January 04, 2024
Episode 44: Could 2024 be the Year of Value-based Care? Brian Drozdowicz of PointClickCare explains why HCIT interoperability could finally accelerate the industry transition
Hospitals might seem like the quintessential healthcare setting, but only about 11% of care episodes actually occur in these facilities, according to the National Institutes of Health. The other 89% of care is delivered through a complex continuum of outpatient settings that span everything from primary care offices to ambulatory surgery centers to long-term care facilities, just to name a few locations. Brian Drozdowicz, SVP and GM of acute and payor markets at PointClickCare, joins Justin to chat about the technological, legal, and incentive barriers to coordinating value-based care (VBC) across the healthcare ecosystem. Brian draws from more than two decades of leadership experience in healthcare tech to share his perspectives on VBC: how accountable care organizations are using data to improve outcomes at lower cost, why the rest of the industry always seems to be just one year away from activating VBC, and why 2024 may be the year that VBC truly, finally takes off.
Justin and Brian ask the questions that may hold the keys to unlocking VBC: Who’s responsible for providing visibility into patients’ journeys—payors, providers, or the patients themselves? What’s the secret to HCIT interoperability? Can healthcare learn anything from the financial industry’s approach to data privacy? Why are payors suddenly open to sharing data? And what big changes are in store for healthcare in 2024?
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"Definitively Speaking" is a Definitive Healthcare podcast series recorded and produced in Framingham, Massachusetts. To learn more about healthcare commercial intelligence, please visit us at definitivehc.com.
Hello and welcome to another episode of Definitively Speaking, the podcast where we have data-driven conversations on the current state of healthcare. I'm Justin Steinman, Chief Marketing Officer at Definitive Healthcare, and your host for this podcast. Welcome to 2024 and Season 3 of "Definitively Speaking." We have got a great episode today to kick off the new year. When I say the words healthcare delivery, the first image that probably pops into your head is a hospital. That's understandable. But did you know that according to the National Institute of Health, approximately 89% of the healthcare in the United States is delivered in outpatient or non-hospital settings. Hospitals may be the setting for the most acute healthcare delivery situations, but they're really just a point in time, a critically important, frequently complicated, and highly complex point in time, but still just a point in time. The real trick to lowering cost in our healthcare system is managing all that care outside the hospital, and even more importantly, connecting all that care. That care coordination is a foundational requirement to deliver value-based care, something that we're talking about all the time it seems. But for some reason, value-based care always seems to be just one year away from becoming the success that we all want and expect it to be. My guest today sits at the heart of those care coordination efforts. Brian Drozdowicz is the Senior Vice president and GM of the Acute and Payer Markets at PointClickCare. PointClickCare is a leading healthcare technology platform enabling meaningful collaboration and access to real-time insights at every stage of the patient healthcare journey. More than 27,000 long-term and post-acute providers, over 3,100 hospitals and health systems, 2,200 ambulatory clinics, every major U.S. health plan and over 70 state and government agencies use PointClickCare enabling care collaboration and value-based delivery for millions across North America. Before joining PointClickCare in 2022, Brian served as Head of Integrated Care for Bayer Pharmaceuticals. And prior to joining Bayer, Brian held senior leadership positions at Bottomline Technologies, Siemens Healthineers, Verisk Health, Caradigm, and Picis. For those of you who care, Caradigm was where Brian and I first crossed professional paths more than a decade ago, which additionally makes us old, it's also back in the early days of population health management. And we had the unique opportunity to work together on a joint venture between Microsoft and GE trying to deliver one of the industry's first PHM solutions. So Brian, happy new year. It's great to have you here on "Definitively Speaking."
Fantastic to be here, Justin. Really excited to spend some time with you today.
All right, let's jump right in here. So to help everyone kind of orient them to your perspective, can you share a little bit about what you're doing at PointClickCare today?
Yeah, yeah. So I've now been at PointClickCare almost a year. Came in to lead our Acute and Payer business, which is a incredibly strategic expansion of what PointClickCare's core business has been. So I think most know that core business pretty well. We're the market-leading EHR for senior care. That's made up of skilled nursing and assisted living facilities. Again, as you noted, 27,000 different facilities that we are in today. And PointClickCare made the strategic decision a couple years back as value-based care continues to evolve to expand into the mainstream of the Acute and Payer landscape. So today, I'm leading that business for PointClickCare. What that essentially is is a real time nationwide network connecting all the different constituents in the ecosystem today: so payers, providers, ACOs, ambulatory clinics and, of course, our core business, post-acute ecosystem together to coordinate care across the entirety of that continuum.
So let's just start with some basic questions here. What do you think the role of the payer is in delivering value-based care? And actually, let's even take a step back before that. How would you define value-based care for our listeners? 'Cause not everybody here is an industry insider like me and you here. We get kind of a broad audience. So give us a VBC definition, then talk about the role of the payer.
Yeah, so I mean at the heart of it, value-based care is all about optimizing for cost and for outcomes and paying the right price for that outcome. And it's an entirely different mindset shift from the traditional fee-for-service where, order another test, order another diagnostic without any real understanding of the impact and how that drives the outcome. So this really aligns reimbursement with the outcomes that we seek to achieve. And sounds super simple, but given the technology that we've all been dealt with and the ecosystem that's been built up over the years, not the simplest thing to solve for.
Well, I'm glad you brought that up. Why is it not the simplest thing to solve for?
There's so many reasons. Of course, technology is one of the key reasons and interoperability across different, you know, places in the care continuum. So health system to clinic, to specialist, to diagnostic facility, to post-acute. Of course, post-acute, that is the bread and butter of our business. If you just think about following the patient across all of those different places in the ecosystem, there's no clear and easy way to understand what is right for the patient, what's happened with that patient. The presentation of that information is not standardized and it's really difficult to know the exact right thing to do for that patient at that point in time.
So why is that? And, you know, how can we begin to fix that?
Again, lots of reasons. We've been on a journey trying to improve interoperability. This goes, you know, well back before my start in this industry 20-plus years ago. We've been on a journey to improve that interoperability. There have been some major improvements with time: HL7 first and SMART over FHIR, data use and sharing rights, HIPAA. There's many different things that complicate this. Ultimately, every one of them has been a barrier to having full visibility into the patient, you know, across that continuum.
Who do you think has the ultimate responsibility for that full patient visibility? Is it me the patient? Is it my doctor? Is it my payer? Is it somebody else?
I'd love to say it's the patient, but I don't think the patient has a full appreciation for the complexity that sits behind the curtain that we here all operate, you know, working on the vendor side. Those that know and understand it, I think many would put the vendors and the types of organizations that I've worked with and for for some time really on the front edge of trying to break down those barriers. But there's a whole bunch of other things to consider, like HIPAA, and who has rights to the data, how that can be shared, what it can be shared for, how long they should have access to these things. And as you think about how that pertains to technology, there's a lot of considerations from a vendor standpoint that we have to operate by, which really complicates it.
What are some of those considerations?
Who has the right to see your data. And HIPAA outlines this well. Technically, us as patients, and we all are patients, we have the right to know whoever has access to our record. And from a technology standpoint, like building in that audit trails and, you know, the full visibility of who's got access to it. That is a feat in itself, just being able to produce that. So having to build that, you know, as a software company is not an easy thing to do.
Yeah. It's interesting though because like there's a lot of analogies between healthcare and finance, right? And finance feels like they have solved this problem faster than we have as a healthcare industry. I mean, all of my financial transactions are online. I access 'em off my phone, for crying out loud, right?
Sure do, super simple.
Super simple, all right? And they seem to pass information back and forth. Sometimes I have to like reauthorize them and stuff like that. But I'm pretty comfortable that, you know, my financial advisor has most of my money. Bank of America has a little bit of my money. But everybody can kind of see everything. But when I think about my healthcare, it's all over the you-know-what place, right?
It sure is.
We can't seem to figure that out. Why do you think that is?
If you think about what gets recorded in that financial system versus what gets recorded in a medical record, the complexity is hundreds of times greater in the medical world than it is in the financial world. It's dollars and cents, it's shares, it's interest rates. You know, you've got your logons and, you know, your regular statements from your financial systems. When you think about what gets recorded in a medical record, it's problems list, it's diagnoses, it's meds, it's med adherence, med rec. There's transitions to different types of providers in the ecosystem. It's just infinitely more complicated and trying to share all of that information in a way to the next provider that you're gonna see in a way that they can actually make sense of it and make a better informed decision is a really difficult thing to do. There's different transmission standards of data. Of course, different vendors present it differently. It's very siloed in the way that we store this data today.
Yeah, and I think it also goes back to something we've talked about with other guests on this podcast is just the lack of incentives. No one's really incentivized to fix this.
100%, 100%, it's a huge issue. It's obviously changing quite a bit. Like if you go back to our old days where you and I crossed paths 10-plus years ago, everyone was dipping their toe in the water with some of the early based ACO programs. And data sharing was really, really difficult to even have that conversation. Today, I think we're past that, but it's still real early and those incentives are just starting to shift. Certainly happening today.
And now I'm glad that you brought up ACOs or Accountable Care Organizations. 'Cause I actually think they're one of the few places that I could point to value-based care actually being successful in the industry as we've struggled across things. But the ACOs have started to figure it out. And I think you can point to some shining successes. Whether you're looking at Geisinger or you're looking at Kaiser or you're looking at some of the stuff, you know, in New York City, why is the ACO model working, and how do we accelerate that?
Yeah, it's been fascinating to watch over the past 10 years. And we've seen many different iterations of ACOs: shared savings programs, some commercial ACOs, the New Reach programs. The commitment that we've seen from CMS to continue to fine tune the different programs around the different levers in sharing risk has been helpful. I think most would actually argue that we're still very much in an exploratory phase around what that right model is. But if you think about the concept of an ACO, which is managing the risk of that patient, they've taken on the liability for a certain outcome, in some segments of the market, an emergence of ACOs that are geared very differently to deliver care than what we saw 10, 15, 20 years ago, which is organizations that much more technology oriented, much more data driven, and they're constructed in very different ways than the traditional healthcare delivery provider systems. We're getting there; we still have a long way to go.
So, but now I'm gonna use your own words against you. Sorry for this. But I looked you up on the PointClickCare website. And it had this wonderful quote. And I'm gonna read it here. "Brian envisions a future in healthcare technology "that revolves around embracing value-based care models. "He believes the industry is at a pivotal moment, "ready to accelerate its adoption of technology "and innovative solutions." So my question to you, Brian, is, why do you believe the industry is at a pivotal moment now considering all the struggles we've just talked about?
I will tell you, today, like here and now having spent the last 10 years in value-based care, I've never seen more action than what I'm seeing right now. And it makes my job really fun to work with such a wide array of different organizations that are all showing a commitment to move forward with value-based care. I, of course, have spent most of my career with health systems and payers. I'm seeing them behave very differently in the things that they're asking for and how they're willing to share their data. You know, the senior care business is one that's relatively new to me. And, of course, we're at the epicenter of that. And I've had a front row seat of learning from some of the best and brightest of our senior care customers on how these value-based programs, how they're being adopted and implemented and the questions that they're asking. And I really think that we are at the intersection right now of all these stakeholders at a really interesting time where there's so much at stake to get it right.
So you mentioned the payers. And we asked this question a while back and we lost it. I'm glad you brought it back up again. How are the payers behaving differently now? And why are they behaving differently?
So they're absolutely behaving differently. They understand, I think, in a different way the role that they play in helping to coordinate some of the things that happen within the networks that they operate within. They are also much more open to sharing their data. And because data is much more available now, because I think that bar has been lowered for all stakeholders. You know, 10 years ago, a payer would never consider sharing their data. We now have access to what happens before they even get their claim through ADT data which totally changes the conversation that we have with them. So data sharing is probably the biggest change in behavior that I've seen from them in 10 years. The way that they are also working with some of our providers out in the community is entirely different. And this is fantastic to see and is absolutely driving the adoption of many of the value-based behaviors out there. We've got a variety of markets today that we're working with, really large and credible plans that are ultimately subsidizing the cost of the technology that we provide to their provider partners within their network to drive a better outcome. That could be data sharing. It could be looking at things across the continuum. It could be with care management services. It could be placing a care manager within one of their own facilities. So because that bar on data sharing has been lowered, it's really forced everyone, I think, to lean in and figure out how they can best contribute to this value-based world that we're moving towards.
You know, maybe this is my background from having worked at Aetna coming through, but my own personal perspective is that the payer should be a heck of a lot more active in coordinating our care or my personal care. Because if you think about it, they're really the only person or organization that sees my entire healthcare journey. 'Cause they're paying for it, right?
And so if I go to different doctors and different networks, they're still getting the bill. And then you could argue that the payer or the insurance company has the most to gain from keeping me healthy, I guess after me, of course. But keeping me healthy ultimately saves them money in the long term. Where I think some of the friction comes into this model is I think the model of buying your health insurance directly through your employer is a severely outdated and incorrect model for our economy going forward. But if we could figure out some way for the payers to get to a much more direct-to-consumer model, I think that would potentially be a real accelerator for value-based care. 'Cause they also still have the size and the scale to deliver that, and the care management capabilities.
Yeah, 100%. So a good chunk of the business that we are working on today is providing payers essentially access to the data in real time. They get all the data and they've had all the data for a long time, but that comes through a claim. That might be 45 days old, that might be 90 days old by the time that they actually get that back, then run through the system and it's ready to bill. They then know, you know, at that point in time what's happened, and they can figure out what needs to happen next, especially if, you know, you've got multiple conditions, multiple comorbidities, whatever it may be. When that data is 45 to 90 days old, you're limited in how you can actually bend the cost curve for that individual. So getting them access to the real-time data to then be able to ensure that the right thing happens in a timely fashion is absolutely critical. And that's a huge growth area of where we're focused today, in some markets more than others. But I will tell you where value-based care has been most adopted. It's where payers and providers are collaborating together. There's access to that real time data and there is a reliance on the payer, getting back to your question, to help coordinate the next services that need to happen. Take a really simple example of someone that has a heart condition that enters through the emergency department. If they're waiting for that claim 45 to 90 days post discharge to figure out what that next best service is, you're too late.
There's nothing that you can do. That patient may actually go to the ED four or five more times before you even get that claim. So having access to that real time data and being able to assign a care coordinator that can work together with the provider on the right services, you know, the right social determinants of health, whatever it may be, to really get that patient on the right path is the path that we need to take to really put the payers in charge here.
Yeah, and I think that real time access is the key thing. And honestly, it's almost inexcusable that we can't get them that real time access. We can get real time access to anything these days. I mean, think how many TV shows I can watch on demand in real time in my house now. I keep telling my kids how lucky they are. They have no idea. I told them that I had three channels growing up looking like they had six heads. But, you know, if we could get the payers that real time access, I think that would really solve the problem. The flip side of that is it's gonna make the providers life a living hell I think. Because Aetna's gonna say, treat Justin one way. And then United's gonna say, treat Brian a different way. And then, you know, Blue Cross is gonna say, treat Janet a third way. And it's gonna get real confusing real quickly for their provider.
And like everything else, for those that have experienced healthcare, just trying to get an appointment recently has been really, really challenging for anyone with the shortage of providers out there. We're not making their world any simpler yet. So absolutely needs to be a big area of focus.
Yeah. All right, so let's get you with another interesting topic here. A common theme here on "Definitively Speaking" has been the move of care from hospitals to ambulatory sites. And in fact, a few episodes back, and I hope you listened to this, we had Jonathan Bush: industry luminary, provocateur, pioneer, you name it. All at the same time, by the way. Jonathan was on the podcast. And he concluded the episode by talking about his vision of the hospital of the future, which is basically an ER and a helipad. And the rest of the service is being delivered through a network of ambulatory facilities. Do you think he went too far? Or do you think he's onto something, right? I mean, I think this is a really relevant question for you given the company you work at and the space that you're working in, right? If he's onto something, how do we coordinate all that care? What do you think?
So we're absolutely moving in that direction and super provocative, as one would expect from Jonathan, to paint the picture that way. Healthcare as we've consumed it in our lifetimes for most that need it the most, the emergency department is the most expensive way to enter the ecosystem, which is incredibly broken and directly in line with, as Jonathan sort of crafted, that vision. There's a tremendous amount of initiatives underway today to sort of bend those patterns of care and push services to the appropriate setting. We're doing a bunch of work on that today with ED avoidance and getting referrals into the appropriate care setting. You know, so while certainly provocative, that is the direction that it needs to go. The emergency department absolutely needs to exist for emergencies. Most visits to the emergency room are not emergencies today. You know, when deferred to the appropriate care setting would save us all a whole hell of a lot of money.
Well, I think that's a lot of the fact behind driving the move towards retail medicine, right? CVS buying Aetna, vertical integration, taking advantage of the MinuteClinics. You know, UnitedHealthcare I saw recently now employs 10% of medical professionals in the United States, which is scary when you think about that number. But the idea that if we can get people before they get to the emergency room, and again this comes back to this common theme, but I think the payers have the incentive to drive people there. And the question is, can we actually get enough of the retail presence and get to people in there?
Yeah, yeah, I mean it's retail presence. It's also some of the alternative models, right? Like pre-COVID, I knew that I had a telehealth benefit. I had never used it. I've got three young kids here. I'm probably going on 40 telehealth visits in my household here, you know, since COVID. Because it's super convenient and it's not an emergency that, you know, we need to get into the ED for. So whether it's a retail clinic, whether it's tele, whether it's, you know, some other alternative method that is lower cost, these are all things that need to be, you know, properly incented for in incentive design to bend that cost curve and get the outcomes that we can get to.
Yeah, but I actually would tell you that you're an outlier around the telehealth utilization, and our data would support that. You know, telehealth spiked, obviously, during the pandemic. But our data says it's now down to like, you know, less than 20% of visits again. I can tell you that in my family, you know, my wife's a chief medical officer, and she hasn't used telemedicine since she got that second shot, and neither have any of our kids, right? She's back in the front of the doctor. She does use retail medicine. That's only 'cause I force her to. Because I'm always like, I know it's cheaper. We don't need to go to the doctor. But, you know, old habits die hard.
Yeah, yeah. I will tell you in this house, we have continued to leverage 'em. Access is a big question and convenience is a big need. I think retail solves a part of it. Tele definitely solves another part.
You know, I'm a big believer in virtual primary care actually as an option. And I think a lot of the work that both, you know, Amazon is doing and a lot of the other areas are gonna solve a lot of problems. The one challenge I think with VPC is the laying of the hands. At some point, I'm not taking my own blood. Now maybe we can get a device from Apple or iPhone or something that can get all the information that it needs by putting the phone on my skin, but we're not quite there yet.
Not there yet, for sure.
Not there yet. Alright, so speaking of not there yet, I mentioned this in the introduction. What's your perspective? Why does value-based care always seem like it's just around the corner?
So it's felt like it's around the corner for a while. But like I mentioned a little bit earlier, like now is as much of the time as it ever has been, and we are definitely seeing a much greater adoption than we were in years past. I do think, you know, having spent a lot of time with our customers and prospects out in the field, the different things that we need to solve for by market are wildly different. And, you know, what you see here in Massachusetts where I live versus New York City versus California, we're solving for lots of different things. And it's really difficult to standardize amongst those things. I do think that some of the experimentation we've seen around the newer ACO Reach model helps to scratch the surface on getting to some common ground and social determinants of health and the things outside of, you know, the core healthcare ecosystem and incenting payment for some of those things, if it's transportation, if it's meals, whatever it may be. I do think we'll see tremendous grounds gained over the coming couple years with the focus that we've currently got around social determinants of health.
Got it. All right, so we're gonna have a little bit of fun here before I let you go. All right, we're at the start of the new year here, so I feel like I should ask you to make a prediction for 2024. So I'm gonna ask you for two predictions, and I'm not gonna give you a lot of time to prepare. So one, I'd like your prediction about your corner of the healthcare industry. And two, I'd like your prediction about the healthcare industry writ large. So first, what's your prediction for value-based care in 2024? And what do hospitals and IDNs need to do in response to your prediction?
So I'm spending a ton of time here right now. So the prediction relative the corner that I sit in is that the relationships between hospitals in post-acute are going to be wildly different at the end of this year than as they started the year. And if you think about all of the value-based care programs that have been in place, all of the newer iterations of these, so whether that's ACO REACH, any of the the SNP programs, I-SNP, D-SNP, C-SNP, et cetera, it's forcing a convergence of health system and post-acute provider to come together and work differently. We've got some solutions there that we're working on to bridge that gap. Watching that relationship evolve between acute and post-acute is a fascinating intersection. And I think we're gonna hear a whole heck of a lot about how that evolves this coming year.
All right, second prediction. This is the more fun question. What's gonna happen in 2024 that we're gonna be sitting here a year from now saying: Oh my god, I can't believe that happened in healthcare. And I got one of my own after you.
So we follow all of the data standards, transmission guidelines, all of the guidance with TEFCA and other things. I'm hopeful that TEFCA and some of the legislation around data sharing, data use rights and how that translates to data availability in a way that is useful for providers makes a difference. We've still got another, you know, sort of full year of implementation and rollout before that will really make an impact. But I think by the end of the year, TEFCA, certainly a known name for those of us that are on the inside today, I think it's gonna become a household name across all of healthcare and how data is shared.
And what is TEFCA for those people it's not a household name?
It's the trusted exchange framework on how both ADT and claims data will be shared amongst payers and providers.
See now, you're thinking about like data exchange and providers. And here I'm gonna go the other end and I'm gonna say that one year from now, we're all gonna be saying, UnitedHealthcare bought Walgreens. I can't believe it. Because you're gonna see UnitedHealthcare going right after CVS. And they're gonna try to get the retail clinics. And that's my crazy prediction.
There will absolutely be continued consolidation from a lot of players that maybe some should, maybe some shouldn't continue to consolidate. It's the nature of the market.
Alright, so we'll get back here a year from now and we'll find out, hey, if UnitedHealthcare did buy Walgreens. This should not be construed as stock advice or any sort of financial planning advice. I have no idea what I'm talking about here to all of our listeners out there. Or we'll see if you're right, Brian, and TEFCA is rapidly adopted and it's a household name.
But regardless, thanks for coming on. This has been a lot of fun.
Thanks for having me, Justin. Much appreciated.
And for all our listeners out there, thank you for listening to "Definitively Speaking," a Definitive Healthcare podcast. Please join me next time for a conversation with Charles Nader, CEO of doc.com. Charles has a self-described mission of providing free basic healthcare to the entire world. And he plans to use a combination of artificial intelligence and blockchain to do it. Have I got your attention yet? If yes, please join me and Charles on the next episode of "Definitively Speaking." If you like what you've heard today, please remember to rate, review, and subscribe to the show on Apple Podcast, Google's podcast, Spotify, or wherever you get your podcasts. To learn more about how healthcare commercial intelligence can support your business, please follow us on Twitter or X at Definitive HC or visit us at definitivehc.com. Until next time, take care. Please stay healthy. And remember, value-based care is really just around the corner. It really is.