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      Healthcare Voices Series: A Dual Perspective on Value-Based Care from Dr. Jubelt and Dr. Neil

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      Recently, we had the opportunity to interview two impactful healthcare leaders, Dr. Lindsay Jubelt and Dr. Gianni Neil. Through our discussion, both leaders offer insightful perspectives about the intersection of technology, data and value-based care. Cutting through the complexity, they provided a pragmatic glimpse into innovations reshaping the future of healthcare.



      Headshot-Lindsay Jubelt Headshot-Gianni Neil

      Dr. Lindsay Jubelt

      Dr. Jubelt currently serves as the Chief Population Health Officer for the provider side of Massachusetts General Brigham, as well as the Chief Medical Officer for the organization’s health plan operations.

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      Dr. Gianni Neil

      Dr. Neil serves as the Chief Medical Officer at ChenMed, a value-based primary care provider for seniors in 15 states, who have traditionally lacked access to coordinated, whole person care.

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      Patient-Centric and Digital First is Imperative

      From coordinated care to collaborative efforts, both leaders emphasize the pivotal role of innovation, collaboration and patient-centered approaches in the evolution of value-based care. Dr. Jubelt shared examples of successful initiatives at Mass. General Brigham that demonstrated positive outcomes, particularly in terms of patient health.

      “We’ve had success in closing hypertension gaps for African American and Hispanic patients relative to Caucasian patients," she said." There was a very personalized approach for each population that included community programs and traditional primary care office settings. Taking this experience and learning how to scale it to a larger population is the next phase that we want to work toward.” 

      She highlighted the current digital era's potential in coordinating whole-person care and the shift towards healthcare consumerism. “I’m excited about healthcare entering the digital era and catching up to other industries. There is a rising trend of consumerism and it’s time to have that same experience throughout the healthcare journey.”

      Recent studies have shown that a patient’s experience at the doctor weighs heavily in their decision to return or find care elsewhere. Meeting these growing expectations by providing a convenient and seamless experience can be crucial to an organization’s long-term success.

      One way to offer a positive experience is for providers to focus on building relationships with patients over time. Dr. Neil believes this approach is imperative in driving better outcomes.

      “Building trusting relationships becomes pivotal to be able to really influence the patient’s overall health,” she said. “If providers can evolve to act as a health coach, this encourages them to recognize their patients’ health goals and help those patients through each step of their sickness or recovery.”  

      Dr. Neil underscored the paradigm shift in healthcare responsibilities, emphasizing a proactive, preventive approach to chronic illnesses and the financial incentives tied to avoidable hospitalizations. She shared a humanistic tactic championed by the ChenMed team, called the “Socks Off Initiative”, to take a more preventative approach with high-risk patients. 

      “By looking at our patients’ feet during their scheduled visits, we can detect early stages of ulceration to help reduce the need for them to face amputation down the road. Clear and regular communication with all of our high-risk patients, even outside of their scheduled appointment times, lowers the chance that their health will deteriorate and keeps them doing what they love most, for longer.” 

      Together is Better

      Collaboration was a common theme among both leaders but achieving it hinges on the need for healthcare organizations, health plans, providers and community organizations to work in unison to advance health equity. Dr. Neil highlighted the vital role of health plans in linking patients to essential resources like food banks and transportation. “It involves so much more than provider and patient –it’s the entire ecosystem of payers, providers, communities and politicians. That collaboration must happen for effective change.”

      Dr. Jubelt agreed on the significance of collaborative efforts in addressing disparities and serving underserved communities. “The biggest opportunity to cut costs is to start managing chronic diseases, which historically we have not had a great way to do. If we can bring together community groups, providers and health plans, it’s feasible to move the needle for the consumer and get their health under control.” 

      Small Wins Towards Health Equity

      Data analytics and non-clinical socioeconomic data are proving to be effective tools for furthering health equity. Identifying social determinants of health should be a priority for leaders in healthcare and it’s clear that factors such as loneliness, food insecurity and housing status can positively or negatively impact patients’ health risk.

      icon-symbols-checkmarks  RELATED: SDOH Data Drives Community Health and Healing

      “We need to know more about the consumers,” said Dr. Jubelt. “Do they live in rural or urban communities? What are their preferences? It might be that drivers of healthcare data are so granular, and it will take time to understand and design solutions around them. We need to know their narrative and scale that for a population.”

      Brian Urban, Director of innovation and Emerging Markets at FinThrive, recently addressed this in an interview with HFMA. “The challenge is that healthcare systems and payers have not traditionally used data outside of claims or clinical encounters,” Urban said. “Healthcare data is like a faucet. It goes on and off. But socioeconomic data is like a faucet that’s always on. It’s always happening outside of a doctor’s office. You can collect it and put it into a big central repository, but now you need to put labor on it or use RPA [robotic process automation] or AI to pull out the most important elements.”

      He recommends these three approaches for any healthcare organization:

      1. Administer SDOH screenings and collect data internally
      2. Leveraging external data (e.g., data from health information exchanges, other healthcare organizations, the state and community organizations)
      3. Potentially partnering with third-party vendors that provide near real-time SDOH data 

      The challenges surrounding health equity are evident and Dr. Neil agreed that it’s a long-term approach with incremental wins. “We need to take a little bite of the elephant at a time.”

      Possibilities Ahead

      Looking ahead in 2024 and beyond, both leaders anticipated key advancements, including the integration of fragmented information and data, remote patient monitoring, and predictive models that include non-clinical socioeconomic data to better understand an individual's health risk.

      These innovations will play a pivotal role in enhancing the effectiveness and adoption of value-based care models, especially in achieving health equity.

      The right SDOH data can provide better insights into your patients’ potential risk factors so that you can help them achieve better outcomes. Download our insight guide to learn how you can improve your SDOH strategies.

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