the crucible for new ideas in healthcare
Cliff regularly brings together the best minds in the business for a one day summit where they tackle the most pressing healthcare issues of the day. In this section, you'll find our announcement of Cliff's latest upcoming Confab, as well as summaries of some of the more recent Confab summits. Contact Cliff to have him assemble one of his special expert-level summit teams to work on issues that concern you and your company.
Market Segmentation and Barbell Physician Supply – A Scenario and Forecast
(article, June 2021)
Our TD3 deliberations have highlighted that there are differences in primary care consumption patterns
among younger and older populations, Medicaid and commercial insured patients, and other
demographic descriptors of people. Similarly, we have identified that certain configurations of PCP
delivery work better for some populations than others – intensive PCP and team visits for Medicare and
Medicaid patients, quick convenient care for younger adult patients, telehealth visits and regular visits
for chronic care patients. We describe the process for PCP optimization as a matching problem fitting
the patient characteristics with the most appropriate PCP care delivery model. Well…. Looks like the
market is tackling this matching problem right before our eyes.
Private Equity-backed entrants to the PCP marketplace are making a big push into Primary Care for
Medicare Advantage patients. VillageMD, ChenMed, P3, Iora and others are aggressively expanding
into these market segments, city by city. These PCP companies pay their physicians well and offer them
huge bonus potential from savings from downstream utilization management. Physicians with these
companies can make double the income that they could make as hospital-employed or private practice
Walmart, Walgreens, CVS and others are pursuing the younger adult patients with convenience care and
front-of-store shopping offerings. They are contemplating expanding chronic care services but mostly
for commercial insurance aged patients.
And now One Medical is purchasing Iora signaling a shift in their commercial strategy to emphasize
Medicare Advantage. Iora made that pivot 3-4 years previously because the savings opportunities in a
well-managed Medicare Advantage population are much larger than in commercial insured populations.
So, what does this mean if these trends continue? Trouble for the Middle.
Medicare Advantage is hugely profitable when managed well. Managed Medicaid can be very
profitable for PCPs using team care as well. Dual eligible can be likewise profitable and all these
populations are better served in these arrangements as measured by health outcomes, care gap
closures and patient satisfaction.
Entities serving these populations can pay their physicians very well through a combination of salary,
bonus, pay for quality, pay for outcome, and shared savings from downstream utilization management.
Double the pay of hospital employed physicians.
How big is the need and demand for physicians in these MA/Managed Medicaid private equity
supported models? HUGE.
Where will they pull their additional physicians from? …… Disgruntled hospital employed physicians
and new graduates are prime targets, along with independent physicians looking for a landing pad (a
rapidly diminishing pool). Hospitals cannot continue to pay top wages in the face of declining referrals
for specialist procedures at hospital facilities. As payers continue to push mandatory outpatient
services, non-hospital outpatient services, and stiffer approval criteria for any hospital service, the math
associated with the downstream revenue offset to PCP costs no longer works.
So, ten years from now out we have a wave of productive physicians retiring, new graduates pulled into
private equity backed MA/Managed Medicaid practice corporations, and a few hospitals still paying top
dollar for PCP talent. Walgreens, CVS and others are still grabbing other PCPs looking for a transaction
practice without much stress or afterhours call. For the rest of hospitals, employed primary care
physicians are scarce, APN’s are common and provider burnout unavoidable. A destructive cycle
started inside the current Covid-19 cycle highlighting the misery and vulnerability of hospital-employed
PCPs, and as more physicians retired, and were unable to be replaced, the remaining physicians’
burdens got heavier and heavier. The appeal of the lifestyle, wages, and relief from the daily grind of
the hospital employed physician model led more to migrate to other models, which made filling PCP
slots even more difficult for hospital medical groups.
Hospitals’ ability to subsidize PCP salaries will be limited as payers drive patients away from outpatient
hospital services, as technology enables patients to receive more care in free-standing non-hospital
facilities, and PCPs are less able to deliver downstream revenues to their hospital employer.
Commercially insured populations do have utilization problems, but not near on a scale that is present in
Medicare populations. Taking a Medicare population from 300 admissions/1000 to 180 admissions per
1000 generates a huge savings pools for PCPs. Taking a commercial population from 80 admissions per
1000 to 60 admissions per 1000 does not have near the same lift opportunity for PCP incomes.
The emergence of non-physician providers giving services to patients independently, or at-home, or
under physician supervision may stretch the providers’ reach within a given patient population segment,
but such dynamics will further enhance the “team care” approach and exacerbate the dearth of
available providers for commercially insured patients. Team care makes economic sense in a provider
risk-bearing system. In a fee for service model, it’s just more mouths to feed and more fights over the
leftover table scraps of the health insurance premiums not going to prescription drugs, hospitals and
Ten years from now we end up with adequate PCP supply for Medicare Advantage practices, Managed
Medicaid practices, and very inadequate supply and access for commercial insured patients – THE
BARBELL of PCP supply. What a strange outcome compared to today! So long as risk adjustment for
high-risk patients remains within Medicare Advantage and Managed Medicaid, the funds to pay primary
care physicians for curbing downstream utilization and managing the health of their patients, PCP wages
and bonuses will far exceed pay that is available in today’s traditional hospital employed model.
Provider Risk Immersion Day
March 29, 2019 - Tampa, FL
In the covid-19 era, and like everything else, Cliff's Confab is going virtual. A new concept for the Confabs has been born as well - healthcare topics covered debate-style between industry experts. The first three sessions covered six debate topics, two each session, over the 3 day period of Dec. 9-11, 2020. While these are private, invitation-only events, we're excited to share videos of these debates with you here.
Note that the videos are individually downloadable, so feel free to download those that are of interest (see below).
For further information on Cliff's Confab or the Debates or any of these videos, you can reach us here.
Video Directory - note that the videos immediately follow the directory.
(To download any video, use the download icon on each video)
Debate event 1 - Wednesday, Dec 9, 2020:
Confab 1, Debate 1:
Resolved - That employers will demand a "best of breed" network configuration from BUCAs or they will find a payer that puts together such a network.
Debaters - Michael Brouthers, Founder/Principal, Ikigai Growth Partners; Fred Goldstein, President and Founder, Accountable Health, LLC
Confab 1, Debate 2:
Resolved - That entrenched forces (PBM's, hospitals, insurers, regulators) will squash any significant innovation that threatens any class of these entities.
Debaters - Tom Nasby, Senior Director Network Management, Aetna; Chuck Reiter, III, Esq., Partner, Reiter Burns, LLP
Debate event 2 - Thursday, Dec 10, 2020:
Confab 2, Debate 1:
Resolved - That healthcare is NOT a normal economic good, and programs/policies that encourage healthcare's treatment as such are misguided and should cease.
Debaters - John Harris, Director, Veralon; David Kibbe, Senior Vice President, Network Development and Contracting, Cone Health
Confab 2, Debate 2:
Resolved - That provider burnout is getting worse, and physicians will become key recruits to new technical and product development jobs, thereby exacerbating the PCP shortage.
Debaters - Sanjay Seth, MD, Executive Vice President, HealthEC; Wayne Jenkins, MD, Chief Medical Officer, Centivo
Debate event 3 - Friday, Dec 11, 2020:
Confab 3, Debate 1:
Resolved - That increased payer hassles of providers will lay the groundwork for Provider risk-transfer arrangements to avoid denials, appeals, and legal friction costs for providers.
Debaters - Mike Guarino, President, Practice Management of America; Brent Estes, Senior Vice President, Business Development, Advocate Aurora Health
Confab 3, Debate 2:
Resolved - That primary care supremacy in managed care is unwarranted, unsuccessful and unnecessary to manage cost/quality/outcomes.
Debaters - Mike Shumer, Chief Executive Officer, Medical Life Holdings; Shawn Bassett, Executive Director, Collaborative Health Systems
Cliff's Confab - Provider Risk Immersion Day March 29, 2019
Those who joined us recently in Tampa, FL for Cliff's Confab: Provider Risk Immersion Day agree that it was an informative, interesting, interactive, and intellectually stimulating experience.
As an example, be sure to check out our Media page, where you'll find a few video clips from Cliff's presentation: "Risk Deals are...Risky!"