Leverage Insights

Issue 5, April 2020

Today Leverage Insights interviews Dr. Jeff Kang, Chief Executive Officer of WellBe Senior Medical (WellBe).

WellBe is a Leverage Health Portfolio Company, and Jeff’s extensive healthcare experience as both a doctor and executive offers lessons of particular relevance as healthcare shifts to more virtual and in-home care.  It is important to highlight solutions that drive critical healthcare services to populations that are vulnerable, at risk and under served in general: the frail and elderly with comorbidities.  The ability to provide those medical services in-home is precisely the solution that can have a major impact.

This interview is not intended to address the current challenges around the COVID-19 pandemic; however, it is important to note that the pandemic is another reason why in-home care is more important than ever.

Dr. Kang began his career as an internist and geriatrician. After practicing medicine and running several full risk provider groups in Boston, he joined the Centers for Medicare and Medicaid Services (CMS) as its Chief Medical Officer. While at CMS, Dr. Kang was responsible for national coverage decisions, regulation of the healthcare industry, and health plan and provider quality measurement and improvement. He used that platform to develop the HCC risk methodology for CMS for sicker, chronic patients, developed HEDIS and STAR measurement programs and made investments in information technology to improve data tracking. Following CMS, Jeff joined Cigna as the Chief Medical Officer. Dr. Kang led the development of high-performance networks, medical home and collaborative accountable care initiatives – all designed to improve patient care while managing costs. Next Jeff became Senior Vice President of Walgreens’ health and wellness services and solutions. Dr. Kang ran the company’s emerging walk-in clinics and the employer-based clinics that we all know. He then served as President of ChenMed, a privately held, full-risk Medicare Advantage primary care practice that delivers high-quality, concierge-style care for low-to-moderate income seniors.

Jeff received a BA from Harvard, an MD from UC San Francisco, and an MPH from UC Berkeley. Dr. Kang currently serves on the Board of Directors of NCQA, Blue Cross Blue Shield of Minnesota and ChenMed.

Through its experienced and strategic lens, Leverage Insights offers a uniquely insightful and actionable view into the healthcare marketplace. Our relationships with experts like Jeff are a critical asset to our organization. We are proud and grateful to share the experiences and knowledge of the industry leaders participating in Leverage Insights.

— Richard Lungen

Q & A with Leverage Health

Q: Richard Lungen of Leverage Health

A: Dr. Jeff Kang

Q: Why is there increasing focus on home care and house calls now compared to the past? 

A: Doctors have understood for decades that home care can solve access issues by bringing care to the patient, in the comfort of their own home, rather than requiring the patient travel to their many providers. In the home, clinicians can not only provide traditional primary and specialty care, they can also assess the social determinants of health by seeing them first-hand. This allows a doctor to address the patient’s physical, social, environmental and nutritional needs where they spend most of their time. The largest reason home care is growing is due to adoption of new value-based models – especially, full globally capitated risk on the population. Comprehensive home care was not viable in a volume-driven fee-for-service world where economic impact of improved health and decreased utilization accrued to others. Only recently, the move to value-based care reimbursement models has made home care feasible. The move to value-based care and payment models allows us to focus on the right things which is providing complete care for the frail and poly-chronic members who have comorbidities, transportation challenges, high mental health needs and manage all their healthcare needs from the home. Modern medicine and technology allow us to provide nearly 95% of the same care being done in a primary care office, all in the comfort of a patient’s home.

 Q: What do you see as the main challenge(s) that health plans face regarding home care?

A: As the world of value base care continues to expand and become a larger percentage of a health plans network relationships, solving how home care fits into the current strategy is typically the largest challenge to solve.  If a member is currently part of a risk group, whether simple upside bonus or full risk, the plan must be clear on how rolling out home care to the patients in need will impact the current attributions. We believe that a health plan shouldn’t pay multiple risk-bearing provider groups for the same patient, so care must be given to either moving the member from one group to the home care group, or have a home care model that allows the bonuses to be earned and paid, without disruption.

The second challenge is the narrow focus of many current programs like palliative care, post-hospital care transitions, senior wellness exams, and hospital at home are just a few examples. The patient and the health plan want someone who can deliver all home-based services in all care settings. So, picking the right provider willing to take on global risk, across the entire continuum of care will be key in the future. It decreases the administrative burden to juggle and manage multiple providers down to one and can avoid care management/ROI programs.

Q: The home care you are talking about really makes sense for the complex, elderly patient, but does it have a role in responding to public health crises such as currently with COVID-19?

A: Frail, elderly or disabled individuals are precisely the same high-risk patients that we are worried about in the current COVID-19 pandemic. As health care systems get overwhelmed, medical care at home through physician house calls can assess and triage patients safely in isolation, thereby relieving hospitals of acute care, which creates needed capacity for COVID patients and reduces the patient’s risk of exposure to the novel coronavirus.  The principle is, don’t bring the patient into the hospital where they will get exposed to COVID; bring the test and care to the patient and keep them isolated in the safety of their own home.  These small changes for the high-risk citizens will be amplified through the entire healthcare system allowing the peaks to be managed easier, less patients being infected, and chronic care continuing to be provided for these populations.

 Q: What do you think about telemedicine? Can it substitute for house calls?

A: Telemedicine is a valuable service for a general population and today with issues related to COVID-19 it is being widely accepted. However, telehealth cannot substitute a house call for the frail, poly-chronic population. We’ve seen some home care providers halt visiting patients homes due to COVID-19 which doesn’t seem right – now more than ever these patients need providers coming to their homes to continue to manage their needs. CMS expanded coverage for telemedicine during the coronavirus epidemic, which was the right thing to do.  It definitely improves access, and reduces risk to the entire population.  Unfortunately, telemedicine cannot bring a test to the patient’s home and perform the test. Nor can telemedicine start an IV, so it cannot be used as a true substitute for a full visit. It is definitely a good step to assist the general populations for minor episodic visits (e.g. sore throat) and routine care visits.

Q: What does it mean to take full global risk or global capitation? This term is used a lot, but it means different things to different people.

A: Taking on full risk guarantees a health plan costs (or a set medical loss ratio – MLR) for managing a portion of the membership. Typical risk arrangements are structured so that the health plan would see a reduction in costs (or improvement in MLR) if the same population was not managed differently. These costs are locked in so that from a health plan perspective they are set.  Further, it allows the provider group to move from volume-based care to value based care.

Longitudinal Home Care is not economically feasible in a volume-based world due to time spent traveling to a patient’s home which can be up to 50% of a provider’s workday.  In a typical primary care setting the providers can see up to 40 patients a day, and any travel time would negatively impact their earnings. In a value-based world it is not only the right thing to do, especially for a frail elderly population, but the economics are aligned to do this. Spending more time (e.g. 4-5 visits a day) with patients allows clinicians to be proactive and prevent illness, versus the traditional PCP who is seeing 30 to 40 patients in their office a day and are simply reacting to illness. In the home setting a provider may spend up to an hour with a patient being proactive. Global capitation allows providers to have their economics set so they can focus on prevention and the quality of the care they provide.

Q: What can our readers be doing now to prepare for the inevitable increase in demand for in-home care?

A:  The first step is to identify your Medicare Advantage (MA) memberships that are complicated and unprofitable to manage in the traditional brick and mortar world, which is typically 5-8% of the MA population. What we found is this cohort has a MLR (medical loss ratio) that is above one hundred (implies the health plan loses money on this group), and trending to become even more unprofitable.

Once you have identified the population, you should evaluate your current network’s value-based agreement (VBA), and find opportunities to apply the focused in-home care approach for the right patients.

Once you have your arms around your network and the population, you can design and implement a high performing in-home program.

Q: What do you see as the 10-year outlook for medical care at home?

A: More innovative longitudinal solutions providing care that are willing to put their money where their mouth is – meaning more care delivery programs that take a comprehensive view of the patient across all their care needs.  And doing this over years, so that the patient-doctor relationship is long-standing, is where medical care at home is moving.  We believe WellBe Senior Medical is going to take advantage of these trends.

Richard Lungen: Jeff, thank you for your time today to help us all better understand how impactful and important home healthcare is in today’s world.