Episode 157: Navigating Healthcare Complexities: A COO’s Perspective

Mike O'Neill: Welcome back to Get Unstuck and On Target I'm Mike O'Neill with BenchBuilders and whether we're working with supervisors to improve their people skills or it's me coaching a leader one on one getting leaders and companies unstuck is at the heart of everything that we do and that's exactly what this podcast is getting leaders It's all about joining me is Craig Worland

Craig is the chief operating officer at Southeast Primary Care Partners his company is physician founded and led I've invited Craig to come on the podcast because we've got leaders listening who have responsibility for making healthcare dollar choices for their employees and I think what he will share with us will be of particular interest when you're looking at the complex world of medicine

welcome Craig

Craig Worland: thank you thank you Mike I'm glad to be here

Mike O'Neill: Craig I know you as a COO with your current company but you have kind of spent a number of years in health care can you just share a little bit about your background and kind of what led up to your current role

Craig Worland: yeah no happy to so after college I actually went did not go into health care

I went into the military I did a a stint in the Marine Corps as an officer love my time in the military and really you know learned about leadership leadership and complex dynamic situations leading really diverse teams that come from very diverse backgrounds all to be at one point to accomplish you know one mission

and so this is it was it was a great experience for me being in the military I loved my Marines I loved being able to serve my Marines but what got me into health care was when we were when I we had our 1st daughter she had several significant special needs so I was uh kind of thrown into health care for the 1st time

as you know through the eyes my daughter seeing what it looked like being a chronic patient a chronic user of health care services previously I was your typical kind of you know mid 20s male who wouldn't go to the doctor unless they you know couldn't make the cut stop bleeding or like the bone was sticking out

And now I was seeing you know a daily weekly and monthly visits to doctors and coordination of care and and you know and really seeing not for the fault of the the clinical providers but just for the fault of the system how siloed things are and how inefficient they are and the transfer of information being so core

so when we made the decision to transition out of the military it was really through that experience that I decided I wanted to go into health care and I've always been very systems oriented and eventual I like processes I like understanding you know what what was the the breakdown in the process that created that inefficiency or that mistake not who's the person to blame there

And and healthcare just seemed like there was a lot of opportunities for improvement and it felt like if I could spend a career you know trying to make those improvements it would be it would be a career well spent so I after leaving the military I was was lucky enough to be hired at a nonprofit community health system in Georgia

They really brought me in as a as a what they call an administrative resident I'm not clinical I don't I don't have a clinical background but but they did bring me in to to bring me into kind of a training program to become an administrator it was through that experience that I um

was able to you know really understand just how complex health care is from the provider side and and was very fortunate that the the the system I was working for was a well run system a very profitable system in terms of it was able to make the necessary funds to reinvest it back into the community

so that they could provide robust services to the community they were serving which was which is really really great for me but what I started to see very quickly was just a fundamental disconnect and this is I call it just kind of a fundamental tension in health care in general which is you've got providers on one end and I include health systems and individual doctors and groups like ours groups of single specialty doctors

those the providers are incentivized and a fee for service way and a fee for service system to do as much as they possibly can to the patient because that's how they make their money that's how they make their margin on the opposite side you have the payer who is oftentimes and rarely the patient

So oftentimes it's you know it's it's your typical your Blue Cross Blue Shield your Anthem your Humana United your employer sponsored plan and they're incentivized to try to pay as little as possible to this provider who's incentivized to do as much as as as possible and and the patient oftentimes gets caught in the middle

so that's where things like prior authorizations come in and denials and these frustrating surprise billing these frustrating things that patients experience and and I just I attribute it to a very misaligned intention field filled system so for me I got very interested in what's called value based care

And that's a broad buzzword of a term but what I mean by that specifically is the healthcare provider being at risk financially for the outcomes of the patients that they're treating so so what it does is it takes this this payer on this side and the provider on this side and it starts to align them to where we're all trying to do the right thing and not trying to ration care or reduce or reduce necessary care but to actually think about

what's the long term implications if I if I invest more on the front end so I'll you know the example I use a lot as a patient that may have been recently diagnosed with diabetes if we invest more bring them in teach them how to manage that chronic disease and and bring them into the primary care office to get their A1C measured to get additional labs completed to talk to the nutritionist

we have we've now made that front end investment so that down the line that patient is not having to go to the emergency room we have some patients that go you know 30 and 40 times a year and or they're admitted for 100 days a year and so what we're what I wanted to do is be part of a system that was that was trying to do preventative medicine on the front end and avoid costly downstream downstream

impact and it's it's difficult to do that in a health system where a lot of the margin is made on operating rooms and and the hospital beds and expenses imaging procedures and at no fault of the system that's just how the financials are set up and so I I really wanted to to make a transition to an independent group that was focused on primary care and focused very much on value based care

And that's how I ended up here at Southeast Primary Care Partners

Mike O'Neill: we are in the United States we have listeners literally all over the world I think at last count we have listeners who have downloaded these episodes from 50 plus countries so our conversation is going to be limited with the US healthcare system but you now kind of align yourself with an organization that that kind of leans into primary care namely primary care physicians and I'm I'm making the assumption is that there are a lot of advantages to embracing what a primary care physician does

can you walk us through you know what are the advantages of one the patient and And maybe to some extent also answer what might be the advantage to the payer be it the employer the insurer to use primary care as a way to bring those 2 entities maybe more aligned for a value based care approach

Craig Worland: yeah it's a great question mike and a couple of points in 1 to your comment on having international listeners I think it's oftentimes when when I speak or members of organizations speak at different events we show a graph and it shows

kind of a on y axis here you've got length of life or or average age at death and then on the X axis you've got cost and so presumably you would think as you move along the X axis the you know your your length you're spending more on healthcare so your length of life goes up the fact that's completely untrue

you've you look at that with the with other OECD countries and they all kind of skew to the left side meaning it's lower cost and a higher length of life and then the U S sits very much as a as a just this huge outlier way out here to the right and low on the Y axis which just shows Hey we're spending more than anybody else on healthcare

I mean almost 20 percent of our GDP is spent on healthcare that is unheard of and and like a Scandinavian country or or other well developed countries but we're not getting anything for it I think the life is is is the bottom third of all of those countries and so you know we we're not doing anything that other countries haven't already figured out which is

when you prioritize primary care and you enable primary care to also look at things like social determinants and behavioral health and other other factors that are not directly clinically related or going on inside of you know can't measure you know by by putting a blood pressure cuff on me what do I have food insecurity or transportation insecurity

But when you ask the right questions and when you resource the primary care provider appropriately that's what takes you the cost back towards the lower side of that graph and ultimately brings the outcomes which are measured you know in this particular instance by longevity further up

so when it comes to primary care traditionally in the U s healthcare system well if you go way back primary care used to be all there was think of the you know the country doctor shows up horse and buggy goes into your house delivers babies takes care of your your cancer takes care of you know your flu and and that's they are the doctor

as as the health care system got more evolved especially in the U s it became more and more specialist and and and kind of facility centric which is where most of the higher reimbursements were and so by default the primary care provider became less and less and less important in terms of a financial outcomes of um

you know making making a profit health healthcare while you're taking care of of of people and you're trying to keep them healthy which is a really really worthy cause at the end of the day it's also a business and the economics I don't remember which president was but said it's the economy stupid same applies in healthcare

and so when the economics are aligned to where you get paid more you're incentivized to do these surgeries and these expensive sites of care and all of these things primary care then just becomes the feeder to that and so what is what has happened over the last couple of decades is and you talk to most primary care providers they would they would echo this that they have kind of become with what they have said to me personally is I feel like I'm a referral factor like the only reason I'm here is for a patient to come see me and I'm just supposed to refer to that expensive specialist or to get a patient into the or or or where whatever I can do to to extract more cost to go back to that original tension extract more cost away from okay

away from the payer so what we're trying to do and what I think you know other developed countries have done that that have lowered cost is they take they flip that back on his head and they say no no no primary care should be at the center of all of this and all of you all the or is the imaging centers the specialist

you are here as a tool to the primary care provider whose number one goal is to to increase the quality of care that their patient is receiving not feed you because you're going to get reimbursed higher but if if this patient needs to go to a cardiologist great we're going to send them to a cardiologist but a cardiologist is aligned with us and isn't overly incentivized to go do a stent when it may or may not be necessary

if it's necessary absolutely let's go do that and so it it is really You know I think for for some who have especially in in other countries that have kind of figured this out already it's such it's not rocket science but it's just taking the the provider who's most concerned about the total patient care and the outcomes for the patient and then putting them back at the center of it instead of being the the kind of the bottom of it and feeding it up

and then the last kind of stat I'll I'll share on that is in most countries Primary care in most countries that have figured this out and done it well primary care is 20 to 30 percent of the total spend in the US it averages somewhere between 5 and 8% and so you just see if 5 percent of your dollars spent on the only doctor that is truly concerned about all aspects of your care we have we've kind of got a misaligned system and a little bit of a a

you know upside down system

Mike O'Neill: yeah I know we've had a little bit of kind of a philosophical discussion here about this state of health care in the United States the build intentions we've kind of begun talking about what are the advantages of a primary care physician versus a specialist versus these other things

and what I'm hearing you say is that it's an ecosystem and Southeast Primary Care Partners is a business admittedly where part of your employees are in fact primary care physicians and so let me go to the practicality of this when you go to med school they really don't teach you really how to to to run a medical practice do they

Craig Worland: no unless you are lucky enough to also do an MBA or something like that but yes they do not teach you the business side of this

Mike O'Neill: so could you maybe in in terms that I might understand would you kind of describe the business model you have physicians who join your organization and I'm making the assumption is that what you have this is maybe not the right choice of words but where appropriate kind of backroom functions that can support them

but can you walk us through the kind of the business model for your company

Craig Worland: yeah no it's absolutely and I'm happy to share this so for our physicians our our selling point when you join our group is especially as an independent provider so we we focus very heavily on the independent primary care providers

those that have gone and hung their shingle and have continued day in and day out to see patients treat them well and run their run their business well or they're coming out of school and they don't want to join a health system they want to join a group that really prioritizes primary care so when they come in

our pitch is you know what we do for you is is we take care of to your point all of the ancillary kind of business functions that need to be taken care of and we want you just to focus on the patient care and so and because of the business model where we're taking risk and our revenue is generated and our profit is generated by actually reducing Unnecessary care downstream we are very incentivized to resource these providers with things that traditionally they haven't been able to get

so it makes a lot of sense for us to give them an ultrasound and an x ray and cardiac telemetry devices and robust set of labs that they can order either in house or send out for for rapid returns because they they are very concerned and very focused on making sure that they are doing very comprehensive visits with these patients understanding everything that's going on with these patients and then establishing a care plan that prevents that patient from using unnecessary downstream services

and so for them to your point it goes back to why they went to medical school which was to take care of patients and to help patients live healthier longer happier lives and with us they don't have to worry about all that outside stuff the CPT codes the you know the are we are we getting reimbursed for this

are we getting denied for this that's our problem we'll figure that out we just want you to see the patients do a conference visit with the patient and ultimately be thinking about you know where is this patient going to be next year 10 years or 20 years down the line not just how can I do as much as possible for this patient in the room just to maximize my reimbursement which is which is traditionally what they've been what the system has has had it set up as

Mike O'Neill: you know in my intro I described your company as physician founded and physician led why might that be a differentiator

Craig Worland: yeah so and I'm saying this is a non position so fully full caveat there but Dr tom Bat was was the founder of the original group that that started our company he partnered with our he's still a chairman of our board

he partnered with our CEO Eric Lyle who is also not a physician but together they they set out to build this this large group and it's important for physicians to know that this isn't just a bunch of guys with MBAs or business degrees coming in and trying to squeeze profit out of out of uh

you know a particular part of health care we really are through the leadership of our physicians we have 20 I can't remember the exact number but 25 plus of our physicians are actual owners in the company meaning they have equity and an ownership stake in the company in addition to Dr bat who's still the chairman of our board

so knowing that we have physicians who are at the helm leading it really keeps us oriented on kind of a clinical focus versus just a straight business or profit or bottom line focus which is you know coming out of this again from my background of wanting to improve health care because I saw how much it sucked for my daughter

That's that's what I want to stay focused on that's what I want to be our North star and having those that position leadership and the buy in of our positions is absolutely important for that

Mike O'Neill: Craig you know my frame of reference is typically that from an HR perspective when I was leading HR one of the responsibilities was the overall benefits that are made available to the employees

the biggest chunk of that cost was health care but as a company grows they have to look at this not just in a community but multiple communities and it can get complex pretty Fast I was working for a company that was we end up being self insured so we had to look at this from a business perspective and look at

look at cost but look at quality and the like for a moment can you describe kind of what are the advantages can a employer contract with your company or are you working primarily through the payers

Craig Worland: so we today we do not have any employers that are that were contracted directly with but we are actively seeing that that's been on our roadmap since the company was founded to start to do that in 2024

so we're moving into that today and we are looking actively to find companies that are pretty progressive in their thinking that want good robust primary care either embedded at the site or local enough where patients can come and have easy access and then we want to provide that and an aligned way with the employer which is we're going to see these patients quite a bit

Especially and let me kind of explain this a little bit so we we look at the entire patient population and we strata no matter where we are we stratify the patient population because we all know not every patient is equal if you look at the the statistics the top There's 5 percent of your patients that account for I think 40 percent of cost your top 20 percent of your patients account for 90 percent of your cost

so we know we have to treat those those patients that are struggling with chronic diseases that are struggling with some acute disease that we have to treat them differently and they can and then the patients that are relatively healthy need to come in for their annual physical but not much more than that

We don't ask them to do much more than that so point being from an employer standpoint you need to align with a primary care provider who treats your population that way who looks at 'em just like you do when you're when you're managing your benefits on a monthly basis and you're saying Hey we have this you know this large expense here

we had you know this thing happened here you know those patients as a benefit manager are those employees as a benefit manager that are habitually you know some of your top spenders in your company at no fault of their own but they need a good aligned primary care provider to help them learn how to manage whatever they're struggling with

and so the importance there is finding that making sure you're aligned and that if the you know if if that primary care provider does a really good job of managing those patients they should share in some of the savings that they're generating for the company just to be frank you need to align the economics

the same thing we're doing on the payer side pairs have said if you can reduce cost we'll give you a percentage of that employer should be willing to do that as well and then but the flip side is also true as as as the provider if we don't reduce the cost and actually cost goes up we should be on the hook for for taking some some of that risk on as well

and it shouldn't all be on the on the organization so it's it's a nuanced conversation as you're to your point it's community by community it depends on what resources you have what your relationships are with the larger network in that community but it's a it's a conversation that needs to be had

and I am obviously biased but I recommend has had with the primary care provider 1st okay

Mike O'Neill: well I'm acknowledging up front that I have a bias and that is I've had a primary care physician for many many years I'm happy to say that that physicians is a regular listener to this podcast but I have I've seen the value that that

that this doctor can provide the over a a much longer time period you know Craig you've had an interesting background from from military to work in a large nonprofit system to now as COO of the group that you do can you reflect on a time when perhaps yourself or a client or something something got stuck

and when that happened what did it take to get unstuck

Craig Worland: yeah you know I think I think every time we are because we're growing rapidly we have you know we we have tripled in size over the last two years so when from about 40 primary care providers to now well over 150 and so through that growth inevitably you're having these these individual conversations with positions

some of them have been running their own clinic for 30 years and they have finally decided you know it's time to find a partner for whatever reason that they don't want to partner with the local health system or they don't want to partner with some of the other players in the market they want to stay with somebody who's independent

so when they come and talk to us there's always that point that you you you hit a you hit you hit a sticky point of hey how am I going to handle this situation how am I going to do this situation yeah and and you feel like okay we're stuck here we're not going to be able to get this completed

they're not gonna be able to join our group like we were originally hoping or whatever and what I found without fail is it's a let's sit down let's explain I'll be very transparent and explain why we're doing this it's not just to be owners here's here's why we approach whatever the topic is this way

And I'd love to get your perspective on why you why why this is so important to you to approach it from a different way and then let's find that middle ground and then I always and I and this is not my saying but if you leave you know a negotiation like that where one side is happy then you failed

you should both have felt like you gave a little bit up but you've reached kind of a more common good which in our cases is having that provider having that physician as part of our group part of the largest group in our state and continuing to help us grow and improve how we're doing clinical care

Mike O'Neill: Craig when we spoke prior to scheduling this podcast I learned about that rapid growth of your own organization to to grow as fast as you have presents us a whole new set of challenges as I step back and look at the clients I've worked with that's a recurring theme growth is good but with growth oftentimes comes growing pains

from your vantage point what might be if you don't mind sharing what might be the biggest growing pain that your organization has experienced

Craig Worland: yeah you know I could there's probably a list of four or five things that could hit up the gate but I think for us because of our emphasis on really good quality clinical care part of the challenge is you know we all now operate out of these electronic medical records that were mandated back in the early 2000s and everybody loathes them

but it's part of business now and when you bring when you grow like we have and you grow from 12 sites to 50 plus sites everybody's coming on with a different electronic medical record everybody's coming on with their data located in different areas and so part of our biggest challenge is is getting all of that kind of source together so that we can get the insights we need to and be able to to apply the resources

so we have a team of of RNs and LPNs and pharmacists and social workers that kind of sit at the quote unquote corporate level but are there to provide resources to the providers that are at the clinic site so but they need the data to know which patients that they need to reach out to which patients need a medication reconciliation on we need to be able to see and go back to what I said earlier and really stratify out that population

so we can tell hey Dr O'Neill we need you to focus on these patients and bring these patients in a little bit more frequently than you're you're bringing in these patients because we see them you know when we look at the historical data this cohort of patients is in the emergency room far more than the national average or is admitted far more than the national average

and we want to try to bring that down it is a huge challenge and it typically takes months for us to feel like we've got a good access to seamless data and ability to provide good clinical care yeah at the kind of the macro level so that they can really enjoy the resources that we're providing to them

Mike O'Neill: excellent I smiled when you referred to me as Dr o'Neill what people may not know is for a weekend I was I was yeah I was managing benefits for a larger organization and the American Dental Association asked me to speak Chicago but they had no way of putting me in the system unless they put a doctor in front of my name

and so for the weekend I was a doctor so I think I still have the badge to prove it so I was a dentist for a weekend but you know this topic that we're discussing boy it is it's complex it is broad but as you step back and kind of reflect on our conversation if you reflect on the people who you envision are listening to this podcast what do you want their takeaways to be

Craig Worland: yeah you know I think two things one is just the importance of primary care and and admittedly you know it's likeh mechanic telling you the importance of getting your oil changed I understand that it's it's it's a little self serving but it is you know I work here and our entire team is part of this organization because they believe that primary care should be kind of the foundation of which our health system is built on

And we can point to models all over the world that have done that and done that well so that that's thing 1 is is you know If you're a Aspiring physician think about primary care if you are a benefits manager think about who are those aligned primary care providers in your network in your communities that you can access and allow your patients to access

so and if you haven't been to a primary care provider in several years it's time to go get your checkup you know it is I can tell you countless stories of where a routine physical has literally saved people's lives because of of things that were found things that were discovered that we were able to get in front of before that before it got worse and

almost to a tee all of them said you know I'm really glad I came in because I almost skipped this I felt I felt good I felt healthy it was inconvenient but I'm glad I came in and maintain that and you spoke to it yourself with having that long standing relationship so primary care 1st and be very focused on that

the 2nd thing is just this idea of of creating alignment within the economics of health care the the the you know the federal program that does Medicare which is the largest you know funder of health care in the country that said they want 100 percent of their patients to be in a value based reimbursement model by 2030

so they've indicated this is where healthcare is going commercial plans always follow where healthcare is going so think about this idea of how do we align if we align those incentives how do we feel like the provider is just as incentivized to to take care of of the long term care of the patient and prevent unnecessary downstream costs as we the payer are and ultimately is the patient wants them to be and and creating that economic alignment and keeping you know keeping it from becoming that that tension filled tug of war that I think we've experienced the last couple of decades

and we've proven just doesn't work very well

Mike O'Neill: Craig you've opened my eyes to a number of things I haven't thought of thank you for just sharing your expertise it was most interesting if folks want to reach out to you what's the best way for them to connect with you

Craig Worland: yeah and I've still appreciated this conversation

and I think what you're doing with the podcast the leaders you're speaking to it is It is something that we often don't think about which is everybody is it feels like you're facing you're stuck and you're the only one facing this problem and then I hear hear your podcast and here's some of the people you talk to

no this is the common thing and I've learned so much from from you know hearing how other individuals have addressed have addressed their their darkness if you will but if people want to reach out to me Okay we're at southeasoutheastPCP.com our website emails are associated there

linkedIn is a great way to reach out to me not a huge social media guide but I do try to follow up on my LinkedIn and then you know please my my cell phone is on the website welcome people reaching out I'm always interested to meet people learn how other people are playing in the health care industry and what we can do to potentially work together to solve for what's a really really difficult problem but a very worthy problem to try to be solving

Mike O'Neill: Craig we met via LinkedIn therefore we will include the contact information that That you have shared in the show notes so if folks are driving down the road just be assured you can go to the show notes and get all that correct thank you

Craig Worland: thank you Mike I really appreciate it

Mike O'Neill: I've got a question for our listeners

are people following you because they have to or because they want to I'm a leadership coach I work with executives typically men who have a track record of success behind them but they're now feeling stuck they're frustrated because they're finding out that with each level of success that follows The bar it gets set even higher and they're discouraged because they've worked so hard and what worked in the past is no longer working

so my clients despite all their successes in the past they're lacking the clarity and the confidence to make the decisions needed to get to that next level so through coaching we work together to unravel hidden blind spots challenge limiting beliefs and establish a strong sense of accountability so if you're feeling stuck and that describes you or someone you know let's talk head over to bench-builderscom to schedule a call so I'd like to thank you again for joining us and I hope you have picked up on some quick wins from Craig they'll help you get unstuck and on target