Dr. Henish Bhansali shares insights on the impact of value-based care and Oaks Street’s holistic approach to care navigation
Value-based care is our future, and Chicago-based Oak Street Health is living that future. The network of value-based primary care centers has drawn national attention for delivering high-quality outcomes and cost-effective care. Currently operating across 11 states, Oak Street Health primarily serves adults who are Medicare-eligible and often low-to-moderate income.
Ribbon Health recently hosted a fireside chat between the Ribbon team and Dr. Henish Bhansali, Oak Street Health’s Senior Medical Director of Care Navigation, to discuss the impact of value-based care on vulnerable populations and Oak Street’s holistic approach to care navigation.
Navigating patients to better health
Dr. Bhansali has spent his career working with Medicare and Medicaid populations and other vulnerable communities, including patients experiencing homelessness, undocumented immigrants, and low-income seniors.
When asked about the most striking part about working with vulnerable patient populations, Dr. Bhansali shared that, in his experience, social and behavioral factors, better known as the social determinants of health (SDoH), often determine a patient’s ability to access and navigate the healthcare space. He found that patients who don’t experience as significant of an impact from SDoH tend to live in areas with infrastructures and resources that allow them to make healthy life choices. And if making healthy life choices becomes difficult, that same infrastructure enables them to navigate our complex healthcare system with additional resources along the way.
In his experience working with vulnerable populations, Dr. Bhansali noted these support systems are not as readily available because of the limited infrastructure and resources around them. The implications of these disparities are dire. “Patients’ access and ability to navigate the healthcare system makes all the difference in their health outcomes, and ultimately, life expectancy,” Dr. Bhansali explained.
Primary care doctors as quarterbacks
Oak Street approaches care navigation by providing personal, equitable, and accountable care. “Our goal is to spend more on preventive, primary care and decrease the need for emergent, acute care,” Dr. Bhansali commented. “We do everything under the sun to ensure patients don’t have to go to the emergency department and be hospitalized for avoidable and unnecessary reasons.”
He explained that Oak Street has a holistic primary care structure that ensures patients utilize the emergency department (ED) appropriately. Once patients are in the acute space, Oak Street also works with hospital teams to support care coordination and secure safe transitions upon discharge. As a result, Medicare Part A spend has dramatically decreased: Oak Street Health has driven a 51 percent reduction inpatient hospital admissions compared to Medicare benchmarks, 42 percent reduction in 30-day readmission rates, and a 51 percent reduction in ED visits, all while maintaining a Net Promoter Score of 90 across patients.
But while Part A spend has decreased, Oak Street continues to explore new approaches to reduce Part B spend further. Dr. Bhansali shared that a significant part of his role involves collaborating with population health and managed care operations to optimize outpatient services, such as helping patients get care from accessible, collaborative, high-value specialists. “It’s clear that we want to minimize acute care (Part A) by providing great primary care. For diagnostics and specialty care (Part B), it’s not as straightforward since both are a part of the optimal outpatient care model,” Dr. Bhansali notes.
He also shares that this year, a large part of his role will focus on optimizing point-of-care decision-making processes to drive high-quality care and reduce unnecessary escalations. He describes each Oak Street clinician as a quarterback, giving patients the care and attention they need, which may be more difficult in a fee-for-service environment. “The typical fee-for-service PCP cares for about 2,000 patients,” he explained. In contrast, Oak Street Health PCPs care for about 500 patients, allowing for more frequent, in-depth, high-touch, longer visits.
A strong referral network, built with data from Ribbon Health
Ribbon Health has been working with Oak Street for the last two and a half years, and before the collaboration, Dr. Bhansali notes that getting patients the Part B care that they need consistently and reliably was challenging. “Many of the neighborhoods we serve are healthcare deserts,” he said. “We couldn’t just send a patient to the cardiologist down the street.”
Oak Street learned that existing provider data sources weren’t as reliable. Questions arose about which clinicians provide the requested care, accept new patients, and accept the patient’s insurance, all in a convenient location.
Answering these questions was the key to unlocking their ability to connect patients to medically necessary services. “We provide primary care, but we are at risk for nearly all of it. The best way to minimize acute care is by keeping people healthy and out of the hospital, and a large part of that is outpatient diagnostic and specialty care,” said Dr. Bhansali.
To overcome these challenges and build out its existing network of specialists with accurate and reliable data, Oak Street worked with Ribbon Health. “Working with Ribbon Health has been very valuable,” Dr. Bhasali says. “The last two and half years at Oak Street have been a transformative journey where I now fundamentally believe that value-based care is the solution to much of what we’re trying to solve for in healthcare.”
To learn more about how Ribbon supports new patient care models with accurate provider data, download our ebook, Simplifying Healthcare Navigation.