Coordinated Care for High Use Patients: CareMore Health CEO Sachin Jain on Improving Outcomes

Dr. Sachin Jain

[Mu sic]

Margaret Flinter: Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a weekly show where we speak to the top thought
leaders in health innovation, health policy, care delivery , and the
great minds who are shaping the h ealth care of the future. This week ,
Mark and Margaret speak with Dr. Sachin Jain, President and CEO of
CareMore, an innovative coordinated care delivery model for high use
patients in Me dicare and Medicaid , u sing team - based interventions,
wide services, a program to target loneliness and inactivity to yield
better outcomes and a better quality of life for patients.

Lori Robertson also checks in, the managing editor of FactCheck.org ,
looks at misstatement s spoken about health policy in the public
domain , se parating the fake from the facts. We end with a bright idea
that ' s improving health and wellbeing in everyday lives. If you have
comments, please email us at [email protected] o r find us on
Facebook or Twitter. We l ove hearing from you. You can find us on
iTunes , or Stitcher , or where ver you listen to podcast s . Please feel
free to leave a review there.

Now , stay tune d for our interview with Dr. Sachin Jain on
Conversations on Health Care.

M ark Masselli : We're speakin g today with Dr. Sachin Jain, President and CEO of
CareMore Health, an integrated health care system, focusing on
improving care coordination with high - risk Medicare and Medicaid
patients. Previously, Dr. Jain was CareMore's Chief Medical Officer
and Chief Operating Officer. He was first Deputy Director for Policy
and Programs at The Center for Medicare and Medicaid Innovation
under President Obama and CMS Administrator, Don Berwick. He was
just named Modern Healthcare's 50 Most Influential Physician
Execut ives. He earned his BA, MBA, and medical degree from Harvard.

Dr. Jain, welcome to Conversations on Health Care.

Dr. Sachin Jain: Thank you so much. It ' s great to be with you.

Mark Masselli: Yeah, and as a physician with real focus on care transformation, it
seems like you've landed in the perfect spot at CareMore, which is an
integrated health plan and delivery system, designed to target high -
risk chronically old patients through focused care coordination. You've
been getting lots of national attention fo r significantly reducing
hospitalization and poor health outcomes. I'm wondering if you could
tell our listeners about your unique approach and why it's been so
effective .

Dr. Sachin Jain: Yeah, I'd say the great thing about CareMore is that it's not so mu ch a
model. It's actually multiple models. More importantly, it's an
approach. I think it's a philosophy of care, the idea of that we need to

Dr. Sachin Jain

better manage chronic disease, we need to understand the social
determinates of health, and really manage the disc onnection that
patients experience when they receive care across the care
continuum. We are fundamentally organized around the problems
that patients experience and work to try to solve those problems. We
have multiple different operating models, but what I would say is one
common culture, one common philosophy, and one common
approach to actually dressing the needs of the patients that we serve.

Margaret Flinter: Dr. Jain, you've laid out this three - pronged approach that's been
developed. You've got the Ca reMore Care Centers, the CareMore
Chronic Care Management Programs. Then you've got something
called the CareMore Extensivist. Talk with us about how these three
entities are designed around the patient experience.

Dr. Sachin Jain : Let's start with the car e centers. I think the care centers take all the
things that you'd love to have in a primary care office. Most primary
care offices are sub - skilled to deliver. We have Chronic Disease
Management Programs for all the most common chronic diseases of
the seni or population. We have integrated behavioral health. We
have dietitian to help with counseling. We have exercise programs
that are focused on the senior population. What all of that amounts
to is really risk stratification of patients, and then targeted an d
focused interventions to keep our patients healthy.

Extensivists are really about taking care of the patients when they are
in the hospital, but then also taking care of them in post - discharge
follow - up as well as in a post - discharge clinic. Ordinarily, that would
be three different care teams that are actually taking care of the
patients. We have one team taking care of the patient across all those
sites. What it does is it creates a higher level of coordination across all
of that care.

Then the third pi ece is really the case management infrastructure.
That really, it is the glue across the system. It's our case management
that actually keeps it altogether. That's in addition to the patient's
primary care provider. There's this whole extra infrastructure that
wraps around the traditional health care system that actually makes it
work for the patients. What we feel is that we have fewer hospital
admissions, shorter lengths of stay, more satisfied, more loyal
patients, and delayed progression or slowed progr ession of chronic
disease.

Mark Masselli: Well, and I think your whole model, this approach, is about a
philosophy of care. Your organization was one of the first systems in
the country to provide ride services for patients to keep
appointments. As you wer e talking about, CareMore also decided to
deploy your program to improve diabetes management that I'm
wondering if you could describe some of those targeted

Dr. Sachin Jain

interventions?

Dr. Sachin Jain: What we do is not rocket science. I think managing chronic disease is
a relational art. We focus on building really strong, durable, engage
relationships with our patients, so that they know that somebody is
actually concerned about their overall well being. It's old school
medicine.

Margaret Flinter: Right.

Dr. Sachin Ja in: As many of us know, old school medicine has gone out of stash in a lot
of places. Part of our, I think, role is in promoting a system that really
works. One of the key enablers of the CareMore model is the chassis
on which we're built is not a fee - for - service chassis. We are built with
a notion of full delegation of risk, meaning we get paid a per member,
per month risk - adjusted payment. Because we have a high level of
loyalty, our patients don't leave us. We are not playing the game that
a lot of insur ance entities play, which is not being concerned about
longitudinal health care costs. Our average member stays with us for
nine years.

We are investing. We are spending more money upfront with the idea
that our patients will have fewer medical complicati ons, the slower
progression of disease. The average acute episode of illness l a nd s
somebody in the hospital and cost $12,000 or $15,000. If you were to
take that money and actually reinvested in prevention, you get
phenomenal outcomes. That's how we are ab le to provide
transportation to our members because we noted that's one of the
barriers to access to care. That's how we are able to provide post -
discharge meals for patients. That's how we are able to deliver a
Togetherness Program, which focuses on provi ding social interaction
engagement for our most socially accelerated members. Those are
expensive interventions. They are far less expensive than sending a
patient to the hospital for an ICU admission.

Margaret Flinter: Well, Dr. Jain, obviously the burnin g question is, so how come this
isn't available to everybody. Let me start with an earlier question that
I wanted to ask. We've been carrying a lot, and we had Dr. Charles
Alessi from the National Health Service in England on the show
recently, really zero ing in on this question of loneliness that's faced by
so many people, and just how bad it is for health outcomes among
the elderly. Sounds like you've taken that to a higher level in terms of
specifically targeting loneliness. Tell us a little bit about th at. What
dementia prevention strategies are showing promise in your work?

Dr. Sachin Jain: Loneliness is an epidemic in plain sight in American society. There's
been a change in our family and social structure in this country.
Seniors are living longer. Th ey're also living lonelier. One of the things
that we've recognized is that lonelier seniors oftentimes take less

Dr. Sachin Jain

good care of themselves. We talked about the burden of chronic
disease. The way in which chronic disease is managed is through high
levels of self care, watching your diet, taking your medicines. What we
find is people who are not connected to other people, oftentimes the
first thing that goes is their self care. For the loneliest patients in our
health care system, we create intervention, a pho ne call from
somebody who cares about you, can make all the difference in the
world. They can be that spark of encouragement. It can be a nexus
point for a connection to community resources.

We have, what we believe, is the world's largest and oldest lonel iness
program, we call the Togetherness Program because we want to de -
stigmatize this condition. We connect people with togetherness
connectors for particularly socially isolated members. We send social
work interns or other individuals into the home to tr y to pull people
out of their homes and connect them with others. We encourage
them to participate in group exercise activities at our senior gym. We
make sure that their medical needs are met.

What we are seeing from the early data, we just celebrated the first -
year anniversary of this program, is that patients are healthier. They
are participating in preventative health care measures more. They are
participating in exercise more. We saw 75% greater participation rate
in group exercise activity, and in int ervention group as compared with
the control group because people are participating in this
Togetherness Program. Incredible opportunity I think for us to skill
impact and make a dent in a problem of greater and greater
importance in our society.

Unfortuna tely, dementia is one of these areas of medicine and clinical
care, where we don't have a lot of good medicines or treatments.
We're really going to look to the pharmaceutical industry. They come
up with some solutions to this problem. Before those solutio ns get to
market, we need to figure out ways to take better care of dementia
patients. One of the worst places you can take care of a dementia
patient is in the hospital. We take a demented patient. You put him in
an unfamiliar setting. It's literally a re cipe for delirium. Delirium is a
recipe for downward spiral for a dementia patient.

A lot of what we do is teach families how to proactively intervene
when they have health care, medical problems, and what to expect.
Ordinarily, there's this phenomenon of sundowning in many
demented patients, where they become a little bit delirious in the
evening hours. That can be very scary for families. The first place that
they'll take their family members is to the emergency room, which
then can sometimes create this downward spiral of a hospitalization.
If they know what to expect and oftentimes they can stay out of the
hospital, and staying out of the hospital, they can avoid downward

Dr. Sachin Jain

spiral, which I observed so many times when I was more regularly
practicing inpatie nt physician.

Margaret Flinter: Right, absolutely.

Dr. Sachin Jain: This is I think one of the great opportunities we have is to while we
wait for these great pharmaceutical interventions to come to treat
the disease of Alzheimer's and other forms of demen tia, helping
families learn how to use the health care system for patients who do
have cognitive impairment, can be a huge opportunity, improve the
quality of care and decrease health care costs.

Mark Masselli: We're speaking today with Dr. Sachin Jain, Pr esident and CEO of
CareMore Health, an integrated health care system, focused on
improving care coordination for Medicare and Medicaid patients,
significantly improving outcomes. He was just named Modern
Healthcare's 50 Most Influential Physician Leaders.

Well, I think we've all read in the news, Dr. Jain, that Atul Gawande
has been appointed the CEO of the newly formed Amazon, Berkshire
Hathaway, JPMorgan organization. I'm wondering as you think about
this broad charge that he has, improved efficiency, sa ve money,
better job, caring for patients, do you have any other advice that
you'd pass along as he takes on this enormous challenge?

Dr. Sachin Jain: Absolutely. I think that the most important thing we can do is to make
sure that we have happy physicians and happy nurses, and that we
support clinical models, where we're restoring the joy of practice. We
need to make being a physician or nurse in America sexy again. What
it used to be 20, 25 years ago, that this was considered the greatest
profession of al l. I think we really need to do that. Sometimes people
say that we need to create a more patient - centered care to the
exclusion of a physician - centered health care system. I think you need
to be centered on both. You can't have a patient - centered health ca re
system without taking care of the workforce that delivers the care.

I think there's been a devaluation of the health care workforce. We
tend to treat health care workers and clinicians like they are
commodities. We used word like provider to describe t hem, when in
fact they're highly trained professionals with high values and a moral
code. The thing that makes me most excited about Atul taking that
position, and he's just a giant in the field, and that he's probably one
of the most sophisticated thinker s on health care. I know he gets this.
I know that the solutions that he's going to be thinking about are
going to be holistic and thinking about patients, physicians, system -
wide stewardship, care teams. These are all topics that Atul has
inspired the who le industry around. I think that that's going to result
in solutions that are inclusive of more holistic view of the whole thing.

Dr. Sachin Jain

Margaret Flinter: Well, Dr. Jain, I'm really excited to hear about your excitement about
and focus on training both the curren t and the next generation of
physicians, nurses, nurse practitioners, and sounds like Pas, and social
workers, and may be community health workers, since much of this
kind of model is not something that people are trained to in depth.
This is something tha t we've put a lot of focus on in our work around
post graduate trainee in particular, but also now with medical
systems, we do with our ends in primary care to train people to
clinical complexity, but also train them to a evolving high performing
model of care, and just the idea of having the same care team caring
for the patient as they are in the acute care setting. Maybe just talk
with us a little bit about what kind of infrastructure you've built for
that.

Dr. Sachin Jain: I think that at the center of the infrastructure is something we're
calling the CareMore Academy. We have just recruited our first Vice
President for the CareMore Academy, which is a gentleman from
Connecticut, named Bob Tedeschi. Bob, he's so skilled across so many
different domains. He's a college athlete. He really understands
teams. He’s a Pulitzer nominated journalist for The New York Times.
He's got the gift of personal articulation. He's the spouse of a nurse, a
mother of a nurse. He has a deep understanding of the health care
sy stem and the central role of compassion, and the need to preserve
that compassion for people, who deliver care. What we're really
working on with him is designing programs that are around the
culture of true team - based care for the sickest of the sick. It' s the
central task in building the health care system of the future is actually
getting these elements right.

A second part of it is having a real focus on what the product is and
product definition. For that reason, we recently appointed Dr. Vivek
Garg, CareMore's Chief Product Officer. It's the first time we've had
that role, really recognizing the need for us to build scalable platforms
and chassis onto which we can layer different components to serve
different populations. CareMore is kind of known for its historical
model that you're referring, the care centers and the extensivists. We
are now live in Connecticut with a home - based primary care model.
We have a 10 - year history, providing institutional care for nursing
home and homebound patients that wr aps around our kind of
traditional health care delivery model.

All health care is very local. For that reason, we're just getting much
more rigorous about how we define our product, how we scale our
product. You asked this question before about why this m odel hasn't
scaled to more places. I would say this is at the heart of it is kind of
getting really rigorous in the same way that Apple is rigorous about
designing products. We in the health care delivery world have not
have been that rigorous about design ing products. At the same time,

Dr. Sachin Jain

the foundation of all of this is world class clinical care.

That's why we appointed Dr. Zubin Eapen, our Chief Medical Officer,
last year. He's world class cardiologist. He was an associate professor
at Duke University, a r enowned clinical investigator, and he sets the
standard for the quality of clinical care in every single interaction.
That's what this takes. It takes the right culture, the right product
definition, and the right clinical care to actually take care of the
patients that we serve.

Ma rk Masselli : I was thinking as you were talking about a world class cardiologist, we
just had Dr. Eric Topol on the show talking about Texas central role in
advancing personalized medicine. I was thinking over your 25 - year
journe y, the aggregation of data, and the new technologies coming
into play, must have a profound influence on what you can achieve
now. Talk to our listeners a little bit about actionable data and any
particular digital application that you find that's been use ful?

Dr. Sachin Jain: I think data is going to enable the hyper - personalization and the
hyper - customization of health care. One of my big frustrations in the
health care system is that no matter who you are, the system treats
you exactly the same. The prob lem is that all of us don't have equal
needs. Some of us are sicker. Some of us are more complex. The
system needs to adapt in real time to meet people's needs. Your
average medical office visit does not look different today than it did
30 or 40 years ago. We are on the bleeding edge of this, starting to
think about how different types of data can be brought to bear on
making these clinical encounters even more personalized.

Some of the types of things we're exploring are things like integrating
the use of pharmacogenomics data by actually gene sequencing all of
our patients to understand what kind of drugs will work for our
patients. That hyper - personalization is going to unlock lots of
opportunities for us to improve the quality of care, reduce costs, and
really make it, so that we're not just practicing trial and error
medicine. I think the average American thinks that our health care
system is much more precise. I thought that before I went to medical
school. Then you quickly realize that we're just begi nning to scratch
the surface and some of life's greatest mysteries.

40, 50 years ago, we didn't even know the structure of DNA. Today,
we're inventing custom treatments based on the single base pair
deletions in the genome. There's just a rapid evolution that's going to
evolve, the underlying basis of which is just greater and greater
amounts of information. We need systems and processes to organize
that information, so that's actionable for clinicians at the point of
care. That's what's needed. That's wha t I think we're most excited
about.

Dr. Sachin Jain

Margaret Flinter: We've been speaking today with Dr. Sachin Jain, President and CEO of
CareMore Health, an integrated health system, focused on improving
care coordination and care for Medicare and Medicaid patients. You
can learn more about their care model by going to caremore.com, or
follow him on Twitter @sacjai.

Dr. Jain, thank you so much for your innovative work in transforming
care delivery and for joining us on Conversations on Health Care
today.

Dr. Sachin Jain : Really appreciate it.

[Music]

Margaret Flinter: At Conversations on Health Care, we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award - winning journalist and Managing
Edito r of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U.S. politics.

Lori, what have you got for us this week?

Lori Robertson: Several democrats in Congress have made preexisting health
cond ition an issue in their fight against President Trump's nomination
of Brett Kavanaugh to the Supreme Court. The issue concerns a court
case filed by Texas and 19 other states, arguing that the ACA
individual mandate, that's the requirement that you have in surance, is
unconstitutional. Therefore the whole law must go. The Department
of Justice has cited with the point and send the case, but said it
doesn't think the entire health care law should be scrapped. It said
only two provisions would have to be elimi nated if the case were
successful. Provisions guaranteeing that those with preexisting
conditions won't be denied coverage or charged more based on
health status.

We don't know if this case filed in a district court in Texas will even
make it to the Suprem e Court. If it does, it likely won't be until 2020.
Several democrats have made this a main talking point. A week before
Kavanaugh's nomination, a TV ad from a democratic group warned
that the nominee could eliminate the ACA's preexisting condition
protect ion, a move that "would take us back to a time when insurance
companies could deny you coverage". Prior to the ACA's enactment,
insurers could deny coverage based on health status, but only on the
individual market, where those without employer - based plans or
public coverage buy their own insurance. 7% of the population has
individual market coverage.

Under HIPAA, employer plans couldn't deny insurance to workers. If a
new employee had a gap in insurance coverage of more than 63 days,
employer plans could e xclude coverage for a particular preexisting

Dr. Sachin Jain

condition for a limited period up to a year. Pregnancy couldn't be
excluded however. The ACA's preexisting condition protections mainly
affect the individual market. The law also gave peace of mind to those
with employer coverage or those who might want to start their own
business, and therefore need to get insu rance on the individual
market.

That ' s my fact check for this week . I ' m Lori Robertson, Managing
Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, email us at chcradio.com. We'll have FactCheck .org's
Lori Robertson check it out for you here on Conversations on Health
Care.

[Music]

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. One in five
Americans will suf fer a diagnosable mental health condition in a given
year, and most often don't seek treatment. For those with serious
mental health conditions, the consequences can be devastating,
hospitalizations, loss of job or home, or even early death. Seeing the
ris e in mobile apps aimed at behavioral health entering the
marketplace, the University of Washington researcher, [inaudible
00:22:51] and Zev thought a comparative effective analysis study
would be a good idea.

Male : My team and I conducted a three - year comp arative effectiveness
trial, having a head - to - head comparison between a mobile health
intervention for people with serious mental illness, called FOCUS and
more traditional clinic - based group intervention called WRAP. The
study really gets at some of the c ore differences between mobile
health and clinic - based care.

Mark Masselli: More than 90% of the mobile app group engaged in the online
program, both groups of patients saw roughly equal results from their
completed treatment. The mobile group was more lik ely to engage in
therapy.

Male : Probably the most important piece of the study are the clinical
outcomes. 90% of the individuals, who were randomized into the
mobile health arm, actually went on to meet a mobile health
specialist through the use of the int ervention app, that was assigned
to them at least once, whereas in the clinic - based arm, we saw that
only 58% of the participants assigned to that clinic - based intervention
ever made it in for a single fashion. We know that the very existence

Dr. Sachin Jain

of a group ca n be quite helpful. For others, the interaction is anxiety
provoking. When it comes to the clinical outcomes in both
intervention arms, people improved both in terms of reduction in
their symptoms and improvements in their recovery.

Mark Masselli: A target ed mobile app aimed at facilitating access to clinical care for
those experiencing serious mental illness symptoms, improving access
to intervention for behavioral health needs. Now, that's a bright idea.

[Music]

Mark Masselli: You've been listening to Con versations on Health Care. I'm Mark
Masselli.

Margaret Flinter: I ' m Margaret Flinter.

Mark Masselli: Peace and health.

Margaret Flinter: Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at chcradio.com, iTunes, or whe rever you
listen to podcasts. If you have comments, please email us at
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Health Center.

[Music]