Navigating Change in the U.S. Healthcare System - Susan Dentzer, President & CEO of America’s Physician Groups

Shiv Gaglani: Hi, I'm Shiv Gaglani and today I'm delighted to welcome one of the nation's most respected health and health policy thought leaders to Raise the Line, Susan Dentzer. Her remarkable career includes many years of reporting on healthcare for major national news outlets, editing the influential journal Health Affairs, and being senior policy adviser to the Robert Wood Johnson Foundation, and Senior Policy Fellow at Duke University's Margolis Center for Health Policy. 

Earlier this year, Ms. Dentzer was appointed president and CEO of America's Physician Groups, an organization representing more than 350 physician groups providing clinically integrated, coordinated, value-based health care and accountable for the costs and quality of patient care for more than ninety million patients nationwide. She's also board chair of Research America, which advocates on behalf of biomedical and health-related research and innovation. 

A trustee-emeritus of Dartmouth College she was the first woman to chair the Dartmouth Board of Trustees, was a longtime member of the board of advisors at the Geisel School of Medicine at Dartmouth, and was also a member of the Dartmouth Hitchcock Health System Board. She's an elected member of the National Academy of Medicine. She's also editor and lead author of the book Healthcare Without Walls: A Roadmap for Reinventing U.S. Healthcare. I could go on listing her accomplishments, but we'd run out of time. So, let me stop there and thank you, Susan, for taking the time to join us today.

Susan Dentzer: Great to be with you Shiv. Thanks for having me.

Shiv Gaglani: I know I came across you first through the Robert Johnson Foundation, which was one of the first organizations to back Osmosis when we were getting started. But for our audience that doesn't know as much about you yet, what first got you interested in reporting on healthcare and then ultimately becoming a policy analyst?

Susan Dentzer: Well, like a lot of things in life, it was pretty much of an accident that I got interested in healthcare. I was at Newsweek magazine at the time. I had come off of several years of covering Wall Street. I was moving into more general business and economics coverage and one day, my editor came to me and said, “You know, we really want to do a piece on the effort of some for-profit health systems to move from their traditional home mostly in the southern part of the U.S. into the Northeast." A couple of those entities -- including the company known today as HCA which, was at the time was Hospital Corporation of America -- was attempting to buy into entities in the Northeast. Specifically, HCA was trying to buy McLean Hospital, which is a Harvard-affiliated psychiatric hospital. At the time, as is the case now, a lot of the states in the Northeast have corporate practice of medicine laws that forbid corporations from practicing medicine, so this was going to challenge the regulatory framework in the state. Beyond that, though, it finally caused a lot of the establishment in the Northeast to wake up to the existence of for-profit healthcare systems and hospital systems, and so for the first time, there was a lot of attention being paid to HCA and a number of other for-profit hospital chains. 

So, we ended up doing a cover story on what seemed at the time to be an unusual, unexpected push of the for-profit world into hospitals. At that point, it was on the eve of the introduction of diagnosis-related groups, and the prospective payment system in the hospital world. The hospital world was essentially divided between people who thought this was a good thing, and many, many people who thought it was a fundamental threat to their existence because much of hospital-based reimbursement had been on a cost-plus basis forever. If you're told suddenly, you have to live within a budget as opposed to being paid on a cost-plus basis, that gets a lot of people's attention and caused a lot of fright. So, many people in the healthcare system were predicting the end of hospital care as we knew it and all kinds of terrible things happening. 

So, there were lots of interesting issues going on that, frankly, were getting almost no attention in the mainstream press. It's hard to believe this being true given how much coverage there is about these things now, but at the time there was almost nobody covering it. Part of the reason was that you had reporters who specialized in medicine, and you had reporters who specialized in business and nobody was specializing in the business of medicine, which was growing by leaps and bounds. So, I said to myself, “This is really interesting, there's almost no competition, I could learn a lot and have a really interesting beat.” And that's why I ended up starting to write a lot about the business of medicine and that got me interested in the underlying policy issues and that's what I've been doing almost ever since.

Shiv Gaglani: It’s great to hear about that first story, and also good advice for our listeners about finding a niche. You know, there's that saying, “It's better to have a thousand true fans, a thousand people who love you and what you've put out, than seven million people who are like "meh.” So, let's turn to America's Physician Groups, because that's what you're currently leading. I remember when I was in medical school, I worked with a gastroenterologist who was part of a physician group. But even during that period of med school, he wound up getting absorbed by a large hospital system. There's been a lot of consolidation. Tell us about APG...what things are top of mind?  You serve ninety million plus patients -- which was surprising when I heard it because I thought most had been consolidated at this point -- so I'd love to hear more about what your goals are there.

Susan Dentzer: So, our groups have one unifying principle, which is that they are very much committed to value-based care. They want to make money in healthcare, as most people and entities do, but they want to get paid the right way. They don't want to be paid on the basis of volume. They don't want to be paid for things that patients do not need, regardless of that. They want to be held accountable for costs and they want to be held accountable for quality. Many of our groups -- for example, the medical groups affiliated with Kaiser Permanente -- they're used to living in what system wide is an overall capitated environment, and they are paid largely on a salary basis. But the system overall lives within a budget every year. The budget is kind of the number of patients times the capitated amount and that's what they use, and they attempt to make the wisest decisions about how to steward those resources.

We have groups that have what are known as delegated relationships with insurers where the risk is delegated down from the insurance companies to the groups themselves, and they are held accountable for costs and quality. We have a number of members who are engaged in a lot of the models that have come out since the enactment of the Affordable Care Act, either the Medicare Shared Savings Program, Accountable Care Organizations, or previously, they were engaged in other versions of ACOs. ACO Reach now is a model that's a couple of years old in which some of our members are highly engaged. 

But as I say, they all have pretty much rejected the notion of living in the fee-for-service world and being paid again on the basis of volume and without the serious efforts that they make to coordinate care, to integrate care -- such as primary care with behavioral healthcare and increasingly with various forms of specialty care -- and again, create environments where they are taking the full accountability for the health and well-being of patients and the cost of that care. 

What we are doing now as groups is trying to navigate these waters. The various programs that I mentioned are all different in their own way and I would add another one which is Medicare Advantage. Many of our groups are engaged in supplying care under Medicare Advantage plans. Some of them are directly at financial risk for the care of those patients. The risk has been delegated by their plan partners. Others are being paid on a fee-for-service basis, which is not their preference, but that is the reality and so across these various programs, there are a number of issues. 

In the last couple of years, there's been a lot of attention in Medicare Advantage to risk adjustment, and whether the risk adjustment sometimes results in unnecessary upcoding of patients and the efforts that some allege have taken place on the part of insurance plans to really get paid too much for taking care of patients. That's an interesting debate. We think there has been some abuse of the system, but overall, if you think about it, Medicare Advantage puts a premium on finding out what's really going on with patients and being able to create care plans and treat them accordingly. That is not the case in traditional Medicare, necessarily, where you're at the mercy of random providers, depending on where you are in the system and there really is almost never anyone who is coordinating your care, let alone fully evaluating what is wrong with you, let alone accepting responsibility for the health of a population. 

Now, most doctors who are in the fee-for-service environment care about who shows up in their offices every day. They don't care about who doesn't show up in their offices every day. There's no financial incentive for them to do that. If you're taking responsibility for an entire panel of patients, you care about what's going on with them and you want to reach out to all the diabetes patients you have who haven't been in to see you in a year and find out what's going on with them, because if they end up in the hospital, it's on you, or you collectively as the entity that has signed on to these various ACO or other relationships. 

So, our groups want our help in navigating through these various models, dealing with some of the policy concerns that come up, and more or less advancing the cause of value-based care because universally, they believe that this is a far better alternative than what has been traditionally the case with fee-for-service healthcare in America.

Shiv Gaglani: Yeah. It's very compelling and over the course of the last two years of having run the Raise the Line podcast, we've been fortunate to have on a number of leaders in value-based medicine. For example, Rushika Fernandopulle of Ira health, Christopher Chen of Chen Med and Vivian Lee, who I'm sure you know quite well. I know COVID seems to have accelerated the adoption of value-based medicine and conversations around health equity and social determinants of health, which clearly play a role in how these practices are structured and how they provide care. I was wondering, do you have any facts or figures for that, or other kinds of trends that are here to stay, or have been greatly accelerated because of COVID?

Susan Dentzer: Well, it's certainly the case that the pandemic seemed to offer proof of concept... that it was better to be in a value-based payment model than not. If you were a system or even a practice that was dependent on a lot of volume and suddenly that volume dried up in the first couple of months of the pandemic -- and even now lags behind some traditional norms to some degree -- that wasn't a good financial model for you. If you were a capitated organization, and you were receiving steady payments you had the ability to survive, and frankly do things for patients that were not possible in the fee-for-service context. 

Kaiser Permanente was one of only two entities that took the provider relief payments that came through the federal government and sent them back to Washington because they didn't need them, most of them at any rate, almost $500 million worth, because they were still getting paid and they had the opportunity to take the payment and do things that people need.  For instance, they could make sure people got food during the pandemic, particularly for some of their patients whose health was potentially compromised and who were isolated in many instances and needed that kind of support. So clearly, there was proof of concept that this is a better payment model. I'm not sure that we see an enormous amount of take-up right now in value-based care in terms of new entrants into value-based care. Part of the reason is that a lot of the system remains financially very challenged. Not all -- some systems are doing quite well, thank you -- but others are facing a lot of financial pressures exacerbated by the current bout of inflation and workforce shortages, which are really "topic A" for many healthcare entities around the country right now. Not only are they facing difficulties hiring, they're paying a lot of money to get people on board. There's inflation across the board in a lot of supply areas, etc. 

So, the system is stressed, and when you're a stressed organization, you're not that inclined to enter a whole new payment model particularly one that is potentially going to put you at risk for losses if you can't control your overall expenditures, and that's the reality with some of the forms of value-based care. We're always hopeful that there will be more take up. I think one interesting item, of course, is that Medicare Advantage enrollment continues to climb and while Medicare Advantage isn't exactly the same thing as other forms of value-based care, it is in principle that because, in essence, the plans are being paid more or less on a risk adjusted but capitated basis. There's a budget around the care of individuals and in some instances, that's delegated down to some of our groups and others not. But essentially, the effort is the same as the premise of a value-based model: coordinate the care, spend the resources as effectively as possible and increasingly, be able to provide some supplemental benefits to address health related social needs that are not even paid for or even identified in traditional Medicare. 

So, if we believe that Medicare Advantage is already close to being half of overall Medicare enrollment -- and at least according to some projections could be 60% in a matter of years -- that suggests that from the standpoint of value-based care in that context, that is going to probably increase.

Shiv Gaglani: That's fascinating. That's a really good overview, I think, for our learners, many of whom are going to be entering these models or leading systems that adopt these models. You know, one of the things that's top of mind for many of our learners is provider burnout, and what struck me when I talked to Rushika and Chris Chen and Toyin Ajayi from Cityblock was that these models seem to cause less burnout because the clinicians don't have to just produce a certain amount of RVUs. They can do what's right for the patient and don't feel stressed about that. Do you have any data around that or any commentary on provider burnout and what we can be doing for our workforce?

Susan Dentzer: Well, you're right about the fundamental belief of our groups...that they're providing a better model not just for patients, but for themselves as well. That they really are in a position to do what is best for patients, and they don't have to worry all the time about RVUs, they don't have to worry about twelve-minute visits with patients and that itself brings a lot of provider satisfaction. Also, in some of our larger groups, a lot of the considerations around billing, etc, are taken off their shoulders and delegated to others within the organization. Now, they still have to keep their notes and everything and do at least some amount of coding, but it's not necessarily the type of burden that falls very heavily, particularly on smaller practices that are still in a fee-for-service environment. 

I think that the biggest thing that everyone is hopeful about is that we're going to get past the pandemic and go back to just the run-of-the-mill problems in healthcare, as opposed to the extraordinary set that we've had to deal with for the last more than two years. Hopefully, this coming season won't be quite as bad despite the concerns about flu and RSV, and so on, because that alone could go a long way, I think, to alleviating some of the incredible sense of burden and difficulty that so many people in the healthcare system have faced for the last more than two years.

Shiv Gaglani; Absolutely, absolutely. And I so appreciate you commenting about the state of practice. Switching gears, first to medical education, because of your involvement with Dartmouth's Geisel School of Medicine. Do you have any commentary on how medical education has changed because of COVID, and how we need to continue improving it? 

Susan Dentzer: I'm not aware of many changes that took place during COVID other than the fact that to some degree, people did what everybody did throughout higher education which is spent a whole lot more time on Zoom. However, it is also the case that many institutions had already moved to the so-called flipped classroom model where you might have lectures that you're watching on Zoom that are recorded ahead of time, and then when you get into the classroom setting, you're actually doing much more in terms of interaction and problem solving.

It's that second piece that I think was compromised during the worst phases of the pandemic, when people had limited ability to get together and do that. But it's interesting, I still lecture annually at Geisel in a fourth-year elective and I'm struck that there's a bit of a dichotomy. You have this incredibly well-educated generation of medical students that are digital natives from way back, so they can't even imagine living in a world without electronic health records, without a lot of technology and they're inclined to think about some aspects of technology that they could incorporate into their practice. On the other hand, when I've lectured to them, I found them surprisingly conservative...and I don't mean that in the political sense. They're conservative about how medicine should be practiced. 

I'll give you an example. We certainly had proof of concept during the pandemic that virtual care was a pretty good substitute -- not a 100% excellent substitute -- but a pretty good substitute for in-person care for a while, right? And not that it's ever going to be the complete substitute, but think of all the aspects of healthcare that are about exchange of information as opposed to the laying on of hands. You can do a lot of exchange of information virtually, and we've learned that particularly in the mental health arena. What is mental health care? It's mainly exchange of information. There isn't that much laying on of hands, and when you think about the enormous labor shortages that we face in the mental health profession, the maldistribution of mental health care providers, which is enormous, the fact that it took a pandemic to prove to us that we could actually support people remotely and virtually, and it would be useful for them and helpful for them, you know, it's astounding that it took that kind of a shock to the system to knock this into a better balance. 

It's very apparent to me as an outsider, but you bring this topic forward to medical students or you tell them that the future is going to bring about more One Medicals, and CVS owning Signify and Optum-owned groups, and they are frightened by that, many of them, and scared about it. You get a lot of push back. I have traditionally asked them questions like, "Okay, how many of you in this room are not members of Amazon Prime?" One or two hands will go up, at which point the other people in the class say, "Well, how is it that you live? How do you even survive if you're not a member of Amazon Prime?" Then you say, "Okay, well, so how big of a switch do you think it is for Amazon to go from being effectively engaging with you day in and day out to supply almost everything else that you need and then moving into health care?" And they'll say, "No way. No way." 

It was Amazon Care for a while. Now they've realized they can't make a head-on entry into healthcare in quite the same way, so they're back-ending it by buying One Medical, which of course has already bought Iora. But Amazon is going to be a major force in healthcare, not necessarily the front door of healthcare, but through One Medical. And one thing we know about Amazon is they learn and then they continue innovating around what they've learned. But this is a very frightening prospect to a lot of medical students who are still in that academic medical environment. 

I often find that it's only if I'm speaking to an audience, say, of older physicians who are maybe coming back to get an executive MBA and they have lived enough of the system to say, "You know what, it probably could stand to be shaken up a bit, and we've at least got to explore these other avenues of delivering care particularly in an environment where we know that we still have access problems.” The business model of U.S. healthcare appears to be that it's going to price itself out of the affordability of everybody in the country. So, what's the solution but to try some different things? And as I say, older docs have kind of gone through the process and are willing to say maybe we should talk about some other avenues here, whereas for the younger docs, they're not there yet.

Shiv Gaglani: That's an interesting and paradoxical insight and certainly one of the reasons we launched this podcast is to introduce these kinds of trends and bring the direct thought leaders right in front of the audience. For example, we had Marcus Osbourne and John Wigneswaran at Walmart Health talking about the things that a major retailer company is doing in healthcare from nutrition to having a fully integrated grocery plus Pharmacy plus healthcare delivery system. It's very interesting, very consumer-centric. I could see how it's threatening, and we've heard similar feedback, but certainly our medical schools and medical students need to know how the system is changing underneath them. 

Switching gears to Research America. Elsevier acquired Osmosis last year so we've gotten to know the research side of things a lot better.  I think my colleague Jan Herzhoff actually presented at the Research America conference a couple months ago. I've said wonderful things about the organization in terms of what you guys do to promote evidence-based information and combat the infodemic that we're all going through. Can you tell us a bit about Research America and what's top of mind for you and any potential solutions for this infodemic crisis that we're seeing?

Susan Dentzer: Yes, it's a big area of focus. So, Research America is an advocacy organization. We essentially exist to advocate for investments in health-related research of all types: biomedical research, such as what goes on at the National Institutes of Health; developmental research, where you take basic science and try to turn it into commercial products that can benefit human beings; health services research as is conducted by the Agency for Healthcare Research and Development; or public health related research, such as that conducted by the CDC. We advocate for basic expenditures in those endeavors, but also for other things that flow from that. 

One of the big issues now has been this mistrust of science that obviously came into really sharp focus during the pandemic. We don't think most members of the public mistrust science. In fact, the polling that Research America has done over the years suggests that support for science and biomedical research is very high. But on the other hand, we know a lot of misinformation and active disinformation surfaced around the pandemic and of course, that isn't entirely due to the pandemic because we had a lot of disinformation and misinformation around vaccines prior to the pandemic. So, we are concerned about this and are seeking to understand more about what are the roots of this misinformation and disinformation. Is there a way to basically help more of the public not exactly insulate itself from misinformation or disinformation but does good information drive out bad information? I'm not sure. 

What are the useful approaches that will help people understand and embrace science? Not surprisingly, we think it starts early in life with education, basic STEM type education. Because if you have been educated from early in your childhood about science, and understand that science is really the quest for knowledge and that we all have to constantly engage in a quest for knowledge -- as opposed to being passive recipients of somebody else's received wisdom -- if you can kind of bake that into people, they're going to approach information throughout their lives very, very differently and have an open mind to understanding science. 

It was always interesting to me in the pandemic that the public was so flummoxed by the apparently shifting understanding of say, the SARS-CoV-2 virus and how it was behaving. As a person who's spent my career in this field, you go well, "Of course, the understanding is going to shift. This is a brand-new virus that we never saw before. It's a pandemic agent virus.” We knew that there were a couple of hundred corona viruses out there, and they just cause colds. This was a whole new thing. So, of course, our understanding was going to evolve over time, and you know that you give some grace to people who say one thing one day and then have to turn around and say something else a couple of weeks later because the evidence has changed. But not all the public understands that, and I think part of it is they really were not reared in science and they don't really understand that science is a constantly evolving effort and entity in and of itself. 

If you don't understand that, I guess it is easy to get resentful of people who you're expecting to give you clear answers and they may give you an answer on one day, but it may be different a couple of weeks later. So how do we cope with that and get more people in a different frame of mind? And again, I have to say, I think a lot of it just goes back to education. So it’s about understanding what's going on out there, what are we teaching our young people and how do we continue to support STEM and other related education so that maybe twenty-five or fifty years from now we're not in quite as dissimilar places as we seem to be now?

Shiv Gaglani: Absolutely. That's why we're so committed to education. You mentioned flipped classroom. That's how we even met in the first place...it was the Robert Johnson Foundation’s focus on the flipped classroom and bringing the other leading organizations like Khan Academy and Osmosis to do that in healthcare. Certainly, it’s an area we're going to keep watching.

I have two last questions for you. The first is, you've had a very storied career across many different segments within healthcare and policy, and research. What advice do you have for our audience about approaching their careers in healthcare or across the spectrum?

Susan Dentzer: Well, I think all of us who are in health or healthcare should first of all count ourselves very privileged because it is a wonderful and important field, notwithstanding all of the problems that we could talk about for hours on end. But the opportunities to make contributions toward humanity and society are legion in healthcare in many, many, many different ways. So, let's all congratulate ourselves on having this privilege really, of engaging in this field. In fact, I was talking with a friend about this just yesterday, so many things stay the same and yet so many things change. We were talking about how years ago -- let's go way back to the ‘80s --people said healthcare is unaffordable and we face a crisis of healthcare expenditures and it cannot go on this way. Well, here we are, right? It's decades later and it's the same set of issues in that broadest sense, and in fact, amplified and magnified by some of the innovations that we see now that are extremely promising, but also very costly, particularly in the realm of prescription drugs. 

What do we make of that? There are going to be some constant issues in healthcare that we will always have to be attentive to. On the other hand, things are different. Who would have predicted that we would be sitting here talking about some of the leading tech companies getting into healthcare, or that one of the leading retailers in the world is getting into healthcare? I was sharing with his friend that I wrote an article way back in the ‘80s about how important it was to get employers engaged in healthcare because they were such big payers for healthcare through self-funding their own healthcare payments. That's still true. Have employers become as engaged in healthcare as they should have been? No. They've been kind of price takers.

I have friends who are trying desperately to get more employers, other than just Walmart, to pay attention to actually what goes into contracts with providers. Do you really understand what your pharmacy benefit manager is doing? Those kinds of things haven't gotten a whole lot better, so there is a constant ability to engage in some of the unique issues that get thrown up in our system, in particular, because of the way we've structured it. So, the only advice I could give is, get in the game and stay in the game. You can have a varied career even within this one sector and you can make an enormous amount of contribution along the way, and I don't know that it gets any better than that.

Shiv Gaglani: That's great advice, for sure. I think get in the game, as you've said, and actually go work for a company to go try different things, try different models, lead different models, and you may be one of those innovators. My last question for you, is there anything else that is top of mind for you that you'd like to share with our audience before we let you go for the day?

Susan Dentzer: I guess what I would make a plea for is that we all try to engage in developing a greater understanding of the issues, as opposed to seeing them through a narrow lens or seeing them through a highly politicized lens. Reality is very complicated, especially in healthcare, so it’s important to seek greater levels of understanding and understand the evidence about what's going on. I'll go back to some of these payment models and innovations. Let's go back to Medicare Advantage. Basically, more than half of those who are signed up to receive Medicare benefits in this country right now are in the Medicare Advantage programs. Either they're all doing something very, very bad for themselves, or they're doing something that they think is in their best interests, right? So when you hear a lot of the pushback on Medicare Advantage, go talk to some patients and find out why they found this model appealing. 

Was it only that it paid for eyeglasses and hearing aids and transportation and meals? Was it the notion that they didn't have to go out and spend a separate amount of money on a Medigap Plan? I mean, let's try to understand the complexity of reality here as opposed to just living in a world of sound bites and also living in a sort of Manichaean existence where there's good and there's bad and there's nothing in between. Because we know that there are downsides to almost everything and there are upsides to almost everything. So, let's put together the big picture. 

That's, I think, what I would make a plea for as we think through where do we want to go to in this country.  How do we get to a healthier society? How do we create an affordable healthcare system that does provide access and high quality to as many people as possible and how do we do that in the context of who we are as Americans and the capitalist economy that we live in? We could spend a lot of time imagining a very, very different world, but I don't think we're gonna get to one in our lifetimes. So, how do we work with the one we have and make it better? That's what I would ask for if you gave me a magic wand and a wish.

Shiv Gaglani: Well, it's a very pragmatic note to end on and some great advice throughout this interview. So, with that, Susan, thanks so much for taking the time to join us on Raise the Line and, more importantly, for the work you've done throughout your career to actually raise the line and strengthen our healthcare system.

Susan Dentzer: Well, I'm delighted to be with you, Shiv. And back at you. Thank you for all you've done to foster this understanding and engagement.

Shiv Gaglani: Thanks so much. And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to strengthen our healthcare system. Take care.