[00:00:01.290] Announcer:
Welcome to APG on American Healthcare, the official podcast of America’s Physician Groups, where we discuss current issues in the healthcare value movement. APG members are at the forefront of national healthcare reform, practicing at risk-based prospective payment and other population-based payment models, the very models described by federal legislation for the entire nation. And now for an inspiring and educational look at the transformation of America’s healthcare delivery system, here’s your host, APG president and CEO Don Crane.

[00:00:36.480] Don Crane:
As I considered who I might want to have as my next guest for this podcast, I thought it time to check in with Intermountain, the famed and renowned integrated system in the state of Utah. Famed in large part, I think, because of the notoriety achieved when President Obama, then-President Obama, in attempting to
sell the Affordable Care Act, held up Intermountain as being a prime example of value, but also integration between hospitals and physicians done right.

Part of my interest has been spiked by the nomination of the current California Attorney General, Xavier Becerra, as the new secretary of HHS. That nomination has occurred and drawn a lot of attention, in part because of Mr. Becerra’s prosecution of basically actions against some hospitals, most notably the Sutter
system in California; asserting that that particular example of integration actually increased costs without improving quality. So that’s the hot topic. And I know Intermountain to be an example of integration done right fuels into our thinking that integration, when done right, produces value and when not done right and not for the right reasons, does not.

And it would be interesting to explore that subject with Raj. He has the most amazing portfolio you’ve seen. He’s principally known as the president of Castell, basically the physician arm or wing of all population health matters for Intermountain. So, an amazing role and an amazing gentleman. And I’m
proud to have him be on the board of APG.

So, with that, take a listen.

Raj, good to have you with us today. Raj Shrestha, so, so nice to have you with us. You’re an APG board member. Let me do a little introduction right now and you can then elaborate or add or subtract or correct my misstatements, if any. Chief Executive Officer of Castell, an Intermountain Healthcare subsidiary.
Want to hear about that. Chief Operating Officer for Intermountain Healthcare. This then puts you in charge of the Intermountain Medical Group consisting of two hundred plus clinics.

I think something on the order of twenty-four hundred physicians. Three thousand physicians…can’t remember, some very, very large number. In charge of Intermountain at home. So, this is all your hospice and palliative work. And most, I think, interesting for my particular standpoint, the hospital home program I want to hear about. Oh, you’re in charge of the senior clinics and the affiliated provider groups and population health management. That is indeed a very, very large portfolio.

But it doesn’t stop there. You’re the President for Intermountain Healthcare, Nevada, which for APG members that are listening, this is formerly HealthCare Partners, Nevada. So, you’re now in charge of what was a HealthCare Partner’s division. I find that interesting and important, given Healthcare Partners’ reputation for excellence, et cetera, et cetera. And the net of this, Raj, is that you’re responsible for all of the risk and value-based business across the entire Intermountain franchise enterprise.

That strikes me as being a very, very large portfolio. So anyway, I’m really looking forward to this opportunity to talk with you. Did I get it about right, Raj, in terms of the bio?

[00:04:22.040] Raj Shrestha:
You did, thank you so much and it’s a pleasure to be here with you as well.

[00:04:25.490] Don Crane:
Great. Tell us a little more about Intermountain. I mean, you know, just as we were in our little prep here a minute ago, I mean, I know Intermountain pretty well, but what I know about it is its reputation for innovation. When the Affordable Care Act was first enacted, then-President Obama made a big example
of Intermountain as being an example basically of coordinated care and innovation. And I think that etched its reputation in my mind at the time and has done nothing to other than to just enhance it since then.

So, talk a little bit about Intermountain and then we’ll move into Castell and your portfolio.

[00:05:06.200] Raj Shrestha:
Yeah, absolutely. And Don, thank you. And, you know, just to ground ourselves…so, Intermountain is an integrated, not-for-profit hospital system, if you will, health system. We have twenty-four hospitals, which includes one that is a virtual hospital, which we can talk about. Medical groups across now the states of
Utah, Nevada, and Idaho with our acquisition of the Saltzer Clinic here a few months ago. We also have a health plan that’s been around since the 80s called Select Health.

It’s the largest health plan in Utah. And our mission, Don, really is helping people live the healthiest lives possible. And that really resonates across everything we do at Intermountain. As you said, we’ve been, you know, tagged as one of the more innovative systems. And I think part of that is because of the
integrated approach. And when you have an integrated system that has everyone swimming in the same direction, our health plan, our hospital organization, which we call specialty-based care, our community-based care assets, which is everything you talked about.

Right, that’s under my portfolio, we’re all swimming in the same direction for high quality, high safety, affordability, low cost to the community. And just this focus that healthcare, as it is, is unsustainable and we want to be on the forefront of making it sustainable. Clayton Christensen also said, look, the
integrated system is one that can change healthcare and be on the front end of innovation. And we truly believe that as well.

[00:07:03.380] Don Crane:
Very, very good. Tell us about Castell. First off, an interesting name, Castell, I assume there’s a story
about that.

[00:07:09.950] Raj Shrestha:
There is.

[00:07:10.790] Don Crane:
Yeah, go ahead.

[00:07:12.710] Raj Shrestha:
First, and I’ll correct you probably the first time in our careers…it’s Castell.

[00:07:18.050] Don Crane:
Very good.

[00:07:19.670] Raj Shrestha:
And so first and foremost, in our journey to deliver population health and value, which is a core mission of Intermountain, we said there has to be an entity that helps us manage multiplayer risk. So, we have our own health plan, which is fantastic. But, as we see the world, we’re not a closed system like a Kaiser, I think very highly of Kaiser.

But most health systems in the US aren’t closed with their own health plan or with one health plan that they’re contracted with. We elected to say we are going to manage multi-payer risk extremely well. And a couple of things we did is prior to launching Castell, we created a new care model we called reimagine primary care or now sort of tagging that as our value-based care model. And, you know, most great organizations like Oak Street and ChenMed and IORA, they really focus on managing MA really well. We said that’s fantastic.

Our model does that as well. But we really want a model that can manage all sorts of risk, all products. So, this reimagined primary care model manages MA risk, commercial risk, exchange risk and Medicaid risk. And that is the anchor of Castell. And what we built around these models then is the tools and
services and capabilities to not only help our medical group transition even further to value, but help affiliates that we’re contracted with transition of value and help them manage multiplayer risk.

And now we’re getting into helping other IDNs or AMCs manage multiplayer risk as well. So, Castell, is this new sort of organization that we’ve launched, I’m going to say 18 months ago, that is on the forefront of transitioning not only Intermountain, but our affiliate practices and others towards value-based care.
The story behind Castell. So, what is a Castell? In Barcelona and in other parts of kind of southeastern Spain, Valencia, etc., there’s a festival where human pyramids are built and you can Google ‘Castell’ and see these large human pyramids standing people standing on the shoulders of each other.

And there’s festivals for this. And we said, what a great concept of working together, reaching for the sky and leveraging each other. There aren’t any machines or anything like that. But it’s human interaction and human touch. And we felt that was a great sort of aspect of what we wanted the company’s culture to be around, let alone, I’ve teased the team that we’ll have a retreat next year, hopefully in Barcelona. So that’s sort of the story behind it in terms of how we envision the culture of the company and really transforming and leading out in value-based care for the benefit of our country.

[00:10:49.560] Don Crane:
So, what percentage, let’s say of the business…maybe the word would be revenues…of Intermountain generally is risk-based?

[00:10:59.820] Raj Shrestha:
It’s a great question, Don. We’re at around let’s call it 45 to 50 percent. We would like to get over the next several years closer to 60 percent. And having that amount of risk revenue allows us to, you know, be more innovative, in my opinion, having that prepaid revenue for a health system that’s an open system. We’re probably on the one end of the spectrum. Most organizations that are taking risk maybe are 5 to 15 percent of their top line are in risk-based revenue so we view it as a positive. And because we’re on that end of the spectrum, we view it as an opportunity for us to showcase to the rest of the country what being
in value-based care arrangements can do from an innovation perspective, from a care delivery perspective, et cetera. So that’s sort of where we’re at.

[00:12:08.310] Don Crane:
And from a profitability standpoint, I would ask?

[00:12:13.520] Raj Shrestha:
Absolutely, it helps tremendously.

So, it’s one thing to get risk contracts or to have a health plan. It’s another thing in sort of this world to be profitable. Right? Some of the groups I mentioned that are in these models are yet to be profitable. We pride ourselves on having the best balance sheet and financial outcomes in the industry. And part of that is being able to manage that forty-five to fifty percent very effectively. And a lot of the core innovation, medical management processes, understanding how to manage through an integrated system that DNA that really makes Intermountain different has allowed us to do well in this space as it relates to profitability as well.

[00:13:13.590] Don Crane:
So, if you had your druthers, would you move that 50ish or 45ish percent of risk-based revenue to one hundred percent?

[00:13:23.550] Raj Shrestha:
You know, if I had my druthers, I would, right, in an ideal world, because I do think value-based care is the way to go for both patients’ satisfaction, provider satisfaction, outcomes and making care affordable. That said, it may not be the reality. And so, having the wherewithal to understand how you really play in a value-based world, trying to get that percentage up, but also understanding how to make the fee-for service world more palatable as it relates to cost is what we’re trying to solve.

So, an example, Don, is half of our business we look at two metrics at one half of the business the let’s call it community-based care or the fee-for-value business. We’re looking at per member per month and looking at decreasing that per member per month costs. And everyone’s focused on that. On the
traditional health system or hospital side, we’re looking at costs per case. So even though it’s a more traditional metric, we’re looking at reducing cost per case.

So, those two metrics are the main metrics the entire enterprise looks at. And even though the fee-for-service side isn’t valued yet, we’re looking at metrics that correlate to bringing affordability to the community. So, even though I’d love for us to be at one hundred percent value and it may happen down
the road, maybe not in our careers, Don, but there could be, you know, unanticipated legislative changes, who knows, that potentially drive that, but right now, we are trying to work in both systems, but again, for the benefit of the community and with an eye on affordability.

[00:15:23.180] Don Crane:
You know, I love hearing you say that, that’s so confirmatory because in talking to some of my hospital CEO friends—and I have many of them—and we talk about the advantages of moving into a risk-based payment model.

I asked them the question. You know, they say they’re doing fine with the RGs and case rates and per diems and the like. And I said, don’t you need efficiency within all of those payment models? And they say, well, why of course.

And then I say, but if so, then if, you know, perhaps maybe the single most efficient payment model called capitation breeds that, it can abuse your system with efficiency.

Don’t you suppose that rising tide helps all of the disparate boats within the enterprise? And I think my arguments are making some sense. Does that hypothesis sound about right to you, Raj?

[00:16:15.170] Raj Shrestha:
You know, Don, it does. And I’ll give you an example. As we look at our risk business that the PMPM metric, we are actually thinking about putting PMPM targets on our hospital systems as well. So, even though they’ve got their own sort of cost-per-case metrics, they still have to deliver on the P&L that each of the hospital system owners have. We are now asking them to think out of the box and have per member per month targets as well. So, reorienting hospital leaders to not just think in the traditional way, but to think about capitation and think about how that works.

An integrated system has benefited us. And we’re looking forward to showcasing that to the rest of the country, hopefully shortly.

[00:17:10.670] Don Crane:
Very, very good. Well, we may be calling on you to do that at our next annual conference. I’m not kidding you. One further question on this. Before then, I want to move on to another subject. So, you know, you’re not at 100 percent risk and you’d like to move up from where you are. So, this begs the question. So, of course, generally, why not? And more specifically, are payers within Utah not interested in capitating or paying you risk-based models?

I mean, what’s the problem?

[00:17:39.080] Raj Shrestha:
Yeah, it’s a great question. And each market is different. And I’ll talk a little bit about Utah. And I want to shift to Nevada as well and what we’re trying to do in Idaho. So, obviously from Select Health, our payer, the health system and Castell, we’re taking sort of risk. There are payers, aligned payers, that are moving that way. We’ve just signed a large Medicare Advantage contract where we’re taking risk as the entire system.

We are starting to see more of that. There are payers that obviously are aligned to value-based care, looking for health systems that can take value-based care. So, obviously Intermountain and the region we’re in comes to mind. But it’s not a problem of the payers not wanting to. I think most payers that look at
Intermountain would love to give us risk. And I think that gives me great, I would say, opportunity to think about moving that number up in Utah.

In Nevada, we talked about HealthCare Partners, Intermountain now named Intermountain Nevada. It’s you know, 90 to 95 percent of the top line comes from capitated MA contracts. And it’s a great model for the rest of Intermountain to learn from. It’s a phenomenal model of really understanding government
programs and how to deliver better care to the community, but at the same time do well for the enterprise. In terms of, as you talked about, profitability with that model, that model can be profitable.

And what we’re seeing in Intermountain Nevada is that that proves to be well. And again, incentives are aligned. You take better care of patients, you take better, you ensure satisfaction is there, because next year they’re going to have to sign up with your group. And from a retention perspective, you want provider satisfaction high, et cetera. So, we really like that model. And in fact, in Idaho with the Saltzer Clinic, we’re really looking to transform that market into a value-based care scenario like we’ve done in in Intermountain Nevada.

And what it shows is you don’t have to have, you know, there’s different flavors. We may not have a hospital in Nevada. We may do this in an asset-light fashion, but still take risk and still implement our care process models that have differentiated Intermountain, et cetera. And we’re looking at Idaho as well. So, as we grow, there may be some states where we take a traditional approach, but oftentimes we’re looking at taking the asset like nontraditional approach and we see both of those models working again. What’s best for the community?

What does that community need? We’re not going to go into a community that’s over bedded and add more hospital beds. That’s not what Intermountain is about. Where can we fill gaps for the community and how can we help that market transition to value? That’s what Intermountain is about.

[00:21:08.400] Don Crane:
So, we’re thinking now about Xavier Becerra. So, just for our listeners, whenever this is aired, this podcast, Xavier was just nominated by President Biden and he’s yet to be confirmed. So, we don’t really know whether he’ll have the job or not, but it’s attracted a lot of attention, some objection. I did note that
the American Hospital Association of all trade associations actually issued a press release supporting the nomination. So, that suggests to me that he’s not seen by at least a lot of the hospital community as somehow adversarial.

And yet here in California, where I happen to be sitting at the moment, you know, he has achieved some notoriety for the action filed while he was Attorney General of California against Sutter and produced a settlement. And I know nothing really about the facts of that case, nor would I personally overinterpret it. I think he probably filed hundreds of actions every year and this is but one of them. So, I don’t know that we could overgeneralize in terms of his own philosophy, but it leads me to sort of move to the advocacy we’ve sort of long adopted around APG with respect to this issue of consolidation and whether it’s
monopolistic or collusive in our response to those critics of consolidation has been, look, sometimes there’s consolidation referred to perhaps as hospitals coming together or hospitals acquiring physician groups when done for the right reasons and producing the right kind of outcomes.

Heck, that’s precisely the kind of integration we want. And I imagine with the Idaho system or group you just mentioned, Saltzer, that I don’t know very well, that’s probably the case.

And yet then we’re aware we’ve seen some of the data that where there is consolidation done for the wrong reasons and or producing the wrong sort of results, well, that indeed is a bit of a bad thing for producing higher costs without commensurate higher quality. So, I guess my question to you, and you’ve have answered it now, but with some specifics, how should Xavier Becerra and others in the world know the difference between good consolidation and bad consolidation?

What hallmarks? What characteristics?

[00:23:30.710] Raj Shrestha:
That’s a great question, Don. I mean, you know, I can first tell you what we’re thinking about and then maybe, maybe some suggestions. But as you sort of articulated, we look at it from what the benefit is to the community. And, you know, over time, that should mean care is becoming more affordable. Quality is
increasing. Safety is increasing. Those are the fundamentals we look at. And that would signal success in my mind.

If a combination doesn’t achieve that, then I think there’s questions of what is, you know, what is the value of that combination? Now, there may be other aspects, right? There may be a system that was on the fritz financially and this combination actually helps keep that system afloat. You know, there’s the pressure on rural facilities and rural communities that I would ask Mr. Becerra to really look at, because that is going to be an issue.

And COVID has exacerbated some of those concerns. But what I do think on a go-forward basis is when we look at if combinations are successful, they should be in that matrix or framework around safety, affordability. You know, others may say experience as well. Providers in a community, we are drastically in a shortage. So, how do we ensure? So, there are there are multiple parameters around this. We would love to work with Mr. Becerra on thinking this through. But before then, we have our own matrix and our esteemed leader, Dr. Mark Harrison, has sort of challenged us as we’re thinking about this not
only in the markets we’re in and we’re thinking to expand. It’s doing what’s right for the community and really understanding what the community needs. If a community’s, as I said, if it’s over-bedded, it doesn’t need any more hospital beds. If it has X amount of services, we’re looking to either bring the cost of those services down or if there’s a gap, bring the services to the community. So, I think with a sort of commonsense framework geared towards community benefit and community impact, the stuff around that falls in place. But that should sort of be the North Star.

[00:26:10.780] Don Crane:
Very, very good. So, you evidently have the secret sauce somehow well bottled. So, by that, I mean, you know, hospitals historically, generally, and this is a generalization, you know, make money by having more admissions and there’s more utilization. Capitated physician groups, on the other hand, like those
that you run, make money by keeping patients out of hospitals. Those seem like diametrically opposed sort of strategies and business cases.

So how do you fix that? What are the tricks? What are the secrets?

How do you talk all of your hospital CEOs in taking less money and must make for some interesting meetings, I’ll bet. But tell me how you do it.

[00:26:57.010] Raj Shrestha:
It’s actually a simple strategy that Dr. Harrison and other leaders, Dan Liljenquist, our Chief Strategy Officer, came up with. And we think about it in three ways, you know, because we have Select Health, our health plan or other health plan partners who we really think about growing membership through that
aspect. And that’s, like I said, through our plan or other plans where we’re associated with. And then it’s easy as you think about it in terms of a kind of three-pronged flywheel.

You get that membership. It’s about keeping that membership well and healthy, and that’s the community-based care side, that’s the capitated contracts we have, et cetera. But at the same time, we know people are going to get sick and get ill and need that higher level of care. And so, when people need to go get
that higher level of care, how do we ensure that we’re doing it at the lowest cost possible? So, it’s this sort of three-phased approach.

And it’s a simple strategy. And our strategy is built around that. Grow and retain membership. Keep people well and healthy. And when they get sick to a greater degree, unfortunately, get them the best care at the lowest cost. And that model has worked for us well. And that’s what we’re trying to take to the
other markets. And when people come in and we have a lot of health systems come in and look at our processes, our Intermountain operating model, et cetera, a lot of them are astonished around this simple strategy.

Now, there’s a lot of stuff that hangs underneath it, right? But at the core of it, it is that alignment. And in the entire system, from our health plan to our specialty-based care, which is our hospitals, to our community-based care, everyone’s aligned around that. And that makes a big difference.

[00:29:04.120] Don Crane:
So, that makes total sense to me, particularly where it’s your own health plan, your own enrollees and thus your own nickel, but your multi-payers…so, what happens? Tell me about when you’ve got a patient from United or Aetna or the like where they’re paying the bill. How does that tweak that formula? Does it?

[00:29:24.910] Raj Shrestha:
The formula still works, especially if you’re in a global cap contract, right? So, we push for those type of contracts and we don’t have all of our payer contracts and global cap, but we want to evolve towards that. And some of our payer contracts are in global cap or quasi-global cap. And that then our three-pronged strategy, if you will, still makes a ton of sense, right? Where we’re taking capitated risk for both the health plan and for us. The best benefit and for society is keeping people well and keeping people healthy and investing in care upstream to keep them healthy.

And then when they do need care, they come to our facilities and we want to make sure that we’re providing great care at low cost and in a at-risk environment. That makes a ton of sense. And even if we’re not in an at-risk, if we’re in a quasi-risk, we think about risk corridors or things of that nature. So even in our sort of traditional fee-for-service engagements with providers, we want to help them think about more risk.

One of the examples I’ll give is our reimagined primary care clinics, which is delivering phenomenal results. We leverage that to say if you if you want access to that, let’s get into more of a risk arrangement because that’s how the model makes sense. And we’ve got payer partners that have jumped on board
and obviously want to move towards that type of model and others that are getting their feet wet and wanting to understand it more. But that’s our sort of way to work with our aligned payer partners in a way that allows, even though it’s not our health plan, it’s still seamless and it feels like it would have been with Select Health.

[00:31:35.000] Don Crane:
Very, very good. So, let me segue off to another topic that’s of interest to me, which is your hospital-athome program. So, a fair number of APG members now have those underway and they differ from organization to organization. But I think they are hugely strategic and I think portentous in where healthcare may be going. And of course, there’s an awful lot of light shining on those programs right now in the midst of a COVID crisis where some patients aren’t even able to be admitted and have to be treated at home.

So, let me just start by asking you to describe your hospital home program. What’s it look like and how is it going?

[00:32:15.350] Raj Shrestha:
Yeah, it’s a great question and we’re really excited about it. We’ve launched this through Castell and we’ve been thinking about hospital-at-home for probably two years, Don. And, you know, last year we said, OK, we’re getting close. We think we’ve got the parameters all set up. We’ve actually looked at a couple of vendors as well and said, you know what, we could probably do this ourselves. And let’s really start thinking about the model.

Then COVID hit and Mark Harrison brilliantly said we need to accelerate this. So, we actually launched this in a span of four weeks. As soon as the pandemic hit. It’s really helped to, one, alleviate some of the pressure on the health system at certain times, especially now. But two, really, you know, no longer was
there a debate, right, is this the right thing to do? How is it going to impact the hospitals? It was we’re doing this and it’s the right thing.

So, this model kind of phase one, we really think about the flow of the patient presents right now at the hospital or through the ED. We identify, OK, this patient is a person that could be treated in the home and we transport them back. We set up remote patient monitoring with them. If they’re admitted from the ED, we kind of set it up on site for them. If they’re admitted through the inpatient, we do it in the home.

We’ve got 24/7 tele-nurse monitoring, daily hospitalists and homecare nurse rounding, education for their in-home caregivers, et cetera. And I got to tell you, the satisfaction ratings from our patients has been through the roof for our provider, our caregivers who are part of this program as well. And it’s the future, Don. I mean, we recognize that moving care upstream, and that’s why we sort of launched and branded Intermountain at home last year. Intermountain has been forward-thinking since the 80s.

We’ve had a home care hospice organization for decades. Intermountain has been in the home for decades. But there’s an even greater push to now extend through technology with remote patient monitoring, with telemedicine, et cetera, to look at these new care models. And we’re excited to expand this model further and really look at it as an opportunity to help other organizations think through, think through the push into the home as well.

[00:34:59.860] Don Crane:
So, these patients are pretty darn acute. it isn’t just post-discharge recovery stuff. These are what would formally be acute inpatients, right?

[00:35:09.010] Raj Shrestha:
They would be. Now, look, there’s a level of acuity, right? These aren’t high acuity. These are lower acuity. They’re still patients that would have been admitted into the facility, that’s for sure. And we’re taking those lower-acuity members and keeping them in the comfort of their home. That’s what we’re
hearing from the patients that, wow, I get the same level of care. I am getting used to the technology, that the 24/7 touch point

but I get to be with my family at home. That is significant. And even as we think about how we’re responding to COVID and leveraging this, it’s making a big difference as well.

[00:35:53.910] Don Crane:
I can see why it’s so popular.

I mean, speaking personally for myself, I would certainly opt for it if I possibly could. So, you say it’s the future, Don Crane. So, put some numbers to that, if you can, for me, Raj. I mean, these are going to be estimates. I mean, are we looking at, you know, hospitals since this shrinking by 50 percent because of
hospital-at-home programs 10 years from now or 20 percent, or what’s the future look like, as you describe it?

[00:36:22.450] Raj Shrestha:
Yeah, ten years from now I hope those are the percentages. Right? I think right now it’s early days. Those that are thinking about it or have launched it the censuses are very low, Right, compared to the traditional inpatient census. I do think, though, as patients, health system in general, caregivers feel more
comfortable, you’ll start to see that lower acuity may be moving up a bit to low- to mid-acuity and maybe topping out around mid-acuity in the 5- to 10-year span.

And as more of our country moves to value-based care, these models make a ton of sense, right? Even for hospital systems. So, if I’m a traditional hospital system that’s only taking fee-for-service, this doesn’t make sense for me, because these are…this is revenue that’s actually going away or maybe it’s less
revenue. But if you’re taking risk and managing premium, this makes a ton of sense. So, it’s the growth of these types of models, in my mind,

and it’s just my opinion, are correlated to how, you know, value-based care and correlated to keeping people well. And organizations can do well financially in these models as well. But it has to be correlated to the degree of taking risk or value-based contracts. So, I do see this expanding. I do see this as the future, not just hospital-at-home, but care at home, obviously home-based, primary care. There’s a ton of organizations now, right, doing great work, getting into the home, taking care of people and organizations that are focused on health equity and the social determinants and wrapping all that together, really taking care upstream. I see in the next 10 years, healthcare looking drastically different. Intermountain has doubled down on health equity and social determinants of health and how we integrate that. We’re looking at how Castell plays into that as well as we work with affiliate providers. So, we are trying to shape what health care might look like in the future.

But I think there are such strong tailwinds behind what we’re seeing in terms of innovation that it’s going to happen regardless.

[00:38:58.750] Don Crane:
So, I love hearing that because I must confess, you know, there’s a murmur rumbling across the land about how well the value movement is going. It’s a topic being discussed. And I think there’s a fair amount of focus on the Medicare ACO program, perhaps. But, you know, as I listen to you and as I get to know
Intermountain, I see it’s so much a part of your DNA. I mean, you guys are committed to value, which is who you are and what you are.

So, the question and also it arises by reason of, you know, your community and its multi-product and multi-program. It’s just how you do business.

But the question I would ask, and this is just a hypothetical, and I think we’ll need to sort of wrap up with it…suppose per chance, and really perish the thought, actually, but the value movement doesn’t prosper in America. It doesn’t move fast enough in some Congress someday says we can’t wait any longer, we’ve
got to bend the trend and the way to do it is with draconian price, wage and price cuts. Let’s pay doctors a whole lot less tomorrow morning.

Let’s pay hospitals a whole lot less tomorrow morning. And let’s just live with fee-for-service. It’s just too hard to change. And if that kind of thinking should occur, how would Intermountain react?

Would you guys go back to that? I mean, this is speculation on your part, of course. But or could you just say, no, no, no, this is who we are. And one way or another, we will fashion some mechanisms which allow our business model, our culture and our religion basically to continue. How would you react to that?

[00:40:41.480] Raj Shrestha:
Yeah, obviously we wouldn’t be advocating or be happy with those type of draconian measures. That said, I don’t think we would transition back to fee-for-service. I think we would still try to figure out again, trying to, you know, that’s one mechanism to keep care affordable, that draconian measure. But we still want to ensure that we are focused on quality, safety and still focused on keeping care even more affordable. And all that is in our model.

I don’t see our model changing. The model we’ve built, whether it’s fee-for-value or sort of the quasi-fee for-service, because I don’t ever see it going back to it’s strictly fee-for-service. There’s always going to be quality parameters around that, right? There’s always going to be other parameters that, you know, are adjacent, whether they’re pay-for-performance, et cetera, on top of the fee-for-service contract. So, Don, I don’t think we would change anything.

I think we would say this is how we deliver care. It is the right way to deliver care focused on the patient, focused on safety, quality and bringing costs down. And, you know, going back to the fee-for-service, you know, rat wheel or flywheel, whatever you want to call it, hamster wheel, just isn’t the right way to deliver care. So, I know it was a hypothetical question, but a hypothetical answer is I don’t think we would change.

[00:42:25.460] Don Crane:
It’s important because it shows the strength of the commitment.

Maybe not all organizations have that kind of strength that you do. But all I can say is I love what you’re doing and I am proud to have Intermountain be a member. And you, personally, beyond being on the APG board and can’t wait to keep working with you guys going forward, using you as an example to
proliferate basically the model and the means by which to implement it. So, Raj, with that, I’m going to thank you very, very much.

I want to wish you health and safety and look forward to seeing you soon.

[00:43:02.740] Raj Shrestha:
Same to you, Don. Hopefully we get to see each other fairly quickly here. Thanks for the opportunity.

[00:43:07.840] Don Crane:
OK, thanks, my friend. Stay safe.

[00:43:10.270] Announcer:
Thanks for listening to APG on American Healthcare with your host, APG President and CEO Don Crane. For more information about APG and transcripts of this show, visit the APG website at APG.ORG