had them.

So we can use those reports and say, okay, how can we change our processes in the office to catch these people before they have a gap in care? And by using these reports, we're able to refine our processes, and eliminate a lot of these gaps in care because, as you know, preventative medicine, when you find early colon cancer, it can be cured, or early breast cancer, those type of things, will save patients lives. Immunizations will save patients lives, and will save the healthcare system a lot of money.

Because, as we know, that 5 percent of the patient population, the sicker patient population uses more than 50 percent of the healthcare dollar. And so we want to keep the other 95 percent from getting up into that high illness sickness range. And we can do that by preventative medicine.

Host: Well hear, hear to that. Definitely. And wow, that's a staggering statistic. So yes, prevention is key. Awesome. Well, thanks again for sharing all your insights with us. It was great having you back again. Thank you for the patient story, for sharing a bit about what a day in your practice looks like, and really helping to shed light on what value based care is, what it looks like from both the patient's perspective, as well as the provider perspective.

So, great talk. Thank you again for joining us. Great to have you back, and we'd love to have you back again, Dr. Howlett.

David Howlett, MD: Thank you for having me.

Host: So thank you everyone for taking the time to join us today. Again, remember, we all have a role to play in healthcare transformation, so please join us in Crushing Healthcare.