In a wide-ranging discussion at the virtual 2021 University of Pennsylvania Wharton School Health Care Business Conference in February, OptumHealth CEO Wyatt Decker, MD, MBA, sat down with Leonard Davis Institute of Health Economics (LDI) Executive Director Rachel Werner, MD, PhD. The session was in keeping with the conference theme of “Redrawing the Curve: New Paradigms in Health Care,” in that Decker is both a high-profile champion of the value-based care payment model and the top executive of a sprawling national health delivery network that experienced the COVID-19 pandemic in all its manifestations.

OptumHealth has 20 million patients in 40 states and, in one way or another, touches the health interests of 98 million people annually. Its various operations use fee-for-service and value-based care payment models, as well as “blended” clinics that use both payment models.

Among the topics discussed were how the value-based care model is being used to combat physician burn out; the changes bringing new levels of primary care parity in physical and mental health care; the unexpected “silver linings” the pandemic has brought to some areas of care; and the three biggest changes Decker says are necessary to right the floundering U.S. health care system.

These are excerpts from the interview, edited for brevity:

WERNER: The COVID-19 pandemic has revealed many longstanding faults in the U.S. health care system that couldn’t withstand the stress of a crisis like this one. It seems like the fee-for-service payment system we’ve relied on for so long really started to fall apart during the pandemic. Tell us a little more about how the pandemic has shaped your thinking about health care payment models, including value-based payment and what the future should look like.

DECKER: The pandemic experience has heightened awareness that the fee-for-service has kind of failed. That tells us something, and asks how we think about this going forward from a policy perspective. Now that we’ve seen up close the resiliency of a more value-based care model, how do we accelerate our nation’s journey into more value-based constructs?

What you saw during the pandemic is fascinating because fee-for-service practices basically stopped or had dramatic reductions in their volumes. We were able to leverage our scale and resiliency from a financial perspective to navigate it, but for smaller independent practices, this was an enormous strain. A number of them saw early retirements of doctors and other people trying to leave, but the value-based medical programs saw the opposite. Payers saw less utilization of medical services during the height of the pandemic, and that, in turn, led to better financials, but an unacceptable human cost. It’s estimated that about 45 percent of Americans deferred some form of medical care; the full, long-term consequences of this aren’t even clear yet. It appears there have been at least 100,000 excess deaths due to causes other than COVID during the pandemic. That’s just the beginning. 

Sent to 90,000

We were worried a lot about cancer screening at a time when patients weren’t coming in. Our approach to counteracting this was to use a DNA swab tool called Cologuard. We sent Cologuard kits out to about 90,000 of our risk-based seniors at no cost to them. That’s the kind of thing that’s harder to do in a fee-for-service system because there’s no way to capture the cost of that. We don’t worry about the cost because we’re trying to make sure we identify and treat cancer patients early. From a business perspective, we’re financially aligned to try to identify and treat those cancers and not let them cost more later. So that’s the kind of innovation we are able to drive in the value-based care we deliver.

WERNER: What will it take to get a more complete adoption of value-based care? There are some areas of the country which have been progressive in the adoption of alternative payment models. There are many others that are much less so and rely more heavily on fee-for-service. Certainly, under the Obama administration, the Secretary of the Centers for Medicare and Medicaid Services (CMS) set goals related to the amount of payment that was going to run through alternative payment models. But they never quite reached that goal. Is increasing adoption of value-based payment a goal your company has? 

DECKER: We’re in markets known to be more mature in value based care—like Southern California, Texas and Florida—and we’re in other markets that are in the middle, like the Pacific Northwest, and markets such as the Northeast where there’s little—not none, but less—value-based care penetration. 

I’m a doc. I just want a health care system that works, which is what most of us want. As an emergency physician, I saw the amazing and wonderful ways care can be provided but I also saw all the failings of our health care system in the U.S.—for example, people with chronic diseases who couldn’t get access to care. So, I’m just deeply passionate about the question: how we can we solve this? The fear is our health system can’t continue in its pre-pandemic mode. If its cost curve is not bent, the system will, at some point, collapse under its own weight. It’s hard to say exactly what that means, but the possibility is a very, very compelling case for value-based care delivery.

Full capitation, full delegation

Within that concept is the notion of full capitation and full delegation for almost the whole health care dollar. That means your doctors, nurses, and the team that surrounds them with data and analytics, population health, mental health, and many other services, would really be responsible for your health care spend. And their motivation in that setting is to keep you healthy and well.

The question is how do we create that health system, because value-based care involves such a wide swath of financial arrangements? The full-risk model is by far the most powerful but it’s also the scariest for groups that haven’t been in that space, and it’s the hardest to move to. That’s why you see things like direct contracting and other thoughtful efforts at CMS to try to help that journey happen.

WERNER: I agree with you that alternative models and risk-bearing alternative payment systems are where it’s at for the future. The question is how you get there, because, as you said, providers are understandably nervous about it, particularly as they’ve been operating in a fee-for-service environment for a long time.

DECKER: This is actually part of the value proposition of Optum, because when we talk to doctor groups with an acquisition team—we buy practices—we’re in it for the long haul. Our approach is very, very different from a private equity transaction that is interested in increasing a practice’s valuation over a three-to-five-year time frame and then divesting. If there are any physicians out there in these situations, look very carefully at what their business model is and how they’re going to grow your valuation, because if it’s cost cutting and increasing productivity in a fee-for-service environment, I would just say buyer beware. 

In our model, we partner with physician groups and help them with tools, data and analytics. We actually have much happier doctors once they join our teams because we can provide the support and get them back to practicing medicine. We have examples of family doctors that have joined us that were seeing north of 30 patients a day. They were charting till 10:00 or 11:00 at night. They were super frustrated or even ready to hang up the towel. And then we join them or, even if they stay independent, wrap services around them. They start seeing, say, 12 to 14 patients a day. And those are the patients who need to be seen most because our teams and their analytics have identified them as such.

Proactively identifying patients

This is one of those absurd things about private practice fee-for-service. Primary care is often about who called into your medical system. But there might be somebody out there way sicker who is one of your patients, but you may not know that. So that’s where the whole notion of proactively identifying patients comes in. If we provide that service so the docs don’t have to learn a whole new skill set, then they can do the work they love, and that’s a super exciting thing. 

One of my other passions is how do we address physician burnout? And value-based care is part of the solution. Value models allow us to actually come up with solutions for getting back to the bedside. One of the most obvious, yet perplexing, things in fee-for-service health care is that doctors are relatively highly paid people. So why has the system around us created an environment where the most highly paid member of the team typically is doing data entry for two hours a day per hour of patient care? It’s absurd. It’s an absolute absurd business model and doctors hate it. So there’s just an enormous opportunity for us to get this right. And that’s what I’m all about. That’s what we’re trying to do here at Optum.

WERNER: Another long-standing problem in our current health care system is the lack of parity between physical health and mental health. Are there ways that you think about trying to address that parity and improve it?

DECKER: I think the best thinking and best research challenges the notion that physical health care and mental health care are two completely different buckets doesn’t pass the common-sense test, much less the growing evidence around it. Value-based care models allow us to much more effectively integrate whole-person care. It’s not about a business model per se, it is about having financially sustainable solutions. 

The more we can bring everyone’s health care—behavioral and physical health care needs—together in whole-person care, the better. That’s the care delivery model we have developed and are continuing to deploy in Optum care delivery. Many of our clinics have embedded mental health workers on the team to integrate behavioral care and physical care together when appropriate. It’s a value-based care where incentives are aligned.

WERNER: Telehealth has become a much larger part of health care delivery during the first year of the pandemic. What did Optum do in this area, and what are your thoughts about how you want to integrate telehealth into an ideal version of health care delivery going forward?

DECKER: The pandemic has been a nightmare. At the same time it’s shown us some interesting, weird, and unexpected silver linings. The whole health care community across the US and globally has rapidly accelerated, deploying telehealth and digital health solutions, and we were no different. Before the pandemic, we had under 1,000 providers leveraging telehealth services. We rapidly stood that up to over 17,000. We’ve done well over a million virtual visits. This would have been maybe a three- or five-year journey pre-pandemic, but in the midst of the pandemic, it just accelerated into a matter of weeks. To me it was an example of where we were able to lean into existing infrastructure to rapidly expand it.

Both we and others who are leaning into the space are learning more and getting better at this at a much faster rate than we would have without being pushed forward by the pandemic.

Telehealth and social determinants

Among providers, the attitude has shifted. I have personal colleagues who had some high-risk conditions, and they were grateful to be able to continue to practice as doctors virtually. The skepticism has always been that you can’t, of course, lay hands on a patient; can’t conduct a true physical exam. But there are new things you can do, like get a little peek into people’s homes. So, you might identify things like fall risks, or maybe there’s no food in the house. You’re actually seeing real clues to the social determinants in this new window into people’s lives that you don’t get in a clinic.

So, there are upsides and challenges. We’re still learning nationally and beyond how to best leverage digital health with bricks and mortar care. We’ve found that with established patients whose conditions we’re familiar with, it’s an ideal setting for telehealth because we have confidence in their records and findings. With newer urgent care types of complaints—”I’ve got pink eye”—that works fairly well, too. In specialty care, again, if its a well-established patient, that’s one thing, but if it’s a new patient, it’s a little bit harder, depending on the condition.

What most patients will tell us is that they would like to be able to access their own trusted provider. Currently, there are many telemedicine services that are kind of a random doctor. That doesn’t mean that doctor is not super good, but you’ve never met them, and knowing your doctor makes a difference. For an urgent care complaint at 2 a.m., it’s fine. But over time, people really want to gravitate to their trusted providers.

We’re now deploying a comprehensive telemedicine solution that allows people to seamlessly and easily connect with their own team that they trust. On the provider side of this, the docs need the data. It’s very hard to take care of a telemedicine patient if we don’t know their clinical background, their medications, et cetera. So pulling the relevant clinical data from the electronic health record is a critical element.

WERNER: I’ve seen some statistics suggesting telehealth has been particularly beneficial for behavioral health. And the rates of no-shows have really gone down quite dramatically for these visits.

DECKER: In regular medical care, we saw a huge uptick in telehealth, but then a downward trend as the pandemic appeared to be waning in the summer and fall. But for behavioral health it stayed up. The outpatient care is still 50 percent telehealth.

An estimate I’ve just seen says about 53 percent of the adult population feels that their mental health has deteriorated during the pandemic. That’s just massive. And there’s all the data around substance use disorders. So, this is now like a pandemic within a pandemic, essentially. 

Mental health and digital therapy

And because of the fragmented and inefficient nature of our support systems, we need to just radically rethink that. We’ve begun deploying digital therapeutics and intake systems that can determine what people need. But how do we know if it’s safe to give someone an eight-week digital program on a tablet, or are they at risk for harming themselves, or should they be in a hospital? We’ve developed an intake process that figures out if you can safely be managed for things like early anxiety or mild-to-moderate depression using a digital therapeutic approach. We have some really exciting, cool tools in that space. Do you need a medium touch? Meaning it’s now gotten more serious, but with your primary care provider and maybe a nurse check-in combined with some online therapeutics, maybe that could work.

And then there’s the SMI population—serious mental illness. For folks not in the field, think of stage-three cancer. When you have serious cancer, you no longer are really in the domain of primary care, you’re in the domain of your oncologists for that period of time. And I think the same is true with serious mental illness and advanced substance use disorders.

So that’s what we’re bucketing it into and then working on innovative solutions in these domains. We’re building this up as quickly as we can, but it’s still not fast enough to meet these needs. There are a lot of interesting startups moving into this space. So we acquired a company called Able To that is really forward leaning in this. And we have an internal company we call Sanvello, and that’s where a lot of our digital therapeutics live. 

WERNER: I think one of the things we all worry about with telehealth, along with other technologies, is what it’s going to do to the disparities in care and inequitable access to care. There’s been some recent data coming from Penn looking at the use of telehealth by patients throughout the pandemic and finding that those with higher social risk factors, racial and ethnic minorities, and people enrolled in Medicaid were less likely to schedule a telehealth visit and less likely to complete a telehealth visit. There are a lot of concerns about what this is going to do to disparities going forward.

DECKER: I think the opportunity is for us to figure out how to leverage these technologies to lessen disparities. This shows you the importance of a scientific approach—for example, I initially felt this could be a panacea in rural care. But if you look at telehealth adoption rates of rural communities, it’s much lower. So, I think that there’s more work to do, both culturally and also just in terms of resources and access to the kinds of tools we need to really be effective in this.

WERNER: Last question. If you were to give advice to the audience about the three biggest problems you think need to be solved in health care, what’s the top of your list?

DECKER: I would say we need to continue work aimed at solving the issue of alignment of incentives. Align the financial incentives so that all the great health care workers and data engineers and scientists can start getting the things to hum. 

Interoperability is another big one. I would say let’s get interoperability and, as you know, with the Cures Act and other efforts, there are now some pretty exciting mandates to actually get this done. So, let’s figure out how to make data available, when it can really impact people’s health care journeys. 

And third, let’s really embrace the health care journey of our providers and get out the waste that’s a business inefficiency. More importantly, it’s got a human cost to our nation’s docs and providers. So let’s drive that out. 

And, if you’re an entrepreneur listening to this conference, I’d say that all these domains have big opportunities. The market is super interested in health care right now, and if you have something innovative, people will listen. That’s exciting to see.