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Voices of MCMS:

Value-Based Kidney Care

A conversation with Rajiv Poduval, MD, FASN, of Panoramic Health.

MCMS: There's a lot to your bio and I'm wondering if there's anything else that you want to share highlights with people.

Dr. Poduval: The bio tells half the story. I have practiced nephrology and have been engaged in patient care for a long period of time in the valley. It gave me a unique opportunity to understand what worked in the system and what did not work, and it's that understanding of why we succeed and where we could do better that led to the founding of Panoramic Health.

 

MCMS: What were you seeing in your care for patients or in the system that wasn't working that led you to work with your colleagues and launch Panoramic Health?

Dr. Poduval: Let me take you back to 2009 or 2010. Obamacare had just become law and in my conversations with peers and hospital systems, the one common theme that emerged was the following: While we appreciated the care we were providing to the individual patients, what everyone was looking for was a population health solution to provide better care for a growing group of high cost, high risk patients. And the CKD / ESKD patients, patients with chronic kidney disease and end stage kidney disease and dialysis, pretty much fit that bill. Doing that as part of a practice is hard, especially when you realize to take on the care of large populations, you need a few key ingredients. First and foremost, you need to have a broader geographic footprint. Second, you need access to robust data analytics and, third, you need an enabler arm or a logistics arm that helps well-meaning providers make that all important transition from the fee-for-service world to value based care. It was a recognition that we had a lot of opportunity ahead of us to improve the care that we provide to our patients, and we had a lot of work to get done. We recognized the need for a platform that could bring together these elements and help the providers and the patients make that all important transition.

 

MCMS: How is your approach at Panoramic any different from other groups providing kidney care? For example, how are you leveraging data to provide better care?

Dr. Poduval: Remember we launched what would become Panoramic Health back in 2012/2013, when there was really no glide path to monetization in the space. The CKD space was not seen as a high priority by payers. Everyone was focused on end stage kidney disease and the cost of dialysis. Unlike the other organizations that have come to this space after the launch of the CPC initiative by CMMI, that's the most recent value-based care offering from CMS, where they allow us to take risk on late-stage CKD and dialysis patients. We were launched well ahead of any such CMS measure and that's primarily because we recognized that this was a population that needed care and needed more attention than most people recognized. Panoramic Health is neither serendipitous nor opportunistic. It comes from a true understanding of the ecosystem within which our high-risk patients receive care and a true desire the nephrology community shared that, in buying into the Panoramic Health vision and mission, we could tap into what is our greatest asset, a collective intellect, and build an organization that was capable of transformative change. So, we subscribe to the quadruple aim. We fully recognize that it's important to improve patient outcomes. It's important to contain costs. It's important to focus on the patient’s experience. But to really succeed in delivering those outcomes, we need to have the physician at the center of care delivery and that is what Panoramic Health is focused on and that is the differentiator – engage providers delivering better care using meaningful data that is made available to them at the point of service. We have become a physician-led, data centric, value-based care organization and we're the first to get there.

MCMS: Let me pull on that thread a little bit because we've heard a lot more recently about physician-led organizations. Why is it so important to you to have physician-led practices and groups out there providing care for patients?

Dr. Poduval: There is nothing that can substitute for the sacred relationship that the patient has with his or her physician and to be truly successful, we need to keep patient engagement levels high. To do that, they have to have a conversation with people they trust. For the past few decades, what we have seen is a systemic and systematic erosion of physician confidence. Providers are feeling more and more sidelined. They are feeling less engaged. How can anyone succeed if you don't fix that fundamental flaw in the system? So, a physician led platform brings to the forefront the best that we have to offer, which is a provider using resources and insights from incremental longitudinal data we have in our data warehouse and the holistic synergistic ecosystem that we are building around the patient to improve outcomes. Unless you have engaged providers, you are not going to have engaged patients. Unless you have engaged patients, you're not going to be successful in delivering value-based care. Some of our results speak for themselves. By the way, we have seen how the ESCO initiatives struggled. This is the prior version of the CMS value-based care program which focused on dialysis patients where we have resources that were planted into the practices and resources that the practices were not familiar with. The patients did not understand the value. As a result, the ESCO pilot, by and large, was not a huge success, and we're very grateful to CMS for recognizing that to be successful in such initiatives, you have to have physicians lead the charge.

 

MCMS: Let's talk more about those outcomes and the data feedback loop. What are some of the data that you receive as a team, or an individual physician would receive and analyze, and how does that go back to the patient?

Dr. Poduval: It's quite the story. We start out with a very simple goal to quantify the quality of care we are providing to our patients. We started out by integrating data coming in from the clinical EHRs. We launched our data warehouse and our data analytics company in 2014, initially to assess the clinical data from the EHRs and as we started to digest that, we realized we had an opportunity to benchmark our providers against others in their practice and the practices against our national benchmark. What was traditionally accepted as standard of care, which is the use of evidence-based medicine, the practice of medicine could be slowly changed to practice-based evidence that provided doctors instant feedback on how they were performing. So, the benchmarking idea worked well. We were able to show the reports to providers every quarter, give them insight into where they had opportunities to provide better care and they loved it. Initially everyone had issues with their own data, but they realized that, for the first time, we actually know what's going on and we can see where we have this incredible opportunity to improve care and improve outcomes.

 

MCMS: Was that eye-opening for some people?

Dr. Poduval: It was eye-opening for everyone. It's not that any one of us wakes up in the morning saying that we want to do a suboptimal job, but we're so caught up with our daily routines, with the unscheduled calls from patients who need our help, calls from the emergency rooms or ICUs that disrupt your work in the office. You sometimes forget to do things that you know are defined as standard care and are stage appropriate measures for our patients. And having that data in front of you serves as a reminder that, hey, these are things I need to do. As we started to integrate the clinical data and publish the benchmarks, we realized we had to innovate the practice management system so that we got a better understanding of how the offices worked so we could recognize opportunities to improve office capacity, efficiency, throughput and get patients in at the appropriate cadence so that care could be optimized. From there we decided, hey, if you can do this, why not integrate the charge capture system? Why not connect with the HIEs and now we have a whole tech stack. We have hundreds of thousands of patients integrated through our data repository and that gives us access to incremental longitudinal data. In the past, the payers used to look at the claim space data which comes after the service has been utilized. It's retrospective, giving us very limited opportunity to do things in real time. We can only use that data to predict outcomes in the future and intervene on what we define as a high-risk cohort. So, we started with descriptive analytics and as we had access to this incremental longitudinal data I referenced, we moved to predictive analytics that allowed us to identify the highest of high-risk patients who are highly likely to progress to end stage kidney disease. That allowed us to optimize resource allocation, and from there our hope is to transition to prescriptive analytics where we can define unique care models or case strategies for individual patients. It’s precision medicine. And how does this impact care in real time? Well, the data coming in from our doctors rounding in the hospitals, caring for patients in the dialysis clinics, caring for patients in our offices, all helps inform our modeling and informs staff on where we should be focused, who are at the highest risk of progression, who are at the highest risk of crashing the dialysis, who need more frequent visits. The HIE data alerts us when patients are going to be discharged from the emergency department so we can intervene. We can deescalate the EDs. We can avoid unnecessary hospitalizations and when patients are hospitalized, we can plug them into the right post-acute care initiatives that will decrease readmissions. As a result, what we've seen is this data centric approach has resulted in reduced hospitalizations and reduced readmission rates. Our care coordination efforts using providers who are embedded in the practices has reduced the spend in both the CKD and ESKD populations significantly. It has also promoted that sense of autonomy and well-being that patients crave. In fact, they are more confident to take on self-care at home. Patients enrolled in these programs have a higher rate of choosing home modalities like pregnant dialysis, which preserves the quality of life, and we accomplish all this through initiatives that reduce the total cost of care.

MCMS: What is that learning curve like for physicians as you grow and build and ingest more and more data, and how long does it take for people to understand how that works?

Dr. Poduval: It's a great question. When we launched all this, we wondered that ourselves, which is why we recognize the need for that enabler arm. It’s great that we have this platform where providers could come and work on initiatives that improve outcomes. It's great that we have the data analytics platform but as you're aware, it's very hard to implement change of this magnitude within a practice.

 

MCMS: And just having the data doesn't mean that people pay attention to it.

Dr. Poduval: That's correct. They want to, but they just don't have the time. More and more is being asked of our providers and they expect to deliver that in less and less time. That's the nature of the beast. So, the adoption came through two or three key initiatives that we launched. First and foremost, we gave every practice a resource through Panoramic Health to help interpret the data, to help visualize the data in a user-friendly manner where the providers understood what the ask was and what the opportunity looked like. We also created these interactive tabs using software that enabled better visualization where providers could not only see how they performed, but they could also distill that data down to an action plan by identifying the patients who needed their care. For example, if they had 10% of their patients whose blood pressure was not controlled, they could easily use our dashboards to identify those patients and then come up with a plan of action to adjust medications and get those patients under better control. We made it easy to use and we gave the necessary support staff to do it. Secondly, we realized that one of the reasons why the doctors have previously been reluctant to do all this is because they've never felt that they had enough skin in the game. They wanted to do the most they could, and they just felt that they were not truly part of an organization that supported them. Our doctors who are a part of the Panoramic Health platform are truly our partners. They have skin in the game, and they recognize that this is their platform and through that comes pride of ownership. Our platform has to be best if we are a physician-led platform. The messaging resonated with all of them and they wanted to be part of change and they wanted to lead that change. So first, make it easy to access and give them resources. Second, we had to ensure that the providers are 100% aligned with the vision and mission and they were our partners all the way. And third is the ability to reinforce this behavior by showing them how our patients have benefited – better outcomes, lower costs – that’s compelling, that's any provider’s dream, that's what we want to see. I mean, what we are doing through Panoramic Health and what physicians are seeing as an incredible opportunity in front of them is this win-win formula where we can do good by doing good by embarking on these value-based care initiatives that require adoption of technology and data-centric operations. We are opening the floodgates to 100% of the global spend. And therein lies the key to our success. If we do the right things for the patients in a value-based care arena, if we deliver better outcomes for the first time ever, we can actually participate in some of those shared savings.

 

MCMS: I want to connect the dots between what your team is doing and primary care physicians who may be referring patients to you. How is information shared with the PCP and have you received comments saying, wow, this is something that we need to adopt? Are the systems integrated and you see the medical community coming together or do you still see roadblocks and walls between specialists like nephrologists at Panoramic and a lot of PCPs?

Dr. Poduval: First of all, every specialty and every specialist in America should wake up to the fact that the primary care providers are the quarterbacks. We offer a service. We definitely are willing to take on more responsibilities, especially for specialty care and especially for patients who need specialized services that a PCP office may not be able to offer. At the end of the day, patients really need a good PCP to be the quarterback of their healthcare and my thought is that we have far more in common with the PCPs than not. We both wake up in the morning saying we want to improve the care we provide to our patients. We want to work in an environment where our work is valued. We want to have a seat at the table when decisions are made on policies that impact care delivery. We want our voice to be heard when it comes to implementing change. And, to that end, I don't see any distinction between a primary care provider or a specialist. We all recognize that, hey, for all the work we do, we may not be reimbursed fairly in a fee for service world, and we're looking for opportunities to do more, to do better and participate in some of the value that we're creating for everyone in that ecosystem. So, the PCP is a partner in all aspects. At Panoramic, we recognize that. One of the things we do is educate the PCPs in the community on what services we can offer. We explain how we can reduce the total burden of work on their plates by taking on the responsibility for the care of some of the patients who would benefit from seeing us. We talk with them about the benefits of the referrals. We talk about how much we respect their work and how this is always going to be a team sport. We also make sure that all aspects of care coordination end with a feedback loop to the primary care provider to inform them of the decisions made of things that we're doing for the patients and to let them know how much we value them.

MCMS: Is that well received? What's the feedback that you receive from PCPs?

Dr. Poduval: It has been very positive. In fact, some of our doctors give the PCPs their phone numbers and say if there's any issue, just call us. Let's bypass the roadblocks and the bottlenecks in the system. If you're as a partner, just call me if any of my patients need my help and we'll be there for that patient.

MCMS: That's great. Dr. Poduval, I want to ask you some questions now about the primary care system in general. Are there any parts of the primary care system today in America that you think are achieving parts of the quadruple aim?

Dr. Poduval: There definitely are organizations built to scale with the quadruple aim in mind with good physician leadership, with good provider alignment, with great provider engagement that have not only adopted the quadruple aim but preach it. And that comes from the realization that to deliver on the other three components of the quadruple aim, you need to have the physician at the center of care delivery. You need to have an engaged, involved provider who's committed to doing all those things. Without that, you cannot disintermediate between the provider and the patient. You’re not going to succeed. The large groups and even the smaller ones that are committed to that and identified with that and have invested in themselves to not only adopt the quadruple aim but to invest in it because to really get to that point, you need to build a holistic ecosystem around the patient and around the provider, and you truly need to have a panoramic view into that ecosystem. The organizations that have done that have succeeded. Organizations that are not there yet recognize it and aspire to get there and, over the course of time, I think the entire healthcare system will recognize the need for adopting the quadruple aim.

MCMS: One area that I've read a lot about over the last few decades that we are falling short of is cost. We may have bent the cost curve. Maybe, maybe not. But of those four aims, which one do you think needs the most improvement and why?

Dr. Poduval: So, let’s look at the four components. It all starts in patient care. You gotta improve outcomes. The only way you're going to have an engaged patient is to improve the patient experience. How do you improve any consumer experience? You have to deliver better service. And if you can do both, which is keep patients engaged and improve outcomes, cost containment will follow. Now you ask yourself a fundamental question. What has the government prioritized and advertised and put out there on all websites? And what is the quote unquote missing aim? That's provider engagement. Because the key to success in delivering better customer service, the key to improving outcomes is having that involved provider who feels that sense of fulfillment for doing this job day in and day out. If you ask me what's most important, it's always going to be patient care, patient outcomes. But what needs the most attention? It's the missing aim of provider engagement because it's not advertised anywhere, and it's a key part of the equation that leads to success in delivering the other three components of the quadruple aim or success in CMS’ triple aim.

MCMS: If you don't have anyone in the job, you can't deliver the care. We've seen the surveys that there are more physicians who are going to scale back their hours or retire earlier than they originally planned. Some of that for the individual physician is probably good. We've been harping on the need for wellness programs and a better balance between your day job and your personal life and your family and taking care of yourself. If that means scaling back hours to keep that person as a physician, then maybe that's better. Some of the frustration stems from the administrative burden and what's going on in primary care that has a detrimental effect on provider engagement?

Dr. Poduval: Well, how many things can we do well at any given time? If you burden providers with administrative duties, that's time they'll have to carve out of delivering active patient care. One of the things we did develop at Panoramic Health is went to the practices with the message that, hey, why don't we take care of some of these administrative responsibilities and we keep you fully engaged in doing what you do best which is delivering cost-effective, high quality population health and let's arm you with the data you need so you can be a very successful provider in the value based care space. And keep in mind, change is upon us. To be successful in the future, we have to know how to be a successful value-based care practice and organization. Unfortunately, what's happening with a lot of the other small organizations and smaller practices that there's no one to unburden the doctors of those administrative responsibilities and a significant percentage of their time is consumed in focusing on those things. They're not able to work at the top of their license. As a result, there is lost manpower that could be put to incredible work delivering superior care. So, the answer to your question is frustration sets in and people say enough is enough when they feel that a disproportionate amount of their time is spent on non-revenue generating non-quality of care improving activities that are routine and mundane but needed to keep a practice viable in operation. If you can unburden the providers of that, if you can reduce the administrative burden, if you can respect doctors for what they really do well and promote that sense of fulfillment within the provider community, you will see doctors wanting to do more. And that is the secret sauce to success.

MCMS: As there is greater integration in medicine, what do you see in the crystal ball for the future of primary care? Is it heading in the right direction for patient care and provider engagement?

Dr. Poduval: It's a complex question but let me talk about what we're seeing in the Panoramic world and then we can talk about the PCP world. In the Panoramic world, I think one of the things that we recognize long back, even before the government programs were implemented, is that CKD, chronic kidney disease, should not be a waste basket diagnosis. It is a point of intersection of multiple comorbid conditions coming together to create a cascade that results in progressive organ damage ultimately ending in end stage organ disease or end stage kidney disease. Similarly, the outcomes that concern us are not necessarily all linked to kidney failure. Most of our patients die from cardiovascular passes. So, the same comorbid conditions that result in kidney disease are the same comorbid conditions now with chronic kidney disease acting as a catalyst that result in bad outcomes. To be successful in the kidney care space, it's not enough that we are great nephrologists. We have to be great providers, which is why in Panoramic Health we have launched Global Vascular Solutions to help our patients with vascular issues, whether it's access issues for dialysis or other services we can offer. We have launched Panoramic Science to bring cutting edge or bleeding edge research opportunities for our patients to participate in trials that can slow down the progression and which is why I believe that it is foundational to understand what leads to kidney disease and how we can prevent kidney disease and where to go as far upstream as possible. Now take all of this and look at it from the point of view of a primary care doctor. We are just a part of their universe. They are dealing with multiple comorbid conditions causing multiple target organ diseases. If we expect the doctors to do more and more for less and less and be held accountable for more and more with fewer resources made available, then I don't think we need a crystal ball to see where this is going. I truly believe that we have to work with the primary care doctors to relieve them of some of the burden to be true partners to them. To ensure that they are reimbursed adequately for the tremendous workload that they carry. To find opportunities for them to transition to value-based care, where they are rewarded for their hard work and ultimately to create that sense of fulfillment. Otherwise, our issues are not limited to what's going to happen to those in primary care today. It's going to be one of how are we going to find future primary care providers in this country? So, the time to act is now. The narrative has to change. The recognition has to be there. The opportunities to engage have to be broader. The sense of fulfillment has to be felt and the support from the healthcare community and the government has to be total, without which we are all going to have a very, very difficult situation on our hands that we don't have enough PCPs. And that will be a disaster for healthcare in this country.

 

MCMS: Dr. Poduval, thank you very much. I want to close this conversation today with what you learned in the early days of Panoramic Health. Whether it's the administrative side or organizing the physicians or dealing with all the vendors, were there obstacles you had to overcome that you weren’t prepared for? Consider the big lessons and watershed moments during that journey.

Dr. Poduval: Quite the walk down memory lane. But I’ll tell you this. When we started what would eventually become Panoramic Health, we had a very simple founding principle, partnership without boundaries. Most of us, including myself, initially thought the boundaries are state borders or your I-10, or your 101, or your 202. The two true boundaries exist here in our heads and here in our hearts. Getting doctors to start a conversation is key to launching any platform that is capable of transformative change, especially to be a successful value-based care provider or platform. The more providers engage in conversation, the more likely it is they'll realize that they have far more in common than not. And starting a conversation and starting to build something with the right intent, which is to deliver better care, is key to success because if we don't have the right shared vision or the right mission to rally around, all our efforts are going to be for nought. Because it’s hard to keep a large group like this together and focused. Ultimately, my advice to anyone who wants to do this is don't let anyone tell you it's not possible. Don't let anyone scare you and don't let anyone take away that opportunity, that privilege to serve patients in a better way. Be the change you want to see.

 

MCMS: Dr. Rajiv Poduval, thank you so much for being on the show today.

Dr. Poduval: My pleasure. Thank you.

MCMS: If you'd like to connect with Dr. Poduval and his team at Panoramic Health, simply visit panoramichealth.com.

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