Reducing Administrative Burden

Dr. Kyna Fong, CEO and co-founder of Elation Health, was recently featured on the latest episode of 3M’s Inside Angle podcast. Below is a shortened version of the discussion Kyna had with Dr. L. Gordon Moore, the senior medical director of clinical strategy and value-based care for 3M Health Information Systems on the importance of health care innovation that supports the core of care: the physician patient relationship.

Listen to the full podcast here. 

It’s fascinating when you describe a clinical-first technology company, and yet you also touch on the economics of practice. Obviously, you know a ton about that. And I’m thinking 70 percent of practice revenue goes to overhead before a physician salary. That’s a huge nut and a problem to solve, and yet I’m seeing probably the same experience you had, which is that a lot of technology adds processes to the workday and adds a significant amount of work to the clinicians and the entire team within a practice as we start to use technology in a way that’s supposed to serve us. So how did you overcome that? And why is this clinical-first technology? What does that actually mean?

Kyna: Very simply put, clinical-first technology just puts first and foremost the physician/patient relationship and really respecting the sanctity of that. And that technology is being invited into that and needs to support and enhance that as opposed to disrupt or change that. And I think it comes from our experience on the front lines of care, seeing our dad care for his patients and interacting with patients directly. I think a big takeaway for my brother and I was really health care, it’s a human relationship and it’s really built on foundations of trust. And so you could be the best doctor in the world, but if your patient doesn’t trust you enough to tell you really what’s going on with them and really what they’re experiencing, feeling, thinking, and not only that, but if you don’t get that and you don’t have that trust, then it’s going to be very hard to do your job as a physician. I mean, you’re a physician. So you know these things that I’m saying.

And then on the flip side, even if you do know what a patient needs to do, there’s a relationship and a trust there that’s needed for the patient to actually follow through, right? So physicians, a lot of times, there’s the language of orders that physicians provide to patients. But really, they’re not more than wishes, right? When you have a patient walking out the door and you send them with a bunch of things you wish that they will do, and I think it’s that trust and that relationship and that understanding of that patient as a human that helps those wishes be followed through upon and for the patient to get the follow up and ongoing treatment that they need.

So I remember years ago, I was reading a study about the likelihood that somebody goes for a recommended colonoscopy. So an uncomfortable procedure, not something that naturally occurs to me as something to do if I’m not in health care, but a net good for a person. And it turned out that one of the predictors was waste and delays in office practice and trust in the physician, which in some deep interviews was identified as, “You don’t keep me waiting and you listen to me when I talk to you. So you don’t waste my time.” And so this is from the patient’s perspective. “And so if you demonstrate those behaviors, you are demonstrating respect for me, so therefore I respect you and I’m more likely to trust you and follow through in your recommendations.” So how is it that technology enables that relationship? What is it that you do that makes that work?

Kyna: Fantastic question. I mean, it starts from the very simple things, and that’s a big part of where we started, which is when the patient and the physician are together, let them be together. Let them interact with one another and not be distracted by a computer that’s in front of them and really have the physician, or sorry, the patient feel like the physician is paying more attention to the computer than to the patient, right? So that’s this simple, straightforward thing that, at the same time, I would say a vast majority of health care is experiencing challenges with today. It’s just that human connection, despite being physically present together.

I think from there, I think technology can really lower the barriers to ongoing interaction and make it just a lot easier to do that. And when a patient hears from their physician or from their physician’s practice, their care team, it makes them feel cared for, right? It makes them feel like they matter to their practice and that builds trust as well. And so when you think about today, in our everyday lives, we can communicate with very low friction with anybody around the world. Just pick up our phone, send a text and the message.

And I think those abilities to have just much smaller touchpoints and express that the physician cares and make the patient feel connected to who’s taking care of their health, I think those are all fantastic ways to build trust. And it’s all a bunch of small things. And then from there, when the important times come up and bigger events are happening, I think that’s the foundation that you want to have to then really help guide the patient and support the patient and hopefully have prevented any more serious incidents for the patient.

I remember seeing [in the late ‘90s] a big consulting company saying that the more employees you have in your practice, the better able you are to draw down revenue and do all sorts of wonderful things. But I was looking at some other work that was looking at overhead in practice, and quoting that 70 percent number of revenue going to overhead beyond the physician’s salary. And that made me think, “If friction and wasted time using the lean concepts in primary care are the times spent not face-to-face with the clinician, and that non-physician time is also a lot of the overhead, then maybe I could downsize and spend more time in relationships.”

So I was lucky enough to get to prototype a practice that was just very, very small with an EMR, just me direct connection with patients. And that was a lot of fun, and it worked within fee-for-service, but only possibly because in Rochester, New York, the mix of payers and the primary care rates were okay. But we found out that that’s not true across the country, that there are many practices where you could be fantastic with your overhead, but still not successful financially. And so I completely agree. So where do you think we should go? What incentives should be in place to, again, enable terrific primary care?

Kyna: There are a couple threads that you pulled on there that I would definitely love to dig into. But in terms of how we can enable terrific primary care, I think the starting point is one where the statistic I cite often that’s just so incredible that comes out of the Oregon Patient-Centered Medical Data shows that an incremental dollar spent on primary care can save 13 dollars in downstream medical spend. And that’s the type of ROI that you could only dream of in any industry, and in health care, nonetheless, where we have so much challenge with spiraling costs and inconsistent patient outcomes.

I think it behooves us to really think about, “How do we incentivize ourselves to realize that value?” And then you also put it against the facts that say that we spend about five to seven cents of our health care dollar on primary care, whereas much developed countries, OECD countries, are spending 12 to 14 cents on the dollar, and probably realizing much more of that ROI than we are. And I really think it starts from a place of primary care needs to be the primary way that care is experienced. When I think about in an effective health care system, I think a KPI that the US health care system could really benefit from is one where we’re simply measuring the number of people that have a primary care doctor they trust, and that they have a longitudinal relationship with.

And I think we enable that through really, first, incentivizing primary care led organizations, where I think we’re going in the right direction of saying, “Hey, how do we reimburse primary care, not just for the incremental minutes that they’re spending with their patients, but really the overall impact on their panel of patients, whether it’s in terms of total cost of care, and importantly, the quality of the care delivered, whether we’re talking specific, measurable patient outcomes, or even just simply patient satisfaction?” Which gets back to that notion of trust that I’ve been talking about. And I think that is really the paradigm that we need to get to and incentivize.

And I mentioned you pulled on a couple threads, I think one of the huge challenges in primary care is the fact that when you look at specialties by pay, that primary care just consistently sits at the bottom of that list. And so we’re really handicapping ourselves from getting the best and brightest into health care, sorry, into primary care, whereas primary care is where we can really use the best of our physicians. So it all comes back to, “How do we put primary care in the driver’s seat in terms of being accountable for panel in terms of cost and quality, and then how do we make it so that primary care physicians actually become the highest paid specialty?” And given the ROI of a dollar, primary care can save 13 dollars in downstream spend. There’s a lot of opportunity to reward primary care more financially. But even beyond that, it’s how do we do that so that we really get the best and the brightest into the specialty where we need it most?

The percent primary care spend, there’s some really interesting work. Chris Koller was the health insurance commissioner for the state of Rhode Island, and about 10 years ago, started working on the percent of primary care spend. He’s now with Millbank Memorial fund, and so he’s leading, along with the Peterson Foundation, a number of state Medicaids that are looking at measuring across all payers the percent primary care spend, expecting them to move from the five percent, as you mentioned, up to 10 percent, at least of dollars. This is not net new dollars. We have tons of money in health care right now. Let’s shift it, like you said, from unnecessary downstream care delivery from the potentially preventable things that are happening at very high dollar and shift it upstream where it’s going to work.

I think about measurements and the reasonable consideration that we should tie payment to quality, and I think about the different ways of measurement. The typical way, for instance, is a lot of process of care work that is very granular and frontline and creates a significant amount of work burden for a clinician and team, like for all your people with diabetes who have their A1C greater than nine, you’re doing X and Y and Z. I mean, that’s good. I don’t mean that’s a wrong thing, but boy, it creates a huge reporting burden. And then those factors are necessary and appropriate, but may not be sufficient to also achieve some impact on necessary health spending, like reducing unnecessary emergency room visits and the like. So we need measures at that level, and I wonder what do you think about those two different approaches, and how would you bring them to life in a technology environment, or is that the wrong venue?

Kyna:  It’s definitely the current value-based conundrum we find ourselves in, right? Because in order to reward based on value, we need to be able to measure value. The ways we know how to measure value are somewhat immature at best, right? And they don’t really encapsulate the complexity of what really high-performing primary care can drive. But it’s a process, right? And as players in that field, we need to accelerate and create the capabilities to help accelerate, and in the meantime, while it’s happening, minimize any negative impact on patients. So I think a couple ways to think about it. I think in the very near-term, it’s progress right direction, just to start thinking about value, and I think technology, like Elation’s, we try to reduce that administrative burden.

The last thing we want is for a physician to have more that they need to document or prove or explain about what they’re doing with their patient. So the more intelligent the technology can be to understand and anticipate what administrative documentation or coding is needed, the more we can help advance value-based care while reducing the burden on the physicians. So I think technology has a significant role to play there. I mean, I think as you play forward, I’m not confident that we’re going to get to a place where we can minutely measure every aspect of what high-performing primary care is.

I think that is a difficult endeavor. And I personally am more attracted to models where there’s shared accountability or even up to full accountability for a total cost of care and quality across a population by a group that’s helmed and led by primary care. I think that these models allow for the type of innovation and broader and more long-term perspective on their patients that gets them away from minute checking of boxes and delivery of codes that really hampers our health care system today. I mean, we haven’t talked explicitly about administrative cost. I mean, those are pushing 15 percent of spend, right? And so much of that is miscoordination or excess need for communication and documentation and coding that happens in health care.

So Dr. Fong, as we move towards wrapping up this conversation, I’d love to get your thoughts on if you had a magic wand, you could wave it and change some things in the near term, and then maybe in the long term, what comes to mind?

Kyna: So on the technology front, interoperability, and true interoperability. I think it’d be so powerful to just allow data to flow and move. And there are so many reasons that’s hard, and totally understood. But I think getting some of the major repositories of information and some EHRs, I won’t name them by name, but some that hold a bunch of data that went unlocked can really deliver a lot of benefit to patients. And we’re making a ton of progress on this front. But if I could wave a magic wand and fast forward us to where we’re on track to get to in 10 years, I think that would be phenomenal.

I think the second thing, like I said… Right now, I feel like there’s this tremendous understanding, and sometimes I call what’s been happening over the last few years a renaissance for primary care, because I think there’s an understanding that primary care is one of the most powerful levers we have in building a sustainable health care system. And the things that get in the way of that really amount to the complexity of just getting from we have dollars we want to give to primary care, and on the other end, we have primary care providers who will take those dollars. But creating those win-wins are just so hard in our health care system, whether you’re talking about contracting and the complexity of the number of payers out there, whether you’re talking about some of the regulations that make it difficult to enter markets.

I think there is an appetite and a desire. Most payers that I talk to, they want to pay primary care more. They have incentive dollars and pots of money that they would like to pay primary care more. But the mechanisms to do that require innovation, and that’s a function of the complexity of the systems we’ve built so I think that’s what I would point at. But yeah, that’s a stumping question. I should ask myself that more often.

About Kyna: 

Kyna Fong is the CEO and Co-Founder of Elation Health, the platform for independent primary care that strengthens the relationship between patients and physicians. Kyna’s expertise as a health economist and digital health leader has been featured in publications including Forbes and Fast Company and she is the recipient of several awards including Fierce Healthcare’s 2021 Most Influential Minority Executives in Healthcare and The Top 100 Harvard Alumni In Technology Of 2021.

Kyna graduated at 19 years old from Harvard University with a bachelor’s degree in applied math and a master’s in computer science and then received her Economics Ph.D. from Stanford University, where she focused on health care. In 2008, Kyna was selected as a Robert Wood Johnson Foundation health policy research fellowship at UC Berkeley. She spent four years as a tenure-track professor in Stanford’s economics department before starting Elation to support more primary care medical practices like her own father’s in Northern California.