Dr. Betsy Johnson, MaineHealth ACO

Dr. Lisa Belisle:

Dr. Betsy Johnson is the President and CEO CEO of Maine Health Accountable Care Organization at MaineHealth Just up the street. Nice to see you today.

Dr. Betsy Johnson:

Nice to be here.

Dr. Lisa Belisle:

So I'm interested in the type of work that you do because I know that you and I both have a background in primary care medicine really, but also in public health and you've gone into an increasingly important area of medicine and it's sort of the administrative, more of the administrative aspect of healthcare. I want to talk about that, but first why make that decision?

Dr. Betsy Johnson:

My journey in health care I can't say that I ever knew where it would take me when I went into primary care 20 odd years ago. But certainly what puts me where I am today is where I started back then and practicing. So I'm an internist and got out of residency and jumped into a primary care practice, Boston, which I loved. And in fact I worked for a HMO managed care organization which was then called Harvard Community Health Plan and they provided excellent superlative care. It was kind of everything under one roof and that was my first experiencing practicing medicine and I learned how to manage a population of patients. We had capitated care and in the 90s as I was practicing there kind of healthcare blew up. I mean truly, you probably experienced that too. Lisa, you know that the HMOs for all some good reasons really kind of blew up under pressure and we kind of moved into I kind of experienced moving into a FIFA surface world of medicine. So it kind of went backwards for me. So I started in one place and then moved into this world of fee for service and volume and more is better and let's do everything. And as I continued on this journey, I also got involved in kind of the business side of medicine and had opportunities to seek some business education and learned more about. As I watched this unraveling of kind of one time of care to another and was truly concerned and bothered by it, I thought I need to do something about this. I need to. I wanted to get involved. So ultimately my path to where I am now in an accountable care organization is an opportunity for me to take all those years of experience and kind of watching, as we're all watching, kind of how medicine is unfolding and the problems persist. I think feel that in Maine and this accountable care organization is a place where I can hopefully make a difference.

Dr. Lisa Belisle:

Let's define a couple of words for people who are listening. One is capitation. What did it mean to be practicing under a capitated system?

Dr. Betsy Johnson:

Right. So we talk a lot about we want to move to a fully capitated model in healthcare or we want to move to a partially capitated model. What does that mean? So that means that a physician or provider group or a hospital by the insurance companies, which can either be commercial companies or it can be our government, Medicare will pay the system kind of upfront. The global capitation is when we figure out how many patients, Lisa, you have in your panel. You have 2,000 patients. And we're going to pay you a certain amount per patient per month to take care of that patient. And you get it up front and you manage under that budget. It's no different really than having a household budget. It's kind of how I like to compare it. Sometimes we know how much money we have and we have to live within it. And so it's kind of a similar concept for the health system, total capitation. And then there's lots of intricacies involved in that. We have targets we have to hit. And there's lots of ways we calculate how much money you would get per member per month. And then sometimes we try to calculate. We don't do a full capitation, but we capitate only the primary care doctors. So that's a little bit what capitation. It's different than the system that we live under now. So we pay providers and we pay for hospital care and we pay for nursing home care. Basically we bill out by how many services we rendered. So it's a volume based world.

Dr. Lisa Belisle:

So when you say fee for service, essentially somebody comes in, we do something with them. And then we ask the insurance company or the government to pay for that one particular encounter versus getting paid whether a person comes in or not into the practice because they've been capitated.

Dr. Betsy Johnson:

Right. And there are pros and cons of both systems and having lived under, under both of them. In a capitated model, you know, you have funds to take care of the patient whether they're there in front of you or not. So in a fee for service world, you're thinking about the patient only when they're in front of you in your office. But there's lots of other things you need to help the patient think about for their health and wellness. That's not only that one moment when they're in their office for 15 minutes. So having funds for your practice to have a nurse, a population health nurse who might outreach and tell them it's time for their flu shot or it's time for them to check or how they're doing on their diabetic diet or their exercise, all those other things in health that we don't necessarily pay for up front.

Dr. Lisa Belisle:

Since we've made this really dramatic shift, and I think we're still shifting.

Dr. Betsy Johnson:

Oh, absolutely.

Dr. Lisa Belisle:

We've gone completely from one to the other. What were some of the pluses and minuses of capitation when we were actually in a system where we had the ability to have a certain amount of money for each person and really focus on wellness? I guess.

Dr. Betsy Johnson:

Right. Well, that was the issue. I mean, in HMO days and capitated models, the danger is that if you don't constantly check for quality or patient experience, there can be kind of first incentives to have a pot of money and not perhaps do everything that you should do. You know, if you do less services, you're going to have more money. So that's what, you know, that could happen. Not all health systems did that or would do that. You know, there's ethics involved here, but, you know, the incentives can get mixed sometimes. So in Accountable Care, which people ask me a lot, how is Accountable Care different from capitated HMO days? There is such an emphasis today on having quality metrics in place, kind of the checks and balances of if we're going to provide these services or we're going to be given this money to take care of these funds, these precious funds to take care of a community, then we need to make sure that we are living up to what we said we would do for quality and that we would do what we said to live up to the patient's experience of that so those are in place now, and that's what we're doing. And so now we're in a world of. There's a lot of emphasis on quality. And I don't know, Lisa, you tell me. You know, it can be really frustrating for providers, all this emphasis on metrics and comparing ourselves to each other. How well do I manage my diabetic patient versus someone else? It's continuing to evolve. And what's the right way to incent the quality without putting the people and the providers who are trying to take care of patients under more duress?

Dr. Lisa Belisle:

Having now been working with Central Maine Healthcare for four years and previously in my own private practice, I can see good and bad things about all the things that you're talking about. I mean, I do love the idea that we want to take care of our patients. We want to give them the best possible care. So if you have somebody who has diabetes, you want to make sure that their blood sugars are down, and you want to make sure that they've had their eyes examined, and we want to make sure that the nerves in their feet are still working and that we've checked their cholesterol and all of these things that are being measured because this is important for somebody who has diabetes. On the other hand, these are still people. It's not like.

Dr. Betsy Johnson:

Right.

Dr. Lisa Belisle:

It's not like somebody's bringing.

Dr. Betsy Johnson:

They're not a metric.

Dr. Lisa Belisle:

They're not.

Dr. Betsy Johnson:

Yeah.

Dr. Lisa Belisle:

And it's not like somebody's bringing their cocker spaniel to the veterinarian. And you say to the. The owner of the cocker spaniel, okay, well, you need to do this to your dog. I mean, these are people who can make decisions, and. And sometimes they don't want to do the things that we're asking them to do, even if they completely understand why they. We think they should.

Dr. Betsy Johnson:

We are all only human. And I think that that's in the field, the profession that we're in for taking care of people. You know, it's our job to inform, to help, to connect, to listen, to give them the best services. But you're right, even every. Every human being is a different part of their life, and sometimes they're going to connect into that, able to listen and do what's best for their health. And other times they're not. And there's many reasons. And one of the things that we can also talk about is this kind of emerging theme of understanding the social determinants of health. I think that has been neglected in the healthcare world, as we think. So what are the social determinants of health. That's everything else that affects someone's life other than their medical issues. So their financial situation, their transportation opportunities, their education, all of those things impact how well, as you said earlier, someone's going to be able to take care of themselves. And we haven't. I don't think we've paid enough attention to that in the healthcare arena.

Dr. Lisa Belisle:

I think you're absolutely right. One of the things that I've noticed with patients is that sometimes we don't even try to figure out what it is that could be socially impacting their situation, because we don't know that we have anything we can offer them. And we like to solve problems as

Dr. Betsy Johnson:

doctors and science use science. Exactly.

Dr. Lisa Belisle:

So if you have somebody who has diabetes and they also don't have access, maybe they aren't able to drive themselves to the supermarket and get healthy fruits and vegetables, and they're relying on the food pan. And as hard as the food pantry tries, they give them a lot of starches and things that are going to shoot their blood sugars up. Then, you know, it's this really complex system that as a doctor or, you know, nurse practitioner or physician assistant, it's not so easy to kind of get in there and say, okay, so how do I get this person a ride more frequently to get fresh fruits and vegetables? And then it becomes, you know, I think one of the things that really bothers me is that it becomes almost a. It's almost as like there's a conflict that comes up between the provider and the patient, because the provider wants one thing, and the patient, even if they like to do that, they can't.

Dr. Betsy Johnson:

They can't.

Dr. Lisa Belisle:

And that's tough because that really impacts the relationship between two people, which is supposed to be a healing one, right?

Dr. Betsy Johnson:

Absolutely. And then when it becomes not a healing relationship, then you. Then you could lose the patient, and then you don't know where they are or how you can help them. So that's the risk we take. I think another area that I think a lot about in this context is then therefore, the health system can't do it all by itself. So as a community, and I think about that in Maine as a community, how do we come together differently than we have already? Maine is a wonderful innovation, collaborative community, and there's many good people trying to think about this. We still live in some silos of trying to help the same person. And how do we continue to kind of integrate that and come together as a community differently than we are now? That's one of the things I think a lot about.

Dr. Lisa Belisle:

So what are you seeing that is positive in that area? What types of innovations or what types of organizations are working on this problem?

Dr. Betsy Johnson:

Well, in fact, one of the things that an Accountable Care organization does, a place I work which brings together groups of providers and hospitals to take care of for a certain population of patients. One of the areas that we focus on is called care coordination. And in that we have a staff of people who are working directly with the practices and the providers who are in our network and we work with them to be able to coordinate. And I think there are some real success stories of coordinating that kind of transition of care from the hospital to the skilled nursing facility to home. I think there's been an increasing emphasis on how well home health can help a patient. And so our care coordination department is working to tie those services together. I think our care coordination and our care managers also have at their fingertips the information about transportation or about access to medication programs. There's a centralized place where we can be a repository of that information and give it out. We have providers in our Accountable Care network that are both employed by the Maine Health System, but also small independent private practices like you use to be in. And so we try to provide those services across the spectrum of all the different types of practices. So I think there's some real success stories in there.

Dr. Lisa Belisle:

I would agree. I mean, I've seen this firsthand when somebody else other than just a doctor, nurse practitioner, physician assistant is there at the one time visit every two months. If there's some, it's really a team of people that are there to support people that need the most support. That it's nice to have someone who can be calling the patient on a regular basis and just saying, you know, how, how are you feeling? How was your blood pressure today? How are your blood sugars looking? Because that regular checking in, not only does it help us to know how they are clinically, but emotionally, socially, I mean, even the loneliness factor that comes into health can be mitigated by the type of interaction. And I've seen really nice relationships build and people's health improve because of it.

Dr. Betsy Johnson:

Absolutely. So I think. And again, that gets back to that community isolation, loneliness, you know, greatly impacts health and just knowing that someone's out there who's going to check in with you and then also help you to feel accountable, kind of that accountability world, you know, accountable to your health, that you followed up, that you went and picked up your medication, it's easy not to do that. It's easy to get mixed up on whether you took your medicine this morning or not. You know, so, you know, having people. But the other really, when you asked about advances that I think successes that is just happening faster than we can then keep up with in healthcare is the technology aspect and using other modalities other than just the nurse care manager that might visit the home. But you know, using things like our iPhones and telehealth and other ways to connect with patients. I think that's just an exploding emerging field. And you know, healthcare is trying to wrap its arms around it, but we have a lot we can do in that area to help improve health.

Dr. Lisa Belisle:

Well, I think it's important that we really be exploring this more and we've been very reticent as a field to even engage in the most basic things like electronic medical records.

Dr. Betsy Johnson:

Right. I know just the idea that we

Dr. Lisa Belisle:

need to put something in place so that more people have access even to their own health information, that was really something that we were dragging our feet on only 20 years ago.

Dr. Betsy Johnson:

Oh, right.

Dr. Lisa Belisle:

And we're still really working on this.

Dr. Betsy Johnson:

We have a lot of catch up to do.

Dr. Lisa Belisle:

We do. And simultaneously, you know, our patients still need to be cared for and we still need to take care of the social issues in our community. So it is exciting to see, but there's, it's sometimes it can be a little frustrating to be a provider within the system.

Dr. Betsy Johnson:

Yes, it's really, I mean, well, let's talk about providers, whether they're physicians, nurse practitioners, PAs nurses, medical assistants who are caring. It's easy to get burned out and overwhelmed and trying to keep up with not only just as, you know, taking care, even in our healthcare world 50 years ago, taking care of people as they travel through life and making sure they have health and wellness, a challenge. But with all of the change and having someone just understand an electronic health record, which is complex at best, and then all of the other things they need to keep up with, you know, the messages from the insurance companies, the messages from the Accountable care organization, you know, you need to do this, you need to do that. It's overwhelming. So how can we simplify it and cut through, through some of the clutter and utilize our tools in a way that is both efficient and effective for the care team and then ultimately the patient.

Dr. Lisa Belisle:

Well, I've been speaking about nurse practitioner, PA and doctor because I think of them as like almost most of the time the endpoint in a medical visit. But you just raised a really important point and that is that it's, there's not really an end point that you do have. It starts with the patient service representatives at the front desk and then the medical assistants and then the nurses. And I know that the people that I work with in my practice, I mean, they make our practice run. And every doctor I've ever spoken to who is happy in their practice, or as happy as one can be, it's because they have a really great team working with them.

Dr. Betsy Johnson:

It's all about the team.

Dr. Lisa Belisle:

And at the same time, you're right, I mean, we talk about provider burnout, we talk about doctors getting frustrated. I mean, a lot of people who are mid or, you know, their medical assistants or their nurses, they look around at other potential jobs that they could make just as much money for, and

Dr. Betsy Johnson:

they say it's not always in healthcare. Right, exactly.

Dr. Lisa Belisle:

That's the thing, is there are other ways that they could live their lives and be happier. And as dedicated as they are to being in the medical field, sometimes they just say, listen, I don't have to put up with this anymore. So how do we also keep other members of the team healthy and well?

Dr. Betsy Johnson:

Right. Well, that's another passion of mine is thinking about in any organization. I'm sure that's true here for yours. Thinking about the health and wellness of your employees. And it's hard because it's not always about the money. I mean, certainly everybody wants to get paid for what they're trained and licensed and educated to do and paid fairly and well. But beyond that, there's all those other factors of what makes a healthy work environment, what makes you want to wake up in the morning. And in healthcare, we've already attracted, we've already attracted the do gooders, we've attracted the people to this profession who want to care and heal others. And so how do we then support and care and heal them too in a work environment? I think. So what do you do? I mean, I think making sure leadership is attentive to what's going on to their employees. Making sure you have programs in place, whether it's employee engagement, vents, going off site for a field trip of some sort, or just in the office having coffee and a place to decompress in the middle of the day. I mean, all those things, I think being attentive to, again, the health and wellness employee. If you have a happy work staff, it makes for a very rewarding work environment. And therefore, if you feel good about where you're working, you're passing that on to the patient who you're seeing and that's been supported in lots of studies. That Happy healthcare team is going to have a more rewarding and happy patient engagement experience, too.

Dr. Lisa Belisle:

When you were making the decision to go into medicine, what was it about being a doctor that sent you in that direction?

Dr. Betsy Johnson:

So I was very. I am very influenced by my upbringing and my family life. And my. I didn't have any doctors in my family. My dad was an Episcopal priest. And so I grew up with a mother and a father whose life was committed to a congregation. So community. And we basically lived in two places. We're from the South. We lived in New Jersey for a while in a small community, and moved back to Nashville, Tennessee. And watching my parents as they. I mean, our life, so our life as kids, I have three siblings and, you know, we went about our lives, but our lives were like. We lived right next door to the church. There could be phone calls in the middle of the night. Everything from happy and sad. Often the middle of the night calls are the hard ones. Something bad happening. Grew up to weddings and funerals, people knocking on your door, asking for money for gas. So I just grew up in an environment of taking care of others. As I began to sort myself out and think what I wanted to do with my life, I knew in college and I figured that my love of sciences and humanities and taking care of people, that being a physician would be the right path for me. And I love being a doctor. I love the profession. And I, again, that's part of why I do what I do now, because I feel very passionate about trying to continue to make it a field, a profession that is sustainable.

Dr. Lisa Belisle:

And what type of family culture are you, yourself providing now?

Dr. Betsy Johnson:

For my own family, yeah. So my husband is a cardiologist, so we have two sons who are 15 and 11. And family first. In my life, it's always been family first. It's part of why we moved to Maine. My husband and I had both gone to college in Maine and kind of go back and forth. And when we decided where we wanted to raise a family, we knew Maine was the place to do that. And I think in our lives, even in our professional lives, we have made decisions for the next job or the next activity. We always weighed against how that fit into our family life as, you know, childhood for our kids, it goes fast. And having a teenager son and a preteen, you know, you realize how fleeting it is. And so attending to them first and foremost is certainly our approach now. Does work and life and everything else get in the way? And, you know, yes, but we all juggle those things. I'm sure you do, too.

Dr. Lisa Belisle:

Well, yes, absolutely. There's always a juggling that goes on. And I also think about my own kids when it comes to being. My dad was a doctor, I'm a doctor. They have lots of. We have lots of doctors. And my brothers and sisters and sisters in law and brothers in law. And I think, you know, if the worst thing that they hear about sitting around the dinner table is our struggles with helping other human beings, that's not so bad. Right. I mean, even if we are as frustrated as we possibly can be because we don't have the answers or we're bumping up against some huge social issue, at least there's the effort.

Dr. Betsy Johnson:

Yep.

Dr. Lisa Belisle:

At least there's some sense that we're in the struggle, we're working on it, and that, you know, that there's hope because people are still doing this. Yes.

Dr. Betsy Johnson:

Yes. And sitting around the dinner table is one of the most important things you can do in a family.

Dr. Lisa Belisle:

That's a very good point. Yes. Well, I'm really. I know it's taken a while with your busy schedule to get you in here, but I feel great about the conversation and I appreciate your taking the time to do this. I've been speaking with Dr. Betsy Johnson, who is the President and CEO of the Maine Health Accountable Care Organization here in Portland. Keep up the good work, and thanks for coming in.

Dr. Betsy Johnson:

Thank you so much.