Dr. Rupal Badani: Historically, virtual care had been set up as a choice between continuity and convenience. So, years ago, when I started working in the access space, they would say, “Continuity is king.” It was all about seeing your doctor. We knew, coming out of the pandemic, that convenience was starting to be a big factor for patients. Patients had gotten pretty good at knowing when they wanted virtual care and when it was appropriate, and when they needed to come in. And we wanted to start there and say, “What if you could have convenience, the convenience of virtual care with a doctor you know?"
Matthew Weinstock: That was Dr. Rupal Badani, talking about the evolution of virtual care at Cedars-Sinai in Los Angeles. Badani is a pediatrician by training and now serves as chief of innovation and medical director of organizational advancement at the health system, and she's been at the forefront of the rollout of an enhanced primary care model at Cedars. Through a partnership with K Health, Cedars has embedded virtualists in primary care practices with an aim at not only increasing convenience for patients but ensuring continuity of care. In this podcast with Oliver Wyman's Ran Strul, Badani and Ethan Fischer from K Health explore how to build trust between traditional brick- and- mortar physicians and virtualists. They also look at the potential of expanding the model to other specialties. The Oliver Wyman Health Podcast is brought to you by the global management consulting firm Oliver Wyman. For more insights on the business of transforming healthcare, visit our online publication, health.oliverwyman.com. Now, let's pick things up with Badani explaining how the enhanced primary care model got started.
Dr. Rupal Badani: 10 years ago, Cedars-Sinai made the commitment to really turn primary care into a group practice. And what I mean by that is it went from supporting doctors as individual providers in their office with their staff and their space to really creating a group practice where the physicians were practicing in a more standard way and delivering a more consistent experience for their patients. And so what that looked like 10 years ago was coming to agreements around how to appoint patients, agreements to see each other's patients, collective call answering, teams. And they were on that journey, and then when the pandemic hit in 2020, that allowed them to pivot quickly into delivering a lot of their care virtually because they had a standard platform. Coming out of the pandemic, we weren't quite sure where virtual care fit in anymore. Some of the providers came back to their brick- and- mortar practices exactly as they were before the pandemic. Others continued to do some virtual care. We had set up a program called Video Visits Now, where we had allied health professionals doing virtual visits for patients or video visits on demand when they called into our call center, and we didn't have a cohesive way of integrating virtual care. Then we also were faced with the pent-up demand of coming out of the pandemic; so many patients wanted to come in, and access, which had always been a struggle in primary care, really became of paramount importance to address. And so when this partnership came on the scene, I think we were in a place of not quite clear on where virtual care fit in, facing a pent- up demand of patients and poor access, and a workforce that was increasingly burning out that we couldn't go and say, “Hey, can you add one more patient a day?” They couldn't. And so our objectives when it came to advancing primary care at the time this partnership came to life was really trying to solve for access in that environment.
Ran Strul: Solving for the promise of virtual care, but in a long-term sustainable manner versus a pandemic response and access for patients and workload work-life balance for the staff. Ethan, how did it look for you guys at K Health? What were you faced with and how did you set out to help Cedars in their journey?
Ethan Fischer: Yeah, so we, giving a little bit of the history, I think piling on to Rupal, we met Cedars- Sinai probably early 2022, middle of 2022 to start talking about what we might be able to do together. And we were really hearing, I think, as Rupal mentioned, three problems being articulated that we wanted to figure out together. I think one was this idea of pent-up demand and access, the ability to grow access for folks that are already patients of Cedars-Sinai that cannot get into primary care. How do we do this as a way to support the existing brick-and-mortar network of Cedars-Sinai? So not taking this and saying, “Let's replace what you're doing,” but really like Rupal's saying, they were tapped out and how do we really be able to create incremental access? And I think from a system level, we were also hearing, “Look, creating incremental access also serves as a way that Cedars- Sinai as a health system can think about growth in its patient population, growth in the amount of folks that we can manage, and growth in the way that downstream for specialty care at the academic centers or otherwise, we might be able to use this as a mechanism to grow outside of our current geography, virtual care more broadly.” It really started the conversation with us as K. We are what we would call a clinical AI company.
So we are really focused around building tools for patients and providers in primary care that are going to really mimic the jobs to be done by a physician. So what we do and how we combine that with clinical operations, we say, “Look, how can we use a machine to collect all of the relevant information from the patient before they walk in the door at their provider?” So this can be things like, “Hey, I've got a headache.” Okay, what is that? Let's investigate that entire HPI and have that served up in the perfect chart to a provider, but let's also have the EMR data to say, “Hey, that patient may have hypertension, diabetes, maybe overdue for a mammogram,” and we can capture that whole picture of the patient and deliver that to the provider at the point of care.
So really, when we came to Cedars, we said, “We can take this technology and we can take this concept of a 24/ 7 care delivery operation and we can give this technology to virtual Cedars- Sinai clinicians that are part of the Cedars- Sinai Medical Group and integrate it in with the network so that we can create this longitudinal relationship with patients virtually that's an extension and a complement of what they do in break- and- mortar.” And Rupal, I might turn it over to you a little bit. We've been on this care model for 16, 17 months now. Could you just talk a bit about how it works for patients, how it's evolved, where we started, where we are now, and how this integration clinically has worked?
Dr. Rupal Badani: From the get-go, the idea was we're going to bring this in and really deeply integrate it. That started with the commitment to make a joint venture and hire physicians to deliver this care that were Cedars- Sinai- vetted and credentialed. So we partnered with K to find the physicians that we ultimately used to deliver the care virtually so that we could make sure that they understood what it meant to join the Cedars-Sinai family. In the start, I think Cedars really did think of this as an access solution. That was the biggest problem facing us, and we had historical success with delivering certain types of care, mostly for acute, simple concerns, virtually. It was a natural place for us to start, setting up almost a virtual urgent care, if you will, where patients could self-direct to care that was available 24/7. We were able to set it up so that the C- S Connect doctors would send their charts to the primary care doctors. Every chart was reviewed in the beginning by our medical leadership really to build trust.
As that stabilized, we started to think about other potential use cases and ran some quick tests of change to see what else we could do. We tried linking outreach efforts for gap closure to having the patient see C- S Connect. Ultimately, that resulted in a lot of work. As we know, the yield of outreach for anybody is low, so that was another learning. We also tried to, with K's partnership, develop some programmatic offerings like weight management or behavioral health. So again, with the rise of the GLP-1s, primary care was facing a fairly large burden of work trying to authorize these drugs, get approval from insurance companies, have the access to see the patients back as frequently as they needed to be seen, and a lot of that could be done virtually. And so by creating that offering, it furthered the trust in partnership for the primary care doctors to send their patients who needed this particular type of care to K. I think after that point, those were humming. We expanded to pediatrics, we introduced Spanish-speaking providers, and offered the visits in Spanish. That's really when we were ready to take on more and wonder what could a deeper integration look like? And that's where the enhanced primary care model started to take shape.
Ran Strul: Tell us a little bit about how this works today, Rupal and Ethan, in terms of the actual care model, the role of the provider. How does it work in practice for a patient of those physicians?
Dr. Rupal Badani: Historically, virtual care had been set up as a choice between continuity and convenience. So, years ago, when I started working in the access space, they would say, “Continuity is king.” It was all about seeing your doctor. We knew, coming out of the pandemic, that convenience was starting to be a big factor for patients. Patients had gotten pretty good at knowing when they wanted virtual care and when it was appropriate, and when they needed to come in. And we wanted to start there and say, What if you could have convenience, the convenience of virtual care with a doctor you know?” So what we did was we selected two virtualists, as we call them now, to support about 14 primary care doctors. So, they take care of about 23,000 patients. And these two doctors who are exclusively virtual, provide exclusively virtual care were positioned as partners of these 14 doctors and the patients would have continuity with them. So when they had a need that could be taken care of virtually, they would see a doctor they knew, and when they needed brick- and- mortar, they would see a doctor they knew.
Ethan Fischer: I was just going to build on what you're saying in that first, we said, “Hey, let's just position this to help with the overflow,” what people have traditionally thought virtual care was for. Then, “Okay, let's experiment with these providers are really enabled to do anything a PCP could do. They're just happening to be practicing virtually. So let's figure out how we get them to help that brick- and- mortar team in a different way, whether that's the care gap outreach to help on population health or whether that's that weight management, behavioral health, things that are overflowing providers in brick- and- mortar's inbox and they need someone else to help them manage.” And I think those kind of building blocks then taught us, okay, that trust is the fundamental key for this virtual clinic really being successful.
And so if we really set up that trust and that relationship and Rupal and team really figure out how to embed these virtualists as part of the brick- and- mortar care team, and embedding means both the change from the physician side, but also from a technology standpoint, making sure that everything flows just as it would for the virtualist providers as it does for brick- and- mortar so it feels seamless to the patient. You'll see most of the care team beyond just the PCP. We don't have to choose between continuity and convenience. We're able to have patients directed by this care team into the right place for them.
Dr. Rupal Badani: I want to pick up on the concept of trust that you mentioned, Ethan. I think that also has been foundational to the success of this. And so there's a moment that I recall that I thought was a real turning point in that. So we were holding a design event to figure out all the operational workflows of how the patients would flow and how the information would flow between the virtualists and the brick- and- mortar doctors, and we invited the brick- and- mortar doctors into the room along with the C- S Connect providers. They came in person. And we were sitting around in the conference room and we were talking about the nuts and bolts of this, and one of the brick- and- mortar primary care doctors turned to the virtualist and said, “Well, what do you do for hypertension titration? What is the protocol that you use?” And in the most respectful way possible, the C- S Connect doctor said, “Is that something you ask every new hire that joins your group?” And just that question really opened the minds, I think, of the brick- and- mortar doctors to see that they were holding these doctors to a greater level of scrutiny. They really felt like another, and what we wanted to do was make them feel like part of the team.
We built on that moment in some concrete ways. So, the C- S Connect doctors came on-site for the launch of our pilot. They had lunch with the doctors. We had them speak to what they could care for virtually. And ongoing, we embedded them into the practice in ways that still respected the fact that they're virtual. So they attend our team huddles once a week. They attend the provider meetings once a week. We're starting to have them come share interesting cases to showcase what can be done virtually. I think when doctors trust, patients feel it.
Ran Strul: And both of you have been mentioning the term virtualist, that's a term that's been used in recent years a number of times. It's more than someone who sees patients virtually and remotely. There are certain capabilities, competencies, expertise. One would say, in some ways, it may be more challenging actually to provide care virtually versus in person. Can you talk a little bit about what are these skills and what is unique about a virtualist compared to a traditional primary care capability?
Ethan Fischer: You know, one thing that sets this group apart from maybe other types of virtual care that we've heard of is that these folks are actually selecting this to be their career. What we've built at K and what we're really excited about is helping them do this safely and with high quality, is these providers are getting all of the information from the patient prior to the visit collected. So they're using technology for that patient to give every possible bit of information about themselves so that when they walk in the room, they've got a pre-populated chart. They're not worried about asking every little question from an HPI standpoint. They can focus really on what matters. And that frees them up that, “Okay, I'm dedicated to this career. I've got the tools that are making me really walk into the room with a lot of my white coat job done, and I can focus on really doing my top of license practice with these patients in such a way that I feel very confident in the medicine that I'm delivering.” And that medicine is as broad as Rupal was saying, from the person who comes in with a UTI, and by the way, might be overdue for a mammogram, or that person who's coming in to manage their weight that also has anxiety, depression, diabetes, hypertension.
It's a really complicated patient that we've got to work through a lot of things with them. And I think the final piece that makes this model work is the integration with the brick and mortar, is the fact that this is not a standalone service sitting out there without the ability to escalate a patient when it's appropriate. Being connected and part of the system, part of the same medical record really enables these virtualists to have the confidence that this career they're choosing to embark on and the tools that are helping them do this are going to have the right place to land their patient and continue helping manage them.
Dr. Rupal Badani: Even when I was in pediatrics, we would, at night, take pager call, and I always found it so much more difficult to assess a patient on the phone than if I just saw them in front of me, but my pediatric advice nurses were terrific at that. They had really honed a skill to be able to talk to patients on the phone and discern things that I found it very difficult because I didn't train that way. That wasn't what my expertise was. I was good at taking care of the patients in front of me. I think there's an analogy there to the virtualist. So in addition to the things Ethan said, I think the virtualists, over time, because they've dedicated their career to this, can really understand nuances of what can be done virtually, what they can pick up on, even in a virtual setting, that somebody who primarily does brick- and- mortar care may not feel as comfortable doing or may not pick up on the same way. There's nuances there that I think are important. In addition to having the tools, I think, Ethan, you brought up a really good point that a virtualist is best suited when they are integrated into a entire ecosystem.
Our primary care doctors have a lot of services and support, social workers, case managers, the inpatient team, that they leverage and utilize to care for their patients. And so when we built this model, the virtualists were very happy being integrated and saying, “Oh, so if I come across a high-risk patient, I can refer them to your case management team? I'm connected with your post-discharge patients where a virtual visit is appropriate? So I have a connection point to the case management team that's taking care of patients coming out of the hospital, and I can be the bridge to their brick- and- mortar return to care.” So a virtualist is not simply a doctor you pluck out of a brick- and- mortar practice and put in front of a computer. It is a, I think, emerging, evolving subspecialty that we still, I don't think, have fully realized the capabilities of and the limitations of. I mean, let's be real. You can't do everything virtually.
Ran Strul: You talked about the intentional introduction and gradual ramping up of the virtual care model and capabilities. I'm thinking, Rupal, a little bit about the bricks- and- mortar physicians that you have. Physicians love their patients, they care for their patients, they care about their panel. Was there ever a notion of competing for patients with these new virtualists that will now be able to serve my existing panel?
Dr. Rupal Badani: We pulled the providers together two months into the launch of this pilot to have that very discussion. And what was happening at that time was a high level of comfort for the acute visits, so much so that the providers were very happy that the team we had developed to read their patient messages that were coming in, anytime there was a new concern that was appropriate to be seen virtually, which is a long list, the patients were getting redirected and invited to have a virtual visit and many, many patients were taking us up on that. So instead of the new cough cold or new back pain going to the primary care providers' in-basket to read the message and try to take care of it virtually or try to squeeze the patient in, the primary care doctor didn't even know what was happening. The team saw the message, they connected the patient with a virtual visit, the virtual visit took care of the patient's acute need. That was going really well, so we brought the providers together to say, “How do we start to share and co-manage patients with chronic disease? How can we have more planned visits to the virtualist?
Maybe we start to even do preventative care visits more robustly.” I was expecting, Ran, what you said, that they would feel a sense of competition, and it really wasn't that at all. I think, again, it goes back to the trust that we built. It wasn't competition. It was a feeling that they had held for years that they are responsible for the health and care of these 2,000 patients. Honestly, the doctors found it hard to say the words to these patients and invite them to see a virtualist because they felt a high degree of responsibility to make themselves available for the patient in front of them and, “Was I punting them? Was I going to send the message that I don't care about them enough to see them or fit them in?” That's what the doctors were struggling with. And as we opened up that discussion, it was really interesting because there were some doctors who had figured it out or had said, “Hey, this is how I position it to my patients. I'm here for you. I'm always here for you. But if you want the convenience of doing your next diabetes check virtually, I have this great colleague. They'll see all my notes. We manage similarly. They can take care of you. If there's anything at that visit that I need to know, they're going to let me know, and I can always see you."
Ethan Fischer: And Rupal, if I actually bring that, tie that back up to what we were talking about at the start of the conversation on the more macro level of access, I think what we're seeing is, my latest number that I remember is about 20% of daily primary care at Cedars is happening on C- S Connect. And with that, we've actually not seen any change to brick- and- mortar volumes. By adding this access platform in, you're able to see your patients more often. You're able to see it in a way that is continuous and convenient.
Dr. Rupal Badani: You know, you're reminding me of another piece of this that I think is really important. Our call team who appoints patients really is, for many patients, that first decision point of, “Which appointment am I going to take?” So when we rolled out the virtualist and these virtual visits, we really were intentional about how we explained to our call team what this was, what the virtual visit was, what the virtual list was because it is very easy to say, “Well, the first thing I'm going to do is look for an appointment with your primary care doctor. If that's not available, then I will go to plan B and give you something different. Maybe a visit with one of their colleagues. Maybe it's urgent care. Now maybe it's a virtualist.” And what we were really trying to impress upon our call team is that if the patient needs an appointment and there's an appointment tomorrow morning in their primary care doctor's office, it might still be the right thing to appoint them with a virtualist because that's what they want.
So how you position the options to the patient as equally good or, “You can take care of this virtually,” instead of, “well, your doctor's not available so I'll give you this other thing,” it's subtle, but it's real. We send the message in that latter way that somehow this is second-rate care, and it's not. It is just as good. It might be more appropriate it might be more convenient to see the virtualist in this case, even if your primary care doctor has access. And I think that's also what the primary care doctors right now are struggling with because their access is getting a little bit better, and so they are able to see their own follow-up. What we're trying to say is there's a lot of patients in our community who want to be your patients, and maybe it is time to think about how we further your reach and we serve more patients in a way that keeps you healthy, in a way that keeps your patients well- cared- for and satisfied, and I think that is the next place we might go with this model.
Ran Strul: This has been very focused on primary care, obviously. What's the scope, what's the potential of in primary care and importantly in other specialties, how big and wide can this become?
Ethan Fischer: One of the things that we're really keen to do next, and I think, Rupal, you're going to echo me here, is take what these virtualists have from an intake and synthesis of what's going on with the patient at the point of care during the visit, and we want that to enable every visit in primary care, not just visits with virtualists. So I would love to support the brick- and- mortar doctors, give them this same exact tool. Then as Rupal was mentioning, as we're thinking about how do we give our providers the ability and the support to serve more patients and really serve more of the community that really needs this access, I think if you're taking the virtualists and you're having that model, you're also giving the same tools to the brick and mortar. You're tackling it from two angles at the same time, and I think it can lead to an outsized impact.
So that's goal number one is, how do we get this over for the brick and mortar? I've worked with many health systems across the country, and I've heard, “Oh, neurology's a huge problem for us that you guys can help us solve. Weight management is a huge problem you can help us solve. Cardiology.” You hear it from every specialty once they get a little bit of a sense of what's going on in primary care. When you have better technology to understand what's going on with the patient at the point of care, you're also able to empower those primary cares to do more, to say, “Hey, I know what's going on. I know this person needs to get escalated to the headache clinic. They shouldn't be with me.” And so I think that's where I get excited of how to, okay, how do we build on this chassis to do two more and different things? But Rupal, curious how you're thinking about it really from the health system lens of what's next and what else is going to be most impactful for you, your providers, your patients?
Dr. Rupal Badani: There's several places where I think we could take this. So the first is this enhanced primary care model and scaling it to the remaining 80% of our primary care practices. The second piece I'd like to really look at is our urgent care brick and mortar and a deeper integration with the virtualist. I don't think that there's anybody who is joyous about needing to go to an urgent care. You have this picture of long waits and unpredictability. What's going to happen? So, let's say you do walk into an urgent care, and there is a full waiting room. Could some patients be vitaled, triaged, and then see a virtualist with the support of the brick- and- mortar team to do labs, to get the X- ray in real time, or even potentially the ability to escalate to a hands- on visit if that patient really does need an abdominal exam?
I think that we could really push the envelope on design of what a comprehensive end- to- end urgent care experience looks like, and where does a virtualist fit in, even in the brick- and- mortar setting. The third area I think we're actively talking about is how do we really get much more intentional about chronic disease and the role of the virtualist? So in the model, we've left it to the primary care doctors to send their patients, pick the patients that you think are open to it. We haven't really put any rules, if you will, around it. We're learning as we go, but I think we have the opportunity now to say, “What is the ideal patient? Is it the more complex patient who needs high touch and the virtualist can see them much more frequently? Is it the less complicated patient that could do pre- visit labs and have their every- three- month check every other one or at whatever frequency with the virtualist?"
So we're bringing a team together of doctors, our quality folks, our pharmacists who support patients with chronic disease, our virtualists, to understand how do we put our arms around that in a rational way? And then the last area, like you spoke about, Ran, for me is specialty. So I break that into two. One is our specialists, many of them receive primary care- like complaints or issues from their patients. How do we help them connect those patients to C- S Connect as it stands now when it's appropriate for those kinds of needs? So the urologists who get UTI concerns, for example. The second piece really is where can we design and innovate a partnership with a virtualist to, as Ethan said, either extend for the specialist or ensure that the appointments the specialists have are not wasted, are as efficient as possible? So some areas do virtual visits before oncology patients have their infusion visits, just to really make sure that everything is as it should be before that patient comes in for their infusion, we're not surprised or find something and then we lose that slot or that opportunity to care for patients.
Ran Strul: This has been a great conversation. Thank you for taking the time talking to us.
Dr. Rupal Badani: Thank you.
Ethan Fischer: Thank you.
Matthew Weinstock: Thank you for listening to the Oliver Wyman Health Podcast. This podcast is brought to you by the global management consulting firm, Oliver Wyman. For more insights on the business of transforming healthcare, visit our online publication, health. oliverwyman.com.
