Care Redesign

Rebuilding Health Care as It Should Be: Personal, Equitable, and Accountable

Interview · August 3, 2018

Griffin Myers and Tom Lee head shots


Thomas H. Lee, MD, interviews Griffin Myers, MD, MBA, Co-founder and Chief Medical Officer for Oak Street Health.

 

Tom Lee:  This is Tom Lee from NEJM Catalyst, and we’re talking today with Griffin Myers, who is the Chief Medical Officer for Oak Street Health, an interesting start-up company that is doing great work and that has appeared in NEJM Catalyst multiple times. We’re going to be talking with Griffin about his work, that of his co-founders’, and how the business model has been evolving.

Griffin, at the beginning — before you opened your doors — you and I talked, and you told me the business model for Oak Street was going to be delivering the world’s best primary care to the poorest, sickest elderly patients. I was impressed, and frankly, I was worried. But here you are 6 years later and Oak Street is thriving and growing.

I’m not sure the word “start-up” is appropriate anymore. I know you’ve learned a lot and I’m grateful that you’re willing to share some of these lessons with our audience today. Let’s have you start by talking for a couple of minutes describing Oak Street for any of our audience who might not be familiar with your organization and comment on whether that still is your basic model.

Griffin Myers:  Sure. Tom, I appreciate you having me on behalf of the team. You’re right: It may have sounded insane, but it does, in fact, work. We started the organization with a mission of rebuilding health care as it should be, and we thought it should be three things: it should be personal — which is the shortened word we use for evidence-based because it sounds a little better — it should be equitable, and it should be accountable.

For those three things to be true, you’ve got to deliver evidence-based care; you’ve got to deliver it to everybody regardless of who they are and their ability to pay. And then interestingly, we talk about being accountable, and that sounds good in of itself, but it is what allows us to have the model work.

It’s probably worth giving a little bit of an introduction to Oak Street and what it is that we do. We are now a network of 25 fully value-based primary care centers headquartered in Chicago, but with centers in Detroit, Indianapolis, a few other spaces around the Mid-West, and in the city of Cleveland and Philadelphia open in over the next couple of months. In those 25 centers, we have a full-risk fully globally capitated model taking care of patients on Medicare and Medicaid, mostly dual. Duals are the biggest part of the population, but it also includes Medicare Advantage, traditional Medicare, an ACO product that we built, and full-risk Medicaid, as well.

We take care of about 43,000 people at this point. The entire team is about 1,200 and the medical group, the folks who license providers, who make medical decisions on behalf of our patients, is about 150 people.

Wrapping it up in terms of thinking about how we judge success — what is the impact we’re having — we talk about keeping patients happy, healthy, and out of the hospital. We can get into all three of those things, but we have a 92% Net Promotor score so I feel like our patients are happy. We’re a five-star practice on the HEDIS scale so we’re a high-quality practice delivering evidence-based care. Thirdly, we’ve cut the hospital admission rate by over 40%. That’s not only good for patients, but those savings then are what we use to invest in making the model bigger and better as we grow over time.

Lee:  Addressing social determinants of health is clearly critical for your population. For most in health care, I have to say it’s like the weather. We all talk about it, but we don’t do much about it. What’s your take? How are you building the addressing of social determinants into your model?

Myers:  It’s funny you ask. This initially was trouble for us in terms of how we think about it because what everybody else wants to use to describe Oak Street is that we’re a primary care practice, and we get that. We understand why that is. Internally at Oak Street, we don’t even say that.

We refer to ourselves as a social determinants practice and primary care is a part of that, but there is a piece of literature early on — and I’ll give away that I’m an MGH trainee — the Shattuck lecture given at MGH in 2007 was given by a gentleman from UCSF, and it was really formative to Mike and Jeff and I, and has been to our entire team since we launched the business. It’s this idea when you look at what determines morbidity in this country, 80% of that has nothing to do with the quality of health care received. It means that effectively for those of us in the health care system, we know the 80/20 rule, and we’re focusing on the 20 and not the 80.

We built our model specifically to address social determinants and then obviously where primary care is required and can help, we do that. There are a few examples I can give you. Number one, our centers don’t look like primary care centers. They don’t look like health centers. They’re not located in medical office spaces.

They’re specifically built in the neighborhoods we serve in high-traffic areas where people live and work and play, not necessarily where they go to get health care. As a part of that, every one of our centers has a community center that’s open to the community with a self-serve café, a computer lab, and an event space. Even from the space of the building and where we put the buildings, that tells you a little bit about our orientation being far more about community and what goes on outside the exam room.

The second thing is, we offer transportation to and from our centers. Now, I will tell you that initially we didn’t do that. There’s no CPT code for that. This is something that is enabled and powered by our value-based model, but we did it and we are nice people, Tom, but we didn’t do this because we’re nice people. We did it because a lot of our patients weren’t making it to the clinic. They couldn’t get there, and if we can’t intervene, then they’re going to go to a hospital and we have to pay those bills, and so we did it because it was the right thing and it’s what our patients needed.

The third thing is more what we’re working on now than what we currently do. We do quite a bit to support our patients in terms of finding stable housing and finding access to healthy food, but not only are there some limitations on what we can do from a compliance standpoint — and tons of credit to CMS on new value-based insurance design and things like that that are really going to open up what we can do — we’re spending a lot of time working with our community partners on helping people find access to housing. We’re doing a lot of work to host produce sales at our community centers and things like that.

Increasingly, over time, this is our number one focus: What can we do to bring in the things that we know our patients need that may be outside the exam room rather than on the inside? The good thing for us in all of this is that you have to have the right business model to be able to do it.

There is no CPT code for healthy food, but the good news is that we feel like we’re a long way down the path in having a business model that allows us to know to invest in what we know that patients need. The folks who don’t have that are likely to be left behind.

Lee:  When we get in to the nuts and bolts of how your organization works, I hear you talk about patients a lot, about teams a lot, but I don’t hear you talk that much about doctors. Have you replaced them all with non-physicians, or most of them? They don’t seem to be the unit of analysis for you that they are in other organizations.

Myers:  Well, that probably means is I don’t brag enough about the medical group because they’re obviously a core piece of what we do — if they’re listening, lesson learned. A big part of my job is to build, develop, and support that medical group. It’s 150 experienced, committed, diverse professionals . . . [voice cuts out]. It’s interesting, because when you look at the balance sheet, there’s not a line item for medical group, or for talented physicians, nurse practitioners, psychiatrists, podiatrists.

Those are expensed on the income statement of salaries, but if accountants let us capitalize it, far and away for us at Oak Street the most valuable thing, the most expensive and therefore the most valuable thing we have would be the capitalized wisdom and experience of our medical group. [Another] piece is that we focus a lot on investing in and developing that medical group to make them not only higher quality, but, frankly, to give them joy back in their practice and help deliver better outcomes for our patients.

Three examples of that: Every one of our providers, physicians, nurse practitioners — everybody — has a full-time scribe to support them. Something we wrote up in NEJM Catalyst not too long ago. The second example is that we invest a ton in education, whether it’s on leadership and team-building skills, because everybody has a quite large team that they practice with in their care team, or chronic disease training and things like continuing medical education. The third is around leadership because as we grow, having great clinically trained leaders who understand value-based care is important. It is crucial. That accounting example demonstrates it, and we spend a lot of time investing in it.

But I think what you may be getting at with the question is the platform, which is, what are the things that go around our medical group that would allow us to do this and frankly make you ask the question of, is this is as much about the physicians here as it is elsewhere?

I say a couple things. First is, if what we were doing at Oak Street was taking the top — and we have a great team, like I said — but if all we were doing was taking the top 1% talent from other groups, they came to Oak Street, that other group got worse and we got better, that doesn’t change the health care system. The second thing is, it’s definitionally not scalable.

What we see over time is practitioners who share our values around evidence-based medicine, around health equity, around accountability, if they can join us, and because of the tools and the platform that we have at Oak Street, they get better, now we have something. That’s what we’re trying to build. A lot of the results that we see are consistent across clinic, across region, across market, time, and space, that very statistic and robust findings that suggest to us that platform is a real thing and delivers consistent results.

The best way to wrap it up is there are three important implications of this. Number one is, in a traditional fee-for-service model, you have non-clinicians often, and executives in a lot of cases, asking clinicians to do more work and drive up RVUs, and it creates conflict. In a fee-for-service model, your return on assets comes from getting more out of the workforce. In our model, which is a fully value-based model, our return on assets comes from our teams building relationships with patients, creating behavior changes, driving better outcomes, and creating a surplus.

The first implication is that it aligns our incentives as a leadership team with our clinicians in a unique way. The second thing is — and this is where I am again maybe off the reservation in terms of peer-reviewed evidence — but I’m convinced that a big part of the burnout that we see in this country, and globally, in folks who have the privilege to take care of patients comes from this conflict or this disconnect between values and the environment.

I had this as a medical student where I was told that if I’m not a certain subspecialized provider ideally with a scalpel in my hand, my work’s not as important. Or, even worse, to say rather than taking care of patients, delivering great care, my job is to deliver a finished, signed chart. What that does is it separates values of, “I want to invest my skill and training to take better care of people” from what I feel like I’m doing during the day. We don’t see that. We do a blinded survey at grand rounds every quarter here at Oak Street and find 98% of our clinicians in a blinded survey say this is the best place they can find to practice medicine, that 96% say this is the place they would recommend to their residency colleagues to practice. That ability to address the burnout in a value-based model is almost inherent and something valuable.

The third is not just avoiding burnout — it’s genuinely about putting joy back in the practice, that we have an ability to Oak Street to celebrate great outcomes and celebrate the stuff that we want to celebrate that we didn’t previously have.

I get emails forwarded to me all the time of the teams virtually high-fiving each other for great team work that allows somebody to either stay at home or avoid a readmission, or have a special experience with a patient, that I wouldn’t otherwise see [and] that comes from this integrated model. You started by asking about how important our physicians are in this practice, and they’re hugely important and nicely complemented by the platform.

Lee:  Let’s turn, as we close, to some lessons learned for leaders. I know from following all along that the Oak Street case sounds fabulous, but it’s been hard. Why has it been so hard, when what you’re doing is clearly better than business as usual for patients and for providers and for payers? It has taken you a while to get to a stable footing. What are the key messages you would like to share about the nature of this kind of work for leaders of other health care organizations?

Myers:  I love this question. There are three specific things that come to mind. The first is, we would call it change management or leadership, but it’s really the ability to share the optimism we have around our values, around equitable access to accountable care. I think it’s an incredibly exciting time. There’s so much pessimism out there that in general the status quo wants you to fail. It’s decreasing over time because the proof’s in the pudding, but it used to be very, very hard to convince people that they should share our optimism for what’s possible under these value-based models.

The second thing’s real simple, it’s just capital intensive. It’s natural that everybody wants to start by an app because software, by its very nature, is not as expensive to build and develop. As much as I wish you could download the Oak Street care models from the app store, you can’t, and it’s just hard and slow work.

The third piece is really a thing around complexity. The best comparison I can give you is that NASA has few astronauts, but a whole lot of non-astronauts. It requires a lot of expertise. We at Oak Street need people who are great clinicians. We need people who are great operationally. We need great actuaries. We need great developers. We need people who are experienced in health plans. We need folks who have run delegation audits and have done delegated care management and know how claims systems work. If you think about our frontline practitioners and the astronauts, there’s a whole bunch of us behind there trying to help them accomplish the mission, and there’s a lot of complexity behind it.

Three things that come from those three hard things: Number one is that it’s not magic; there’s nothing in the water. It’s far more about the platform and the routines and architecture of the practice than magic or some cultural phenomenon. The second thing is, we’ve learned to embrace the complexity that we see in the health care system. I think there are a lot of folks waiting on the sidelines saying, “This value-based health care thing, they’re going to solve it and I’m going to wait until they give me the simple answer.” But there are millions and millions of transactions going on in the health care system every day. We are convinced every one of them has an opportunity to be made more value based, and we think that it’s going to be far more complex rather than simpler.

The third thing is, I don’t know where we are in the process, but when people ask how far along are we at Oak Street in this transition and what does this mean for the rest of the system, what inning are we in as we transition to these new models of care, we think we’re a lot further along — seventh inning, not second inning kind of stuff.

The last thing I would say is, again, we started with optimism. This is way better for patients, and we’re seeing it in their outcomes. And we appreciate how many folks there are out there, in all kinds of organizations, like Oak Street and not like Oak Street, changing what they do to take better care of patients.

Lee:  Griffin, you and your colleagues have a lot to be proud of, and you’ve shared a lot of wisdom today. I want to thank you for your time today, and you can be confident that we’ll be tapping into the lessons learned by you and your colleagues for years to come.

Myers:  Thanks for having us, Tom, and thanks for the conversation.

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