 I'm your host Vikram Acharya. I'm the Chief Executive Officer of Cloudwell Health, an all-virtual telemedicine provider based in Hawaii. We have a great show for you today. I am very excited to introduce Mr. John Williams. John is the Chief Executive Officer of the Honahoe Medical Group here in Hawaii. John, how are you doing today? Hey Vikram, doing good. Thanks for having me. Thanks for being on. It's good to see you. Good to talk to you. To kick things off, John, tell me a little bit about your background. You're a healthcare administrator. You're the CEO of a medical group. Tell me a little bit about what got you into healthcare. Sure. I'll give you hopefully just the two-minute version. I think I've gotten it down to two minutes. So I originally trained as a clinical pharmacist, came out of UCSF. I can't even think the right number of years. I think 40, no, not 40, 35 years ago. So I got trained out of UC, practiced pharmacy. The majority of my career at Kaiser Permanente. And then about 15 years ago, I transitioned over, was the Chief Operating Officer for a Federal Qualified Health Center in California at San Francisco. And then eight years, 10 years previous to this, transitioned again, became the CEO for a legacy IPA medical group in San Francisco, Chinatown. And then most recently, my gig is here with Hanoi Home Medical Group. So you have made a transition from being a clinical pharmacist, really kind of involved in the day-to-day aspects of patient care to more of an administrative role, it sounds like. What made you want to make that type of transition? I mean, a little bit of a cliche to answer, Vikram. A lot of people say that to be able to impact more lives, have more influence on systems, understanding where healthcare was heading. But it was sort of, for me, was a natural progression. You know, how individuals, maybe not everybody, but myself, you're like, oh, you should do this or you can improve that. And you end up signing just like you're complaining about stuff. And so instead of doing that, with each step in my career, I took a step up, so to speak, and then tried to improve what I thought I could improve. And it just almost naturally led me here. It was never a goal of mine to become a CEO or CEO in a healthcare space. It was just sort of a natural progression, Vikram. Interesting. Okay, that's great. Now, you're in charge of the Hanahoa Medical Group. What exactly is the Hanahoa Medical Group? Yeah, so in Hawaii, we are in Hawaii language, we're a medical group which stands as a risk bearing entity. And what that means is that we engage payers, whether they be direct payers, like Medicare or plans or health plans, to engage in risk bearing contracts where we partner with health plans to provide services to their beneficiaries, whether it's Medicare, commercial, or even Medicaid or MedQuest here in Hawaii. We are a physician-based organization. So there's physician governance, physician committees. We are physician-centric with the belief in terms of, you know, maybe I should have started off this way. And I'm not very good with promoting my own organization sometimes. But, you know, our vision and our mission really is to sustain, grow independent community practices or physicians, if you want to call them that. There's been a trend both at a local and national level where that number has been decreasing over time. But we think community physicians play a very valuable and critical role in healthcare delivery, not only in Hawaii, but everywhere. Yeah. It's an interesting theme you mentioned, the importance of the independent physician, independent community physician. What was the thinking behind setting up an organization like HAHO? How did you go about organizing the pieces? Because it's very complex, you know, the space and very critical. What type of planning was involved to put it all together? The, fortunately for me, you know, I had the opportunity to work with the IPA and medical group in California. And in managed care and in California, they call them RBOs or risk-paying organizations. Those structures are relatively common. And it's more established. They never, it caught on in the 80s and it sort of stuck. There may have been groups that had, you know, sort of either consolidated. Some of them sort of, you know, weren't successful. But the ones that stuck around, they have established structure. California itself is a little bit more, what would be the right word, rigid in terms of monitoring and controlling sort of risk-bearing organizations or entities. They have a department called DMHC, department of managed health care. So I have experience in doing that. I understand what the structures are, how the operational flows are, how the financial risks are set up, how the contracts are set up, you know, what's needed to really be a successful risk-bearing entity. Now, when you call it that, it still links to, you know, the common terms about, you know, value-based contracting and value-based outcomes. So they're all interrelated in my so we can talk about all those things. Yeah. Yeah, that's a good segue for someone who doesn't know what value-based health care is. What are risk-bearing entities? How can you unpack that for people who may not be familiar with the lingo? Sure. I get accused of using way too many acronyms. I think in health care, we do use a lot of acronyms ourselves anyways. In terms of risk-bearing, so when you look at, when people talk about health care in the United States, and you talk about health plans and health systems, it's still anchored by insurance, it's health insurance, whether it's Medicare, Medicaid, commercial private insurance, Medicare Advantage, it's health insurance. And it used to be, and unless so now, most health insurance companies didn't provide the actual care. They don't deliver the care directly themselves. What they do is they engage in our terminology providers of health care services, whether they be physician or non-physician, hospital-based, and used to be the older model was it was very transactional. You provided a service and someone paid you a contractual amount. More recently, it's either the Medicare fee schedule or the Medicaid fee schedule. In terms of trying to get to quality-based outcomes or outcomes that have been proven to show improvements in overall health, whether it's for a larger population or a community, health plans, payers, health systems started recognizing that there were leading indicators or leading outcomes that downstream proved to be valuable to predict whether a population remained healthy or stayed healthy or whether they continued to deteriorate if, for example, they didn't have access to really good health care services. So slowly, and it still exists, there's still a mix, but slowly the trend is to moving towards some value-based outcome where entities, organizations, accept the responsibility, both clinical and financial, to take care of a population. Typically, it's related to health plan beneficiaries that signed up for the health plan. And with that responsibility, you are given, I don't know how much, at what level you want to have me use the terminology, but they're given a capitation. The way I look at it is you're given an allow it, so to speak, and you have to provide the services associated with that capitation or finite amount of money, and you take risk on it. So to really kind of unpack that, these are organizations that you're part of that take care of patients and measure based off how populations do from an outcome standpoint. So from taking care of them, you'll get, let's say, for example, $100 from an insurance company. And within that amount of money, you have to take care of X amount of members. You have to stay on top of them, make sure that the preventive care is in place, that they're getting all the checkups they need, and there is some financial risk that you're taking by obtaining that $100 in a very simple example. Yeah, in sort of straight numbers or easy numbers, I like that you used $100, it's easy to break down. But that $100 is what we call a capitation amount, or a finite set of dollars associated with it. And there are camps who support this methodology and there are others who still believe the older FIFA service model is still better or still valuable. And quite frankly, there's a mix of it depending on type of providers. But the data to date so far shows that under a capitated structure, physicians, providers, systems who are paid more based on quality, start focusing on outcomes that improve both the quality of care, the quality of life for members. And when you focus on that, it translates to not only better health outcomes, but it also translates into what Medicare, Medicaid also need is accessible, affordable health care services. Where I don't know what the number is now, Vikram, and if it remained FIFA service like 100%, probably we'd be past 20% of the GDP for health care by now. Whereas now I think it's still pushing up to 17. I don't remember the exact number, but it's still pretty high, still creeping up a little bit. Yeah. So you're getting paid for how patients do versus the more you do for patients. So taking care of them versus let's order this test and do this and this and this and then get paid for it, which is a much more efficient quality based model in terms of how you take care of people. Yeah. You know, when you look at the FIFA service model, because it's transactional, it's really granular and no one take, not no one. It's harder to take a step back and take a look at whether it's the total patient, the total panel, the total community, the total state. I think when you look at a population level, that's where you can see the benefit of having a reimbursement structure linked to quality programs. You can see the benefit and the improvements that you see at a population level. It's harder to see, you know, when you talk to an individual physician, whether it has a true impact, if his panel is like, you know, I don't know, 20, 50, even 100, it's harder for them to see. But when you step back and look at it at a population level, or even at a national level, you do absolutely see the improvements associated with it. Definitely. Definitely. Now you're working with medical staff positions across the entire state. Are there specific islands that you're focused on right now? What's the trajectory looking like in terms of, you know, who you're working with as part of the medical group? Yeah. Right now we work with positions on all the islands or put it another way. We don't exclude any islands in terms of engaging with physicians. Based on density of population, whether it's patients or physicians, the bulk is in on the island of Wahoo. There's a little bit Kauai, Big Island, Maui. I don't think on the smaller islands, I don't think we have a physician in Molokai. But yeah, there's no exclusion, maybe to think of it that way. Yeah, that's great. Now, when you're approaching the insurance companies on that end, what types of information do you provide to them in terms of who you are as an organization and what your goals are and how you can work with them? Yeah, the way we approach health plans, whether, you know, the plan, if you want to call them that or the payer, is Medicare or whether they're health plans, the larger health plans in Hawaii. We present to them, like I said earlier, as a medical group, first and foremost, or collective of physicians, but the group as a risk-bearing entity in that we're willing to engage them as partners for their members and beneficiaries, which become our patients or the physician's patients. And we provide the bridge to the local community physicians. Instead of health plans working with 100 individual physicians, they get to work with a medical group who is able to coordinate programs, coordinate messaging, and then provide additional support to the independent doctors. Yeah, I'm sure when you are having your discussions with the independent doctors, there are some common themes in terms of what's important to them, what they truly value. What are some of those things that come up when you're in your discussions with your current group, as well as in the process of obtaining additional partners? Yeah, I think the biggest thing is, and it's a fairly general term, Vikram, but it expands and touches a lot, right? You hear the word transparency quite a bit, right? And transparency is both with measurements, whether they're outcomes-based, transparency in reimbursement across the system, not just for themselves. They want to be good stewards of how the medical dollar is spent, so to speak. And then last but not least, either however you want to negatively administrative burden, positively support structures. So how is the medical group and what support services do they provide to independent practices? Those are the three main themes that we run into most commonly with doctors. And what kind of support services do you provide for your partners? Yeah, so one of the things that we think is unique is we invest in what we call member relations and provider relations. Member relations is the outward facing with their patients. We help them with questions, with claims or bills. You know, sometimes the department even helps with non-healthcare stuff, quite frankly, because of the cultural competency that's required for some of the communities when they can't get a hold of anybody, because they have a relationship with a member of relations, they'll ask them to figure out, you know, why is my electric bill this way? You know, why is my telephone bill? But most of the times their healthcare bills, whether it's co-pays, whether it's coverage, whether it's helping them coordinate a referral with a specialist or, you know, prepare for an outpatient visit to a hospital. In terms of provider relations, it's the same thing. We do that at the provider and the provider staff level. You know, when they have questions about what's covered, you know, who's in network, who's not in network, you know, I submitted a claim, where is that? We provide more granular support. I think sometimes, you know, to no fault of their own, larger health systems don't have the boots on the ground, so to speak, locally to be able to provide that support. And we do and we provide it for our physicians because we know them well, there's a relationship. So things are a lot smoother and easier that way. On the clinical side, we've started programs for care management, care coordination, and complex case management. Those are, and we can dig into that a little bit more, but you know, that's probably maybe another podcast. But then we also provide, you know, data and analytics down to the provider level, down to their panel and patient level as well. We chop it all up, reorganize it, present it to them in a user interface platform that's really easy for them to digest. We have, and maybe you should talk to them one of these days, we have a tech partner in Elation Health. They're a technology company. Their main focus is electronic medical records, but they do also what they call a tech stack, I guess, in their field, which is, you know, EW, analytics, reporting, you know, clinical outcome support. So it's, we provide all that through the medical group. And it's at a very individual, almost personal level for the physicians. And that's something that we think is valuable. Yeah. I mean, that's a robust set of services and not only provides significant value to the practice, but it sounds like it, because you're helping these practices so much, it allows the providers, the physicians to really focus on patient care. You know, they do what they do, what they want to do, and knowing that they have this night's support structure behind them. When we look at it, maybe we're, as a medical group, maybe I am a little bit biased. It's like a win, win, win. It's a win for the patient because they get added support. It's a win for the doctors. They get additional support. And it's a win for the plans in that we become the intermediary support structure that the physicians and their staff and the patients are very familiar with. With that transparency, it leads to an even more broader term, I think. You know, transparency then leads to trust. And when you have trust, then you start getting engagement and participation. But that engagement and participation is not just with doctors, it's with patients and with doctors. Yeah. Yeah, definitely. And what are your thoughts, John, on an asset like telehealth, for example? You know, it can help support patient care. It can help keep costs down, open up more access. What are your thoughts on something like telehealth? Yeah, I think telehealth is, you know what everybody is saying, Vikram. It's here to stay. I think with the pandemic in the last two years, it unfortunately, you know, unfortunately, in that it required something like a pandemic to show it. But it was almost a proof of concept as to is there value to telehealth? There was incredible amounts of back and forth argument. No, it doesn't work well. No, patients aren't going to like it. No, you're going to kind of get uptake on it. No, it's not effective on outcome, just on and on, just back and forth, pre pandemic. However, the data and I guess some people say data doesn't lie, you know, the data coming out of it is showing that actually it's the opposite of all the naysayers from what I can read. I'm sure maybe someone pull up something. But in general, it's been proven to be extremely valuable, both in access and in clinical quality, especially for those patients, and I'll call them patients, patients who have difficulty accessing services, whether it's due to socioeconomics, whether it's due to their lifestyle, whether it's due to their, you know, physical inability to go somewhere, right? And so now telehealth has given them a platform to communicate with providers, with physicians, with support structures. I think it's going to expand quite frankly. I haven't heard or seen telehealth being used or leveraged as much on the administrative side of things, but I think it's going to, I feel it's going to, right? Because there's still there's still stuff lost in translation when somebody sends you a paper bill and it's like four pages long and you don't have to understand. I mean, you know, getting someone on the phone is great, but for me personally, you know, like we're talking now, in person would be better. Hey, let's go over this piece of paper. But, you know, through some virtual platform or telehealth, which I think is a part of the whole thing. I think that could be approved upon as well. But telehealth has been shown, I don't think, I think slowly, and I thought there was a new release. I was going to talk to you about that later. I think CMS has extended, I think coverage for the current services all the way to 2023. I think ultimately, once the data continues to flush through, it's not going to go anywhere. And I think it's going to be a part of the healthcare delivery system. I still do, however, don't view it as, it's a piece of the delivery system. I don't think it'll ever be, you know, the only mechanism to deliver healthcare. And I think that's what people worry about when they hear telehealth. They're like, Oh my God, I'll never get to see my doctor again. It's like, no, that's absolutely not true. You know, that's a misconception, I think, that's put out there, you know, people who worry about that happening. I don't think that'll ever happen. Yeah. You raise a great point. I mean, where I see it as a, as a complimentary asset, let's take, for example, behavioral health. So I'm sure many of your, your medical staff have patients who have behavioral health needs and people like the opportunity to see a therapist when they want it and in the format in which they want it. And then something like telehealth, if it's easy to access, they could talk to their therapist from the privacy of their home, the comfort of their home. I would think something like that would be very beneficial to the patient, like you said, to the provider, the primary care provider, as well as to the insurance company. Yeah. I think having the opportunity or the choice of, of how you want that interaction to occur for behavioral health is really important. I mean, some people absolutely are like, no, it has to be face to face. Other people, quite frankly, may want to start with a telehealth visit. I've even heard, you know, the companies are flexible enough. It's like, you know, is it okay if I don't do video and just talk to you? It's like, yeah, that's okay too. Whatever the comfort level to engage individuals and that in, and I think it could be a broad spectrum, whether it's temporary and transitional, whether people are going through a loss and a tough time and they never need behavioral services again. Having telehealth to be an easy access format to have someone to talk to, get them through, you know, a tough period in time. And then of course, the more chronic conditions, having regular constant feedback that's easily accessible, I think is important. And I think telehealth fills that need rather well. Right, right. You know, John, you're, I give you a lot of credit, you and your team, a lot of credit. You're really changing the landscape in the way healthcare is being delivered, the focus on value, the focus on the independent community physician and what's important to them as well as what's important to the patient. And I really appreciate you being on the show. You really have broken it down very nicely in terms of the vision of Honahoe Medical Group, where you're going, why the, what's the mission of the organization. And it's just really great work and congratulations on your progress so far. And I know it's going to do very well in years to come. Mahalo and thank you for being on. Hey, thank you for having me, Bikram. It was fun. It was and you were right. The time passed in the blink of an eye. But I really appreciate the opportunity to talk with you. Hopefully, this message gets out a little bit more. And we really are trying to support not only doctors, but the communities in Hawaii as well. Thank you very much. Absolutely. We have much more to unpack in future episodes with you. So we'll pick it up again soon. All right. Thank you very much, Bikram. Mahalo. Thanks, John. Mahalo. Bye-bye. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, and LinkedIn, and donate to us at thinktechhawaii.com. Mahalo.