Dr. Bella Tendler Krieger, Director of Value-Based Care at Envision Physician Services
How do we transform health care to accommodate both patients and clinicians? Dr. Bella Tendler Krieger, Director of Value Based Care at Envision Physician Services, takes off her historian hat to give us a glimpse of a health care future that is already in transition. With incremental change guiding her vision, she explores patient-centric, transparent, integrated, and high value health care.
Bella Tendler Krieger is the Director of Value Based Care at Envision Physician Services, a large national medical group with over 25K clinicians. Together with clinical leadership, she has been helping steer the clinical behemoth from fee-for-service payment structures to value-based care.
Bella has had a circuitous route to healthcare management - she started her career as an historian and academic, earning her PhD from Princeton University and teaching for several years before turning analytic skills to what she considers the primary national concern of the day - addressing the astronomical cost and elusive quality of healthcare.
Show Notes
Dr. Bella Tendler Krieger shares her background, an atypical trajectory into health care. [3:25]
What impact does Envision Physician Services have on our healthcare system? [6:47]
What does it mean to have patient-centric, transparent, integrated, and high value health care? [8:28]
How is it possible to shift the healthcare model to accommodate both patients and clinicians? [19:51]
Who has the most influence on decreasing medical costs? [22:25]
How can we change the healthcare system from fee-for-service to value-based? [24:15]
Why do the payers (insurance companies) have a bad reputation in the healthcare model? [24:50]
Around 30% of annual waste in health care occurs in the hospital. [25:47]
How can we incentivize emergency medicine doctors to support a value-based care system? [28:08]
Transcript
Bisi Williams 0:00
Hi. I'm Bisi Williams, you're listening to Health2049.
Dr. Bella Tendler Krieger 0:08
In my vision technology played a very big role. I think technology is going to be the key that opens this to success. But I also think that we really have no choice. I mean, nobody is happy with the current system. Doctors are burnt out, patients are broke. There's a constant battle between every stakeholder, the payers, the health systems, the physicians, the patients, everybody is fighting against each other, and we need to find a way to get out of this mess.
Bisi Williams 1:54
It's no secret that the medical industrial complex is ripe for disruption. Today, American health care is offering payers and providers alternative service models that could revolutionize care. Many companies are offering different health care solutions and challenging the status quo. My guest today is advocating for a revolution in health care, but she believes the payers have a leading role to play in the transformation to value-based care.
Dr. Bella Tendler Krieger has a PhD from Princeton University in Near East studies and an MBA from University of Miami School of Business. She's the director of value-based care for Envision Physician Services. She designed and developed value-based products together with clinical leadership. She also helped design and execute her company's national strategy for emergency medicine, anesthesiology, radiology, women's and children's medicine, pain and surgery in coordination with service line presidents. It is my pleasure to welcome Dr. Bella Tendler Krieger to our show.
Dr. Bella Tendler Krieger 3:00
Thanks Bisi, that sounded probably a little more impressive than is accurate. Thank you very much.
Bisi Williams 3:06
Well, it's incredibly impressive. And I just wanted to, before we jump into the future of health and wellness, I want to jump into your past a little bit and tell us how does one become a national director of value-based care and negotiating payer contracts? How did you get there?
Dr. Bella Tendler Krieger 3:25
Well, I wouldn't necessarily recommend my path as the typical path of getting there. I've had a very atypical trajectory towards health care. And, in fact, most people I interact with have no idea about my past, prior to health care. As you mentioned, I was an academic studying Middle Eastern history, in fact, medieval Middle Eastern history.
Bisi Williams 3:48
Oh, wow, I love you even more.
Dr. Bella Tendler Krieger 3:51
And constructions of orthodoxy and heresy, and I was teaching in publishing. And then my husband, who's a neurosurgeon, finished his 30 years of training and finally got his first job. And I had to leave my job in academia, and I decided it was time to refocus myself. And I went to business school and kind of fell in love. Well, actually, it wasn't falling in love. It was more falling into frustration with health care. And it became kind of the new thing I wanted to crack.
When I was first starting my adulthood, the Middle East was the biggest thing on my mind. I spent a year in Israel during the Second Intifada, and I was in New York during 9/11. And so of course, I was fascinated by the Middle East and what was going on and that was the nut I wanted to crack. And then I actually discovered that there was a problem closer to home that I wanted to focus on. And after finishing my MBA, I took a job with Envision, first as Director of Strategy for Anesthesia, then I moved to work on multiple service lines. And then as the company decided that it was time to move into value-based care, I jumped at that opportunity, because it's something I deeply believe in. And those previous years had seen so many issues with the current healthcare model we were operating under.
And it's been really a trip, really exciting to work with really smart, sincere people. And the advantage of having done that through my company is that they're humongous. I think that we've got over 25,000 clinicians and over 900 facilities, and the pilots we do, the models we do, the contracts we do will really change the way health care is done in this country. I mean, for example, I think 15% of all ED visits in the country happen with our company.
Bisi Williams 6:05
Wait, sorry to interrupt, 15% of all emergency department visits ...
Dr. Bella Tendler Krieger 6:13
Yeah, in the country it happened through an Envision provider. So the models that we introduced really have a huge impact, or will have a huge impact on how health care develops in this country.
Bisi Williams 6:26
So before we jump into the future, let's stay in the present for the moment. So the question, Bella that I want to ask is that 15%, is that a big number or a small number? And what's the design solution that you did to either achieve that number, or reduce the number?
Dr. Bella Tendler Krieger 6:47
That isn't something I did, that's something I walked into. Our company, first of all, it's a massive number, obviously, 15% of all ED visits of every American patient, it happens with one of our providers. But the way that happens is because over the last 20-30 years, provider groups have realized that they have no bargaining power against the payers, and the health systems on their own. And they've started to just aggregate and aggregate and aggregate. So we are a company that's really an aggregate of dozens, more than dozens of smaller provider groups. And the biggest problem that we've been facing the last decade was really, how do we streamline that? How do we move from 60 billion different billing systems and HR systems and how do we standardize that and become a united medical group? And now that we're reaching that goal we're realizing that being a behemoth is not sufficient. We have the ability to change the way health care is done in this country and that's where we've been putting our efforts.
Bisi Williams 8:16
That's so exciting. Okay, we're gonna talk about that a bit more. But right now, Bella, I'd love for you to share with our listeners, your future for health and wellness in the year 2049.
Dr. Bella Tendler Krieger 8:28
Okay, so this was a tough project for me to think about. I'm a historian, so I'm used to thinking about the past and picking apart the past and analyzing what went wrong. I never had enough hubris really to say what will happen in the future. But I've tried, in order to do this, I set myself some parameters. I didn't want to think about revolution, I have no idea what revolution would bring. So, I didn't want to say, single payer system, even if that might be the best for the country, which I'm not saying it is. But I didn't want to say anything that would put many industries out of business.
I wanted a kind of a gradual change, as we change to let the rats be able to swim out off the sinking boat. And so, I envisioned something that is really just the culmination of a lot of good ideas that people are already having, but that we have not been ready to implement. We haven't had the technology or the will or the burning platform until now. So in my mind, 30 years is a decent amount of time for gradual but massive change, and I would want health care in 2049 first of all to be patient-centric, transparent, integrated, and high value, and I'll break these down.
So by patient-centric, I mean that there should be universal health insurance, but it should be tied to the individual patient not to the employer, you don't want a situation like we just had with COVID where people lost their jobs, and at the same time lost their insurance. It doesn't seem to make sense, I also think there should be personal health records that are tied to the individual patient through some kind of universal identifier, instead of keeping separate records that don't talk to each other in 10 different offices and urgent care centers and hospitals for each patient. That was one of the big problems we came to when we united all these practices was, wait, how do we unite the medical records? And frankly, I don't think that it needs to be our job to do so, I think the records should belong to the patient. And it should follow the patient around with some kind of, I don't know how exactly to design it, but some kind of password that they can share with different providers to be able to access that record. And the record should obviously be easily transferable. And not tethered to any hospital or practice EMR.
The next point I was saying was transparent. One of the biggest problems everyone discusses is how costs aside from being astronomical are completely opaque. Different patients could pay different prices, at the same institution for the same surgery based on their insurance. And they won't know that price until after they've already gotten the procedure. And so they can't object to the price or shop for anything cheaper, or anything like that. And aside from the price, we really don't have very good quality tracking. And so people choose a doctor based on really just hearsay or or the hospital's reputation, but we don't actually know who does the best knee replacement surgery or who does the best. And so I would say in 30 years, that needs to be fixed. And there should be very transparent quality and cost data available to everyone, so that we as consumers, as patient consumers, can make intelligent decisions.
And there is another idea I'm not 100% sold on, but I want to put it out there is that I also think that patients should have the ability to view, obviously they have the ability to view their medical record if they own it, but they should also be able to comment on their medical record, and object to certain things. Again, that'll have to be worked through. But really importantly, I think that healthcare will have to be integrated. If you have a single medical record, the PCP and the specialist, pharmacies, or urgent care clinics, ASCs, they'll all be able to access the same health record. And this will be very important for cost and quality as I'll discuss a bit later.
Now, I also think that all health care professionals and companies should agree that health data should conform to standard API's, so that there's interoperability, so that different health apps could plug into this health record if the patient allows it. And I believe that this kind of integrated, connected healthcare system will allow us to focus on preventative care, not just on waking up and realizing, oh, so and so has cancer, now we're going to deal with him, and on condition management through various clinicians and centers, and coordination across the continuum of care.
And most importantly, and again, all of these are related to each other, health care needs to be high value. And by value, I mean quality over cost, you have to have high quality over low cost. Now, you do that either by raising the quality and keeping the cost constant, or by lowering the cost and keeping the quality constant or even better. So I'll give some examples of what I mean in terms of high quality that we need to have clinicians around the country conform to evidence-based medicine and standardized clinical pathways.
One of the things I noticed in reviewing different metrics at Envision which is around the whole country, is that you could have clinicians in different parts of the country and actually even in the same town or even in the same hospital who have vastly different clinical decisions and processes of care. And even if one is proven to be better than the other, because they don't know that and aren't encouraged to conform, they're not doing that, obviously. And I also think we need to have outcomes tracking across the duration of the medical condition. So not just how did this surgery come out, but how do they feel a month later, a year later, five years later, and by low cost, and this is a difficult one for some clinicians to swallow, I think that patients should be treated at the most appropriate but lowest acuity setting. And I think that this would encourage health systems to integrate vertically.
Right now we've been seeing huge aggregations and consolidations of horizontal integration, so that say, a hospital system is more powerful. But I think what is needed is actually vertical integration, so that the hospital does not mind sending the patient to a cheaper alternative, like an urgent care clinic that maybe they own or don't own, but they're not losing out by doing that, they're doing what's best for the patient, they're giving them the right care at the right time, the right place.
I also think clinicians need to operate at the top of their license. And this has been very controversial. I mean, we've had struggles between APPs and physicians over who gets power to do what, and I think it's very important to allow clinicians to operate at the top of their ability. For one, it's important for the physician, to feel that joy in health care and, and to push themselves. Two obviously, it's a cost thing, but I also think it will allow health care to advance because everyone is going to focus on what they can do best.
I think of my father, who's an internal medicine, an internist, pulmonologist, he is so busy in his office, I think the joy of health care has been sucked out of him. Because he's busy doing all sorts of things that actually someone else could be doing for him. And he could be spending more time on the care that only he can provide. So I think that that's a very important move that we will make and have to make, it's already happening because of cost pressures. But I think it's not something to be feared. I think it's something to embrace.
And finally, low cost and we need to avoid duplication and unnecessary testing and treatments. Obviously, it would be something we can do if we have that integrated medical record. But it's also something that we can avoid doing if we move from our current fee-for-service payment structure, which is the predominant payment structure in health care today, and has been since the beginning.
And that brings me to the final point of high value, is I think that payment models need to encourage value over volume. Currently there's been a lot of pressure from insurance companies wanting to pay less, for example, for a procedure. So clinicians feel that they have to do more of the same procedure in order to make the same amount of money they made last year. And this has been kind of a race on the hamster wheel. And I think we just have to put a stop to that by gradually shifting to models that do not encourage over utilization that encourage long term thinking. And that's what we call value-based models.
Bisi Williams 19:12
Bella, your future sounds amazing. I mean, I feel that those are all really lovely models that one, allow you to practice at the top of your game and your skill set. Two, really take pride in your work and spend time in the art of healing. Three, really building relationships within the communities of deep trust through competency and exchange and transparency. I want to ask you, why are you confident that your idea can be achieved within 30 years?
Dr. Bella Tendler Krieger 19:51
I think that these ideas, and most of them really were introduced by CMS in the Medicare, Medicaid populations, but these ideas are already being practiced in certain places. And some of them are successful, and some of them are not successful. But I think that 30 years gives us enough time to iterate and to get it right. I mean, I think about 30 years ago, where technology was, I was writing my papers on a typewriter, so a lot can change.
And I think in my vision, technology played a very big role. I think technology is going to be the key that opens this to success. But I also think that we really have no choice. I mean, nobody is happy with the current system, doctors are burned out, patients are broke. There's a constant battle between every stakeholder, the payers, the health systems, the physicians, the patients, everybody is fighting against each other. And we need to find a way to get out of this mess. And I think, for example, in my company, why did we turn, after so many years, to value-based care?
I think many people are genuinely concerned with what's going on in health care, and they're moving and pushing for these things out of altruism. I've spoken to several clinicians who have said, Oh, my God, I've been waiting to have this conversation for 30 years. But I also think that there's been just too much rate pressure from the payers, everyone wants to bring the price down. And because of that, as I said, doctors have to work more and harder and prices go up. If an insurance company is only going to pay a certain amount, I don't know 80% of the cost, then you're going to have to raise the price. So it's just like a vicious cycle and we've become aware of it and we can't let it continue.
Bisi Williams 22:15
If you think that most people think that the payers are the villains in the piece, how do you make them the superhero with your vision?
Dr. Bella Tendler Krieger 22:25
Exactly as you're saying, the payers have have been the villain in a lot of the narratives. And certainly coming from a physician group, we do approach the payers from an adversarial perspective. And people also complain that having a third party payer is what keeps patients from actually understanding what they're paying for health care and doctors, from actually having any empathy for their patients and what it's costing, because frankly, nobody knows, only the payers know what it's costing.
But the truth is that in the current model, the payers are the ones that are most incentivized to bring down costs. And they are also the ones that have the national influence, and the data to demand quality. So I think they're the ones who have to lead us into this future. Now, it could be a single payer, like the government, but I actually am wary of any kind of single control, I think that it will lead to too much bureaucracy. And I think different companies are good at doing different things. And so there should be competition, instead of allowing a single payer to keep things stagnant.
Bisi Williams 23:54
I love that. And so if you think about the payer, leading the charge to value-based care, and really setting the table for a lovely coexistence for health and wellness, what would be the very first thing that you think that they could and should do?
Dr. Bella Tendler Krieger 24:15
I think that they should encourage, in their contracts to include value-based agreements, as opposed to just fee-for-service. They have the power to do that. Fortunately, unfortunately, they have most of the power. And so if they start shifting towards value-based care, and encouraging a shift away from fee-for-service, then I think that's the direction that we will all move ...
Bisi Williams 24:42
... to a more relational model rather than a transactional one, which would be lovely, too, wouldn't it, you'd have a relationship with all these folks?
Dr. Bella Tendler Krieger 24:50
Absolutely. I've had a wonderful time the last few years, discussing these ideas with different payers. And it was funny going into that because we've always thought, oh, this payer is the devil, that payer is the devil. We've been in lawsuits with all of them. But it's been really fabulous. sitting down together and figuring out well, how can we make this better for our patients? How can we make this attractive for clinicians? How can we make all the players involved leave feeling like they've done something good, and they're happy with their payments.
Bisi Williams 25:28
I think that's amazing. And actually fascinating. I want to ask you another question, most people focus their attention, when they think about value-based care on primary care providers. But how do you imagine that specialists could be involved for example?
Dr. Bella Tendler Krieger 25:47
Yeah, thanks for asking that. I believe that there's a great role in all the specialties to get involved in value-based care either by joining up with an ACO or an accountable care organization or by creating their own kind of pathways to value. Now I work in a company that is primarily hospital-based. We have anesthesia, radiology, emergency medicine, hospital medicine, some neonatology hospital-based, so we don't have a long a term relationship with patients. We see them during their acute care, and then we leave them.
But if you think about it, actually 30% of annual waste in health care occurs in the hospital. So it's tremendous. It's like $300 billion annually of waste, not just expense, waste happens in the hospital. So we are in a unique position, to get involved in that and try and fix it. Emergency medicine doctors, they hold the key, whether they admit someone or not. And so getting them involved in value-based care is extremely important. And you've got to get creative in order to do so because you've got to incentivize them to do it. And also, you've got to figure out how to connect these specialists who live in a hospital, the population that they serve in a more holistic way than just when they have a heart attack or break their ankle.
Bisi Williams 27:46
How would you imagine that they could bridge that gap without it being scary? I think that what you describe is a very dynamic and creative role for somebody who already loves the dynamism and the creativity of being in an emergency setting. How did you imagine they could enact that today, let's say and still feel okay?
Dr. Bella Tendler Krieger 28:08
Yeah. So at Envision, we put a lot of thought into that. And we've already put together a suite of clinical programs that moves the patient and the clinician through that acute care episode in a way that focuses on value. I think the thing that encourages them to participate in it is, number one, the data. If they see that this is better care for the patient, and many doctors are excited about that. But also the payment model. If you encourage doctors to safely discharge a patient home, as opposed to just admitting them to the hospital, then they would be more open to doing so.
I'll give a good example, one of our most exciting programs is called ET3, Emergency Triage, Treat and Transport and the way it works is as follows, in general, EMS providers are not paid by insurance companies unless they bring the patient to the emergency room. Yeah, that is true, so if somebody calls 911 because they fell off their chair or because they needed a puff of their inhaler, the paramedic will not get paid unless he brings them to the emergency room. So that obviously leads to a huge incentive to bring patients to the emergency room. But the emergency room is not a fun place for anyone, you're waiting six hours, you could get sick, you're miserable. It's also incredibly expensive and from there, you might easily just get pushed along into admissions, into in-patient. So many patients would be happier if they could just be treated at home, pick that patient up, make sure they feel okay.
And so, we have this program where we join together with EMS providers to treat the patient in place, if possible, and we pay them for that, instead of them just sending them to the hospital, or if they need to be treated somewhere sending them maybe to a lower acuity setting, like let's say they have a small laceration, they go to an urgent care center instead of going to the ED. And why would we want to do that, we're ED doctors, we get paid when they come to the ED. So as I said, we do that, one, out of the goodness of our hearts because that is better for the patient to be at home, or to be treated in a lower acuity setting. But also because we've created a payment model, together with insurance companies who also have a real incentive to keep patients out of the hospital. And we say to them, you pay us to take care of the patient at home.
We'll set up virtual health with ED doctors so that the patient can actually talk to the ED doctor on a video camera at home and feel like they're getting the full emergency room treatment, but from their living room, and you pay us for that. Or we have a shared savings model, maybe if we've saved you this much money in emergency visits, maybe you give us a percentage of that, so that we can encourage our clinicians to participate in this.
So just changing the way we think about how this business is run. It's not just about the acute care visit, it's also about preventing the acute care visit. And it actually really creates an entire paradigm shift for hospitalist medicines, both hospitals and hospital-based clinicians, both in terms of their day to day work, what they do, also in terms of how we think about data, and how we think about payment for services. Everything has shifted from this small instance of care to something that is holistic and longitudinal.
Bisi Williams 32:33
Bella, I have to say, I love your incremental change vision. It feels humane, smart, and wonderful. And I know if I could be at home, that would be my preference for anything. So to be treated at home and have that contact with a professional in the comfort of my own home, just seems like a dream, in the event that something untoward should happen. I find this just fascinating. I so enjoyed my discussion with you today. Thank you for joining us on health 2049
Dr. Bella Tendler Krieger 33:12
It's my pleasure, so much fun talking to you Bisi.
Bisi Williams 33:15
That was Dr. Bella Tendler Krieger sharing her vision for health and wellness in the year 2049. If you liked what you heard, please subscribe, rate, review and tell one friend about us. Thank you for listening. I'm your host Bisi Williams, take care and be well.
