In this episode of SoundPractice, host Mike Sacopulos speaks with Susan Dentzer, the president and chief executive officer of America’s Physician Groups (APG). Dentzer is one of the nation’s most respected health and health policy thought leaders; a frequent speaker and commentator on television and radio, including PBS and NPR; and an author of commentaries and analyses in print publications such as Modern Healthcare, NEJM (New England Journal of Medicine)-Catalyst, and the Annals of Internal Medicine.
Although coming together to make this country a better place is not new, it is still needed. Organizations such as America’s Physician Group help the medical profession and our nation. In this insightful conversation, you’ll learn the initiatives the APG is putting in place to benefit all physicians.
This transcript of their discussion has been edited for clarity and length.
Mike Sacopulos: In one of the darker moments of the American Revolution, Benjamin Franklin said to his fellow patriots, “We must all hang together or assuredly we shall hang separately.” Coming together to make this country a better place, while not new, is still needed. Thankfully, organizations such as the American Association for Physician Leadership and America’s Physician Groups help the medical profession in our nation. Today, I am pleased to speak with the president and CEO of America’s Physician Groups. This will be an informative and insightful conversation you will not want to miss.
Susan Dentzer is president and chief executive officer of America’s Physician Groups. She is a national health policy thought leader. Ms. Dentzer serves on many national boards including the National Academy of Medicine. Susan Dentzer, welcome to SoundPractice.
Susan Dentzer: Great to be with you Mike. Thanks so much for having me.
Sacopulos: It is my pleasure. What is the mission of America’s Physician Groups?
Dentzer: America’s Physician Groups (APG) represents about 360 medical groups now across most of the country. We have members in all but a handful of states. And our members share one thing in common, which is that they are committed to the transition away from conventional fee-for-service payment for the services that they deliver to value-based care models, where they truly are held accountable for the cost and the quality of care provided to their patients. They believe that these models have in them the right incentives that will drive physicians and physician groups and all the clinical people associated with the groups, and, indeed, everybody affiliated with the groups, in the common direction of being accountable for high-quality care for patients, but at reasonable cost. This is done by removing the automatic incentives in the fee-for-service system toward more volume and, instead, paying more for results.
Ideally, of course, in the future, we hope that everybody is paid based on the outcomes they achieve for patients as much as anything—not just the processes of care that they deliver, but also being held accountable through the various models, whether it is Medicare Advantage, whether it is of one or another forms of an accountable care organization. That means all the models that have been innovated by CMS and the Centers for Medicare and Medicaid Innovation. By being in one of those models or, in some cases, multiple aspects of those models, they believe that they are really driving toward maximum accountability, again for the quality of care for patients and, frankly, for the costs paid by many of the nation’s taxpayers, premium payers, et cetera, who are really funding the healthcare system.
Sacopulos: You mentioned that you have members in the vast majority of states. Maybe we could talk a little bit more about your membership, and, if there is a typical member, what that group looks like?
Dentzer: Well, collectively, our members serve about 90 million patients across the country, and they do that in various ways. Some of our groups are the very large groups affiliated with Kaiser Permanente, for example—the Permanente Medical Group, the Southern California Permanente Group, the Northwest Permanente Group, et cetera. Those, of course, are organized as separate physician groups that essentially contract with one entity, which is Kaiser Permanente, to provide care for all the enrollees within Kaiser Permanente. Those are at the sort of “large” end. At the opposite end, we have smaller groups, more localized groups, that in some instances may be affiliated with a hospital or health system. They can be stand-alone groups that are competing for contracts. A number of our California groups traditionally have been organized, for years, in independent practice associations, a model that took hold in California a number of years ago.
So we do have a range of members, but the common denominator is a commitment to value-based care, and we pick up more members every day who are moving more and more in that direction. As you know, the government has now called on all traditional Medicare enrollees to be in accountable relationships with their providers by the year 2030. That’s not just a call on enrollees, that’s a call for the system to move more in the direction of these accountable relationships between those in traditional Medicare and those who are providing healthcare services to them. This has been a wake-up call for parts of the country that have not traditionally embraced value-based care. We pick up more members every day who are figuring out: How do I get into a Medicare shared savings program arrangement? How do I get ready to be in a party to an accountable care organization agreement? et cetera. We think the future is very bright for the value-based care movement and, of course, for APG as a consequence.
Sacopulos: Excellent. In preparing to speak with you, I reviewed several issues of Washington Update, which is APG’s newsletter—extraordinarily well done and full of high-quality information. It is clear, to me at least, that APG has its finger on the pulse of Congress. Can you tell our audience a little bit about the newsletter and how they might subscribe?
Dentzer: Absolutely. This is a service that we provide primarily for our members, but it is open to anybody who wants to subscribe to it. You can subscribe just by going to our website: apg.org. In Washington Update we try in a very succinct way to summarize the top issues at the congressional level and at the agency level—CMS, for example, and CMMI in particular—but not just limited to those. If there’s a proposed rule that has been submitted to the Office Of Management and Budget for review—and that is, of course, a White House activity—we’ll capture that in our newsletter as well, assuming it’s of relevance to our members. We try to encapsulate the key items of the week that have appeared either within Congress or within the agencies in a succinct way. We include a number of links to provide additional background on particular issues that we’re highlighting, and we really try to keep people up to speed with what is happening in any given week in issues that matter to them as APG member groups.
Sacopulos: Well, I certainly recommend it to our audience. You have been speaking about value-based care and accountability, and it strikes me that it is really a market economy response to healthcare, not dissimilar to the way the rest of the market works for professionals, whether it is the legal profession, accounting profession, engineer, right? There is accountability, and people get paid more or less based upon their outcomes and abilities. Why do you think healthcare has not adopted that model traditionally?
Dentzer: I think at a very basic level, change is hard, and much of the healthcare sector has done so well, relatively speaking, over the years. I know any given day you can hear loud complaints about the Medicare physician fee levels, et cetera, et cetera. But look, on balance, we didn’t get to having almost a fifth of the economy related to healthcare without people being paid fairly well in the process. And as we know, if we look across the world, the U.S. not only has the highest share of GDP devoted to healthcare of any nation, but we also have the highest price level for healthcare of any nation. The only real reason that is probably the case is that it could happen. You could charge high prices, relatively speaking, certainly relative to the rest of the world, and get paid relatively well for doing it.
Now, this is a generalization. It doesn’t hold up for every aspect of healthcare delivered in this country. God only knows we have safety-net providers who are really underpaid, and we have aspects of healthcare that arguably underpay providers. We give you, for example, the Medicaid program, which clearly—in many states the payment levels are so low that it’s hard to construe that as a really effective way of delivering high-quality healthcare or a payment method that will deliver high-quality healthcare in the end to those individuals who are involved. But, as I say, by and large, the system’s done pretty darn well and there hasn’t been the conventional “burning platform,” so-called, that would force a lot of entities to change. I think that is changing. If you talk to people who are looking at government payment levels broadly—I’m thinking particularly of MedPAC, the Medicare Payment Assessment Commission—payment isn’t going up anytime soon in the public programs.
In fact, there’s going to be increasing pressure on payment in the public programs. For a long time, entities could live with what they perceived as underpayment on the public program side because they could get what arguably was overpayment on the commercial side. That’s probably going away. And part of the reason it’s going away is that everybody’s kind of figured out that the dominant business model of American healthcare appears to have been pricing itself out of affordability for almost everybody in the country. Now, that’s not a long-term viable proposition for survival. Again, not every entity is doing that. Not everybody is trying to make a killing in healthcare, but enough of the system has operated on that level that there really haven’t been overall spending constraints on healthcare in the United States, and, in fact, to some degree we pride ourselves on that.
We talk about the free market still having a home in the U.S. healthcare system. We pay a price for that, and the price increasingly seems to be that it’s simply unaffordable for many individuals. On top of that, we know that the inputs coming into healthcare are driving a lot of cost pressure right now, particularly labor. All of our groups certainly have experienced a very difficult labor market situation over the past year, in particular, even coming out of the worst phases of the pandemic. If anything, they feel that pressure. They see wages going up; they find it difficult to recruit physicians. They see a lot of competition for the available bodies, in particular in areas like mental health. They simply cannot find people to deliver care. You put all of that together and it says, “We cannot go on this way.” The late great economist Herb Stein used to say something that cannot go on forever will stop.
It looks like we’re hitting that stopping point. Or I guess maybe it’s better to say a slowing-down point, where entities, I think, are recognizing that trees are not going to continue to grow to the sky. We’re going to have to work with the budget of healthcare such as it is and try to make care more available and more affordable with the money that we have in the system and with the resources that we have in the system. That is going to compel us to practice care in different ways and get paid for care in different ways. If, particularly, we care about the outcomes of care, we really need to take value-based care seriously. If you think about it, we spend pretty close to double the share of GDP on healthcare in the U.S. that Britain does, but we achieve basically the same health outcomes that they do. A lot of that is related to the upstream drivers of health, the so-called “social determinants,” and the fact that there are many aspects of our individual health that really lie outside the healthcare system.
It’s our incomes, our education level, what kind of communities we live in, those we know from the literature—those are much bigger drivers of individual health status than our access to clinical care. Nonetheless, what we also know from looking at those cross-national data is you can’t take people who are predisposed not to be all that healthy, wait until they get sick, and then throw them into the most expensive healthcare system in the world and expect it all to work. And that’s what we have historically been doing as a nation. If we’re going to do things differently, we’re going to have to think about, just as I said earlier, working within the amount of money that the society’s willing to devote to healthcare, making it more affordable, making it more accessible, and, frankly, being held accountable for producing better health outcomes to the degree that clinical care matters than we’re getting. That’s the argument for really embracing value-based care models, and that’s why our groups have already had that wake-up call and are encouraging so many others to come along with them.
Sacopulos: Well, it certainly is a strong argument. Let’s shift gears, for just a moment. As you know, in June of 2022, the United States Supreme Court released its decision in the case of Dobbs versus Jackson Women’s Health and this opinion has far-reaching implications for physicians. Does APG provide information on these types of issues to its members?
Dentzer: We are watching how this issue plays out for our members to try to see whether we can discern any concrete patterns that are really disadvantaging them at this moment. One reason why we are somewhat different, I think, from other groups that are very laudably focused on this issue night and day and alerting their members almost 24/7 on implications, is that our groups largely tend to be focused on more primary care. Some of them obviously are providing obstetric and gynecologic services. Many of them tend to be in states that have not enacted particularly stringent anti-abortion provisions either pre- or post- the Dobbs decision. So there has been relatively little impact on practice in those areas of the country. By contrast, we have other groups that are in areas of the country that are very much affected by this, and they are getting a lot of very useful information already from more local entities than from national groups such as APG.
I think, more broadly, what we have tried to acknowledge to our members, and I think they fully recognize, is that if the very restrictive anti-abortion provisions that many states have enacted are any guide to what could happen in the future, there are going to be other measures that intervene to really militate against physician–patient relationships and the ability of patients to consult with their physicians and get the physician’s best advice about what is an optimal avenue of care for them in any particular situation. Obviously, right now this applies especially to pregnant women who are at risk of very bad birth-related outcomes, who may be outside the window that a lot of states are now allowing for abortion, with the result that anything that physicians could do in that context could be potentially criminalized. That is very worrisome to all physicians in all of our groups.
Is this a harbinger where social issues essentially trump that physician–patient relationship?
We’re watching very, very carefully to see not just what is the impact around obstetric and gynecologic care or emergency-level obstetric services, but more broadly, is this a look at things to come? Is this a harbinger where social issues essentially trump that physician–patient relationship and those kinds of very important aspects of healthcare in America that many of us hold very, very dear? We’re watching that closely, and we’re going to inform members if we see signs that this terrible trend is potentially spreading to other areas of care.
Sacopulos: What issues are you hearing from your membership about? What’s keeping members awake at night?
Dentzer: Well, the number one issue at the moment, that I mentioned a moment ago, is labor: labor costs, labor availability. We have groups that traditionally didn’t have a lot of problem recruiting newly minted physicians to come and enter their practices, for example, or that were able to persuade people from other parts of the country to move to high-cost areas of the country—for example, California—by making sure that visits from potential new physicians occurred in February, when the weather is very lovely compared with much of the rest of the country. They didn’t have problems with recruitment; now they do.
The market is very, very competitive for new physicians and particularly for primary care physicians. We can see that that is a classic supply-and-demand equation, because we have so many fewer young medical students and residents going into primary care than we need. So, if you’re looking for a primary care physician, life is tough for you right now. You have a little better odds of success if you’re willing to broaden your primary care network, as many of our groups have long done by building out the ranks of advanced practice nurses and physician assistants. That’s been a very important avenue for many of our groups, and it will continue to be. But we also know that the trends that are pulling physicians away from primary care are also pulling many PAs and NPs away from primary care as well, as specialty care continues to be so much better compensated overall than primary care in this country. So that’s a problem.
They even see difficulties with recruitment at the medical assistant level in some very competitive markets of the country, where they may believe that they’ve hired a new medical assistant only to find out on that MA’s first day that they’ve actually gone to work for one of the tech companies. Now, as layoffs have occurred in the tech sector, maybe that will moderate a bit, but it’s a competitive market. Labor costs and healthcare are, depending on the entity, 50% to more than 60% of the overall cost structure. If you’re having difficulties with recruitment, if wages are being bid up, that’s a problem, and it hits right at the bottom line. As we mentioned earlier, with prospects for reimbursement continuing to be, on the public program side, pretty flat and possibly declining in real terms of inflation-adjusted terms, and commercial payers saying, “Oh, wait a minute, you’re not going to push all of these costs onto us”—that’s a problem. Some organizations have the ability to continue to adapt modes of practice, but others are going to have to do that. On top of that, they know they’re now competing with other business models of healthcare delivery that don’t look a lot like what they did or that have a slightly different approach and with lots of new entrants into healthcare who are prepared to do things differently. These may be all of the entities that have bought primary care groups, or some of the retail entities such as Walmart getting into healthcare more actively. There’s going to be competition. By and large, it’s that labor cost issue as symptomatic of a lot of the changes occurring within the economy broadly and even within society broadly. Because, as we know, some of this is being driven by the aging of the population in this country and people getting to a point where they’re retiring from clinical practice, et cetera.
That’s just a demographic reality that we’ve seen coming in this country for some time. I would also point to some immigration constraints. A lot of our healthcare sector, as we know, has been populated over time by people educated abroad in healthcare who then come to the U.S. or by immigrant populations coming into healthcare. As we continue to constrain the inflow of immigration in this country, which we have done, we are turning off that tap as well, to some degree. All of that’s very much on their minds these days, and I think they’re hoping to some degree that things will come back into equilibrium in the future. We don’t necessarily see a lot of signs at a fundamental level, however, that this whole issue of healthcare workforce supply is being adequately addressed.
Sacopulos: Well, there doesn’t seem to be much happiness down that trail. So let’s switch to a different topic. I noticed that you’re on the advisory board for the Center for Global Health Equity at Dartmouth, and that you are also on the advisory board for Dartmouth’s Geisel School of Medicine. Are our country’s medical schools preparing students to handle professional compensation issues? And is that even an appropriate role for a medical school?
Dentzer: Well, just a brief correction, I was on the advisory board for the Geisel School for many, many years. In fact, I used to joke that, more or less, I felt as if I had gone through medical school about six times because I was on that board for so many years. I’m off that board now, but I do remain on the board of advisors for the Center for Global Health Equity. And previous to that, I was a longtime trustee for Dartmouth overall, and I was also on the board of the Dartmouth Hitchcock Health Center on an ex officio basis during that time. Are medical schools preparing students to handle professional compensation issues? I would say that for all kinds of reasons—mostly good reasons, some problematic reasons—medical schools aren’t preparing medical students to live in the world of U.S. healthcare very much at all.
Part of that is the medical school curriculum. Even though places such as Dartmouth have adapted their curricula over the years, a lot of it is still restricted to some of the fundamental issues of understanding the mechanisms of the human body, number one, and also to the competencies of being a physician, which essentially dominate the medical school curriculum. There isn’t a lot of room left for other things. I have taught a fourth-year elective at the Geisel School that has been in place for a number of years. It’s gone through various iterations, but essentially, it’s called “Physician Health in Society.” It’s an elective, so you don’t have to take it in your fourth year, although a number of students do. For many students, however, the lecture that I give on health policy is the one lecture on health policy issues that they get over the course of their education, even in that context.
Aspects of health policy do creep into some other lectures. If you think about it, if you’re going through medical school, this kind of the first brief briefing, I should say, that you get that says there’s a big wide world out there where all the things I just talked about are happening: labor cost issues; primary care lack of access issues; demographic change; and social determinants producing more of our health outcomes in life than clinical care. This is the first inkling you get that all of that is the fundamental reality that you’re going into. To me, that’s wrong. I don’t know what the corrective is, because I recognize there are a lot of really important things that medical students have to learn, but I do think we deprive them of a lot of understanding about the world that they’re actually going into.
When they go into it, sometimes it’s a rude shock and a rude awakening. Can they adjust over time the way everybody ends up doing? Yes, I’m sure if you’re a really bright person and you’ve learned how to understand reality, you can pick this up. But it is still somewhat surprising to me when I speak with highly competent physicians how little they understand about the policy background to healthcare in this country and how deeply frustrating it must be to them because they don’t have that understanding. Sometimes it’s understanding that the world just doesn’t work all that well, but even sort of understanding that gives you a big advantage in my view—to being able to function well as a clinician and, even more important, why wouldn’t you want to own some aspect of the need for change? Why wouldn’t you want to acknowledge that you have a role, your very, very important role vis-a-vis your patients, but you also have a role vis-a-vis society and shaping policies?
You can’t do that if you don’t, first of all, understand reality. And if you don’t understand reality in the big picture, you can become captive to erroneous understandings. This does happen to many physicians, who become very, very frustrated, and very hostile in such a way that I have to believe that it even has a partial contribution to clinician burnout. If you feel like reality is up against you and you have no control over it, you don’t understand it, why wouldn’t you feel burned out? I think, in a way, all of this hangs together, and I really hope more medical schools over time will at least figure out some way to push a little bit more healthcare policy. I would even put it under one big category—“The Realities of Healthcare Practice in the 21st Century”—something like that. The intent would be to give people a little bit more exposure that this is what you’re going into, and these are some of the longstanding issues that this country must continue to confront, but also here are some avenues and opportunities to actually effect change.
Sacopulos: I asked that question because I think that it’s groups like yours, the America’s Physician Groups and the American Association for Physician Leadership, that step in and fill that gap in education later in providers’ lives. So thank you for that, because it does seem to me that we are preparing physicians to be fungible employees and that groups like yours are helping them move in a direction more appropriate for their role in society and their education.
You gave a keynote address to the American Association for Physician Leadership at their fall institute, and you touched on the threat of violence directed toward some physicians. Can you talk a little bit more about that issue and how APG is helping its members with that topic?
Dentzer: Well, I have to confess, we haven’t done a lot as an association on that topic except to recognize these episodes of violence, and even if it’s not violence, just downright hostility. We think it’s fairly obvious that this has just reached new heights during the pandemic. Now as we are emerging into whatever this new phase is, of the combination of not just COVID-19, but of lots of flu cases and RSV and so on, and lots of a major episode again that we confront particularly in the nation’s hospitals of rising levels of hospitalization due to all of those things. What our members have seen is at one with what others have seen, which is lots of ongoing hostility toward clinicians, especially those who are providing care to COVID patients, although possibly not at the same numbers as the worst instances of hospitalization during the pandemic. It is still the case that who’s getting sick now and ending up in the hospital because of COVID-19—it’s still primarily people who have not ever been vaccinated or people who got vaccinated once or twice, but have not maintained any schedule of boosters. I recognize that it’s not clear that the current boosters are that effective against the current variants, but they do seem to be mitigating the worst instances of disease and hospitalization. So we have this mixed picture.
That said, we still have a number of episodes where people are getting hospitalized because of COVID and are resentful when they’re told that they have COVID and act out against their clinicians. Almost all of our members can report instances of hostile encounters between patients and clinicians in that situation. The violence that we are seeing now, it’s not clear whether that is related to the same set of phenomena of hostility and polarization around COVID and vaccines and so on, or whether it is more related to what we’re seeing throughout the rest of society, which is just abominable rates of violence, gun violence in particular.
Possibly that’s a bigger explanation of what’s going on. But it is horrific to have seen these instances of gun violence in healthcare systems, in hospitals, against clinicians and so on. That probably also is correlated with another significant area of intersection that we have in this country, which is mental health issues and gun violence. Of course, first of all, we need to emphasize that we know the biggest intersection there is suicide—suicides of people who are mentally ill and have access to guns. That’s the worst of it. But we also clearly have another set of issues around gun violence on the part of people who have some level of behavioral health or emotional mental stress issues and who avail themselves of guns and use them against other persons, including healthcare providers.
That’s a much, much bigger issue that I don’t think APG alone can get a handle on, and that’s part of the reason I mentioned this. We all have to be concerned about this, and we have to start to think about these connection points. It’s not just violence against healthcare providers, it’s gun violence in our society broadly. That is an issue that all of us who care about the health of Americans have to continue to take on and figure out what are we going to do about this.
Sacopulos: Hear, hear. Our time is unfortunately almost up Susan, but I am interested in what we should expect from APG in 2023. Can you give me some final thoughts please?
Dentzer: We are going to continue to raise the banner of value-based healthcare and work both at the federal level and, increasingly, at the state level to advocate on behalf of our members for policies that support value-based healthcare. We know that coming up in 2023, we’re probably going to see the federal government try to make some changes in the Medicare Advantage program. We salute that, because we don’t think the Medicare Advantage program works perfectly for anybody at this point, particularly for beneficiaries and certainly for many of our member groups as well, now that Medicare Advantage serves almost a half of all of those in our country who are enrolled in the Medicare program. It’s a big enough program now—in excess of 25 million enrollees—that we’ve got to take problems in that program quite seriously and work to redress them. We’ll be advocating on behalf of a number of important policies to make that program work even better for Americans and for our provider groups as well.
We also will be doing a lot of advocacy around the other models that have been brought out, the other alternative payment models—for example, all the models underway at the Center for Medicare Medicaid Innovation. A number of our members are now in the ACO REACH program, which just reported a very important set of beneficial results in terms of net savings to the government, to taxpayers in the first year of that program. We believe it’s going to continue to improve the quality of care to the patients who are served under that program, but we have a lot of advocacy issues that we will continue to push as we try to make that program function even better. And then for all of the models that have come forward, such as the Medicare Shared Savings Program, which I mentioned earlier, and the other aspects of care that our members are involved in, the care models that they’re involved in, and the importance of connecting those models to other aspects of care.
An issue that our groups are really focused on is the integration of primary care and specialty care in these models. They are also focusing on the fact that you can have a primary care physician who’s functioning very effectively in an ACO model, but who may be somewhat disconnected from the specialty care that patients receive, and that those networks need to be tightened. We’ve got to have everybody marching to the same set of incentives so that specialists also are rewarded for value, and so those practices function in a more connected way, that you don’t just throw a patient over the wall as a primary care physician to go off to a specialist and then remain disconnected from that facet of their care. You really want those connection points to be in place. We are working to tighten the relationships between primary care physicians and oncologists, primary care physicians and aspects of kidney care, primary care doctors and behavioral and mental healthcare, in particular, primary care and pharmacy-related care.
There’s so much work to be done—to make the system function as a system in this country as opposed to a blob is really, really important. We’ll be working to continue to educate our members about what are the best practices out there that can enable these pieces of the system to really come together and function as a system. We’ve got a big and robust agenda around advocacy, around education, around sharing of best practices, and we look forward to welcoming as many new entrants as possible into all of this, into our APG family.
For any more information, please invite anybody listening to this podcast to get in touch with us. I’m sdentzer@apg.org. My colleague in communications is at communications@apg.org. Greg Phillips is another person who can be contacted if people would like to sign up to Washington Update. We have a big open tent at APG and we welcome people who want to share our philosophy of really being held accountable for the cost and quality of care.
Sacopulos: Well, we certainly wish you tremendous success going forward. My guest has been Susan Dentzer. She is the president and chief executive officer of America’s Physician Groups. Thank you so much for being on SoundPractice.
Dentzer: Thanks so much, Mike. It was a real pleasure.
Sacopulos: My thanks to Susan Dentzer for her time and strong efforts on behalf of the medical profession. America’s Physician Groups is doing good work. My thanks also to the American Association for Physician Leadership for making this podcast possible.