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Robert Groves, MD:

Welcome, I’m Dr. Robert Groves you host for the Groves Connection Podcasts.

The Groves Connection brings you intimate conversations with pundits, providers, patients, leaders and lay people. All to help us understand the contradictions. How can our health care system be both magnificent and yet, so deeply flawed. We’re going inside healthcare to talk candidly with those who know. What they have to say may delight, surprise, frustrate or at times even anger you. But, I invite you to get curious and listen to the truth about health care and those who want to fix it. Maybe the answers have been there all along. We just need to make the connection.

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Robert Groves, MD:

In this inaugural episode of the Groves connection I’m speaking with Dr. Ed Clarke. Dr. Clarke is a respected leader in Arizona who is highly skilled at cutting through complexity and combining his experience in private medical practice as well as IT and informatics to identify and implement meaningful measure of physician practice performance. The final step then is getting information to physicians so that they can make good decisions for patients leading to better care. Ed does this as well or better than anyone I know and that’s not easy in a complex organization like Banner Health comprised of a nine billion dollar integrated delivery system with 28 hospitals across six states and an insurance network of more than 10,000 employee and independent physicians. This is a big job. So without further ado let’s make the connection with Dr. Ed Clarke. Ready?

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Robert Groves, MD:

Welcome, Dr. Ed Clarke. It’s good to see you. It’s been awhile.

Dr. Ed. Clarke:

It has been.

Robert Groves, MD:

We’re going to have a conversation about the pandemic and what’s been happening in health care in your world but where I want to start is how did you arrive at the position that you now occupy? Give us a little bit of background and start wherever you want but first of all why a doctor? And then describe your journey to where you sit today.

Dr. Ed. Clarke:

Be happy to and thanks for having me. So, why a doctor? That’s not a clear path. That’s one that kind of zigged and zagged growing up. Going to school as a kid I always did gravitate toward the sciences, mathematics, things of that sort. I grew up in a small town in West Texas and most of my family and my aunts, uncles, grandparents were on the other side of the country so they were kind of around the east coast and the Gulf States around Alabama actually so I didn’t see them all that often. And I had a physician in the family, my grandfather was one of the old school GPs who did everything. Who was a surgeon and obstetrician a family doc who did everything and I always heard stories about my grandfather who we called Papa Doc but didn’t see him that often because it was a two days drive for us and so

  Robert Groves, MD:

What a sec, Papa Doc? Really? I love that.

Dr. Ed. Clarke:

Yup. We called him Papa Doc. That wasn’t just the grandkids that was my mom, her brothers and sisters and everything. She was in a family of five and so I always heard these stories and just being romanticized this idea of this Doc in Alabama doing everything. You know being in a small town where all there were really were GPs there weren’t specialists. We had to drive at least an hour to get to what we would look at now as these specialist community that was in Amarillo. I tended to see what impact primary care physicians had in a community. And so always said that’s a good place to be, I can have an impact and again I had this idea that I could be Papa Doc. I could be in a community like this and be successful and really help out a community. So, as I approached college my folks, who you know were very conservative with pretty much approaching life in every way recommended that I have a backup plan because they understand that not everyone gets into medical school and everything. And so my dad was an engineer by training which is why we were in kind of rural Texas working the oil and gas industry. So studied engineering and found that there was a path for bioengineering which seemed like a great backup for medical school. But again some zigs and some zags and found myself studying civil engineering specifically the environmental path there. Was getting close to graduation, was applying for jobs and as I met with recruiters and companies nothing really just grabbed me and said hey this is the engineering version of Papa Doc.      

Robert Groves, MD:

That’s got to be hard to find.

Dr. Ed. Clarke:

Right and you know what I said I do think I need to get back on the path towards medicine. And so I finished my degree in engineering but had to backtrack and get a lot of my pre-recs in. One story short, ended up at UT Southwestern for medical school and

Robert Groves, MD:

Did you know that we share that in common?

Dr. Ed. Clarke:

That is right. I believe you did your residency there.

Robert Groves, MD:

That is correct.

Dr. Ed. Clarke:

Yah, so competed medical school there and still did have this path were I wanted to be a primary care and so residency came around and I kind of looked on the coast, wanted to something different having been kind of landlocked. Mainly looked on west coast, east coast, on the coast, I wanted to be near water. The greatest irony is that on my way out to the west coast to interview I stayed with a friend in Tucson, fell in love with the desert and was like wow, I think I need to look at some of the programs here. So I trained at what was called Good Samaritan at the time in Family Medicine, now called Banner University Family Medicine. Completed Sports Medicine fellowship after that at U of A Tucson.     

Robert Groves, MD:

Wow, I didn’t know that.

Dr. Ed. Clarke:

So, I practiced in family care sports medicine for about three and a half years and had an absolute blast. Got to do lots of great things not only in primary care but was involved in various levels of teams, weather be high school, collegiate or professional so I was blessed to be in a practice that really already had some established ties there. One of my attending when I was in residency he was one of the infomaticists at Banner Health at the time. His name was Greg Wrightlowe, great guy. I hadn’t talked to Greg for a number of years. He reached out to me and asked if I would be interested in medical informatics.  And I said, I don’t know but I’m interested in talking to you and learning what the heck that is. So Greg at the time was helping implement electronic health records at Banner Health and primarily converting the employee medical group over to an EHR. I talked to him and learned what he and his team did how it wasn’t just putting and HER in someone’s office it was looking at all aspects of medicine and figuring out how can we make this more efficient? How can we build workflows and other thing to actually make a physician’s practice better?

 Robert Groves, MD:

Now can I interrupt you right there for just a second?

 Dr. Ed. Clarke:

Sure.

Robert Groves, MD:

Because all of the things you have said so far resonate so deeply with me. My dad was a primary care physician in Albany, Georgia. And I idolized that life that he led and I got the same impression about the way health care was going, particularly when I started practicing now I’m one of those specialists. I went through pulmonary critical care training but it was the same thing. I felt like I was on a treadmill. I did a fair amount of primary care, particularly for patients with COPD and it ran into the same roadblocks. I’m going to ask you before we go on with this journey how do you think we’ve done in the transition to electronic health records? And the reason I ask that is because so many of our colleagues who complain of burn out point their finger directly at the EHRs. So what’s your perspective on that?   

Dr. Ed. Clarke:

Yah. That’s a great question. We’ve still not got it figured out. Because, yes, as I look at articles about physician burnout, which I’m incredibly interested in, I’m not practicing right now and I don’t run physician practices but in my current role which we will get to in a little bit a lot of time it is perceived that I and the team are asking folks to do are just extra things and it is pretty common for us to hear well gosh, how come this can’t just be in my ER? You’re making me do more stuff so I think we’ve done better for the industry as a whole because what it’s done it’s allowed us to actually have better access to the data to see who is truly doing what so that ultimately we can study and say are these activities improving outcomes and other things? But have we made practitioners live easier? I say we still have a ways to go. There are a number of things in the courses I talk to physician groups who have scribes that has dramatically improved their quality of life. They get home earlier and you might could even argue that the scribe is many times able to codify or document those things in the chart that they might have lost track of because of all the other things. I think we have a ways to go. I haven’t been frontline in the implementation of an EMR in quite some time but I hear just all the other aids the voice to text technology and other things I think are getting there but I do think it’s a necessary evil because it really is the thing that allows us to mine the data and really say are we having an impact other than that we have to use a human to go look in the chart and that’s really tough so.     

Robert Groves, MD:

 Well thank you for that perspective. I struggle with that same thing. Obviously we can’t go backwards. Paper is not useful for sharing information in population level data. We can’t go backwards we need to move forward and I’m going to put a place holder there and maybe we’ll come back to that but let’s get back to your journey so pick up where you left off.       

Dr. Ed. Clarke:

So when I joined the medical informatics team that really was the first time when I said okay I do think I can have an impact not only on these practices that I’m engaging with but I can be part of figuring the health care thing out to where there has to be a way that we can make this better for physicians and practitioners but really, again, helping broader population because right when we were rolling out EMR there was a think called meaningful use that was a mandate that everyone had to do and there were carrots and sticks. And of course we were rolling out EMRs as part of a big system so there was lots of focus on the care and part of it was to build in or report on performance on some of these clinical quality measures that are endorsed by Edith, SQA all these different entities and it sort of was a handful and I was fascinated by that because especially working with a large employee medical group it was like wow, now that we are collecting this data what can we do with it? How do we improve this over time? Are we under preforming or over preforming because of issues with the data collection? Is it the clinical practices that the groups have adopted? There were so many questions that I had so I talked to Greg, my boss at the time, and said hey I think we need to build out more than just the two or three that were required for meaningful use. Let’s build out a dashboard and let’s really start to see what we can do to impact AIC, blood pressure, all these things, they were largely measures around primary care and the bread and butter things at the time and so we did that. And I was having an absolute blast doing that working with the analysts and everybody just the things that we were discovering,   

Robert Groves, MD:

Quick question.  Did you engineering background help you with that transition to informatics or did you feel like you were starting from scratch there?

Dr. Ed. Clarke:

You know I think it did help because at the time there were not too many programs dedicated to medical informatics at the time there were some, I think there were some master’s programs there wasn’t a fellowship at the time but yah I think just the type of analytic approach that you have going through the curriculum to be an engineer and others I do think that helped me.

So, as we were doing those things and building those I found myself kind of running the quality committee for the medical group. Even though I was informatics I was kind of the guy who was pulling the strings and had access on there  

Robert Groves, MD:

And when you say medical group you are talking about Banner Health?

Dr. Ed. Clarke:

Yes. Banner Medical Group, so large, multispecialty group and

Robert Groves, MD:

How many Docs are you talking about here?

Dr. Ed. Clarke:

I think at that time Banner Medical Group and aggregate was probably about 1,400 physicians across six states.

Robert Groves, MD:

So big, big enterprise.

Dr. Ed. Clarke:

Yah and again as we were building these things at the time for meaningful use it was paper reporting so you didn’t have to hit a threshold or anything. But knowing the direction the system wanted to take.

Robert Groves, MD:

So to clarify, paper reporting what that means practically is that it’s a performance based payment with the performance in this circumstance is simply that you can collect and send information to that regulatory entity. In this case, I’m guessing is CMS. Is that right?

Dr. Ed. Clarke:

Yep.

Robert Groves, MD:

So the kind of information might be a hemoglobin A1C and you are not held accountable for what that level is yet, you just need to be able to send it to them. Is that right?

Dr. Ed. Clarke:

That’s it. So, yah, I was looking at this across all these physicians with Banner Medical Group in multiple states I was like aha! This is it. Okay. If we do things collectively, not only on the IT informatics side, but also partnering with the Boyd medical group and the quality committee and everything and their leadership, either automate this, build work flows or help others on the teams have these diabetics get their A1Cs get their urine micro album tested and other things, really in a broad scale we can improve the outcome of the population and the irony, I started with gosh I feel like all I do is codify my work and reimbursements you know upside down here between a primary care doc and a specialist at times, the irony was for us there was no increase reimbursement for doing those things thought right. So if we did improve the outcome of diabetics we weren’t in a lot of value based contracts or other things that were out there at the time. So but none the less I was having

Robert Groves, MD:

So that was perceived simply as extra work for a practicing physician at the bedside who said I need to take care of patients and here you come and telling me that I have to click these few extra boxes. Is that kind of how it was perceived?

Dr. Ed. Clarke:

Um, for some yes. And we were very aware of that because we had for many of these practices just recently converted them from paper to NGA charts so everything was more work.

Robert Groves, MD:

Yes. Yes, fair enough.

Dr. Ed. Clarke:

And so yes, we did all we could within the limitations of the EHR we had at the time, automate things, build things in, promptings, you know we did all those things, but yes, there was nothing in it for them at the time. So right around that time Banner Health and its network, which was relatively new, was selected as one of the pioneer ACOs at the time. I think Banner was one of the 33 that CMS kind of judged had the chops to kind of start this new demonstration model. I didn’t really know what was happening with CMS specifically with these models and everything but I quickly found out after my boss had the printed out narratives specs for all the quality measures that we were either on the hook for or responsible for improving in the pioneer ACO and given what I was doing with the quality committee and everything else he put it on my desk and said hey, Ed you need to figure this out. And away I went.

Robert Groves, MD:

So let me stop you here for just a second so that our listeners can have a little bit better understanding of what is an ACO? And how did pioneer work verses Medicare advantage or straight Medicare? Most people don’t have to delve into that and this was a novel way of looking at it. Can you give us a little bit of background on what that means?

Dr. Ed. Clarke:

Sure, be happy to. So an ACO is an accountable care organization. That’s the acronym and it’s used quite a bit but in this context it was defined as a group of health care providers so physicians, APPs and aligned entities including hospitals and other folks in there network.

Robert Groves, MD:

APP being advanced practice professionals and that could be nurse practitioners or physicians assistants?

Dr. Ed. Clarke:

That’s it. So it is an organization or collection of those individuals and aligned entities who are working together to lower the cost of care for a population of patients while improving outcomes and improving the experience of those patients. So the pioneer ACOs were a collection of about 33 systems nationwide who had a critical mass of members or patients that were seeing them and in this context they were folks with straight Medicare, so traditional Medicare. They weren’t in Medicare advantage or any other plans so were seeing providers aligned to those systems and those systems had to demonstrate that they had adequate capabilities with electronic health records and integrated delivery systems and other things. 

Robert Groves, MD:

So these systems were literally selected by CMS and it was the innovation arm of CMS which was fairly newly created and so they were selected if they met that bar of having electronic health records, demonstrating that they could manage a program like that or at least in the view of CMS. Is that right?

Dr. Ed. Clarke:

Correct. Yes, and so Banner Health was, luckily, one who got picked and I kind of found myself on the informatics team and heavily involved with the quality team for the medical group in a great position to figure out okay, how do we make this work? Because making this work could mean at least for us and I honed in on this thing gosh, this is what I needed when I was practicing primary care. Because the idea is if all the folks in you ACO collectively do things that end up lowering total medical cost for this patient assigned to that group the delta between what the historical expenditures were for the population or at least the predicted expenditures were to where you actually came in and did all these wonderful things to lower costs those dollars would then be available to be paid to the network in what they called a shared savings payment. 

Robert Groves, MD:

Can I stop you there just for a second? And this is just for the benefit of listeners who may be less familiar than you and I are with how this works. So, Medicare Advantage we will leave on the side for right now. That’s a whole program unto itself and that’s where private insurers compete to serve Medicare patients and there are rules and regulations around all that but it is a Medicare Advantage program and the patient knows that they have chosen Medicare Advantage and before Pioneer there was just straight Medicare which is a broader choice for the individual. They can kind of go to whoever they want to go to and as long as Medicare pays for it there is no restriction in the network. And correct me if I get this wrong, the interesting thing about Pioneers is it is kind of convoluted in that what CMS said, the center for Medicare and Medicaid Services said we are not necessarily going to notify any patients that they are in this new model and they are going to behave as if they are straight Medicare and then at the end we are going to look at who they saw. Which physicians they visited retrospectively and based on that assessment figure out who then is “responsible” for their care primarily and usually that is a primary care physician but not always right? So that’s who attribution happens. It is in retrospect and you don’t necessarily know as a doc what that is going to look like while you are practicing. It’s in retrospect and then the shared savings that you are talking about, the bar that you are trying to beat is a predicted model of what it would have cost in straight Medicare for that one year period. So upfront they predict what it would have cost and then they work backwards from that and say what did it cost? And then the difference between those two you had the opportunity to take advantage of that’s the shared savings. If you exceed the cost there are not shared savings, but there was not much risk but there was some if I remember correctly in the pioneer program. It was a five year program, you had to sign up for you didn’t have to stay for all five years but that was what you were signing up for so it’s a very odd creature and it was an experiment in trying to understand if we link the fee for service payments in place as they are can we incentivize health systems in this case because as you described nicely, it’s not just the physicians, it’s everybody in the system that’s involved. Can we incentivize them to save money without changing anything else? Is that         

Dr. Ed. Clarke:

Yah. That’s a great summary. I was excited to see that here is perhaps that chance and it was a demonstration project right. So figuring out how do we take and I started with the quality measures that were built in there because it wasn’t just that you lower cost it was if you lower costs the percentage of those savings that you received where multiplied by a modifier which was determined by how well you preformed on the quality measures another outcome metrics which did include patient experience so and the reason why those are baked in is because we can lower costs just by withholding care.

Robert Groves, MD:

Right. Some of us remember the eighties, the original capitation strategy, which was hey here’s x number of dollars and if you save money we will split it with you. But there was not counter measure, there was no way, we didn’t have the sophistication then to be clear, but we weren’t measuring quality or experience. So you can see where that leads. If the incentive is simply to save money, then the easiest thing to do is not to take care of patients. And patients figure this out pretty quickly and there is this huge backlash. The difference now is that we can collect that information and we do collect that information so there is a balance. You can reduce costs but you better make darn sure that you are hitting your quality matrix and that you are hitting your experience metrics or it’s going to cost you. Is that accurate?

Dr. Ed. Clarke:

Absolutely. So, we lower cost. Did we perform well on the quality measures which are generally tied to a lot of the chronic illnesses, prevention, screening those sorts of things, just the bread and butter things that primary care physicians and other specialists are trying to do all the time. Did we keep people out of the hospital did we not utilize the emergency room much, did we reduce use of expensive imaging? Those are some other things in there and then the classic kind of cap surveys around how well you rate your provider, where they available? Did they treat you with courtesy and respect? So, combine all that together and you get your quality multiplier and then multiply that by your shared savings and there you go. So the idea is then that these like-minded individuals come together in an ACO and they say wow we do have levers and things we can do to generate the shared savings while including outcomes and then there is a reward so that a practitioner spending hours upon end trying to control someone’s diabetes and obesity and blood pressure, which might only generate a level three or four visit and be reimbursed a hundred bucks, can see some reward on the back end. Because by doing those things they truly created better outcomes for that patient. So that was the beginning. We built that in and we started to really encourage the rest of the organization to develop processes and other things to make this easier. My career changed a little bit right around there. So given that I was so involved with lots of things with the medical I was asked to be one of the chief medical officers and so my title at the time was chief medical officer of clinical operations. In that position I was able to help continue to influence and make decisions and other things to help operationalize largely the things that I just spoke about.        

 Robert Groves, MD:

Now, now if I remember correctly, just by way of background context if you will, at the time that you were doing that you were putting all those metrics together and making sure that we were able to measure them I was sitting in a position similar to the one that you are sitting in now. I have to say that yours has been expanded significantly you’ve got a lot more going on than I did at the time, but my perspective was essentially your seat right how and I have not yet thanked you for all of the work you did to make those metrics available because Banner preformed really well in the pioneer program. I mean ultimately it was I think the top performer overall, five year combined and that’s a testament to the work that you and others did to make sure that we could measure properly and to continually improve those measurements over time. Which we did.