This week I am talking to Randy Hawkins, MD Chief Medical Officer of Carrum Health (@CarrumHealth). Randy is an anesthesiologist who practiced medicine in the Navy and has a long career in digital enablement, electronic medical records, and meaningful use.
He is focused on delivering the triad of healthcare to everyone that brings the appropriate treatment, at the right time and at the highest level of quality at the most economic cost. Randy shares his thoughts on the importance of sequencing the elements of care – there is no point in delivering excellent low-cost care if it is not the most appropriate choice, given that 1 in 4 surgeries performed in the U.S. is unnecessary.
We discuss the importance of the temporal sharing of information and the challenge patients have with the piecemeal way they receive information from different groups. Could the primary care practitioner act as the healthcare navigator or Yoda for the patient that helps with the practice as Randy calls it “Surgical Avoidance”.
We know that there are specialist centers of excellence where we can send patients to receive the best and most economical and appropriate care but the better solution, “No more Pins on the Map” is to think about how to deliver that more broadly and locally. We should be able to find great quality medicine and healthcare everywhere.
Listen in to hear how the burgeoning demand made up of the delayed treatments and surgeries held over from the pandemic that had many places postponing care for their patients. Not only is this a looming financial problem, but because of the delayed care, it is likely to be more complex with patients arriving with more co-morbidities thanks to the delayed treatment and lack of general care many experienced throughout the pandemic. And how bundled payments bring stability to the doctors and the patients and help make lowering costs a reality
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Dr. Randy Hawkins. He is the chief medical officer for carom health. Randy. Thanks for joining me today.
Randy Hawkins
Nick, a pleasure to be here. Thank you very much for having me as your guest.
Nick van Terheyden
So, if you would tell us a little bit about your background, you’re a physician, you’re working in the vendor community, you’ve had an interesting career. I think it lends an awful lot of credibility and relevance to the upcoming discussion. So share a little bit of that background and some of the high points if you will.
Randy Hawkins
Certainly, my name is Randy Hawkins. I am an anesthesiologist and Critical Care Medicine physician. I practice as a medical officer in the United States Navy for many, many years, and also in private practice in New York. And in New Hampshire, where I live now. I have been involved in the vendor community in industry as a chief medical officer for five companies now over a long period of time. My background is pretty straightforward, but it’s progressed in a number of different ways I started in electronic health records are a high tech and meaningful use timeframe is a you’re very familiar with, but then moved into things like the algorithmic approach to chronic disease, state management, FDA regulations, 510 k submissions, bringing interesting products and services to market to help chronic conditions be managed more appropriately. Then I got into predictive analytic modeling and workflow science, how could we use data to effectively target folks subpopulations with specific problems early in their journeys to affect the greatest amount of care and improvement. Then I got into the health navigation space, with patient advocacy, treatment, decision support, surgical decision support, expert medical opinion, second opinion services, things of that nature to really focus on getting folks off the sidelines, getting them comfortable and participating with their healthcare journey. And now I find myself at Karen health as chief medical officer, where we deal with a technology enabled and analytically optimized platform where we bring Centers of Excellence providers onto the platform, and the individual surgeons, they’re in and arrange for care in a true prospective, bundled payment arrangement. So we’re bringing the highest quality care to large employer groups and their employees at dramatically reduced costs. So it’s a pleasure to be here. That’s a little bit about me, and I’d be very interested in engaging in any conversation points that you’d like to discuss.
Nick van Terheyden
Well, so before we get into that, I missed the Navy piece. And since my brother was in the Navy, as a physician, I’ve got to ask you, if the American Navy does the same as the British Navy, and had you cutting hair on board ship,
Randy Hawkins
I wasn’t privileged to cut the hair, I’m sure they would have let me do it, Nick, to be honest with you, because we were all men and women have lots of hats. But it was it was an interesting time, it was way back in the original Arabian Gulf Wars Desert Shield and Desert Storm back in the late 80s. And 90s, served in the Middle East for a very long time, and then came back to the United States.
Nick van Terheyden
Well, I always fascinated by that. And he actually ended up doing hair for the family. When he came back, he learned the skill, because that was one of his tasks on board, the ships, barber, so thank you for your service. delighted to hear some of that and the journey. So tell us a little bit about the background to this sort of bundling. And I think one of the areas that you know, for both of us are relevant in this is what is the appropriate use of our limited healthcare resources. So we have this fantastic system. Albeit it’s not serving everybody appropriately. And you know, some of that’s associated with cost. But there’s an awful lot of this. And you know, it’s a recurring theme in my show, that we’re not delivering the right care to the right patient at the right time.
Randy Hawkins
Absolutely. Nick, I agree with you wholeheartedly. I do believe it is a fundamental aspect of our healthcare system that needs to be addressed. And I don’t pretend to have all the answers, but I do think about it. As you do. We’ve discussed previously, that this surgical appropriateness or appropriateness of care, or some folks are even calling it surgical avoidance is a is a set of terminology that I believe mean the same thing. What we’re asking to your point initially is, is surgery for example, in our surgical subspecialties specialties, the next best intervention for a patient at a given point in their journey or set another way are their lesser invasive, equally effective less costly alternatives that they may consider and if so, have those things been recommended? Those are the things that I think about in terms of avoiding surgery, I use a focal point in my analysis of appropriateness in the following manner, I consider there to be two principles in surgery, there’s, of course, the patient, and then the surgeon, and each, I believe plays a significant role in determining what’s appropriate at a given time, on the front end with the patient. It is in the realm of as we see surgical decision support vendors and expert medical opinion, second opinion services, these things which help activate the consumer, the new healthcare consumer to say, Hang on a second, give me access to some information and a handful of tools and help me build an experience set. So I know how to consume healthcare, goods and services, the way I do other goods and services in my life. And that’s one important thing. I think, in terms of avoiding surgery. When we become educated on what’s right or available to us. We can raise our hand sometimes and say, You know what, I don’t think surgery is right for me at this time. The other component is the surgeon that other principal in surgery. And that’s where folks like Carol mHealth, who really focus on the highest quality individual practitioner surgeons in our communities, and are gravitating towards those who do the right thing, the highest percentage of time for individual patients. So they have a full understanding and appreciation for Randy Hawkins for example, if I have back pain, well, Randy, have you thought about lumbar epidural steroid injections, healthy weight loss, behavioral changes and exercise physical therapy as less invasive approaches than me doing a micro diskectomy laminectomy infusion on your back. Our physicians on our platform, Nick, are skewed very heavily in to that higher quality realm where appropriate surgical practice is the norm. So I think those are ways for us to and large employer groups to focus on appropriate care. The other key point and then I’ll stop is appropriateness is so important in our way of thinking neck, but that we focus on it first. And here’s what I mean by that we think of a triad we think of doing appropriate surgery, and when surgery is necessary, doing the highest quality surgery. And then at the next and final step, we believe that that surgery should be done at a reasonable lower cost than in most cases we see today. If you solve for those three elements of the triad in an order that isn’t specific, I think you’ve run into two specific problems. If you solve for quality, first, you’re doing very, very high quality work, that may or may not need to be done, we didn’t determine if it was appropriate to do yet we’re doing high quality work on stuff that potentially didn’t need to be done. The other problem I see us getting into it is alright, what if we solve the cost component first, and we say, Okay, I’m going to lower costs, then I’m saving you the large employer group and the employee money on something that didn’t be needed to be done in the first place. So that’s why we think it’s important to do those things in a stepwise fashion.
Nick van Terheyden
You know, it’s interesting, you bring up those examples of, you know, the appropriateness of care and it reminds me going back in time, to cancer care. And the standing sort of perspective, and I don’t believe this is still true was if you had cancer and you went to see the oncologist he would poison you. If you went to see the radiation oncologist, he would irradiate you and if you saw the surgical oncologist, he would cut it out. And we’ve approached this with a team based approach, but I think it still suffers from the same kind of challenges that you describe have appropriateness. And you mentioned something in there that I think is critical, and is a challenge is where does the consumer play into this? Because they’re not equipped necessarily, to be able to? I don’t want to say they still make the decisions, but do they have the right information to be able to make those choices?
Randy Hawkins
Yeah, that’s a great point. And I don’t believe we’re all the way there a net I don’t believe, and often, you know, sometimes an overused term of the multidisciplinary approach. Cancer is a great example, Nick, when we talk about the triad of surgery, adjuvant radiation and chemotherapy, and if you talk to the individual providers in their subspecialties, you’re right, you get for lack of a better term disparate information, right you get pieces of the puzzle and not the full complement of what the the full healthcare journey and picture looks like. In answer to your question. I think it is really important that these conversations become unified, where all the participants in all the facets of care are having an informed conversation with individual patients kind of in real time so that they don’t get pieces of the puzzle. They get an idea as to what all the components are and how they fit together. I think the temporal relationship of information sharing is underappreciated. I don’t think we we give enough credit to the notion of when we provide the full picture to our patients, I think it’s important to do it collectively as opposed to individual pieces.
Nick van Terheyden
Yeah. And as I think about that, let me pause it a, an individual in all of this that has struggled over the course of time, that’s the general practitioner or the family health care who sits at the Nexus but you know, many instances, particularly in our system of fee for service gets bypassed a lot of the time people demand the right of, you know, immediate access is the perhaps an opportunity for a renaissance for those individuals, because they’re reasonably well equipped. They’ve been through the same training. They’re not so specialize so they can pull that together, could they be the healthcare navigator that would help support that individual?
Randy Hawkins
I’m the first to admit, when I hear a good idea, and I’m the first to give credit to those who present that idea. I hadn’t heard that before neck, I like it very, very much. I think that the notion of a highly trained person that in medicine that is cognizant of all of these different pieces is the perfect quarterback, if you will, more chaperone of that healthcare journey and bringing those pieces together. I hadn’t thought of primary care specialist and physicians and practitioners as serving in that role. But I love that idea. makes an awful lot of sense.
Nick van Terheyden
Hmm. Interesting. So for those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Dr. Randy Hawkins, he’s the Chief Medical Officer for Karen health, we were just talking about appropriateness of care. And, you know, the, the triad, as you rightly describe, have all of those contributed. So, you know, great, so you fixed the quality, and you got the best quality, but delivering it to the wrong people, and importantly, at the wrong price as well. So, you know, important through all of that, as as you think about this newfound approach. So when I think we’re moving off the fee for service, I mean, we’re still 30% or so as I understand, we’re getting more to value based coverage. I think we’re seeing more in the way of employers taking responsibility and not at just passing that on to an agent, let’s call it how do you start to deploy all of this in a way that they can make the best decisions? I mean, I think we’ve seen some good examples, Walmart, I believe it was Walmart, they’ve, you know, and I don’t know that this is the best example. But they sent patients to another state, even across borders, I think, for care and whatever. And I’m not saying that’s necessarily the right approach. But you know, that wasn’t addressing a piece of the problem. How do we bring this all together? So affects everybody all the way down to the 1050 person, employee employer so that they get all of that great care?
Randy Hawkins
And great question, Nick. And we’ve been wrestling with this for a while, right? The Walmart example, is just that it was that initial foray into the center of excellence strategy, where coverage or penetration of markets was minimal. The quality was there. But access was a real challenge. It was very difficult to without extensive travel, you’re right across state borders, definitely. But across international borders, in some cases. I think the the reality is we need to consider all of those components highest quality, appropriate care, and deliver on that network component deliver on that Access Challenge. Here’s what I say, in my organization and in the market, when I have the privilege of speaking with others. I can’t create high quality that doesn’t exist, but it is my job as the Chief Medical Officer of care and health to find that highest quality everywhere that it exists. So what I’m trying to solve for is, is really I think the answer to your question, we need to tease out we need to extract that highest quality, most appropriate care on every corner that we can find it and not settle for and here’s the true answer. not settle for pins on the map. I don’t want to pretend that everywhere you look outside your window is the highest quality provider because That will solve the Access Challenge. I really think just like cost and quality, it’s an access and quality balance that we need to strike, I want to find it everywhere it is. And I want to provide it more comprehensively than those initial models that just said, Yep, there are two places in the world where you go to have your knee fixed, I’m going to send you to one of those two.
Nick van Terheyden
I like that. And I like the sort of no more pins on the map, I think that’s a good visual that sort of helps amplify that point. So we’ve all been experiencing the pandemic, you know, it’s represented a just a range of problems. But one of those has been the inadequacies of the delivery of care, there was a cohort of patients that I think is going to trouble the system for some considerable period of time that has missed out on interventions that were hopefully appropriate through that triad that you described. How do we go about addressing that is, is there a pathway to help this group because they seem particularly impacted by the COVID 19? pandemic?
Randy Hawkins
Oh, yeah, I think that’s correct. Right. We talked about a backlog of elective surgeries or a pent up demand to have certain procedures done. I think that’s all true. If we look back at 2020, it was certainly true, right? Because we we kind of locked it down, we needed to preserve resources, and increased capacity in our existing healthcare system. And we did that by postponing and delaying elective surgical procedures, knees, hips, backs, certain forms of hysterectomy, bariatric surgery, to be sure, and others. And I think you’re right, that pent up demand did, really three things happened. And I think they’re Some are obvious, but I think all of them are undeniable. The first and the most obvious is the number of delayed surgeries went up, the volume of cases to be done, at least in general terms has increased dramatically, we have an issue. The second thing is a little less obvious. But I think just as important is the whole notion of because of this delay, there has been a concomitant delay in maintenance of health and chronic condition management. My point being that the sub population of those folks who were teed up for elective surgeries did not get healthier, over the course of the pandemic, they still have their comorbidities, their conditions, and they didn’t necessarily improve upon the state of those conditions, diabetes didn’t get better hypertension was sometimes unchecked, because folks were unwilling or unable to engage in a healthcare system to manage those conditions. So I think, and as we think of all of these things, in a go forward fashion, those same patients who are less or less well prepared to have their elective surgery are going to cost us more because of all of these comorbidities that are potentially out of whack. And the third thing is just a truism, as a function of the fee for service model that still to your point remains in place somewhat to this day, we had a challenge to the revenue streams of, you know, acute care providers and their surgeons they’re in. And just, as a matter of fact, the downturn in revenue of 2020, and the intermittent revenue of 2021, they’re gonna look to actively recoup. And we see this in the market, we see folks advertising availability for your surgical procedure that was delayed because of the pandemic, in and of itself, not necessarily a bad thing. But it does bring us back to our first topic of discussion, which is appropriateness of care, does the landscape changing and opening up access to elective procedures, make surgeons more likely to operate, then not all things being considered, we have to take the confluence of these three forces pent up demand and volume, the comorbidities not being as well prepared and this notion of I need to recoup revenue all coming together and making it large employers and their employees suffer from higher availability and likelihood of maybe less appropriate surgical intervention and the cost overrun associated with that, you know, post obstructive diuresis, if you will, of patients coming to the operating room looking for their their procedure to be done.
Nick van Terheyden
I love that post constructed diuresis that’s a perfect, that’s just great. So as you think about it, one of my sort of focus areas is is very much around price. I just, I come from a different system, where price was not the sort of focus point I, I’ve struggled with it ever since I’ve been in this country, it continues to be a problem. The one thing that I’ve seen that I think is helping change. The way that we think about these things is the transparency which we didn’t have. It’s been fought tooth and nail by all sorts of vested interests. Is that going to start to contribute and help bring things down?
Randy Hawkins
Absolutely. Right. I believe, like I was saying about appropriateness of care being the the first step, I believe price transparency is the first necessary step to helping bring down costs, you can’t, you can’t fully appreciate and understand how much more you’re paying for a service or good than somebody else, until you know what that is. So I am with you 100%. On that, Nick, we have to completely instill this notion of price transparency into the cost reduction strategies that we’re looking to employ. The other component, I think we might agree on this as well is the notion of prospective bundling of pricing, making a which is in and of itself, right. By definition, transparent. I know, before I do it, what the price of that service is going to be, that makes me feel better about what I’m going to pay. But it also aligns incentives. Nick, what I love about the bundled payment approaches, but it does things for the surgeon, it does things for the employer, it does things for the patient, for the surgeon, it gets them paid right away, they know what they’re going to get paid. And they don’t have to struggle to get it with individual bills from anesthesiologists, and so on so forth. The thing that it does for the employer is it makes it predictable to a budget for their medical spend, if I know what I’m going to pay the incident rate of the surgeries involved, I can calculate what it’s going to cost me and I’ll know. And here’s a real key point for everybody, that the incentives for the surgeon are going to be aligned with my incentives, the surgeons are going to be very selective in who they choose for a procedure because they know they’re on the hook, there are going to be warranties in place, I have to cover the complications and readmissions for a 3060 90 day period in association with my care, that’s part of the deal. That’s part of the bundle, I have to sign up for that. So I’m going to select my patients carefully. And I’m also going to be given compensation for doing the right thing. So there there has to be in place a consultation fee or a stipend so that if I look at you, Nick, and I say I understand that your hip hurts, but looking at the amount of disease in the joint, and your age and things like I think there were other things we can do if the surgeons are compensated for their time, and their effort for doing the right thing. Again, incentives are aligned. So I think bundling pricing, aligning incentives, giving warranties, and being transparent, will get that last step in my triad, Nick, lowering cost to become more of a reality than it is today.
Nick van Terheyden
Yeah, I think that’s represents a you know, truly positive trajectory. Especially as we move away from this fee for service that you know, you get what you INSEAD It’s inevitable. And I I never start out with the premise that people are doing things because they want to be met. You know, everybody gets up in the morning, wanting to do the right thing, deliver the best possible care, the best possible choices. But ultimately, you are influenced by the system that surrounds you. It just it’s impossible to sort of escape that. And we have to align the incentives and I think bundling of payments, and the certainty that that allows people to be able to plan both on the delivery side, but also for the patient side, it sort of removes that need for no more surprise billing. It as you think about this, over the course of future, the future. What are you excited about?
Randy Hawkins
I’m most excited that to be honest with you at the conversation. I am very fortunate, I think you are as well, through this platform to have these intelligent and informed conversations from a number of different viewpoints. I’m encouraged by that people, benefit leaders from around the country are asking the right questions. They’re aligning priorities with the pain points they see. And then then the employees that they serve. I love that I learned I’ll put it this way. I learned more from Benefit leaders than I do from potentially anybody else in the market, because they’ve got this platform, this benefits platform, but this administration platform and they’re serving a populations that are diverse, and they’ve got input at all times about what’s being provided and how well it’s meeting the needs of the population. So I I’m encouraged by the conversations that are going on nationwide. And I think if we could continue the conversation, we’re going to make progress in a very efficient manner.
Nick van Terheyden
Fantastic. Unfortunately, as usual, we’ve run out of time. So it just remains for me to thank you for joining me on the show. Randy, thanks for coming on the show.
Randy Hawkins
Nick, thank you very much for having me. It has been an absolute pleasure, and I’d be happy to join you at any time. Thank you, sir.
