Meet the Board: Doug Chaet of Value Evolutions Talks Growth in Managed Care, Value-based Care, and ACOs

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Below is a brief Q&A of the interview with Chaet that has been edited for length and clarity.

Q: How have you seen MHE grow as a long-time board member and how managed care itself has evolved over the years?

Doug Chaet

A: Well, it's interesting, my first exposure to manage car started actually back in the 1980s. And it came about because I accepted a position with Blue Cross Blue Shield of Florida. I had the dubious task of being on this team, who would knock on the doors of hospital administrators, and introduce the notion of actually paying the hospital's less than what they charged, which was very unfamiliar concept, because up until then, they basically got paid whatever they would and that was the way it worked.

I had a number of doors slammed in my face. For a long time, it was about rates, it was about discounts, it was about price. And then it became really more about care management. How do we do that effectively? Do we micromanage? Do we use things that we know today think of as care management or disease management? Or do we push risk on to providers? So I actually started my career, and actually spent a large portion of the first half of my career in what we refer to today as rescue agreements.

One of my early jobs when I left Blue Cross was to work for a large health plan that was actually owned by three multi-specialty physician groups. And the way they apportion the risk, because they also own the health plan, was to basically capitate these three medical groups based on their attributed patient populations. Look, you know, 30 years ahead, we're doing the same thing, CMS is doing the same thing. In some respects, I think, as an industry, we've evolved.

There has been sort of a lack of engagement, which, hopefully, you know, with initiatives like direct contracting, now we'll see more of a push in that direction. But I think MHE, in particular, has done an amazing job keeping up with things because, you know, as topics have changed, and as emphasis has changed, you know, so has the publication. I was around when every story was about companies like Fire Core or Med Partners and now you talk about specialty pharmacy, which wasn't even a thing 10 years ago, 15 years ago.

Q: You mentioned dabbling. Are you frustrated that we are, in some sense, still dabbling in managing care?

A: Definitely. Because I think in some ways, we've actually gone backwards. You know, early on, there was a lot of focus on HMOs. As most people know, primary care gatekeeping was was a central function to that. I think that was was actually a good thing, because you took somebody who was a generalist, who knew a little bit about a lot of things, who you would think would not be. And you said, Look, we want you to be the quarterback, we want you to try to insist on a degree of accountability here, and we want to pay you a little bit more, so that you will be the principal manager for this patient. And, and that was a concept that I think, was a good one. But, you know, the pushback that you got, at that time was that people didn't want to be managed. And, and that's just human nature.

You know, I remember just even as patients saying, "I don't want to have to get a referral from my doctor, just to go get my mole checked at a dermatologist. I don't want to get a referral if I think I need something else done. I'm a smart person, I'm not going to go use these services so they don't have to." The patients would get their pushback and then unions got involved and they pushed back and next thing you know, most markets went from being HMO centric to PPO centric. When that happened, it really struck a blow to risk type arrangements, because now you couldn't easily determine which patients were attached to which primary care physicians because they didn't have to choose a primary care physician.

I think as a result you end up with a lot of side liners, health systems and physician groups who have decided, essentially to dabble in these things, just to make sure that if somebody ever turned the switch on, and you had to be really good at this tomorrow, that you wouldn't be starting from scratch.