Clinicians are failing at value-based care because no one taught them the system

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1:02Subscribe at KevinMD.com slash podcast. Today, we welcome back Ken Botello, he's a founding program director of the Doctor of Medical Science program at the College of St. Scholastica. Today's KevinMD article is Value-Based Care Workforce, bridging the gap in medical education. Kenneth, welcome to the show. So much for having me back, Kevin. Happy to be back. All right. So what led you to write this article and share it on KevinMD and then talk about the article itself for those of you who are chance to read it? Absolutely. Yeah. So a quick background because it jumps right into why I wrote the article is that my background is in primary care as a PA. And like many clinicians, I've seen and felt the shift towards value-based care that's happening around us. But without anybody really explaining how to function within the system. And so in addition to clinical practice, as you had said, I'm the founding director over here at the Doctor of Medical Science program, and we're focusing on workforce development.

2:06And so I'm seeing it from an academic perspective, and then you're also seeing it from a direct clinical perspective that there's a gap in our knowledge base from both the academic and clinical perspective. So we're asked as clinicians to impact quality, cost, and population health. But none of us were really trained directly how to think that way in an operational day-to-day workflow perspective. So that disconnect is what led me to write this piece. The article has come from frustration that I've seen amongst clinicians in all those spaces. And it's a common theme. And so that's what prompted the article itself. Now, value-based care can mean a lot of things. So give us your definition of value-based care and how does that contrast with the fee-for-service paradigm? Or, yeah, you're absolutely right. There is so many nuances to value-based care in terms of different plans and different

3:09measures or what-have-you. Let's talk in somewhat generically. So per your mention of fee-for-service, that's more volume over, perhaps, quality, just simply because if we're seeing more patients, the amount of time and effort spent with each patient is going to be inherently less. Value-based care rewards more outcomes in quality than numbers or patient visits. So we can take care of the same amount of patients, but it may not have the same level of burden in the clinic, and I don't mean burden from a negative perspective, but just time burden. And so the understanding of value-based care is inherent to the outcome portion that we're already being somewhat graded on in terms of metrics. So needing to understand what we're being evaluated on, whether it's breast cancer screening,

4:09cervical cancer screenings, HCC coding in terms of how much weight there are for folks that are more ill or are higher risk than those that are healthy and younger. And so we talk in medical education about patient care. There's some population health as well. There's not as much measures in how to manage large patient panels and affect those changes that we're being reimbursed on. And so having that type of education is important. So you talk a little bit about the burden and some of the out of the exam room work that needs to be done when switching to a majority value-based care system. So give us a scenario example of what additional work needs to be done in order to be an efficient value-based care practitioner. Right. Yeah. There's a lot that needs to be done.

5:09I know that's very generic, but let's go into a more specific depth. We had, I just mentioned in regards to value-based care dashboards, we'll say. So the dashboards for value-based care talk not only about how many, or what's the percentage of your patient panel that's getting their mammograms or cervical cancer screenings or colonoscopies. And much of what we are taught as clinicians is how to take care of an individual patient that's in front of us presenting with a problem. But now we're being also asked to ensure that the overall population health of an entire panel is navigated appropriately, and then we're not only just being given metrics on that, but some of our compensations based on that now. So it's a different type of learning structure that a lot of us aren't necessarily privy to until we go out into the field and we're told what we have to be basically upgraded

6:12on. And so abridging that is really important. There's no specific or definitive way that's been proven across the United States that this is how we deliver it and how clinicians learn. But it's clear there's a gap between the way we've structured the workforce and the way we're now going to be structuring the workforce. And that knowledge gap's important for us as clinicians to deliver the care and then have a lot of positive change in our own careers. So that we can manage that panel effectively. So as you know, in primary care and there is more onus on not necessarily the clinician themselves, but there's staff to to really have these dashboards up to date. Because like you said, our bonuses, the amount of money the institution receives from Medicare and insurance companies is dependent on whether these metrics are met and it could be

7:14the percentage of patients under certainly one C. It could be a percentage of patients that have their blood pressure control. There are literally dozens and dozens of metrics that patients have to monitor their patient panel for. You obviously are the program director at a clinician institution. So how much training typically do these future clinicians get when it comes to these value-based care metrics? I'll be very transparent, very little, very little to the point where even in the workforce, they're being asked or we're being asked to deliver these numbers within our panels. But as most clinicians are trained to do, they're not exactly sure why. And really understanding the why as a clinician helps empower us to not only improve the healthcare

8:16delivery for our panel, but perhaps even have more professional satisfaction from that. But if we don't fully understand the system that we're working in or we're not taught that, or it's not really given us a pathway for growth within it, then it becomes more of a documentation burden than it's seen as a better outcomes for our patients, which is really a bit of a PR change if you think about it. We're trying to do the right thing. We need to make sure we bridge the gap with clinician understanding of the system that we're moving into or we're already into in some ways. So specifically, what kind of skills are needed for a clinician to function in a predominantly value-based care system? Yeah. But first off, we need to understand what we're being measured on. So to your point, Kevin, you had mentioned about A1C management, about colonoscopies and ensuring that those are performed appropriately and the patient panel is aware that these

9:23folks that get these type of screenings done, they have a better outcomes in terms of being a patient themselves, they're reducing their risk of hospitalization because we're trying to provide preventative care. In terms of how that translates, it can actually translate into day-to-day our explanation to patients about why these type of measures are so important for their health. But if we're not as clinicians, even fully understanding the system that we're trying to work within, then that type of communication directly in exam rooms may not happen or it might be more dismissed even though it is important and it's also important to the system that we work in. So while I'm not going to tell you a specific A1C measure that you can improve across the board for your patient panel, something as simple as how you communicate to patients

10:23about the importance of getting certain things accomplished in itself is detrimental. In normal circumstances, a lot of these clinicians have to learn a lot of this stuff just on the fly and through mistakes and errors and feedback from the administration. So tell us your ideal world if we were to implement this during training, what would that look like? Great question. And I would say the way medical education is structured right now, it doesn't need a complete overhaul. However, we should continue to teach clinicians how do we go about patient care in the same way, but we need to expand upon the system thought process as to how to manage larger populations. Because a lot of what are we're taught in school is essentially to manage a patient at a time and that is appropriate, but the world we're moving into is more population health

11:25and managing the understanding as to why these certain tests or certain recommendations are given because they benefit not just the clinician and the health system that they work for, but they benefit the patient themselves. And so where to put that education, at least from my perspective, first off, I know there's some residency programs for medical education and MDs and DOs where that's being present and put in the residency program itself. I think that's an appropriate time frame to do that. For PAs and nurse practitioners, it looks different because a lot of what they're being taught is kind of in a shorter time frame than that of a physician. And I understand that completely. In an ideal world, a PANNP would come out of their school. They would start within a health care system and they would have ongoing training and development as to how best to navigate with the skills that they've already learned in school.

12:28So you're taking the value-based care and the concepts that are introduced and then putting that on, likely after being in practice for a bit of time so that they can get their feet wet within practicing directly. And then once those measures are becoming more visible in their day-to-day practice, a better understanding of the why and how to develop professionally is really important so that whether that's an onboarding program or whether that's some type of PA or NP fellowship, doing that in the postgraduate spaces is highly valuable now. And one of the things that you mentioned in your article is that aligning some of these real-world realities with what they learn academically can help prevent burnout and early career attrition, right? It's absolutely right. Because in the end of the day, a lot of us are asked to do more and do more in our day-to-days. And when you ask us to do more without telling us why it's so important, it adds to that

13:34of burnout and moral injury. But if it becomes part of our professional identity where we inhabit the panel of patients that we're responsible for, and we can see that there's a direct impact between meeting these measures and then the quality of the patient care that we deliver, and then just the quality of our own professional trajectory, that can coexist and cohesively exist. We just haven't quite gotten there yet. So what's happening in other PA and NP programs across the country? Are they taking initiatives as you are to hopefully integrate some of these value-based care skills into our graduating clinicians? There is an absolute appetite for it, to the point where my colleague has been doing a number of different value-based care discussions with clinical-year PAs for those that are listening

14:35that aren't sure what I mean when I say that. That's the second year of PA school, so to speak, where these folks are more clinically grounded, but maybe don't fully understand what it is to code or how to code or why it's important. And the problem is it's likely too little information, just enough for them to understand some of what the terminology is, but not what their day-to-day would look like. And that's where that gap comes into play. There's a recognition that the gap exists. I think there's lack of understanding about exactly what to do about that. We're talking to Kenneth Patelo. He's the founding program director of the Doctor of Medical Science program at the College of St. Scholastica. Today's governor of the article is a value-based care workforce bridging the gap in clinical education. Kenneth is always going to end up with some take-home messages they want to leave with the governor of the audience.

15:36Absolutely, I appreciate it. So at the end of the day, clinicians are struggling not because they're incapable. They're struggling because we haven't quite given them a full or complete framework to understand fully the system that they're working in. And when you give clinicians that framework, something important will happen. They regain a sense of control over their day-to-day to a degree. And when that happens, the system just function better. The clinician starts to shape the system that they're working with in. And that's really where the real advocacy comes from. It's not just for clinicians, but it's also for patients. And so if we want a value-based care system to fully succeed, we can't just measure how we, or change how we measure care. We have to change how we prepare the people that are delivering the care. Kenneth, as always, thank you so much for sharing your perspective and insight.

16:39Thanks again for coming back on the show. Greatly appreciated. Thank you so much, Kevin. Thank you for listening to The Podcast by Kevin MD. To share your story and appear on the show, visit KevinMD.com.