Where care is hard to reach: Solving for access to support chronic conditions

About the series

The Business Case for Advanced Primary Care is a podcast series co-presented by Marathon Health and BenefitsPRO.

Speakers

• Nirav Vakharia, MD, COO, Marathon Health
• Michael Krieger, Senior Contributor, BenefitsPRO
• Scott Ferguson, Host, BenefitsPRO

Introduction

"There's a saying in healthcare that your zip code is more predictive of what your health outcomes are going to be than your genetic code. And I think that speaks to the broader set of factors."

Hello, everyone, and welcome to this podcast series, The Business Case for Advanced Primary Care. This podcast series is sponsored by Marathon Health, and it is hosted on BenefitsPRO. I'm your host, Scott Ferguson. In the second episode of this series called Where Care Is Hard to Reach, Solving for Access to Support Chronic Conditions, BenefitsPRO contributor Michael Krieger and his guest discuss how organizations are leveraging advanced primary care to close access gaps, manage chronic diseases more effectively, and improve long-term outcomes. Let's join their conversation.

Episode 2 begins

Hello and welcome to The Business Case for Advanced Primary Care, a podcast series sponsored by Marathon Health and hosted on BenefitsPRO. I'm your host, BenefitsPRO contributor Michael Krieger. In this second episode, Where Care Is Hard to Reach: Solving for Access to Support Chronic Conditions, I'll be talking with Dr. Nirav Vakharia. He's the COO of Marathon Health, a leading provider of advanced primary care through nationwide onsite and nearsite health centers.

76 percent of Americans live with at least one chronic condition, and over half live with multiple. When care is hard to reach, these conditions often go unmanaged, leading to avoidable complications, higher costs, and a poorer quality of life. Access to care shouldn't depend on geography, yet for many employees in rural or underserved areas, it still does. In order to better understand how advanced primary care can help when it comes to managing chronic conditions, Dr. Vakharia is here to share his insights. Nirav, thanks for joining us.

Thanks, Michael. Thank you for having me.

Dr. Vakharia's background

So let's get right into the questions. But before we dive into the conversation, though, could you share a bit about your background with the audience?

I'm a primary care physician by training and still in practice. I also get to serve as the COO here at Marathon. And part of what my career has brought together is before going into medicine, I was actually an engineer. So as I think about healthcare and I think about the systems we need in healthcare to improve access so we can address the problems you've highlighted at the start—it's a very amazing opportunity for me to be able to take what's learned in the exam room and then work with an amazing team to figure out how do we scale that to the whole country.

Understanding the chronic condition crisis

Fascinating. So tell me, in our introduction, I spoke about how many Americans suffer from chronic conditions. Can you help us understand why so many people are struggling with these issues and how that's changed our healthcare outlook over the last several years?

So as we first just level-set on what are the types of chronic conditions we're talking about—many of us have heard about hypertension, diabetes, heart disease, strokes, kidney disease, lung disease, mental health conditions like depression. And oftentimes the same risk factors that are leading to those are leading to diagnoses of cancer.

Why we're having that? It's a really great question. I think that we as a society are asking ourselves, because what we do know is that the outcomes for health are somewhat dependent on the healthcare you get, but mostly dependent on a broader set of factors. There's a saying in healthcare that your zip code is more predictive of what your health outcomes are going to be than your genetic code. And I think that speaks to the broader set of factors, whether they're social, based on practices within your family, they're cultural, they're environmental.

And so as we think about all of those factors, what results today is, as you described, the majority of American adults having at least one chronic disease. The fact that when left unchecked, those chronic diseases lead to complications, and those complications lead to increased utilization of healthcare resources, which are often the more expensive services like emergency room visits, hospitals, surgeries, expensive drug therapies.

And that overall is resulting in what's estimated today at 90 percent of U.S. healthcare expenditures being spent on managing chronic disease, as opposed to working upstream to prevent a lot of those in the first place. Where there's ample evidence to show that if you do swim upstream and you do dedicate enough time, energy, focus, and resource there, you can actually stave off this avalanche of downstream—what's often preventable—spending and utilization, and of course, real impact to people's lives and their families' lives from unchecked chronic disease.

Strategies to overcome access barriers

We both agree that geography shouldn't determine access to care, but for many it does. What are some of the most effective strategies you've seen organizations use to overcome access barriers, especially in rural or underserved areas?

Great question. So I think there's now 50 years-plus of really high-quality evidence and very little debate that if you open the front door even wider to preventive care, most often delivered through a primary care type of service, that you will keep people healthier. There's also evidence you'll keep them happier. They will live longer. They will lead healthier lives. And they will overall, when you think of all their healthcare expenditure, cost less than those for whom that front door to preventive care is too small. So that is an essential truth.

Now, how successful are we at making that front door as wide as possible across geographies? Well, if you look across just the whole U.S. population, today, almost 100 million people report that they are medically homeless—meaning that they do not believe they have sufficient access to a medical home or that sort of preventive primary care type of service. That's almost nearing one in three Americans, and it includes an alarmingly rising number of children as well. So this problem is a nationwide problem. And of course, there are certain geographies or certain areas where that's exacerbated because of even less supply of local providers, which includes physicians, advanced practice providers, nurses, and medical assistants who work in the primary care space.

When we look at what are opportunities to overcome some of those barriers to access—how do you make that front door even wider? In the physical world, it's about bringing care closer to people. So how do we support, for example, in urban areas, as well as rural areas, where there's a significantly high uninsured rate, which is a big barrier to access? You look at opportunities to improve coverage through, for example, states that have done Medicaid expansion. You look at federally qualified health centers and the ability to support that, which is an essential public good for the most under-resourced in our society.

You also look at these employers—I believe it's 60 percent of Americans get their healthcare through their employers, and about 60 or 70 percent of employers who are self-funded. So they are the true payer of healthcare for the populations they cover. You look at these employers who are saying, "When I let my employees and their dependents go out into the community, I'm not getting that sufficient access to preventive and primary care that I want as an investment in my healthcare spend in order to drive some of those downstream benefits we've covered earlier. How can I get more control over this spend because I'm seeing very high year-over-year renewal rates?"

And so these employers who bring care to their members, whether it's onsite or nearsite healthcare, is another way to open that front door and make it bigger in the physical world. And then of course, we're in the age of the internet and AI and technology in general—what are opportunities for technology to bridge this divide, not just in the physical world, and spread the supply of people who can deliver primary care to those who need it more evenly? That's where virtual care has seen a lot of exciting advances, especially with COVID and thereafter—remote patient monitoring, more therapeutic monitoring, and increasingly more self-service available to patients, whether it's through AI-powered chatbots and symptom checkers that help patients start to understand and self-triage before they have to overcome an access gap.

So I think there are some really exciting things happening in the space, because there's again—going back to the data—50 years saying if you just open the front door wider, it's one of the most important levers to managing the downstream runaway train that is healthcare expenditure overall.

The role of technology in expanding access

So let's dive a little deeper into technology. What role does technology like virtual primary care or remote monitoring play in expanding access and managing conditions? And more importantly, how do you ensure it complements rather than replaces the human touch in care delivery?

That's a great point. One of the learnings I think that we've all experienced in healthcare as technology increasingly enters into the relationship is to make sure we view the technology as an enabler of the relationship—and not the destination, if you will. So it's a means to an end; it's not the end in and of itself. And when that is done well, what we tend to see is better outcomes.

So for example, we've talked about virtual care helping bridge access barriers when physical access is just too hard for us to achieve. Probably everyone—or close to everyone—has either themselves or had a loved one go through a virtual visit. We know that increasingly the opportunity to have that feel at parity with an in-person visit is growing as more technology surrounds that visit. There are, for example, very interesting devices patients can now have in their home that measure different vital signs, can listen to the heart, do an EKG, and transmit that information so that you're approximating what would happen in person.

I think there are a lot of exciting things going on there. And what we're seeing, especially with COVID being that accelerant into virtual care, is that for some types of healthcare, virtual has now become dominant. I believe right now, if you look at all mental healthcare delivered in this country, we've tipped over into the majority being done virtually and the minority now being done in person. And there are other types of services that are more cognitive in nature, more conversational, if you will, that are likely going to head in that direction and address some of these access barriers as well.

Addressing affordability alongside access

When you have a chronic condition or live in an area with limited healthcare access, costs also affect things. How can advanced primary care address affordability issues?

Yeah, great question. So if we go back to the essential truth that primary care is good—accessing it will be one of the most important things to improve chronic disease management and prevention of complications. What do we do to reduce all barriers possible so that patients in need can get into the service? One of them is cost, which no doubt, even though it's good, if you have a benefit design or a health plan type of offering that doesn't selectively prefer and nudge patients towards utilizing primary care, that will for sure reduce utilization.

So advanced primary care is on a different chassis—not fee-for-service, where the goal for the provider is to see as many patients as possible, and as a result, you're reducing the amount of time in a day or on a visit that is dedicated to each patient. Rather, it is paid on a per-patient basis, typically monthly. And so what that means is you can now have smaller panel sizes for a provider, which also adds to them not being burned out and leaving the profession early and creating some of the access gaps that we talked about. It also allows for more time during an individual appointment or interaction—however it's done—in order to focus on not just the one or two things that patient needs, but really to explore what are the opportunities to empower that patient with the knowledge, the skills, and create the confidence so that they can start to manage their own health more effectively. Which is ultimately the dividend we're looking for here.

Creating dependency on primary care or providers in general is not the goal, but allowing people to overcome the knowledge, skills, and confidence barriers in order to manage their own health is where we see advanced primary care providers being able to offer that—because of the structure I described: smaller panels, longer appointment times, and more frequent visits per year to keep the coaching going, keep that focus on lifestyle management going so that those risk factors that lead to chronic disease are negated.

What employers and labor groups need to know

For employers, labor groups, or benefits brokers, what should these people understand about how advanced primary care addresses these issues differently than traditional fee-for-service healthcare? I think increasingly there are studies coming out, there are white papers, there are analyses that are proving that advanced primary care yields tremendous benefit for employers and self-funded sponsors. And how that is achieved is through higher engagement in the advanced primary care service, which then yields more utilization there and less utilization in other parts of the healthcare system that you may not have agency or control over, whether that's the specialist's office, the emergency room, urgent care, the hospital, and so on. So repatriating care into an offering that you have more control over—so that you know your valuable investment in the health of your population is yielding ROI—that case is increasingly getting established and aligns with that 50 years of evidence that I've talked about earlier.

I think one thing—actually, I'll say two things—employers and union sponsors should make sure they're also aware of. Number one is understand how much engagement in the model matters and what role does the employer or labor group play in driving engagement into advanced primary care. Because it is still something that is viewed somewhat differently than what community-based access looks like.

The other is to just be aware of the time horizon that it takes for primary care-sensitive types of interventions to take root. So you won't necessarily see savings on day one. If you drive that engagement, you will certainly see savings in the first year around lower emergency room, lower urgent care, lower hospital utilization. Patients have now built trust that that primary care access is there—I can go there, it's easier to go there, I have a better experience than if I go to those other sites. And then the savings just compound year over year as the interventions around lifestyle, risk factor modification, chronic disease management, and prevention of complications continue to add up as patients get more engaged in their healthcare.

So I think going in with that perspective—and knowing that an advanced primary care platform is one that really helps address all aspects of a member's health, as opposed to thinking that I'll get a solution for diabetes over here and add it to my vendor ecosystem, and then one for asthma over here, and then one for mental health over here, creating a very fragmented experience for the end user and not actually driving the engagement and the outcomes of interest—instead, going back to the root cause, which is: let's start with a trusted health service that can help patients navigate to all of the above if needed. That's sort of a way to think about it going in, in order to get the most return on investment.

A real-world example: One member's story

To close, can you share a real-world example where advanced primary care made a measurable difference in increasing access for an individual who is suffering from chronic conditions? Going back to the concept that if you take away as many barriers as possible and then invest the time and build the trust with patients, we can really start to see demonstrable changes in their outcomes. We had a member recently in the Southeast U.S. who hadn't had really any preventive care for about 30 years. He came in overweight, just not feeling well in general, and with a litany of symptoms. He was able to come in because his employer provided an incentive for him to go and get a checkup at the advanced primary care offering that they brought to them—right onsite. The line supervisor where he works said, "I'm encouraging you to go. You can take time off of work to make sure that you get your healthcare." All these things lined up such that he finally came in after 30 years.

And unfortunately, what we found was a whole lot of things that were concerning. His kidneys weren't doing so great. His cholesterol wasn't great. He was quite overweight. He had sleep apnea, and so on. Fast forward about 18 months and about 25 visits in the interim, where we worked on health coaching, we worked on getting him on the right medications, and helped him really master his own health. He's now running half marathons and has lost a lot of weight. His kidneys actually look better than they did before. His diabetes is now in control. He reports a lot more energy because he's sleeping better and exercising.

But here was the really meaningful part, in addition to his individual story: his family saw how he was engaging in his own health, so his wife and his son—who had been living similar lifestyles—also decided to engage in the advanced primary care offering that they had access to onsite or nearsite to his workplace. And they are making measurable progress in their own healthcare journey as well. So it's a whole family story, not just an individual story. And that speaks to what happens when you bring care closer to people.

Yeah, after I had a recent heart surgery, my wife got to cook a lot healthier, I will tell you that. Dr. Nirav Vakharia, thank you for speaking to us and for your insights on advanced primary care. Thanks for your time. And that's all the time we have for this episode. Keep an eye out for future episodes in the series, and thanks for listening. For BenefitsPRO, I'm Michael Krieger.

Series close

That brings us to the end of the second episode in this podcast series. For additional information about Marathon Health and advanced primary care, visit marathon.health. And for more insights into the benefits advisor industry, visit benefitspro.com. I'm Scott Ferguson. Thanks for listening.