Sachin Jain, MD, MBA, FACP became president and CEO of SCAN Group and Health Plan in July, 2020 and has since led SCAN, including its 220,000-member Medicare Advantage plan and Independence at Home community service. Prior to this, he served as the CEO of CareMore Health and Aspire Health, where he led the growth, diversification, expansion and innovation efforts — all of which are actively involved in the business of integrated health care delivery.
Through the Vision Series, Jain shares his vision for the health care system of tomorrow with an emphasis on improving preventative care as a whole. He discusses the dichotomy of a health care system that is both there when seniors need it and less necessary than ever before. He also explains how chronic disease management and prevention ties into this vision in the long run — and why the future is already here.
Absolutely. I think one of the challenges that we have in the current health care system is that we do a phenomenal job for people when they get sick, but we don’t do a lot to actually keep them from getting sick and needing the great health care system that we have. It’s a funny thing: you want a system that’s going to be there for you when you truly need it to be there for you, but on another level, you want a health care system that almost makes itself less necessary.
The way you achieve that is by doing a far better job on early chronic disease management and prevention. It does a lot to actually keep people healthy as opposed to managing their complexities when their care becomes more complex. The way you do that is by investing more in outpatient primary care and strengthening the primary care infrastructure. There are so many points of evidence about how weak our current primary care infrastructure is that come from our own personal experience.
The best example of that is what happens to us between the hours of 5:00 PM and 9:00 AM in almost every geography in America, which is we are pushed out of the primary care infrastructure into the emergency care or hospital-based infrastructure, which is frankly ill-equipped and ill-designed to deal with all Americans, but it’s particularly poorly equipped to deal with the needs of aging Americans who ultimately, are not necessarily well-served in emergency room settings where they’re treated like strangers, because they are.
[Then] they’re pushed out of familiar surroundings into unfamiliar surroundings and ultimately admitted to the hospital, almost regardless of the situation, and they are admitted to the hospital whether it’s absolutely needed or not. As a result, we’re driving a lot of costs into the acute care system, but are inadequately investing in the outpatient system. It ultimately goes back to how we pay for care.
If we pay for care on a fee-for-service basis, then what you get is a lot of utilization of services where there’s margin to be created versus doing the things upfront to actually prevent and manage chronic disease. [Or], you actually pay for care prospectively through a global capitation of some sort.
I would say the future is here, it’s just unevenly distributed. There are organizations that do a phenomenal job of this. Then there are organizations that could be doing a phenomenal job of it, but for a variety of reasons do not. What I believe is the missing ingredient in our health care system, frankly, is change leadership and adaptivity. I think years ago, many people would have said, “Oh, well, the thing that’s missing most is the fundamental transitions in health care policy.”
Having been part of a lot of those transitions in health care policy, through the Affordable Care Act, through the Medicare Modernization Act, through the HITECH Act, what I can tell you is that I would give our policymakers a “B+” or an “A-” for putting in place the policy instruments to actually move us in the direction that we need to go. I would give our health system leadership, generously a “C” when it comes to thinking about how we’ve used the policy instruments that we actually have available to us.
What I mean by that is things like Medicare Advantage, ACO programs and bundled payments, which some organizations have actually embraced and made a core part of their strategy and others have merely done as window dressing for the whole same fee-for-service chassis. Even in organizations where there is a so-called Medicare Advantage strategy, it’s oftentimes a tasty side dish rather than the main way of actually transitioning to value-based payments for seniors.
In my future vision for the U.S., every delivery organization, health system, or medical group of any scale would either have its own Medicare Advantage plan or would be closely partnered with a Medicare Advantage plan to create a highly integrated, comprehensive experience for aging adults and for seniors. Unfortunately, these things end up being small side projects as opposed to main areas of strategic focus. That’s where I think the opportunity is greatest.
Yes. I would say there are parts of the country where the kind of health care I’m talking about is present. It’s not perfect, by any means, but it is how care is delivered. Then there are parts of the country where there’s a lot of rhetoric and there’s a lot of talk about moving to these kinds of models. Lots of conference plenaries are given on these topics. Lots of interviews with organizations like yours are delivered about the move from volume to value.
I read all of that now with a high degree of skepticism and cynicism because I believe that if organizations truly wanted to make these kinds of shifts, they can. Having spent my career trying to support this transition, I can say the real reasons that we’re not getting there are more sociological than they are policy-oriented or business model-oriented. It has a lot to do with organizations being successful in a current state model and in some cases advocating their responsibilities to their communities and their stakeholders and actually moving more aggressively toward models that support the health of aging populations as opposed to profiting from illness that arises from the side effects of aging.
I frequently cite a statistic from Mark Fendrick at The University of Michigan. There are billions of dollars in screening colonoscopies for individuals over the age of 80. Most interpretations of the U.S. preventative task force guidelines suggest that no one over the age of 80 should be getting a screening colonoscopy because of the risks of anesthesia and sedation to individuals that are in that population. Yet for all kinds of reasons, several billion annually of Medicare’s dollars are being spent on screening colonoscopies when it’s not indicated.
That’s because in our system of care, we get paid when we do things and our indications for things are oftentimes soft and squishy. As a physician, I can tell you, you can look at guidelines, and you can say, “Guidelines are meant for populations not for individual patients.” You can talk yourself into doing lots of things that may have some benefit for patients but that don’t in a holistic sense; oftentimes creating more risk than benefit.
I’m just picking one procedure in one indication, in one age group. When you look across the full range of procedures that are actually taking place across the whole health care system, you have a lot of utilization that one can justify when we put on a particular lens but when we actually look at what’s right for people in an overall sense, oftentimes doesn’t take on a realistic view of life aging [or] dying.
It starts with our attitudes and our culture around aging in this country. Because of a variety of business and cultural forces, we have a belief in this country that I think we’re starting to push back, which is that everyone should live forever no matter what. It’s very American to actually believe in the idea that we’re all going to live forever. As a result, we have a health care system that focuses a lot on curing the incurable and intervening upon the non-intervenable. I think we have an opportunity culturally to make death and dying less taboo topics, but as they are right now, it’s taboo to talk about death and dying.
You saw this in the Obama Administration where any efforts to talk about palliative care immediately got colored with this sort of death panel dialogue that came from some corners of our political spectrum. While we don’t want to create a society in which governments are deciding who lives and who dies, in many ways we already have that in the form of price discrimination and the fact that a lot of care is accessible to a lot of people.
I think we have to start having many more authentic conversations about palliative care, end-of-life care, and what a good death looks like in the United States. Right now, too many people are dying in ICUs when in fact they should have been dying at home surrounded by loved ones and again, shaped with a more realistic perspective on what it means to live a good life and death or dying.
I can tell you about a patient I took care of in the past couple of years who came to me with a diagnosis of stage four gastric cancer. This gentleman had one dream, which was to do this family vacation that would allow him to see Fenway Park. He was based in Los Angeles but he had a strong passion for baseball and really loved baseball parks. His oncologist said, “No, no, no, no, you’ve got to start your chemotherapy right away.”
I had a very different conversation with the patient where I said, “You could start the chemotherapy right away but it would mean that you would not be able to go to Fenway Park. If however, you had your visit to Fenway Park and then started your chemotherapy, you may be changing your equation around your cancer outcome but not that much because you’re already at a stage-four diagnosis. I think you could safely visit Fenway Park and you could then come back and start your chemotherapy. Let’s try and move your trip up with your family.”
Again, I don’t think we spend enough time with our patients to really understand what matters to them and what’s meaningful to them. I can tell you, this gentleman was super grateful to me for having given him permission to focus on what he wanted. Too often, the medical-industrial complex focuses on what the medical-industrial complex thinks is right for patients as opposed to giving patients permission to focus on themselves and what they want and what they need in their last season of life.
Technology can fundamentally be a facilitator of ease of the consumer and patient and family experience, but oftentimes, we overstep our view of what technology can and should be doing, and particularly in these highly critical inflection points in people’s lives. Again, this is where the fundamental design principle is around the patient-clinician relationship.
What technology should be doing is facilitating and strengthening that relationship, but not substituting it. I think oftentimes technology entrepreneurs, frustrated with what they see as a broken status quo in health care, think, “OK, how can I use technology to replace these frustrating elements?” as opposed to starting with the fact that this is the design, this is the thing that we have to build around, which is the relationship between clinicians and patients.
One of the things I love about Medicare Advantage is that there’s a measurement system. There’s a degree of accountability for people who operate and practice within Medicare Advantage, which is the stars system. Within the star measures are measures of patient experience, measures of clinical quality, measures of procedural quality, and these are not perfect by any means, but when you look at them in contrast to fee-for-service Medicare, fee-for-service Medicare doesn’t include any such measurements. When we look at fee-for-service Medicare alongside Medicare Advantage, in one system you have a degree of accountability and transparency around performance. In another system, you have fragmentation and payment only for service delivery when people are sick.
The other key piece is really around the fact that we have a chassis that exists, and oftentimes the thing that prevents us from thinking about scaling programs like Medicare, is we worry “Is there a chassis that’s going to enable the kinds of public and private partnerships that will allow this thing to scale and that exists in Medicare?”
I’m not sure Americans totally trust the federal government around the provision of health care. I think if we got to Medicare for all, I think it starts to harken to socialized medicine and some concepts that are less trusted by the broader American population. I think publicly-funded, but privately-administered Medicare, which is what Medicare Advantage is, is something people could rally around.
People think about that proposal in the context of big managed care companies as being the ones who are going to be profiting from it — the Humanas, the Uniteds, the Aetnas of the world — that have massive scale and would profit from this program. My view of Medicare Advantage for all is that it wouldn’t necessarily be all driven by managed care companies. They can certainly play and participate in this, but provider groups and the health systems could develop their own Medicare Advantage offerings that would compete alongside those big nationals.
As a result, you’d have a lot of grassroots Medicare Advantage delivery that’s community-based. As a result, I think you could have a marketplace that’s far more robust than the one that we even have now. I think that the marketplace could ultimately result in even better quality than we have today as it relates to the provision of Medicare services.
The steps that they’re taking around the integration of hospice benefits and Medicare Advantage, are important because the experience is oftentimes disjointed. There’s a sense in which you’re almost abandoned by your Medicare Advantage plan and associated providers when you go into hospice. I think that’s been an unintended consequence of how we paid for hospice historically.
At the end of the day, I think we have to start to see end of life on a continuum. We have to see it as an integration of clinician perspectives, as well as patient and family perspectives, and a system where people can move to the right and to the left on the continuum. One of the things that people worry about when we talk about hospice and palliative care is that it’s a kind of a unilateral progression to death as opposed to a model of better supporting people when they’re facing critical illness.
I do think that the real life experience of clinicians who work with the Medicare age population is that people can look terrible one day and be fine the next day, and the system should want that, and it should be comfortable with that. A deeper integration and a view that people can move to the right and to the left on the spectrum, actually, could result in the better outcomes that we hope to see for patients and for families.
I think palliative care is a super important underutilized specialty that focuses on symptom management for people who are facing complex and serious illness. In an ideal world, palliative care would be integrated into our approach to everything. Between both the field of geriatrics and palliative care, we have a higher degree of specialization on the needs of aging adults who face chronic disease, complex illness and serious illness.
What I do think we need though, is a greater level of integration of these principles and a greater integration of the palliative care team into the core medical team. When I think about how palliative care is used, both in the inpatient and outpatient setting, it’s almost like a, “Hey, we’ve got this complex situation, let’s put this person over here into this palliative care box.” As opposed to thinking, “How do we integrate palliative perspectives in a multidisciplinary team approach to taking care of someone with multiple sclerosis, cancer, end-of life or life-threatening illnesses?”
We have an opportunity to take a deeper look at the integration of palliative care. I was fortunate, my father was actually a pain management physician at Memorial Sloan Kettering Cancer Center in the early days of the pain management movement, so I grew up around these concepts and around the pain management specialty as well as the palliative care specialty. This type of thinking is really kind of second nature to me because those are the conversations I was having at my dinner table with my father, and that was my silent education or silent curriculum in medicine that I grew up around.
I can say that a lot of the profession still doesn’t fully understand or embrace palliative care because they’ve had mixed levels of exposure to it and engagement with it. I think physicians, particularly in niche specialties are oftentimes terrible at marketing their value and marketing their services. We do need to have a broader perspective, but it has to start from medical school, continue into residencies, continue into fellowships, and then continue into how large health systems and health plans think about the integration of palliative care services into the design of patient care.
One of my biggest concerns about palliative care is the commoditization of care and the fact that we don’t necessarily approach the specialty in some cases with as much seriousness as we ought to. The best palliative care physicians have real mastery of the patient’s medical issues, but also their social and psychological issues. I think what’s happened is we’ve seen a number of skilled or sub-skilled palliative care models that inject themselves at moments in a cost saving exercise for patients. I think that we want less of that and we want more holistic consideration of patients. Done right, it will save costs, but that should not be the driving objective. The driving objective should be better care for people and patients and families.
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