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

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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.

And 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

measures 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,

cervical 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.

I 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

on.

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

the 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

delivery 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

folks 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

about 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

and 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.

So 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

of 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

that 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.

Absolutely, 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.

Thanks again for coming back on the show.

Greatly appreciated.

Thank you so much, Kevin.

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