The state of the network, with CEO Bob Segert

Administrative burden is driving rampant clinician burnout. Value-based care programs are becoming more complex. Patients are demanding better tools to engage with their care team. In the latest episode of the athenahealth podcast, CEO Bob Segert provides his perspective on the rapidly changing healthcare industry—and how we plan to support you through these changes.

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Brian: I'm Brian McPherson, and this is the athenahealth Podcast. We're producing this podcast to help clinicians and staff better utilize athenaOne, so athenaOne can best support your patient care. 

I'm joined today by athenahealth CEO, Bob Segert. Bob joined athenahealth in February 2019, and he has over 20 years of leadership experience in the software and IT services industry, spanning sales, marketing, operations, and corporate strategy. With a relentless focus on the needs of the customer, Bob is leading athenahealth as we cure complexity in healthcare. Bob holds an MBA from Harvard Business School and a BS in mechanical engineering from Purdue University. Bob, thanks for joining us today.

Bob: Thanks, Brian. Glad to be here.

Brian: Let's start with a broad look at the industry. Earlier this year, we released the Physician Sentiment Survey, a poll of over 1,000 primary care and specialist physicians nationwide. In your role as the CEO of one of the nation's leading EHRs, what was your biggest takeaway from that survey?

Bob: As you look at that survey, I think it brought forward some pretty powerful insights. One is that healthcare is complex, and administrative burdens, if anything, are growing, and it's driving increased levels of physician burnout. And that's not a good thing for the healthcare system. We want our physicians to be excited about what they're doing, to feel like they're being supported, and to have the energy that they need to move forward.

I think the other thing that was clear from the survey is that there's a lot of financial uncertainty out there, and a lot of the practices that we support and that were in the survey are questioning whether or not they're going to be viable and able to be able to provide the care that's so desperately needed for these communities that they serve, given the financial struggles they're under, whether that be higher levels of inflation, labor shortages, reductions in physician fee schedule, and that pressure is being manifested in the results of the survey.

I think there is some optimism in that survey around AI and the thought that AI can be potentially a help to alleviate some of this back-office burden and to make their lives easier. So those are kind of three key takeaways from my perspective.

Brian: We've talked a lot internally and externally about how care is migrating towards the ambulatory setting, away from hospitals. Why do you see that as a trend across the industry?

Bob: It's interesting. If you look at the data, there's a study around the growth of the acute care sector versus the ambulatory care sector over the next 10 years. And basically, the survey resulted in roughly flat visit volume, bed days in the acute care setting, with over 10% growth expected in the ambulatory care environment. And that's just the point that you're making there, that there is growth coming into the ambulatory world. The reason that's occurring is several-fold. One, if you're a consumer, if you're a patient, and you want to have a procedure done, and you can have it done with equal efficacy in a local clinic that potentially is closer to your home, it's likely to be newer, you don't have to go into the inner city and get parking and go to this big, sterile hospital, I think you're going to do that. And the ability with the clinical advances of more and more procedures to be able to be done in outpatient settings, the fact that CMS is allowing more and more of these services and procedure codes to be reimbursed in ASCs, drives more and more of that volume.

The other key thing is that it’s cheaper. You look at, let's say, an ambulatory surgery center or work that's done in a clinic, it's often at least 50% cheaper than the same procedure in the hospital. So as you think about sustainability in healthcare, and you think about the cost curve that payers are trying to bend, and the government's trying to bend, it makes a ton of sense to drive more and more business into outpatient settings.

I would say the third thing from my perspective is that this whole drive towards value-based care is really about driving preventative care. And once you're in the hospital, you're likely pretty sick. And the key is to have better preventative care up front, and that work is best done in clinics. So, we see a trend towards more and more people, more and more practices actually driving their patients to higher levels of preventative care up front in the process, and that's driving more and more volume into the ambulatory setting as well. I think things are going to continue as we move forward, as clinical advances drive forward. You see it even in the marketplace with so many sites, urgent care sites being opened up. The retail expansion that's happened, though it's slowing down a little bit in recent months, but a lot of folks really focused on how you drive front-door primary care accessibility to US healthcare population.

Brian: From our perspective, how is that impacting the future vision for athenaOne?

Bob: From our perspective, we've always been front-door focused. athenahealth started as a women's birthing center and women's health clinic and pivoted pretty quickly into a technology play around revenue cycle and then extended into our clinical offerings. If you look at what we've been doing even recently, we just launched athenaOne for Urgent Care, which is a specialty play around the urgent care sector of the marketplace, which is very much an ambulatory care, front-door service. In fact, for a lot of young people today—much to many people’s chagrin—their primary care physicians are urgent care. We just launched that. We're seeing tremendous demand in that space. So, we're going to continue to focus on that area. We've seen a lot of demand from the customer base, just in general, either some of these major parties that are trying to expand to retail care, whether that be CVS, whether that be Walgreens through VillageMD, utilizing the services like athena's.

We're also very, very focused on ensuring that our platform and our software is easy to use, not only for physicians, but also for the patients that engage in these platforms to ensure that we can drive increased levels of schedule density, to ensure that we're filling schedules up for physicians because capacity is an issue in the marketplace, and ensuring that free flow of information happens as well. So, we're really focused on driving that overall physician and patient experience that will enable the front door to be even more effective as we go forward.

Brian: You touched on this earlier, but one of the major themes in the survey was physician burnout. The doctors in the survey reported spending an average of about 15 hours per week working outside their normal work hours, what we call “pajama time.” How do you see athenaOne now contributing to reducing physician burnout and that after-hours time?

Bob: From our perspective, we see that as a huge issue. We want physicians to be able to operate at the top of their license. And any time they're spending on administrative burden that can be either automated or done elsewhere, that's an opportunity to improve efficiency and effectiveness. So we're really focused on a few things.

One, we're driving better specialty-specific workflows. So we're taking our best practices, we're taking our knowledge of specific specialties—FQHC, more a site of care but we call that a specialty, I mentioned Urgent Care, we also just launched (athenaOne for) Women's Health—and really building specific specialty workflows that really operate in a way that physicians are practicing in those specialties. So we think that that's going to help reduce clicks, we think it's going to be more intuitive, and it's going to make that entire process run more smoothly.

One of the other big issues that I hear from physicians all the time is the clinical inbox, and it can be quite the burden. You know, you're seeing patients all day, and then you get to get back to your office, or maybe you take your laptop home, you're at home, back to your pajama time point, and you're opening that inbox, and there's hundreds of messages in there. So, part of this, from our perspective, is how do we put together accelerators? How do we allow physicians to be able to prioritize their inbox so that they can address the most important things first? How do we ultimately use AI to help direct some of those more mundane queries to accelerators, AI-enabled solutions and responses, that physicians can review and can then send out to their patients or to other members of staff? So, lots of opportunities for us to continue to improve the efficiency of physicians.

Probably the last area that's important, from my perspective, is this whole thing around what we call experiential interoperability. One of the challenges that physicians face is having the right information at the moment of care when a patient is seeing them in their office, wherever that might be. We're working with payers to ingest claims data, care gap data, diagnosis gap data. We're working with practices across our network to have a common patient data master that can ensure that we have the most complete view of a patient when they see the doctor. And this can help them in doing their care planning. It can help them in making sure that they're efficient in their visit, that they're getting to the right points to the right questions, and that they're addressing the most critical care issues that that patient might have at the time. All of these things are items that we're working on to try to ease this burnout and to make the life of a physician even easier going forward.

Brian: Let's touch a little bit more on that data, the interoperability that you're talking about, because I know our mission is to create a thriving ecosystem that delivers accessible, high quality, and sustainable healthcare for all. One way to do that is enabling clinicians to access patient data from across the ecosystem through programs like patient record sharing. What is your vision when you think about the way clinicians access patient data and use patient data? How do you see that best happening?

Bob: Healthcare, I've said this before, it doesn't have a data issue, it has an insights issue. In fact, we have so much data at times, it's hard to consume it. And as I mentioned just before, the challenge is, how do you take the disparate data sources, how do you then collate that into kind of a common data master, how do you de-dupe the things that are in from multiple sources such that you have a consolidated patient chart and patient record? One of the key challenges that we face in the US healthcare system is the fact that this patient data sits in various doctors’ practices across the United States, whether that's an acute care facility, a medical research hospital, an inner city hospital, a local clinic. I think one of the key challenges is how do you actually “commonize” that data? How do you get access to that data? How do you ingest that then at the moment of care?

One of the things that athena has been a leader in is driving this level of experiential interoperability with tools that allow you to be able to log in to athena and then be able to actually pull over information from an acute care setting, de-dupe that information, trust that source, have that pulled into your clinical chart, but not pull all the details of the acute care chart in. Someone may have had a long hospital stay and there are all the IOs and other data that comes in from that visit, you don't necessarily need all that. But you might want to know if any new allergies were identified or what medicines were prescribed or what are the key elements of the discharge note for that patient.

And we're working with other parties. Oracle Health is one that we've had a very vibrant relationship with, for some of our key customers, to try to drive better interoperability and ensure that physicians operating in those environments can actually easily access that information so they can provide better care. Our view is we need to do that with every single EHR that's out there, from Epic to Meditech to other ambulatory care EHRs in our open ecosystem via our open APIs to ensure that free flow of data. We're committed to doing that, and we believe if we can do that, and if everyone participates as we're trying to drive this open ecosystem, it's going to really improve not only physician productivity, but also the care that's ultimately delivered to patients across the United States.

Brian: You mentioned AI. Where can AI help there?

Bob: Oh, my goodness. We're just getting started with AI. There's so many areas for exploration. I mentioned earlier the clinical inbox, that's one area. We're experimenting with electronic prior authorization and actually using AI to identify gaps that might be in the prior authorization form to ensure that that can get corrected before that's sent out, so it can improve the approval rate of those as well as the speed for those to get approved. We're doing things like insurance identification selection: scanning the insurance card, being able to pop that against the database and properly select the insurance for the patient that applies in that circumstance. I think there's tremendous opportunity to think about how you can do chart summaries of complicated charts, summaries of care plans. We're experimenting across 40-plus different workflows, use cases. I think you're going to see over the next several years a lot of interesting things come from this. I think there's been a lot of hype. I don't think we've necessarily achieved the hype at this time, but I would suggest that in the next two to three years, we're probably going to see more progress, in terms of driving out administrative burden and driving efficiencies, than we can even imagine as we sit here today.

Brian: All this talk about sharing data across the ecosystem supports another major area of focus of ours: value-based care. We still see the industry transitioning from pure fee-for-service to value-based care in terms of models. What do you see the next couple of years looking like in that transition towards value-based care?

Bob: Value-based care is definitely here to stay. If you were building a company today that was a healthcare IT software company, you would build one that was equally strong in both value-based care flows and processes as it is in traditional fee-for-service. I think the desire to drive better healthcare outcomes that value-based care really supports is powerful. I think it's definitely the right way to go. The whole notion of value-based care being preventative care, trying to ensure that patients are healthier. I mean, just look at things like GLPs and some of the benefits that those have provided in the market with lower incidence of diabetes, better kidney, better heart function. Some of these opportunities to actually address issues up front in the life cycle of a health situation are going to be critical. And I think you're going to see more and more payers, more and more practices become more comfortable with it. I think the big challenge for practices has been, “How am I going to do in a value-based care world?” It could either be beneficial to the practice economically and to their patients, or perhaps it could be a disaster if they take on risk that they can't properly manage, and then they're carrying the expense and the burden of providing that care for patients.

I believe that as more and more tools become available, as more and more practices dabble in value-based care and start to go all in, you're going to continue to see that trend. You see it being driven by the federal government in terms of their reimbursement rates. You see it being driven by folks like us who are working on improving the quality measurement tools. We have a new service offering that's coming out where we can actually evaluate the practice and their performance against various commercial value-based care programs, either upside, downside incentive programs, upside programs, the MIPS reporting that we do through our quality engine, the support we provide for ACOs in the MSSP programs, shared savings programs. I think you're going to see more and more of that from us as we continue to help practices identify and participate in programs they may not even know are available, and importantly, they may not even know if they can perform well. Because we have that data, we can start to work with these practices to say, "Look, there's this commercial program in your state that, based upon your performance over the last couple years, you would do quite well, and your patients would thrive under that program. You may want to enroll in that, and we can help you get enrolled in that, and we can manage that process for you.” So, tons of work going on in value-based care. We're fully committed to it, and I think you're going to see more and more adoption as the years go by.

Brian: You mentioned it's all about optimizing experience for the patients and optimizing the patient care, and all this complexity across the healthcare industry now can be a particular burden on patients as they're trying to navigate the system, especially in this world where patients are increasingly feeling like consumers. How are we reducing friction for patients with the tools we're building out to make it easier for them to manage their care and participate in their care?

Bob: You mentioned patients are consumers, and that's fundamentally true. And frankly, when you know more about your Uber driver than you do about the quality of your doctor, that can be a bit of a challenge. We believe that patients are a critical part of the healthcare delivery model. Patients that are informed, patients that can take better charge of their care, patients that have better access to their physician, to their lab results, to easy online scheduling and self-check-in—I think one of the frustrating things for patients is coming in and having to fill out the history form. “Why? I was just here three months ago. Why do I have to fill this whole thing out again?” And the ability to actually digitize that, to have that available prior to check-in where you can call out the key things that might have changed, and patients can fill that information in much more easily. The ability to have your healthcare chart on your own device and be able to provide that to physicians so that that information is widely available. You know, the things we've been doing at athena is, number one, launching our athenaPatient app. And that's available for iOS devices as well as Android. In fact, just recently, I think we’re the number one rated patient-focused application on the iOS App Store. We're really proud of that. We're going to continue to focus on building technology that enables patients to interact with the practices that they're seeing in a way that allows them to have educated, informed information coming to them that allows them to easily interact with those practices. 

One of the other things we've done, and this was a couple years ago, is we launched this thing called the Digital Patient Engagement Index. This is really about understanding all the ways that patients can engage digitally, and that includes things like getting electronic statements, or doing a copay in advance, or doing electronic payment as opposed to either writing a check or presenting a credit card at the time of service. Things like getting a printed statement can be so burdensome and can frankly be missed in the mail. And then that means they didn't know that they owed the money, and they didn't pay the practice. So, we're really focusing on driving engagement in a digital fashion across every single workflow between a patient and the practice. You're going to see us continue to push forward on that to try to drive a better overall experience for the patients that are out there in the ecosystem.

Brian: Switching over to the billing side and the financial side, in our survey that we've talked about already, we heard that fewer than 40% of physicians believe their business is on solid financial footing. And that was in a survey that was before the Change Healthcare cyberattack disrupted payments across the industry. How are we making it easier for clinicians to get paid for the services they're rendering to their patients?

Bob: It's a great question, and this is a core capability of athena. As I mentioned earlier, as we evolved from a women's health clinic, the first thing we did was focus on revenue cycle. And one of the core value props of athena, I think unique in the marketplace at least at its inception, was the fact that we billed and still bill primarily on what's called percent of collections. What this does is this allows our incentives to be aligned with those of the practices. So when we collect more, when we drive faster cash flow, that not only helps the practices we serve, but it also drives better financial performance for athena. That alignment of incentives is critically important. When you think about athena, we process over 300 million claims annually, across probably all payers in the United States, all 50 states. We see over 25% of the US population. Because of that data, and because of our ability to leverage and understand that data, we're able to refine what we call our rules engine. The rules engine allows us to have specific criteria that basically allow us to see the data and identify gaps that will drive denials and claims earlier on in the cycle. One of the things that we're working on with our rules 2.0 engine is to be able to fire those rules in real time, which will allow us to be able to identify gaps in information, in the data that's submitted, such that we can improve the ability for that claim to get adjudicated, approved, and paid by the payers.

There's other things we're doing around automatic claim creation, which is going to allow us to reduce steps between when the clinician closes an encounter and the claim gets paid, where we want to drive about 80% automated claim creation. So, the physician closes that encounter, and it's all through the rules engine, and it all goes to the payer, and it comes back clean without any additional manual touch. The other thing we're doing is working with payers to improve ERA rates. And one of the key challenges is getting those EOB back and doing so in an efficient way. When they come back via paper, they come back via fax, that requires us to scan those, there's data entry requirements, errors can be made. We want to really drive that to be digital. One of the things that's so interesting in healthcare is we take perfectly good digital information in an electronic health record, and then we fax that to somebody. We turn it into paper information that then gets re-entered into perfectly good digital information. If we can stop that process of the fax—and there are literally like hundreds of millions of faxes—if we can get the fax out of the system and we can go digital data to digital data via APIs, via EDI engines, etc., that is going to really improve efficiency. It's going to take costs out of the system. It's going to allow the practices to get paid more rapidly and quickly and appropriately for the services they're providing. And it's going to reduce costs on the payer side. So huge opportunities for us. We're right in the middle of that, extending our services as well through what we call ERCM. We've launched a new medical coding service. We've launched a new prior authorization service. We also have what we call enhanced claim resolution, where we're taking more of the burden for denials management off of practices. So there's really a multifaceted approach to try to drive better rev cycle performance, reduce costs, and improve the economics of the practices that we're serving.

Brian: As we're talking now, I know the federal government is considering a cut to the Medicare reimbursement rate for ambulatory practices, which adjusted for inflation is already down almost 30 percent since 2001. What is your perspective on this federal government policy?

Bob: It's a complicated situation, and it was driven, I believe, by MACRA back in 2014, and the acute care setting reimbursement rates were indexed to inflation on the ambulatory care setting. They were not. The government, rightly, was trying to drive more and more procedures outside of fee-for-service, so pressure on fee-for-service reimbursement. But unfortunately, I think the policy and the way it was implemented is having the opposite effect of what was intended. It's really interesting that the 2.93% reduction that's been proposed on the physician fee schedule, when we looked at 100 small practice customers, and we just looked at their Medicare patients, and we looked at what this would mean to them, they stand to lose on average $65,000 annually, just on this cut alone. If you look over the last 10 years, since MACRA went into place, the reduction in reimbursements has been almost 30%, or just over 30%. So, when you think about that on an RVU basis, with rising costs of inflation, wage rate increases, but yet your reimbursement rate has been going down. That's part of what's causing this pressure, the pressure that these physician practices are seeing. That's why 40% of the physicians in our physician survey said they didn't know if their practice was going to be able to make it. We're supporting the American Medical Association to strengthen the reimbursement through HR 2474, which is currently pending in Congress. We call on Congress to take that bill up. We think it's critically important that we support these independent physicians that are providing the care, particularly in smaller communities and underserved communities where they’re such a critical part of the fabric. If we don't provide the financial incentive for these folks to be able to thrive and to be able to provide the care that's needed, I think the US healthcare system is going to be in a lot of trouble. So we're advocates for the independent physician group. We're taking a more active stance in terms of lobbying in Washington to ensure that their voices are being heard and that we're adjusting this, and ultimately, hopefully get the Physician P schedule indexed to inflation just like it is in the acute care side.

Brian: In terms of clinicians getting paid, the Change Healthcare cyberattack earlier this year was obviously a massive disruption to the system. Can you speak to what our teams have been working on in response to this incident, both to respond to it and to prepare for anything similar happening in the future?

Bob: The Change Healthcare situation was obviously quite impactful for the US healthcare ecosystem more broadly. I think I saw a stat that approximately 30% of all claims somehow were touched by Change Healthcare. Given athena's scale, we have had and continue to have a significant number of what you call direct connects, where we have relationships directly with payers, and we don't have to go through an exchange. But there are many payers that have required us to either use an exchange like Change Healthcare or Availity or Zelis or one of the other ones. So we did have a significant part of our volume still flowing through Change Healthcare.

One of the key things that our team did is, immediately upon seeing the issue with Change and communication with them, we were able to isolate our environment, such that we didn't have any infiltration into athenahealth proper. We immediately worked to try to route as many transactions as we could, ease us through our direct connections and establishing new direct connects to payers, as well as to switch that volume over to other exchanges, like an Availity, like a Zelis, like a Waystar where we could, to ensure that free flow of information.

I know that our Chief Operating Officer, Bret Connor, has communicated with many of the folks that are probably going to listen to this podcast in his weekly emails about what we've been doing with regard to Change. The good news is I think we're largely through at this point. There's still a lot of work that has to be done on ERAs that are coming in manually and the posting backlog that that's created, but we're getting through that and hopefully we'll be through it in the next 30 days or so.

The other thing I think is this is going to drive a little bit more resiliency and redundancy in the healthcare environment, because now we've established connections to additional clearinghouses, we've established additional direct connects, as well as the process that we have with Change. I think many folks have probably done the same. So, I think we're going to be in a better situation, that if one of the exchanges goes down, or there's another cyber issue, the US healthcare system will hopefully be a little bit more resilient moving forward.

It was an unfortunate situation. United and Change have been great partners for athenahealth, and we're continuing to work with them to try to fully remediate the situation and the unfortunate circumstances that occur.

Brian: We've touched on a lot here today, and I know you'll speak to a lot of these themes again in October at Thrive, our annual event that's coming back to Austin, Texas in late October, touching on themes from across the industry. What is your favorite part about coming to Thrive?

Bob: I love Thrive. Where else can you meet 1000-plus customers in one setting, give them a chance to engage with them, learn from them, understand their struggles, understand the things that we can do better to improve their performance and to drive higher levels of satisfaction? You know, sometimes and oftentimes, you hear about the good things we're doing, because it's also good to say, "Hey, that new software that you put in place, that new feature function, that new capability, it actually works. It's actually doing what we need it to do.” That positive reinforcement is really, really important for us. It allows us to engage with some really brilliant outside guest speakers. You always learn from that. And it also allows us to build relationships. I mean, there's something to be said for some face-to-face time, having a chance to eat lunch with somebody and just talk, and just to build that human connection that I think is so critical to relationships, so critical to communication and building trust. It's just an outstanding opportunity to spend time with our clients, to learn, mutual sharing, and really to get aligned on how we can better serve our customers going forward.

Brian: Bob, this has been great. Thank you for taking the time to join us. It's been great insight on a lot of different topics.

Bob: My pleasure, Brian. Glad to do it. Take care.