Episode Transcript
[00:00:00] Speaker A: The future of healthcare must be within a value based care setting. To give you a summary of the difference between the value based care world and a fee for service. It's incentivizing for better outcomes versus incentivizing to do more volume.
[00:00:16] Speaker B: Welcome to skin deep. I'm Dr. Ana Chacon and today we have a very special guest joining us. Get ready for some expert insights you won't want to miss. You are basically the young generation of value based care. He has a blog on Medium and we're very happy to have him in Miami.
[00:00:34] Speaker A: So yeah, Jonathan Gwynner here, originally from New York, lived there till about four and a half years ago and we have a company here called Salute Healthcare in South Florida. And we are disrupting health care in a meaningful way and bringing value based care to independent primary care physicians.
[00:00:57] Speaker B: Well, thank you so much. It's really great having you, Jonathan, I guess tell everybody where you grew up and how you ended up in Miami. What you think about it so far.
[00:01:08] Speaker A: I grew up in far Rockaway, New York. Then I moved to Brooklyn and loved my childhood growing up. Definitely grew up with a single mom.
She's my superwoman and got married at 21 years old. Today I have four kids. Started in health care at a young age at about 21 years old. Mostly fee for service businesses. My experience here in Miami has been nothing but incredible. I mean, who doesn't want to live in such a beautiful esthetic area? I mean everyone is, it's beautiful weather all the time and it's, you know, people live a life here of constantly working on their health and it's a great place to live. We feel very blessed, I guess.
[00:01:57] Speaker B: Also mention to me how many kids you have because I learned this about you as I met you. I have no kids myself, I have pets. And I just find it fascinating we're able to balance all of this with such a big family.
[00:02:10] Speaker A: Yeah, So I have four kids. My, my oldest is my daughter, she's 11. And I have a son that's nine, another son that's seven, and another baby girl that's two. So I have four kids in total. Balancing, I would say, you know, personal and business. I think it's just, you know, a matter of priorities and you know, what you find to be important to you. So, you know, it's important obviously to work hard, but you can also, you know, wake up earlier and take care of yourself. As in go work out and you know, do your own thing in the morning and then make sure that you're there for Your kids before they go to school and still make it in time for work and making them time for. Before they get to bed. And it just matters, you know, what you want to do really. And I think there, you know, there can be a very nice work life balance. And it also gives you yourself a different, I would say, value in life.
[00:03:05] Speaker B: Being married young. And I studied abroad in Israel. So I mentioned to you that as I was bike riding around the. Is it Kinneret, The Galilee? Call it Galilee, I guess in the. How do you pronounce it?
[00:03:18] Speaker A: Galilee?
[00:03:19] Speaker B: Yeah, I met somebody who was orthodox and he helped me as my bike was falling apart. And I was pretty much falling apart at the end of the, the road. And so I kind of learned a little bit about that aspect of religion. I also wanted to mention one thing I noticed when I went to his house was that there are no photos. There were no photos or it was actually a lot of readings, I guess, on the wall. But there wasn't a tv, there wasn't any images or photos. And I was wondering if that was common.
[00:03:52] Speaker A: That's not common. I would say we have at least 100 photos on our walls.
[00:03:56] Speaker B: Oh yeah, we have a guitar and everything.
[00:04:00] Speaker A: Well, this is the office. Yeah. But in my home we have pictures of our family and really, really, you know, we're very much into that. I think most homes really do have that.
[00:04:12] Speaker B: Yeah.
[00:04:13] Speaker A: Regarding, like scriptures. Yeah, we definitely have.
[00:04:15] Speaker B: Yeah.
[00:04:16] Speaker A: Hundreds of books also of different scriptures of, of, you know, whether it be Talmud or, you know, some sort of philosophical book. I would say getting married young was best thing for me. I think that in our culture people do get married young in general, looking back, it very much has its, its pros where sometimes you're just like young and stupid.
[00:04:40] Speaker C: Right.
[00:04:41] Speaker A: And in a way that could be very good because you're both really young and you both are growing and you know, growing together.
[00:04:48] Speaker C: Right.
[00:04:49] Speaker A: Making those mistakes together, I think build that bond, you know. But it could also be risky at the same time.
[00:04:56] Speaker C: Right.
[00:04:56] Speaker A: Because you don't know who that person is really becoming or what they're becoming. And you know, you could be going on two different paths. But I think overall, in general, getting married young, so long as you're both doing it for the right reasons, has more of a positive than a negative.
[00:05:13] Speaker B: Talk a little bit about value based care. And because I didn't understand what that was until I met you, started reading your blogs and started talking with you a little more and also what Medicare advantages. I was telling Dr. Diaz that I don't know what that even is, but go ahead and tell the audience because this is kind of a evolving era in medicine. Yeah.
[00:05:38] Speaker A: Most people, what they understand of healthcare is the fee for service type of healthcare. So for example, a patient goes to a doctor, doctor bills a specific code for that patient, whether it's time based or procedure based. So if the patient's there for a period of time or longer, you know, they could build a different code to get more money. But it's basically, it's, it's exactly how it sounds as they're billing a fee for their service.
[00:06:05] Speaker C: Right?
[00:06:06] Speaker A: So they are, if, let's say you go to a specialist, they'll bill for their time, but also for diagnostics or you go to the hospital, everyone's billing a fee for their service. Ffs, Right, Fee for service.
So if you think about it though, a someone billing a fee for service is incentivized to want to bill as much as possible.
[00:06:28] Speaker C: Right.
[00:06:28] Speaker A: Because they're going to try to find things in order to build that insurance to make sure that it, it is worthwhile of their time.
[00:06:37] Speaker C: Right.
[00:06:37] Speaker A: So let's say, you know, whether it be a procedure or a visit, they're incentivized to try to make as much as possible. The other, the other side of health care, which is managed care side of health care, which is really the value based care side of health care, is that. Okay, look, why don't we give you more money based on outcomes of what you do as a physician for your patients, right? Instead of trying to pay you to see as much patient, you know, as much patients as possible, right? Because if you see more patients or do more procedures, you get more money in the fee for service world, right? Instead, why don't we say, whoa, whoa, slow down for a second. Why don't you see even less patients, spend more time with those patients, really care about their outcomes. And if you have good outcomes with your patients, we will give you more money, right?
So it helps the patients, it helps the doctor, it helps the health payer. Everyone wins. And that's what I think the future of healthcare must be within a value based care setting. To give you a summary of the difference between, you know, the value based care world and a fee for service. It's incentivizing for better outcomes versus incentivizing to do more volume.
[00:07:50] Speaker B: Where can we see this model today you have brought up or I've learned, you know, just in practice, there's a couple of, I guess, Leon, you know, what example would you say exist at Least in South Florida and maybe nationally.
[00:08:04] Speaker A: There are incredible companies doing a great job such as like a staff model like Chen Medicare or Oak Street. Those are great staff models that they're fully in value based care and specifically focused in Medicare Advantage. Value based care now not only is within the ma, the Medicare Advantage space, but it's also within the Medicaid space and within commercial space and it's really, it's really rolling out across really all lines of business. Within healthcare, I think it's really, it's, you know, it's just a matter of time for, for people to truly change the way that they practice.
[00:08:41] Speaker B: What's Medicare Advantage?
[00:08:44] Speaker A: So Medicare is what most people know as the government insurance. From when you turn 65, you're eligible for Medicare, which means that the government will start paying for your health care. Now not necessarily do they pay for the full amount because it's depends on, you know, whether you meet certain financial thresholds, but at minimum they'll pay, let's call it 80% and then you have to get a secondary insurance. But if you do qualify, you can get, you know, full Medicare, call it right and straight. This is called traditional straight Medicare. And now you can go anywhere you want. Usually though, that does cost money because you do have to pay for coinsurance which could be, you know, a few hundred dollars a month. There are many benefits that don't exist within traditional straight Medicare. So what is Medicare Advantage, which is the fastest growing, I would say within that population is large insurance companies such as United Healthcare, Aetna, Humana, these are companies that people know of. They opened up a Medicare Advantage division. So they said, hey, you know what? CMS Medicare let us manage the care of the patients. And instead of patients being able to choose for straight Medicare, they'll have an option now to choose a United Medicare or Aetna, Medicare, Humana, Medicare.
[00:10:10] Speaker C: Right.
[00:10:10] Speaker A: And we're going to manage, this is the payer's talk. We're going to manage the care of the patients and we're going to be, you know, supplying incredible outcomes for them.
[00:10:21] Speaker C: Right.
[00:10:21] Speaker A: And we're going to take risk on that.
So a patient now has an option now to choose, you know, instead of taking straight Medicare and now they get United help. Why would they, you know, why would they choose a plan, Medicare plan, right. Medicare Advantage plan is because usually Medicare Advantage plans offer benefits that straight Medicare cannot, cannot offer.
[00:10:41] Speaker C: Right?
[00:10:41] Speaker A: So they'll get, whether it's, you know, free transportation or gym memberships or over the counter credits or, you know, monthly stipends in order to, to keep them constantly healthy. So there's really a lot of benefits that the Medicare Advantage plans do provide to patients and that's the reason why they would choose that over straight Medicare. Now it does come with a limitation because if you pick within that, within that payer, you have to stay within that network today. These days though, these payers have such a large network that you're really not giving up much because you can still see incredibly, you know, incredible physicians, whether from a primary care or a specialty or hospital system. Most of these, you know, groups are par with a lot of these payers. So it just matters picking the right one that, that fits your needs. And that's really the difference between Medicare Advantage and straight Medicare.
[00:11:37] Speaker B: From a patient perspective, they give them a stipend.
[00:11:40] Speaker A: Medicare Advantage really, Medicare Advantage gives, I wouldn't call, I mean I should say like not really a stipend, but they give, they give credits really like they can, they can use X amount of money on a monthly basis for over the counter medications or for different health needs that typically would have to be, you know, paid out of their own pockets. So everyone had like their flex cards. They have, I mean every plan calls it differently, but some of them even pay for, you know, your electric bill. Like there's so many ones that it's very, very interesting. But that's from the payer side and that's really from a patient perspective. Then there's the whole other side of it, right between like the financial side and how they manage the care. But that's the other side of the Medicare Advantage between them and the government.
[00:12:30] Speaker B: Yeah, I mean, well, that's a good overview, but I still find it confusing.
How do doctors fit into this model?
[00:12:37] Speaker A: So I gave you the understanding of, you know, from a patient perspective of what makes, you know, what's the difference between traditional straight Medicare versus Medicare Advantage.
Now you know, how does it work on a Medicare Advantage? So how do they make money, which is important, right? They're now taking risk. These health plans are being paid a monthly amount in order to manage the care of the patient. But how do they know, how does the government know how much to pay these health plans in order to manage the care? Some are healthier, some patients are sicker, some patients, every patient has its own needs, right?
So they reimburse. The government reimburses based on the conditions of the patient. So the sicker the patient is, the higher scores they have. And that's what determines what the monthly per member per month fee will be. From the government to that payer.
[00:13:27] Speaker C: Right.
[00:13:28] Speaker A: Let's consider it a score of 1.2, 1.31. Call it. You know, CMS is paying the Medicare Advantage plan even, even at a 1.0.
[00:13:38] Speaker C: Right.
[00:13:39] Speaker A: Score. Let's say they're paying on average $1,000 a month for that member. So CMS says, okay, you know what? UnitedHealthcare, we're gonna give you $1,000 a month. You now have to take full risk on this patient. So if the patient now needs to go to the doctor, UnitedHealthcare has to pay the doctor for the visit. Patient needs to go to a specialist, pays the specialist.
[00:13:59] Speaker C: Right.
[00:13:59] Speaker A: Dermatologist, Patient needs to go to the hospital. You got to pay the hospital. But if the patient gets admitted to the hospital, they lose money, right?
[00:14:05] Speaker B: Yeah.
[00:14:06] Speaker A: Getting paid that thousand dollars a month. So the hospital bill is $20,000. They lost money on that patient.
[00:14:11] Speaker C: Right.
[00:14:12] Speaker A: So these Medicare Advantage plans, their goal is to find ways in order to keep patients out of the hospital, because that's the number one biggest expense, hospitalization. So they find every which way to incentivize patients to keep them healthier and keep them out of the hospital.
[00:14:30] Speaker C: Right.
[00:14:31] Speaker A: And that's really what they're incentivized to do. They want to make sure that their costs are not high in the patient. Obviously, if the patient needs to go, they'll go to the hospital and the payer is going to have to pay for it.
[00:14:40] Speaker C: Right?
[00:14:40] Speaker B: Right.
[00:14:41] Speaker A: So their goal is, okay, so now how do we minimize our exposure? Let's. Let's create ways for patients to stay healthier.
[00:14:48] Speaker C: Right.
[00:14:49] Speaker A: Then they have to also minimize their exposure and their expenses. So in states such as Florida, they have capitation rates for primary care.
So primary care doctor would get a per member per month fee.
[00:15:04] Speaker C: Right.
[00:15:04] Speaker A: So call it, let's, for argument's sake, call it $100 per member per month for primary care. Now that primary care, he's responsible, or she's responsible for the entire total care of that patient if the patient comes, you know, one time every month or comes once a week, or comes once every three months, or comes, doesn't matter that primary care is getting paid that same dollar amount per member per month. So now the insurance company now just capitated.
[00:15:30] Speaker C: Right.
[00:15:31] Speaker A: Their primary care line item. So now the patients, anytime they need primary care, they know that it costs them $100 per member per month.
[00:15:39] Speaker C: Right.
[00:15:39] Speaker A: To give an example, on a specialty side, there's a lot of capitations for specialists also. So specialists, it could be cardiology, it could be home care even, right? Home care is also capitated. So if a patient needs home care, they have to go to this group and they determine whether the patient or how much the patient needs of home care.
[00:15:58] Speaker C: Right.
[00:15:58] Speaker A: But what the insurance companies do is they try to minimize their exposure and expenses and keep on coming up with ways for the patients to have better outcomes. And if, if they accomplish both things, then they can be profitable. You know, in general, people have been very much upset with the health plans lately on denials and all these things. And, and the truth is I'm not even, I'm not even defending them because I think that they can do a way better job at doing those things.
But ultimately they really want to have better outcomes for patients because that's how they get reimbursed on, you know, not just a level of scores, but also based on whether their, their HEDIS scores, their, their, their stars are aligned. So if they get a five star plan, they're getting reimbursed at a higher level. That means that they have to meet certain metrics keeping patients healthier and making sure they're taking their medications, making sure that they're, you know, getting their, their annual wellness visits, making sure that they're getting whatever it might be right to be able to take care of the patients. So they really do ultimately care about patient care and they're reimbursed for better outcomes. That's really what it is.
[00:17:11] Speaker B: That's really interesting. And then how did you end up, I guess, entering this space?
[00:17:15] Speaker A: I actually looked at a company about seven, eight years ago. It didn't work out, so we didn't end up buying that company. But I met someone here locally. He had a MSO VSO in the, in South Florida. He ended up becoming an owner of a health plan. Sold his health plan and started up a new health plan. Became very close with him and he taught me a lot about the business and understanding of the business. And I was like, wait one second. There's so many independent primary care doctors out there that there's no way that they could be successful in a value based care environment. You need to have, besides for coders, you need to have, you know, billing people. You got to have not just regular coders, but HCC coders. You have to have platforms to be able to teach you, to give you all the gaps. You have to have a data warehouse to ingest tens of thousands of documents. Like there's so much that needs to be really, really managed and put out there on a, on a platform. To succeed. And I was like, one second, there's got to be something to be able to help out these independent primary cares. Obviously, large groups like Chen Med and, you know, Oak street and those types of business, of course they have them, right? But how about the regular small guys? They don't really have it. And that's what we're really here for, you know, So I met this guy, he taught me a lot about it. And I was like, you know what? There's a need for this. Let me jump in, you know, let me see what we could do. Let me see if we can make a difference.
[00:18:37] Speaker B: How big is your team? And also, how did you. I know you mentioned to me you have about close families involved, I think, and how, how does that work? How, how are you able to manage all those people, including friends and family?
[00:18:51] Speaker A: I think regardless whether it's friends or family or someone. I don't know, I think treating everyone the same is the. Is. Is the biggest key, definitely at work, you know, so maybe after work it's, you know, some people struggle with that, with that balance of personal and business. I try very much to treat everyone the same, regardless of who they are. And I think that that works the most. Works best the most, really. You know, we have probably 75 people right now within our company.
And yeah, we have in. In our corporate office here, we have about 22 people here.
And it's growing. And we're. We're trying to always create an environment of a healthy place, but that also is willing to innovate and work hard.
[00:19:37] Speaker B: And then tell me a little bit, if you don't mind, you're Orthodox, you mentioned to me, how far back does that go and what are some of the things that you learned that you apply to business?
[00:19:48] Speaker A: So, I mean, we go back many, many, many, many generations as Orthodox Jews, but I apply to business, I would say really treating everyone the same, understanding that regardless of religion, we're all really created in God's image. In fact, on my wall, if you can see.
[00:20:11] Speaker B: But the, the.
Wow.
[00:20:15] Speaker A: See that.
[00:20:16] Speaker B: Yeah.
[00:20:16] Speaker A: I even have there on it, like a lot of the meaningful things that are in my life.
One of them, it says that we are all created in God's image. And I think that that's very, very important for everyone to understand that regardless of your religion or regardless of, you know, your background, where you come from, where you are today, it doesn't matter. Just understanding that you were created for a reason. And the day you were born was. Was the day God decided the world cannot exist without you. And I think that's a very, very, very important line for everyone to really take and understand that there's purpose and meaning behind why you're created and treat people the way you would want to be treated, make them valued, make them feel good just like you would want to be.
And understanding that really, like we're all here trying to search for more purpose and meaning and really loving one another is challenge that we all have to go through. Sometimes people do things to you that you don't like, and it's very hard to love them and care about them. And I think that's part of the challenge. But learning these types of traits and learning to constantly be searching for more meaning and purpose and treating people equally is really what I try to take within my workplace.
[00:21:38] Speaker B: Thank you, everybody. This is Jonathan Gruner Kol for Value Based Care.
