Outcomes Rocket Podcast_Miles Snowden: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Saul Marquez:
Hey everybody! Saul Marquez with the Outcomes Rocket. I want to welcome you back to our podcast. Today I have the privilege of hosting a distinguished leader in healthcare. His name is Dr. Miles Snowden. He’s the Chief Growth Officer and Executive Vice President of Physician Strategy at Navvis. Miles is a true expert in value-based healthcare strategy, operational delivery, and performance. He brings decades of experience as both a clinician and executive leader at large organizations like Team Health and UnitedHealth Group. This expertise continues to advance Navvis’s market-based, physician-led, patient-centric solution. As their growth officer, he is responsible for building partnerships with health plans, health systems, and physician organizations in current and new markets across the country. He leads the business development, marketing, and strategy teams at the organization in a way that makes an impact for both the business as well as their customers. He’s had, as mentioned, many great experiences in leadership roles serving as chief medical officer of Team Health. Prior to Team Health, he was at UnitedHealth Group for ten years where he served as chief medical officer of Optum Health’s business, and, as well as spending five years as chief medical officer of Delta Airlines managing the benefits programs for more than 180,000 individuals. This breadth and depth of knowledge is certainly an asset, and we’re excited to dive into a great conversation with Dr. Snowden today. So, Miles, welcome to the podcast.
Miles Snowden:
Thank you, Saul, I appreciate being here.
Saul Marquez:
Yeah, it’s such a privilege. I always think about the pathway that some of the leaders we have on the podcast take, yours has been super unique and you’ve had quite the array of experiences in different industries. Can you talk to us about what inspires your work in healthcare?
Miles Snowden:
You know, I would say despite the fact that for the last 25 years I’ve been doing the sorts of things that you’ve talked about in the area of corporate healthcare, it really still is my roots in the practice of medicine that inspire me today. I hope that’s an asset for the partners that I’m working with. If I can just relate for a moment, as I think about working with physicians, I can’t help but recall the sense of mission that comes from that. This feels trite in today’s world, but I don’t think it is trite in reality, physicians do go through a democratization of society in their training. They, physicians, it’s often not understood that physicians spend an awful lot of time taking care of those who are in really pretty desperate straits, not just physically, but financially and socially as well. And that democratization process, that sense of understanding of all of society, it creates a mission and an understanding that one doesn’t shake even after a couple of decades. I think that as we consider engaging with the physician community and other healthcare providers, no matter what we’re trying to foment in terms of change, we need to first be respectful of those experiences that have gone on. As I think about it myself and how I translate that in my own work, I spend most of my time helping physicians prepare and participate in value-based reimbursement schemes, and I do that with a point of mind that indicates that physicians just simply don’t do population health. They do patient health one patient at a time, incrementally, there is really no other way to participate in the healing arts other than one intimate relationship at a time. And so having that sort of respect for the profession and what goes on in the developing of a young physician, I think is foundational to what we do. It’s that sort of experience that’s led me to find a home at Navvis at this phase in my career, what I would kind of call the back quarters of my career, as I’ve begun to spend more of my time thinking about how can I make the practice of medicine more sustainable, more rewarding, sustainable in the sense that it can be professionally satisfying, that it can offer opportunity, a sense of professional growth, and also rewarding in the broadest sense, in that a physician can really feel that they had all the tools at hand necessary to provide the best possible care for everyone who has chosen them as their physician. Our fee-for-service model just simply isn’t doing that, it is not making the practice of medicine sustainable. It rewards volume and speed and repetition, and to be able to transition to a different way of paying physicians that give them reward and sustainable lifestyles is really inspiring to me.
Saul Marquez:
Yeah, I really appreciate that, Miles. And actually, I have a mentor, he calls it his 3.0, so the stage of his career where he’s been there, done that, had success, and now it’s strictly about value, and how do you deliver value on this 3.0. And it’s something inspiring, right, to have somebody like you that’s been there and done that and now you’re thinking 100% about how do we give back? How do we make this a great place not only to practice medicine, but also receive care? And so let’s focus in on Navvis. Talk to us a little bit about Navvis, what do you guys do, and how are you adding value to the healthcare ecosystem?
Miles Snowden:
Navvis is an operating partner for physician groups, hospital systems, and payers who are participating in or developing value-based reimbursement arrangements, usually requiring population health strategies and tactics. Sometimes we are invited into those partnerships in order to optimize performance that is not sufficiently good. Sometimes, and quite often, as a matter of fact, we are invited in those partnerships to scale. In other words, a physician group, for example, is performing in a desirable manner on a very small … of patients, a couple of thousand. They recognize that having 5% of your patient population in a value-based arrangement is simply not sustainable over the course of time, that one needs to go through the full cycle of maturation into a full value-based enablement, so scaling and also optimizing performance, the two things we do in partnership. I think of Navvis as, and the reason I was attracted to Navvis and engaging in these partnerships is there’s three things we’re doing somewhat differently than the market broadly has done in years past. I think of them in terms of win-wins, standing starts, and all ends. So I’ll describe what I mean by that. By win-win, what I mean is that we arrange ourselves in a manner that we only benefit economically if our partner, meaning the physician group, the hospital system, or the payer benefits similarly, so that there’s this process not of just licensing point solutions, but rather participating in evolution and then having economics at stake alongside your partner. On the standing start part, we don’t believe that one can rip and replace capabilities and investments of capital that are existing when you walk into a partnership. Instead, you need to reflect on and recognize that which has gone before you, take full advantage of what exists today. For example, if an EMR is present, can you run your care management assessments and documentation on that EMR? You quite often can if you really put your mind to it. And lastly, an all-in perspective, we believe that the market has been doing a bit of a disservice in carving up groups of populations by contract type. We believe that as physicians do, that you don’t think about payer contracts when you see a patient, instead, you think of them as a human being, not unlike any other human being that you’re seeing with a different payer contract. So we don’t do Medicare Advantage only or Medicare ACO only, we take all payer types, just like our physician takes all payer types and treat them all the same. We now have about 4 million lives, value-based lives on our platform, and we are finding now that with this scale, we can begin to inform our partners in regard to how one can optimize performance and how one can scale by creating consistency across contracts in different payer types. We now are managing a little bit more, maybe 104 different payer contracts now. So we know what can be accomplished, we put our effort behind it, and we’re able to create some fairly significant change in the markets in which we are participating. It’s also important to think about our work in regard to enabling physicians to lead and participate. If you think about a physician’s perspective, they generally do not get compensated well in a manner consistent with their expertise. Physicians are paid in a manner that completely ignores whether they are performing better or worse on a fee-for-service basis than other physicians. So if we can move them to a model that rewards excellence, excellence in clinical practice, excellence in managing a population or individual, excellence in clinical and economic outcomes, then we have really changed the process through which physicians think about the nature of their career, and we’ve made that practice more sustainable. We think about the secret sauce of value-based care being aligning the incentives that are at work in the examining room or in the operating suite to be consistent with and similar to those which the financial sponsor of that care is working under as well. If we can get a physician, for example, to think about the patient encounter as more than the chief complaint, when the patient comes into the office, all of a sudden we’ve opened up a whole opportunity to close care gaps, enhance quality, save money eventually for those who are funding that care, and we begin to create a situation where the physician is empowered and rewarded for performing differentially. And so all of this is with an idea toward working through the physician, not around the physician. So that is the core belief of Navvis, working through, not around the physician.
Saul Marquez:
Thank you for that. It’s a very unique proposition and I think one that holds true to that quadruple aim, keeping that physician, that care provider at the center of it, it matters. And so I’m inspired by the structure and there’s certainly a lot to unpack there. So let’s dive into it a little bit further. Dr. Snowden, how exactly are you guys doing it differently? You’re an operating partner and so help us see an example. How are you doing this with a partner of yours and how do you add value?
Miles Snowden:
If you think about, Saul, the concept of working through physicians instead of around them, you must disturb the current state of the physician to accomplish that, and this is an area that many in this industry have tipped around over the course of time. You know, payers have this tenuous network relationship that doesn’t allow them to enter into the physician’s practice, essentially. Hospitals often have a rather tenuous relationship with the sources of their referrals, and the physicians in our process, really who are fully independent, are the most able to affect this, but they are the least prevalent of the models out there today. So if we think about moving through, the physician there requires you to invest, this is what Navvis does, invest in taking the time to reset the governance, the physician enterprise transformation strategy, the compensation models, and patient throughput and workflows of the physician. So in essence, we are getting into the business of the practice of medicine for the purposes of informing those physicians and doing it differently. And then to do that, you have to understand the nature of the physician in the way they are trained, and you have to work around some of the biases that exist. And I say that with great respect for physicians because I was one, but if you think about how physician is trained, everything about that training is at odds with what we’re asking them to do as a population health and value-based expert and leader. Physicians are trained on the basis of a high respect for education and certification, they’re not opportunists. They wait for the certification before taking an action. They are trained in specialization, so they’re not generalists in the sense that we would seek in population health. They’re trained to respect repetition, doing it over and over and over again exactly the same way, which drives out innovation, which is so critical to the work we’re doing in value-based contracting and population health. They’re very protocol driven, all very appropriate when you’re a surgeon, but that drives out some of the flexibility that we actually seek amongst the physician leaders who we want to empower to take us forward into the next generation of population health. Physicians abhor a risk, and have that first do no harm promise that we all made as we graduated from medical school. So as a result, they are avoiders of risk, and risk sometimes can be valuable as you take the opportunity before you and seek to solve a problem in population health. And lastly, they can, physicians are very directive, taught to be very directive and very decisive as individuals, which means they tend to lose some of that collaborative juice that others might experience. All of these things are important in the practice of medicine but have to be adjusted for as you get into a population health environment. So we spend a lot of time teaching physicians that there are certain attributes that are necessary to be successful in a team-based model and adjusting compensation expectations and patient throughput so that they can be successful in these new models. We spend a lot of time in coaching. We have a whole separate business segment, that MEDI, that does physician coaching, and that has been very effective in working through, not around the physician.
Saul Marquez:
That’s fantastic, thank you, Miles. And, you know, it sounds like a very unique proposition, one that starts at the core of the physician enterprise and goes from there taking a look at incentives, compensation, workflows, do not rip and replace that, I love when you said that. There’s so much investment that these health systems have made, let’s work with what we have. I really, really love what you guys are doing. So one of the things that we’re all faced with right now is the rising cost of labor and also the challenges of not having enough labor. How does this stack into sort of what you guys are doing? Is there an element of help that you guys provide with that?
Miles Snowden:
We have a number of models that we use in our partnership. For example, in regard to optimizing the use of personnel, we found that when we engage in these partnerships, more often than not, the individuals who are focused on care management and care navigation are being used below their license level. And so one of the things that we do as we start a partnership is, understand what roles are needed, what are the credentialing necessary to fulfill that role, and then how do we make sure that every individual working in this system of care is being used at top of license? Often that means that we need fewer RNs, more care navigators, more physical therapists, more licensed clinical social worker, more pharmacists. And so those RNs, let me make it clear, it doesn’t mean they don’t have work to do. They’ve got other work to do because there’s an awful lot of work to do in a hospital system, of course. And so we allow the redeployment of highly licensed and skilled individuals into other work and bring everyone up to a point where we are really optimizing their top-of-license deployment. That is a really good way to improve some of the challenges we have with staffing. We also do joint ventures where we will use a common shared entity of staff and technology across multiple deployments and multiple partners, that’s a really efficient thing to do as well, particularly helpful to physician enterprises who sometimes are not quite large enough to get the maximally efficient use of care management staff or technology. And so if we can share that in a joint venture structure across several entities, we can really increase the efficiency in that deployment.
Saul Marquez:
That’s great. Thanks so much for that, Miles. This is just something that keeps coming up, keeps coming up because it’s a reality that we’re faced with. So it’s great to know you guys have existing models on how to help with that part of the issue that we’re faced with today. Let’s talk about setbacks. What’s been one of the biggest ones you’ve seen and what’s a key learning that’s come from that?
Miles Snowden:
Oh, setbacks, let’s see, I’ve had more than one. So let me use one that I thought was especially informative in regard to what I do today. In the mid-2000s, when I was at UnitedHealthcare actually, we were doing a lot of work around large self-funded employers who were trying to allow for a very broad network for their employees in order to satisfy the needs and interests of those employees, but also were trying to contain costs, costs for really raising double digits annually there. At my own work at Delta Airlines way back then, we were spending more than $700 Million a year in healthcare, so these were really important times, and we put together a network where we identified physicians in the network who were higher quality and who were more cost-efficient. That did not work. And the learnings I had from that were, first of all, that stakeholder input, every stakeholder is critical. We didn’t have sufficient input from consumers. We failed to understand that when we identified someone who provided care at a lower cost, that was not necessarily judged as favorable by a consumer of healthcare, we also did not get input from physicians, a sufficient understand, what their needs were in that regard. So I’ll give you an example of that. Physician compensation was tied, reimbursement was tied to this designation of high quality, cost-efficient. Yet we failed in regard to the three attributes that are necessary in a physician comp model. First of all, it has to be simple. It has to survive the elevator test. The elevator test is, the average medical office building is about four floors, and if one physician can’t tell their fellow physician what the comp model is in the four floors it takes to get up or down, then you have failed the simplicity test on the comp model. Secondly, has to be timely. Compensation, the reward for performing differently has to be in the same time period, it cannot be subject to some long tail of reconciliation. And thirdly, it has to be transparent, it must be perfectly clear why you performed as you did relative to your own prior period or to your own peer physician. We didn’t have that kind of simplicity and the comp model for those physicians. And also lastly, I’ll say this designation of quality and cost in the network also was exclusionary, and that does not work. So it was only certain members in the health plan were eligible for it, which just created friction amongst those who were not eligible for it and actually ended up ultimately causing that program to fall into decline over the course of time.
Saul Marquez:
And Miles, on the eligibility, is that from a physician perspective?
Miles Snowden:
That’s a member perspective.
Saul Marquez:
From a member perspective, okay.
Miles Snowden:
Yeah, so it was a network, that meant that network was only available to those members who elected into that product.
Saul Marquez:
Got it, got it.
Miles Snowden:
And what we should have done, in retrospect, of course, everything’s so obvious in retrospect, is if you’re going to have something that exhibits goodness such as that, you have to give it to everyone. First thing I’ll say about that, Saul, is, and this is something that is informing our work today, you can’t hold a physician accountable for measurable quality and measurable cost efficiency if you are not also giving them the enabling capabilities necessary to advance quality and advance economic efficiency. We didn’t give those capabilities to those physicians. That is, in essence, the core of what Navvis does today. We distribute those capabilities to those physicians to advance their performance.
Saul Marquez:
Fascinating, that’s great, and when you talk about capabilities, you’re referring to data, you’re referring to anything else beyond data and visibility?
Miles Snowden:
Data to understand what’s happening in the attributed patient panel that you, for whom you are now accountable. What is happening to the person in that panel who you’re not seeing in the office? Secondly, what are the opportunities that exist for the patient you are preparing to see in the office? Treating that is more than the chief complaint. They’re there because they have the sniffles, but have they also missed four or five different care gap closures, preventive exams, etc? And also identifying those people, for example, who are not misusing but using poorly, the system up here, in and out of the emergency department, the urgent care center, etc, or failing to get in for an annual wellness visit, for example. Those sort of insights may sound so simple, but the average physician does not have the technology or the data necessary to develop those insights.
Saul Marquez:
Thanks for those examples, I just wanted to get a better understanding of that. Fantastic, and so we are at a point in healthcare where these things are a must, right? Fee-for-service is not cutting it. We definitely need to move more volume to value, and Miles, you and your company are helping operationalize. A lot of questions, how do I do, I know what I want to do, but I don’t know how to do it. I just have to admit it to myself, and, you know, there’s a lot of organizations that are there. So if you, in the position that you’re in and the things that you’re seeing, could identify one trend or technology that’s going to change healthcare as we know it, what would you say that is?
Miles Snowden:
Saul, in my mind, always in the context of value-based care and population health, which is what I’ll focus my response on, I think about four domains that are necessary for success, and then I’ll call out one that I think is the trend that will most impact the future. You always think of technology analytics and care management technology. You think of innovation and trends and care delivery. How do you deliver higher and higher quality and impactful care? You think about care models, networks, network integrity, and more transparent and higher-performing networks. You think of enablement, which can mean the types of things that I’ve talked about in regard to advancing physician leadership, governance compensation models, or how you contract with payers for reimbursement. In any of those four domains, you can kind of pick out trends that are important in terms of impact. I’m going to shock even myself and call out our federal government as a key trend in where we’ll end up in healthcare. You could smack me if you thought I would say this ten years ago, but I’m really, really encouraged and impressed by what CMS is doing to foment change in a favorable manner in our healthcare system. If you think about the demographics that are at play, we really can’t create meaningful, broad change in the absence of participation from Medicare beneficiaries and the goal of moving a third of healthcare payments in the US to a value-based construct in the near future, which is a CMS goal, is admirable and important. We’re at about 40% penetration now on Medicare Advantage. The ability of CMS, and a relatively broad and consistent support legislatively and on a regulatory basis for CMS and their programs, I think we will look back in another ten years and see that as having been really foundational to creating a pivot from fee-for-service care. So as much good stuff is going on in technology and care delivery, in my world, I think about what’s going on with CMS. Of course, it’s imperfect, but I do believe in the absence of that sort of futuristic point of view from some of those folks doing great work there, that we would not see the advance that we are seeing today.
Saul Marquez:
That’s a great call out. You know, we tend to beat up on them, but they’re doing such great things, and a lot of the change that needs to happen does start with policy change, and I love that you called that out, Miles. So kudos to the folks over at CMS for the work that you’re doing to advance this. And hey, on that policy front, are there any deadlines? Like are they putting things out like deadlines for people to get some of the stuff done by?
Miles Snowden:
Yeah, we just crossed an important deadline for applications for the new REACH model ACO. I will say the REACH model ACO, of course, would be the option you could take as opposed to if you’re already in an ACO, just advancing your maturity model. Although that deadline has passed, for now, I would say we actually did an analysis of all of our clients’ performance in ACOs, and our analysis showed that 70% of those ACOs, not just ours, but looking at all of the national, 70% of the ACOs nationally failed to optimize their performance in their existing ACO option. And so my point being, there’s an awful lot of headroom to improve in terms of your yield and your performance on the current ACO models without going to REACH, REACH being more risk and more reward. And so I think the vast majority of ACOs, 70% or so, are probably better served by just advancing performance and maturation on the classic ACO model rather than jumping to a REACH model, that can come later.
Saul Marquez:
That’s great to know. And folks, if you’re listening to this thinking, hmm, there’s something there, there’s a layered appeal here, there’s the string to pull, we’re going to conclude the podcast here with the best place to connect with Miles and team, as well as where you could visit, and that’ll be in the show notes. We’ll include that in the show notes, so you don’t need to go looking for it, it’ll be right there for you on this episode. And we’re here at the end, Miles, I really have enjoyed our conversation. One of the best things we could do is inspire people to act, not just listen. And so I’d love if you could leave us with the closing thought and the best place for the listeners to connect with you and follow up with you on the topics we’ve discussed today.
Miles Snowden:
Sure, Saul, you know, I’d say for folks like me who are closer to the end than the beginning of their career, closing thoughts are more often self-reflections than they are prognostications about the future. My self-reflection is, and I hope it’s useful to your listeners to hear that my career to date has been affected by finding a way to have the humility necessary to accept mentors and coaches into my career to use opportunity, never waste a challenge, jump in there and take advantage of it, to be bold, to take on roles and responsibilities that I may not feel necessarily ready for, but can rise to the challenge, and then to have the generosity that is necessary to be willing to train your replacement while you’re still in your role, which then frees you to move on to something new and different. So those, humility and opportunism, boldness and generosity are the attributes that I’ve found that have served me well, and I hope that message is useful to yours as well. I’ve benefited from an awful lot of blessings and good fortune in my career. As I look back, I have a lot more gratitude than I do pride about my journey so far, and I don’t want to take too much credit for good fortunes because I don’t want to have to take the blame when things go awry as well, so thank you. My, all my ramblings and writings and discussions are all at NavvisHealthcare.com, on our website, you can find it all there. I really appreciate being with you today, Saul.
Saul Marquez:
Absolutely, what a pleasure. Thanks for those closing remarks, Miles. And folks, Navvis Healthcare has two Vs as in violin, N A V V I S Healthcare.com. So either go to that link or click on the link from the show notes and just a great opportunity for you to take action, not just listen, that’s where it all begins. Dr. Snowden, Miles, really appreciate you, and thanks for spending time with us today.
Miles Snowden:
Thank you, Saul, I enjoyed it.
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