DR. DANIEL KRAFT (00:00):
Clearly we need to expand access and use of primary care, across the healthcare systems.
DR. SREE CHAGUTURU (00:05):
We need to have competition. We need to have continued investment into primary care. There's not going to be one right answer. We need all of these different models to succeed, to get primary care to a better state, than what it is today.
DR. DANIEL KRAFT (00:23):
Welcome to Healthy Conversations, an original podcast from CVS Health, I'm Dr. Daniel Kraft. Primary care is the backbone of the healthcare system, but if primary care were a patient, it's in need of intervention. Today we're going to look at the challenges facing primary care and how we can work to fix the system with someone who spends a lot of time thinking about this very issue. I'm pleased to be in Healthy Conversations today with Dr. Sree Chaguturu, Executive Vice President and the Chief Medical Officer for CVS Health. Sree, thanks for joining me.
DR. SREE CHAGUTURU (00:53):
It's always really fun to chat with you.
DR. DANIEL KRAFT (00:55):
We both trained as primary care docs and primary care is really a foundation of the healthcare system. And for years, we've encouraged patients to develop a relationship with a primary care provider who can help them manage their overall health, but there definitely seems to be cracks in the system. What do you see as the challenges in primary care? And conversely, what do you think's going well?
DR. SREE CHAGUTURU (01:17):
Daniel, when we think about primary care, it is the foundation of how we deliver healthcare in this country. It's that trusted relationship that helps you navigate the complexity of the American healthcare system. It's somebody who knows you and helps you understand, what are your health needs and make sure that you can fulfill them. But when you ask people, "Are you satisfied with your relationship?" Almost 80% of individuals in America say that, "They're unsatisfied with their current healthcare experience." The average wait time to see a primary care physician is almost one month, 26 days. But when you do have primary care, great things happen. And what we see is, that you have a lower risk of mortality of death. So there's a lot of benefits of having primary care.
DR. DANIEL KRAFT (02:07):
We were both residents at Mass General Hospital. I worked at a clinic in Chelsea. I got to sort of see patients through their prevention, their diagnostics, their therapy, their subspecialty care. What have you seen shift in the last couple decades and what do you think sort of needed to improve the system?
DR. SREE CHAGUTURU (02:25):
Many years ago, we thought about primary care, as a doctor patient relationship, but it's evolved substantially, to something that we would call team-based care. It's not just with your primary care doctor, but it's with a nurse, a medical assistant, a front office staff, a social worker, potentially even, a behavioral health support specialist that's embedded in the practice, financial support specialists. And it's not that you're going to be interacting with every single one of those individuals in the care team every single time. And that's a really exciting evolution of primary care over the last couple of decades.
(03:05):
The next big evolution that we're seeing is the sub-specialization of primary care. Primary care over the last couple of decades, has been under invested. If you look at every dollar that's spent in the American healthcare system, only about 5 to 10 cents of that dollar is spent on primary care. But we know that when you increase primary care spending, good things happen. You start to improve quality and reduce downstream costs of individuals healthcare experience. And so what's happened, is that there's been a lot of innovation in paying for primary care. Primary care has now started to identify care models that works really well for seniors and those individuals who are in Medicaid and individuals who are commercially insured, different ways of providing care, depending on your healthcare needs.
(04:04):
If you're a senior, you may need more support for chronic disease management and managing multiple chronic illnesses or help transitioning from hospital care to ambulatory care. If you're a Medicaid member, there'll be more need for social determinants of health, helping you navigate your transportation, needs for food security, and integrating that team-based model with social determinants of health. Underlying all of that is technology. And Daniel, it's been really exciting to see how technology has helped support these team-based models.
DR. DANIEL KRAFT (04:43):
So one technology that we've all been living through, catalyzed by the pandemic, was telehealth. We still have a large gap in the number of primary care clinicians and providers around the country. What has your experience been within CVS Health and beyond, where telehealth and other technologies, whether it's mobile apps and connected devices and chatbots are playing a role, and how do you think that might evolve into the future?
DR. SREE CHAGUTURU (05:05):
The way that I think about technology and especially telehealth, is that it helps us to force amplify that relationship that we have with our primary care team. Previous to COVID, we would go into a clinic, we would take time off from work, and that experience was great when you were able to schedule that time, but wasn't always convenient in the way that we live our lives. Now, telehealth gives us an additional opportunity to see our primary care clinicians, and that is what we would call, omnichannel health, in-person, in clinic or virtually or at home. But what we saw through the pandemic, is that patients love to be able to have telehealth, but it is not replacing that physical relationship, it's augmenting that physical relationship.
DR. DANIEL KRAFT (05:58):
Any sort of ways you've learned to integrate the technology that's worked particularly well in the primary care setting?
DR. SREE CHAGUTURU (06:04):
We launched earlier this year, CVS Health Virtual Primary Care. What that allows us to do, is to be able to see individuals virtually, but when they're need to be seen in-person, they can go to a local MinuteClinic and there is a electronic medical record, your health record, which is integrated across all of those care settings. And that allows us to have that continuous care in these different modalities.
DR. DANIEL KRAFT (06:33):
Care anywhere, anytime. So zooming back, one of the big successes, as we know in primary care, is often the simplest and most cost effective, particularly in public health, which is vaccines and I've been to CVS Health for most of my vaccines. But we've seen a bit of a rebound in some vaccine preventable diseases. Vaccine hesitancy has certainly been on the rise. Can you talk about the current state of vaccine medicine?
DR. SREE CHAGUTURU (06:57):
Vaccines are an incredible breakthrough in medical technology. It helps us prevent illness or prevent the progression of illness or serious consequences of infectious diseases. Yet as you point out, there's been increasing mistrust of technology, such as vaccines. This fundamentally, is about trust in American healthcare, and we've seen trust declining across all sectors of American life, including medicine. However, what we do also see, is that trusted professionals, such as physicians and nurses and pharmacists, really help us. Let's take something like COVID-19. The vaccines have evolved substantially since they first rolled out, and we've also started to simplify who gets it and when do they get it. You'll likely for most individuals, receive a COVID-19 vaccine at the time that you get your flu vaccine. That makes it much simpler and easier for us to understand when to get it and it will protect you during those winter months, when we will likely see more COVID-19 circulating.
DR. DANIEL KRAFT (08:12):
I've been pretty impressed with my CVS self app when I needed to get my last booster, super easy and streamlined. I'm certainly not vaccine hesitant, but how do you identify those who might be, who don't have that trust relationship?
DR. SREE CHAGUTURU (08:25):
One of the ways that we've been trying to drive vaccine acceptance, is to better understand an individual's preferences. This is a program that we call, Next Best Actions. Let's say Daniel, you're a convenience focused person, I, on the other hand, am cost sensitive. I want to make sure that there's no real significant financial burden. And Daniel, you're much more digitally engaged than I am. Whereas for me, I respond to more traditional outreaches, like phone calls or mailings. We can tailor our messages, so that when we reach out to you, we tell you about the convenient locations through email or text messaging. Whereas for me, it's about, "This is a no cost vaccine." By phone call or by a traditional mailer. In addition to Next Best Actions, it's just ensuring that you have the health information necessary to understand any treatment. What are these vaccines and how can they help you in preventing serious illness and hospitalization and why they're right for you? That you can get at cvs.com.
DR. DANIEL KRAFT (09:34):
So let's switch to my favorite topic. Not really. Regulation. Regulation is key to making healthcare work, but often can sometimes feel like it's getting in the way. Regulations are built to ensure patients get safe, quality healthcare. But for clinicians, increasingly complying with these regulations, whether it's HIPAA or star ratings, can sometimes feel like it's taking away from patient care. Can you kind of give some insights into the regulatory environment in primary care, what you find helpful and what might need a second look?
DR. SREE CHAGUTURU (10:04):
I think about this, less about regulation and more around payment innovation. So we talked earlier about how primary care has been chronically under invested. What we see now with a lot of the regulations, is trying to promote these payment innovations. So how do we increase the amount of expenditures spent into primary care, so that we can invest in these team-based models, the technology that we need? And so this has led to something called value-based care, providing high quality, lower cost care, that generally involves increasing payments to primary care with the promise of reducing costs of healthcare and reducing your hospitalizations, reducing unnecessary procedures or ER utilization or helping you to navigate your post-acute care.
DR. DANIEL KRAFT (11:01):
But we're often still stuck in a world where we're sort of fee-for-service in some realms, value-based care in another. Have you seen ways to blend the incentives of value-based care with the incentives of fee-for-service, to help clinicians really do the right thing and be aligned with their incentives?
DR. SREE CHAGUTURU (11:18):
I love this topic because it is one of the challenges that we have as a healthcare system. So let's start with what is fee-for-service? You do something, you get paid for it, and it's a one for one transaction, and there's a simplicity to that. Now, there's a moral hazard to this too. If you're paid for every action, then there's an incentive to do more of those actions, and they might not necessarily be in your best interest. On the other end, value-based care is making sure that we pay upfront, it's something called capitation. But the moral hazard there is that you don't do enough. You're spending less, instead of managing the care that somebody needs.
(12:01):
And so the reality, Daniel, is that we need to balance these two bookends because there's moral hazards on both ends. So it's important for us to measure what's being provided in value-based care. Are we providing the cancer prevention services? Are we meeting the chronic disease management for diabetes and hypertension and heart disease? That's a way for us to count and measure the improvements in chronic disease management. And so there's a lot of models that are out there, that show that you can start with fee-for-service and slowly move by taking on more and more risk to manage total cost of care.
DR. DANIEL KRAFT (12:42):
Let's zoom back and talk about, how do we think about the market forces that have been shifting along with technology, competition and where folks get primary care, whether it's virtual, whether it's physical? We've sort of seen a new cadre of companies spring up that are changing how folks integrate and also, who's providing primary care?
DR. SREE CHAGUTURU (13:01):
Primary care is broken. And so what's happened over the last couple of decades, is that as primary care is looking for that investment, hospital systems have been buying primary care. And the idea there was that, by investing in primary care as a health system, that you would then get downstream referrals for your hospital, referrals for surgeries or hospitalizations, the things that help drive the economics of hospitals. But as we talked about earlier, that isn't necessarily always in the best interest of a patient.
(13:38):
So now you basically have primary care into three buckets. You have independent primary care that's not aligned to a hospital or another institution. You have primary care that's aligned with hospital or health systems and then primary care that's aligned with new organizations, such as ourselves, CVS Health or Optum or Humana. And so you might ask, "Well, what's the right answer here?" The answer is, all of the above, Daniel. We need to have competition. We need to have continued investment into primary care. There's not going to be one right answer. We need all of these different models to succeed, to get primary care to a better state, than what it is today.
DR. DANIEL KRAFT (14:26):
Clearly, we need to sort of expand access and use of primary care, across the healthcare systems.
DR. SREE CHAGUTURU (14:32):
So when I think about expanding access, it's about ensuring that we have a way for individuals to access care the way that they want it, in a manner that's convenient to them. Let's take something like vaccines. What we saw with vaccines and expanding access, is because of our convenient locations, our nearly 10,000 locations across the country, 85% of individuals within a few miles of CVS Health, that then led to our vaccine rollout. 40% of the nearly 90 million COVID vaccines that we have provided, were in high social vulnerability communities. These are disenfranchised communities. We were in the locations that mattered, to provide access where access traditionally hasn't been available. This is very different than how care has traditionally been provided, and we're excited to bring these innovations to the American healthcare system.
DR. DANIEL KRAFT (15:29):
Where would you want to see primary care go broadly in the next decade, and how can other technologies and organizations help?
DR. SREE CHAGUTURU (15:37):
There's something called the quintuple aim in healthcare, and that quintuple aim means that there are five things that we're trying to achieve. We want to reduce the total cost of healthcare, it is just too unaffordable. We want to improve the quality of healthcare, make sure that people get the preventative service and the chronic disease management they need. We want to make sure that they have access to the healthcare that they need, in a timely manner. We want to make sure that it's a wonderful experience and that we have equity in how we deliver that care. So it's cost, quality, access, experience, equity. It's going to take us a long, long time. What we see over the last decade, especially with COVID-19 and getting to the other side of the pandemic, there's been a renewed interest in making sure that primary care plays that central role in improving healthcare. We will get there, but it will take all of us investing more and more into primary care, to make this vision a reality.
DR. DANIEL KRAFT (16:38):
It's definitely an exciting time to converge needs, the technology, the mindsets, and great organizations like CVS Health to move that needle. I'm Dr. Daniel Kraft. You've been listening to Healthy Conversations, the podcast. Subscribe to stay up to date with our latest episodes.
