Insights from a CMO on Accountable Care Organizations with Sarika Aggarwal, MD, MHCM, Chief Medical Officer at Beth Israel Deaconess Care Organization
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: Welcome back once again to the Outcomes Rocket podcast where reach out with today's most successful and inspiring health care leaders. I really thank you for tuning in again and I welcome you to go to outcomesrocket.health/reviews where you could rate and review today's podcast because we have an outstanding contributor to healthcare. Her name is Dr. Sarika Aggarwal. She is the chief medical officer at Beth Israel Deaconess Care Organization also known as BIDCO. It's an accountable care organization. There she leads the organization's clinical vision. In this role she provides medical oversight expertise and leadership to ensure that BIDCO delivers high quality health care services an innovative population health management and quality programs and tools to diverse position and hospital networks. Now she's got an amazing 20 years of experience in medicine. She has been across the different payers, consultancies so she's got an amazing diverse background. I'm so excited to have Dr. Aggarwal on the podcast. Sarika why don't you go ahead and fill in the gaps of the introduction. Welcome to the podcast.
: Thank you so much. I'm so happy to be here. I guess as I was talking to you earlier I have been very deliberate in my career choices, I learned very quickly when I was on the providers side. It started as a primary care doc I'm really working on in my little world on patient experience and excellent and quality service of care that we're pieces that we're missing. And so I worked my way through the Harris factor where I learned a lot about the whole revenue cycle related to the claims to building the premium to understanding how the different populations health program on that civilization moving on to consult saying and working with the industry, working on population health platform and building them for the EMR. And then back to the provider side where I am now, the wonderful part of where I am now is BIDCO it's a very unique organization in that we have providers for TCD and specialists as well as hospitals and they are all linked together contractually but also financially. And this is really important because going forward I think it is key that we remove silos from the care continuum really the money should follow the patients. So I think it's important that the transformation is slow in a system like ours but when it happens it happens in a solid way and it happens in the way that it should. So I think that that has been a great journey and I think brought me to where I am now.
: Super insightful Sarika and you really called out an important fact is that there's definitely a lot of silos still and so before we dive into the what you believe the hot topic in medicine is today why did you decide to get into the medical sector to begin with.
: So I don't know at any time in my life that I did not want to be a physician and I guess that 30 years later I am not that I am in the profession where I get to serve the community and I actually make a living so which is wonderful. But truly I think being able to serve by having evidence they scientific having a scientific background and being able to serve that way I think is a real gift. And I continue to want to serve. I used to be it used to be with the individual. When I was a primary care doc and now it is serving the population. So it's just always been my dream and it continues to be.
: That's beautiful. That's beautiful. Thanks for sharing that and there's no doubt from the tone in your voice that you're living your calling. So what would you say Dr. Aggarwal is the hot topic that needs to be every medical leaders agenda today. And how are you guys approaching it at BIDCO?
: So I think that there's areas where there's a paradigm shift. The first is around the financial thinking and the second is the clinical care. And so the financial thinking has gone from you know good institutional financial management speaking to bond rating inadequate adequate margin to keeping the cost under inflation to really where we are now which is we want to be part of the solution. We need to be part of the solution to support the lower cost of care. So you know that's sort of the shift I think and all the payments reform, the alternative payment model come into that shift. And then the second piece is really the improvement beyond clinical care as we use to think. There are enough models out there including the Wisconsin model, the Robert Wood Johnson model where we know that clinical care is only 20 percent of the problem in terms of health outcomes. And so really the thinking has gone beyond the traditional care to population health management where we're looking at service quality and focus quality. The total cost of care to really population health where we're addressing broader outcomes where we're actually speaking to the well-being and the quality of the patients. So it's really that shift and in this space is addressing all those other determinants of health. But it's also understanding the measurement piece, the quality measurement pieces. Going from where we were in the traditional quality measures, the heated measures to actual patients-supported outcome. So I think those are the two pieces that are very important and where the shifts have occurred.
: I would love to zoom in a little bit further on this two topic approach. One being financial, one being clinical. Can you give the listeners an example of how they should be looking at this or things that you and your organization have been doing to help with the transition?
: So I think of the ACO as we started really to address the first piece which is the shift in the financial thinking. They really work supporting the lower cost of care. That is the pieces to that into the contractual pieces it includes the total medical expense reduction working with population health program that really speak to those. And I mean a total cost of care reduction not just shifted. So it means that from a hospital standpoint, we increase the case and that we reduce avoidable utilization from an outpatient standpoint. We try and shift care so for example we have programs that hate serving medical pharmacy not just out of the hospital, not just out of the outpatients facilities, not just out of the physicians offices but really the fault at home. We take some of the surgeries out of the hospital out of the outpatient facility into the outpatient facilities, out of the n est at home. So it's really addressing the total cost of care. From a contractor point of view we're trying really to share breath in innovative ways with different care both the government payer as well as the commercial payer. So we are working with most of our commercial and large commercial payers and that chooses an upside down .. contract. We are in the Medicare Shared Savings track suite program which is an upside downside risk program with a corridor with the CMS. And finally we are. We began the Medicaids ACEO March 1, 2018 which is unique in really addressing the total cost of care and the quality of care in the Medicaid population and clinical care point of view. Again we are going beyond the physician offices really addressing clinical care where the patient is asked whether it be a community setting, whether it be in the office setting, whether it be in the home setting, whether it be in hospital setting nest as that etcetra. To really addressing how we can get to the patients and how they can get that care wherever they go. So we are deciding that we are going to schedule the patients for say their hemoglobin A1C testing for diabetes.
: They should have that done, that gap should be closed whether they are in fortune care, whether they are seen in the office, whether they are seen in the hospital and so forth. Addressing all the health literacy disparities, Social Determinants of Health is also a key and a large part of the work and mass health ACO has then to really address that in a lot of work going from actually really monitoring the patient every time they come in. Again in multitude of settings and specialty settings to actually connecting the patients to resources. Some directed resources we have a bunch of names. Some are human resources, we have navigators. So really addressing all the different pieces related to formal care. And then last piece related to patient reported outcome addressing their well-being and quality of life. We are now working with our commercial payers to really incorporate a lot of the prom's as we call it in our contract. We're really trying to address the quality of care versus the process measures. The traditional process measures that we used to do in the past. So that is a large part of the work that I'm doing.
: Very insightful Dr. Aggarwal and it's a very methodical approach that is well distributed amongst just the finances and the way that clinically you're addressing the problems, thinking through financial measures, thinking through population health and the social determinants of health. Can you give the listeners an example of some recent wins that you've experienced with some of these approaches?
: We've had a lot of good work being done. One of the programs that we've had, so another focus of ours is really on the rising risk population. These are patient that have chronic diseases and really have not gotten to the point where they have increased total cost of care so are pre-high utilizer. And so we actually have a pharmacy first program where we have a pharmacist-lead chronic disease management program in conjunction with health coaches where a large work is medication management and adherence that the pharmacists do which recommendations to the providers and then the second part of it is a boot camp approach by the health coach. And I say boot camp because really addressing South management can take depending on where the patient is on their motivation scale can take a long while.
The boot camp approach is really what my goal is that every patient with chronic disease such as diabetes, every patient should have a few self-management skills. They need to know what the signs and symptoms are, what the warning signs are, they need to know what are the gaps leading related to their disease and they need to know when they need to call the doctor and where they need to go. There's a few things that I feel are basic and these include the complications of the disease so the boot camp approach is really ensuring that we reach a large population with these small goal.
: I think that's super exciting the way that you shape the program and made a boot camp. And have you gotten any feedback on how the program is working out?
: Yes. So we've got early outcomes. We've been very successful with the pharmacist so it's really two pieces, the pharmacist part of it is we've had about 50 percent of the recommendations that our pharmacists have made accepted by a physician and part of that the heart of the reason why some of the physicians have not accepted is because they are uncomfortable physicians primary care physicians are at various levels on the scale of knowledge about a lot of the new medications so they prefer sending the patients to the consultant which is fine by us as long as someone made that you know taking that recommendation. So we've had a very good outcome actual reduction in our hemoglobin A1Cs. And then the other prices the coach and the health coaching pep, we've actually had a lot of good a lot of good feedback on that. The peak about this program a lot of there's enough literature out there that says this is best done when it's face to face. And I agree with that my goal is small with this program. This is why my goal is not really the transformation of patient behavior and have it really small and that goal I think is achievable by doing the telepharmics. So we do plan to add a face to face component a virtual component to this and this is going to be a next step for those patients to graduate faster. So we've done well.
: Outstanding. Now, that's really great to hear and the focus matters. You know then I think as long as your folks are focused on it, the results will continue to filter through. And I do have to ask, is there anything with the opioid epidemic that your organization is focused on as part of the improvement metrics.
: Yes. So that is a base focus for us. So we started to develop you know so we again everything that we do there's there's sort of addressing things at the individual level and then addressing things of the population level trying to adapt the same problems in a different way. So at the individual level there's been a lot of training and sort of tool kit that we've developed for our providers. I think Massachusetts has been ahead of the car. We've gotten a lot of policy change around the opioid use. So there's a lot of learnings there. We've got opioid chronic for our providers to send their patients to chronic, the patient's who are on chronic opioid use. And then the second part is my belief that we really need two things to complement the opioid cure opioid program. One is we need complementary behavioral health programs because behavioral help a disorders and diseases are at the core of a lot of the opioid use. So we need to expand the scope of those we actually are building programs around that. And the second thing is there is a scarcity of providers that provide medication-assisted treatment. So we have a whole training program for emergencies and for our primary care providers to expand training as well as expand the knowledge base for the MAT. So we've got a lot of work that's going on.
: Lot of work going on over there and it is definite and by the way listeners, Sarika has a really cool story. Her name means singer and her mother was a very well-known singer which I thought was really cool. When I was getting schooled on how to say her name and it's a beautiful name Sarika.
: And it bypassed me the finger piece so.
: But your daughter is the good singer isn't that right?
: Daughter is singing. That's great. Yeah.
: It's a blessing and so you know we do what we do because we care. And oftentimes it doesn't go without bumpy roads and so can you share with the listeners a setback or something that you learned that was difficult and what you're doing now as a result of that?
: And one of the things that, one of the programs that I wanted to begin was sort of a performance improvement facilitator program. And it's interesting that when I was medical director at human health system we developed this program we actually hired we developed a job description and we heightened these were different from navigators and that we're non-sample workers. But the idea was that they understood the both the cost utilization pieces of population health as well as the quality piece and they were really able to bring that together and inform and go to the provider practices and really share report and to help with practice we design. So I wanted to reprise that rule. Here when I when I found was had existing folks who were part of the EMR optimization team. So I thought I'm going to just take our existing folk and train them to become the pits as we call them. So we developed and internal macroeconomics program you know that spoke to the math economics. We develop the quality pieces and sort of training around that. Because I couldn't find the training I couldn't find training around. How do you read the cost of utilization report. How do you read quality and how we connected to. And essentially the staff were not engaged to begin with. They went through the program and you know we were not very successful. And what I learned from that really was that I should have started off by even asking if this was something that they wished to do because you know that being motivated as a first step and really in progressing to it actually execution. And they didn't have the competency for that. SO I think to a certain extent they did understand they were engaged but they did not have the competency and this was certainly not a role that was right for them and so we price the role and we decided we would hire for this role. And since then we've done that and it has gone very well.
: that's a really great share. Dr. Aggarwal and kudos for you and your leadership to have just said you know okay it didn't work this way. The take away is ask for feedback. How would you feel about doing a role like this and then moving forward. So it sounds like you did learn a lot from it and now you've implemented it. And the program's working.
: That's great.
: Much better.
: So let's take the other side of the coin. Tell us a little bit about one of your proudest medical leadership experiences to date?
: So I mean the war is made of small victories. There's been a lot of lot of small, the small wins that get together to become a big win and then when I came to this organization, I was an outsider you know 50% of the organization more than that were insiders. So every engagement with the physician when they call you back, every time there's a very vocal discussion is to win. But, I guess what stands out is when I did my Masters in Healthcare Management couple of years ago, we had some or two business school like capstone project. It was the practicum they called it and what I choose to do I would have that on the pair side it was CMO for health plan at the time. And what I found was that in our senior population our health plan across Massachusetts so we had in this particular program of patients who were eligible for Medicare and Medicaid. These were for frail elders, a lot of them disabled who live in the community and who did not have transportation that the influenza vaccination rates were in the 30 plus percent. It was really low and nationwide wasn't that great either. You know in the 40. So what I decided that I was actually double it. I think i have the aim for 76%. And then in addition to ensuring that was my process measure I also wanted to see if we have fewer hospitalization related to the process measure which was doubling the vaccination rate. And so we did a whole program that was actually very cool. You know the united way the bold that you have where every donation the bulk gets dozed. We have sort of did similar things for each of our sites. We had four regional sites. We went and did the bold breakfasts we call them red, we got the staff. We did this whole program. The program was only between October and December because about the few season starts January and February. And we actually increased the vaccination rates above 80% and even though the new vaccine was not quite as effective that year, we actually reduced our in-patient utilization. So it was really plus it was an amazingly fun event going out there and doing the bold breakfast and then subsequently we started doing it for other pneumococcal vaccination and so forth. And it was really wonderful to do that to implement it in over a short period of time.
: Absolutely. Yeah, and I can imagine you had a lot of fun out there with the breakfasts and just having the conversation you know just like we're doing here. It's all about starting the conversation answering the why and and just moving along with some action because at the end of the day we all have to stand for something and do something. And there's absolutely no doubt in my mind that you Dr. Aggarwal are doing that and you continue to do that. Tell us a little bit about an exciting project or focus that you're working on today?
: So because we are a large network, we really have a we are across the eastern seaboard with a hospital in 8 provider groups and we have a lot of community hospitals, an academic medical center so we really are trying to execute across this network had a lot of challenges but a lot of opportunity. The big piece that we're doing now is really creating network in the post-acute phase really this is for our Medicare savings. We are working the post-acute providers and we are working on the home providers. The home agency, we're working on the infusion providers and it's been a wonderful journey because the providers themselves, the post-acute providers have been very very engaged. So we're using the people-process technologies to do that. We are using a data-directed, we have dashboard that they're giving them, the people are really our stakeholders, are hospitals and providers are giving us the first cut on who is important to them. We then use dashboards to narrow it down. We use CMS data to narrow it further down and then we have processed improvements plans and some of the providers who are not falling within the networks so they get always have a chance to come back in. So it's been a very, and I we also have technology involved in that we're using tools to help with the communication and the referral from our system to our post-acute provider. So there's a lot of work happening in that space and I continue to think as the inpatient utilization exists for the really sick folk. And as we continue to have programs such as this waiver program we can go directly from home to their nest or to home, this piece is very important.
: Now that's super interesting and you're only working inside of the walls but outside of the walls of the hospital and I think that's wonderful. Excited to see how your efforts turn out. I'm sure it will be with success and happier, healthier people. So Sarika let's pretend you and I are building a medical leadership course on what it takes to be successful in medicine today. It's the 101 of Dr. Sarika Aggarwal. So we've got four questions, lightning round style for you and then we'll follow that with your favorite book and favorite podcast if you have one for the listeners. You ready?
: All right. What's the best way to improve healthcare outcomes?
: To focus on the evaluation which is really quality in-patient experience divided by cost, to really cost effective outcome.
: What's the biggest mistake or pitfall to avoid?
: To really ensure that you work on the entire care continuum and not to work on programs that just shift care. They should be actual reduction of avoidable care so you cannot shift from innovations to observation you want to get this patient home.
: Oh that's great. How do you stay relevant as an organization. Despite all the change?
: You continue to ensure that you have your true north in your focus and you have to be agile so you're continuously pivoting, not in your mission and your focus but in all the ways that you are working your program.
: What's one area of focus that should drive everything in a health organization?
: It has to be quality of service and quality of care.
: And finally what book and what podcast as part of the syllabus. Would you recommend to the listeners?
: So there's two books, can I get two?
: Absolutely. You've given us so much value today. You can give to Sarika.
: So there's one that I love of it's called Nudge and it really speak to choice architecture and the call intervention and behavioral economics and it's important to use that in creating incentive programs, I used that in really creating data direct physician engagement. So I think of that I found in this book. And the other one is called Drive by Daniel Pink and that's really speaks to where physicians are, it's really when you want to drive them you don't use the filler drive which is you trying to get them to help at one do this things. And that only happens if they get autonomy and they have autonomy to decide what, when, where and when you give them mastery, you give them the tools and the goals .. and this actually apply both to providers as well as the patients, you really need to give them autonomy and mastery because it's all about self-management.
: That's a great call-out. And how about the podcast, any podcast recommendations?
: So I'm trying to think. I think the standardized health score to improve outcome, how to leverage technology to improve patient engagement, engagement of both patient and providers is definitely my focus because I think you can. What is that thing they say, you take the horse to the water, and got to make them drink. So all people process and technology doesn't, would not lead to outcomes to this actual engagement in the process.
: Outstanding listeners, take these recommendations down or if you're driving don't worry about it. Just go to outcomesrocket.health/sarika. It's S A R I K A. And you're going to find all of the show notes, the transcript to our discussion, links to Dr. Aggarwal's work and as well as links to the books that she recommended. So this has been such a pleasure Dr. Aggarwal, there's no doubt you're doing amazing things. Stay strong keep doing what you're doing. I love if you could just share one closing thought and then the best place where the listeners could get a hold of you or follow you.
: I think a closing thought would be my mantra is really you passionately want to be a participant in this revolution. And it is going forward and you want to be part of the process.
: I love that call out the part of the process listeners do not be passive. And if you're listening to this podcast there's no doubt that you are. So again just go to outcomesrocket.health/sarika. S. A. R. I.K.A. and you'll be able to find all the links and best places to get in touch with Dr. Aggarwal so that further adieu. Dr. Aggarwal just want to say a big thank you from myself as well as all the listeners.
: Thank you very much.
Thanks for tuning in to the outcomes rocket podcast if you want the show notes, inspiration, transcripts and everything that we talked about on this episode. Just go to outcomesrocket.health. And again don't forget to check out the amazing healthcare Thinkathon where we can get together took form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is "implementation is innovation". Just go to outcomesrocket.health/conference that's outcomesrocket.health/conference. Be one of the 200 that will participate. Looking forward to seeing you there.
Recommended Book and Podcast:
Best Way to Contact Sarika:
LinkedIn: Sarika Aggarwal