From WXXI news.

This is Connections.

I'm Evan Dawson.

Our connection this hour was made in Rochester, where a new health care model is attempting to take root.

Maybe not a new model per se, but new to this region and the kind of model that at least looks really good on paper.

Townsquare health is a Chicago based startup.

They've chosen Rochester for their first medical office.

The man leading it locally is a familiar face to many people.

Doctor Michael Mendoza, former public health director for Monroe County.

And while Doctor Mendoza is no longer in public health, he says he still brings that mindset to his work.

He wants to be involved in health care that makes medicine more accessible, makes people healthier.

As reported by my colleague Brian Sharp, the Town Square model will start small 500 patients in a primary care office.

The typical primary care has 2000 per doctor.

I'll read from Brian's reporting now, instead of billing for each medical test or each service and providing referrals to specialists, Townsquare Health will negotiate with insurers and receive a flat fee for Medicare and Medicare Advantage patients.

Then our job is to take care of all of that patient's expenses, Mendoza said.

And the idea is to help them to not need to go to the hospital, not need to have expensive medical procedures when possible so that we keep them healthy and then save the health system money.

The goal is to become a multi-specialty clinic, and patients would see specialists like a cardiologist or urologist in the same visit and at the same time that they see their primary care doctor, rather than getting referrals and having separate appointments.

End quote.

Mendoza says he's not having trouble recruiting doctors and nurses, even though those fields are suffering from shortages in general.

He told WXXI, quote, this is the kind of medicine I think a lot of my colleagues have wanted all along to be thinking about our work, not in terms of volume, but in terms of quality.

End quote.

So yeah, it sounds great in practice.

Will it work?

What are the downsides?

And if it does work, what will that mean for larger health systems?

What could the impact be?

Here to discuss it, doctor Michael Mendoza, senior medical director for Townsquare Health.

Welcome back to the program.

It's good to be back and alongside is Brian Sharp, investigations enterprise editor for WXXI news, who is a the man who brought this story to the public in the first place.

So nice to have you along here.

Thanks for having me.

And Daniel Marino is with us, a principal with EG management consultants on the line with us.

And I should make clear, Daniel is not working with Townsquare Health, but Daniel is joining us to talk about the use of technology, modern technology, AI, etc.

looking for ways to find efficiency and make health care essentially better.

Daniel, welcome.

Thanks for being with us.

Thanks, IRA, and happy to be here.

So just briefly, Daniel, tell everyone what you do with ACG in general.

Yeah.

So I've been in Visor services for about 25, 30 years.

And as you mentioned, we documentos and we've help organizations, physicians, hospitals, transition their strategy into really more of a value based care structure.

And really what that means is to evolve a lot of their operating model to really drive care to patients, based on the patient's needs, based on the community needs.

And then the current financial structures that really help support that high delivery of care.

So a lot of the work that we do is around strategy and strategic planning.

We support a lot of new reimbursement type structures between hospitals, between physicians, between the payers.

And then we put a lot of the operating models in place that really take advantage of or showcase best practice that occurs around the country.

So it's not necessarily a starting from scratch type of a model, but we really leverage that level of knowledge, that expertise that we see in other high performing organizations around the country.

We include that within a lot of our advisory services.

So we're going to talk more about how that works.

Let's get the local story here with Doctor Mendoza, who I mean, again, a lot of our our audience knows you, and they'll be interested to know why you decided that this was a job you wanted to take.

I know you have a relationship with one of the principals in Chicago, so tell us a little bit about the story about how this happened.

Well, the story really began 25 years ago, when I was writing my master's thesis, and it was entitled Medicine is from Mars, public health is from Venus, and I have always been intrigued.

It's a great title by.

Well, you know, but at the time it was very, you know, but I've always been intrigued by the intersection between health care delivery medicine, traditional medicine and public health because on the face of it, they they don't operate in the same systems.

But at the end of the day, what we're looking for is better health for the people in our community.

And as you know, my career has taken a number of turns.

But right now I feel like, you know, perhaps this is the last chapter in my professional career.

I'd like to find something that brings public health and medicine together, brings the concepts of education, health, education, health promotion, prevention alongside with the technical capacity that health care has to cure disease.

But we live in a system that costs $4.2 trillion in this country, and it's only increasing our economy, our businesses, our communities can't sustain that level of growth year over year.

And so something has to change.

And insofar as Townsquare Health can be a little champion in driving some of that change toward a better system, then I'm in.

The skeptics are going to say, all right, but I've seen Patch Adams.

You can't do that on a large scale.

You're talking about an office that will start with 500 patients.

And the typical primary care office per doctor you've said is 2000.

So you're a quarter of the size of just a typical primary office.

We're in a region that has a much bigger need to your initial 500 patients.

And I know you know that the skepticism says you might pull this off at the small level.

How in the world would anything like this scale?

Well, you know, everything scales by starting out from scratch at some level.

And if we can demonstrate this proof of concept here in this community, I know that there are so many strengths and so many partnerships and so many people working toward a common good in this community.

If if we can be the small tail that wags the larger dog in some fashion, then maybe we'll make an impact.

No on a patient.

For patient level 500 patients, it's going to take a lot of those to get to the population.

But if we can demonstrate to the public that we all deserve better care, we all deserve a system that doesn't cost as much as it does.

We all deserve a system that is more coordinated, that's more designed around the needs of patients and families.

I don't think that's a stretch.

I don't think that's something that we can't achieve.

And again, here to put a fine point on this, you're not having trouble filling the staff, is that right?

Correct.

How many doctors are you going to have.

Well, you know per 500 patients it'll be one doctor.

You know, the goal is to have thousands of patients within five years.

Okay?

You're the first doctor.

The first.

Doctor.

Okay?

Right.

But you have interest from your colleagues in the field, even though there are shortages in the field.

Yes.

Which means I'm going to read this quote again.

And I want you to explain a little bit more about this.

You said this is the kind of medicine I think a lot of my colleagues have wanted all along to be thinking about our work, not in terms of volume, but in terms of quality.

So before we get to what you're going to do now, tell me why this system ends up with so many health care professionals feeling like I work in terms of volume, but not quality?

Why does that happen?

Because the system is designed exactly to do that.

And a traditional medical model, which we call fee for service.

Our financials are driven by the number of patients that we see, the number of things that we order, and the number of, orders that we write that do stuff to patients.

It's based on volume and whether that volume generates improve quality.

You know, the hope is that it does.

But we know that it doesn't always.

And if the incentives are around, doing more procedures inherently prevention doesn't pay because prevention maybe will decrease the need for some of those margin earning procedures.

And a knee replacement is lucrative.

It is very lucrative.

But, you know, if what we want is people to be active and fit, maybe there are other ways to get there that don't require going to get a knee replacement.

You don't think you have colleagues who would say, look, that's too cynical.

There's there's plenty of preventive care in this system right now.

And, you know, we don't just incentivize the most expensive procedures.

I mean, you know, whenever you boil something down to a very simple argument, something for, of course, you know, sacrifice.

Yeah, there's going to be skeptics to that, you know, but it all depends on what perspective you're coming from.

And the perspective I happen to come from is let's have a healthier community, let's have a healthier society, and let's have a system that will take care of us when we're sick, when we can't avoid it.

You know, we don't have the dollars in the system to just keep buying more stuff.

Now I can see the future.

And so I'm going to head something off of the pass.

In the next ten minutes, I'm going to get a couple of emails from people who say, wait a second, doctor Mendoza is diagnosing the problem correctly, but the solution is simply a single payer system.

You don't have to reinvent small models and hope they'll scale.

Just go to single payer.

Take the incentive out for profit.

What do you say to that?

I would say that 22 years ago, I would completely have agreed with that.

And I've long been sort of hoping for some answer that would just fix all of this.

And in the 25 years that I've been practicing medicine, that answer in that sweeping of a way has not presented itself.

So, I think that incremental reform is probably the realistic way that I'm going to get there, you know, in the remaining whatever number of years of my career, absent some giant reform at a federal level, I also feel like, well, we got to do something here for Rochester because this is a community.

I care about this the community I've lived in for most of my life.

Let's do something that makes an impact here.

While other efforts at the federal level, take, take, take a big fight.

All right.

So let's talk about how this is going to happen here.

And then, and then we can bring Daniel back in here because, again, his work is, is advising and consulting and helping in this kind of work in places across the country.

And there are understandable skeptics who may not believe that this is going to work out.

What's what stood out to you, Brian, when you reported this story and you're hearing how this is going to be set up, what popped to you?

I think the the biggest thing.

Yeah.

And I was, count me among those skeptics.

Sure.

Like, well, this this sounds like you say great on paper.

And so I went through and I was talking to, another consultant, not Daniel, who was saying, you know, I was like, well, yeah, but so you so you go and you go aim for skimming the, you know, the, the healthiest patients.

He's like, no, because you're not going to see much of a change for if you get a marathon runner.

Part of the way that this has been incentivized is you get this flat fee for a patient, then you deliver the care, like if it's going to cost $1,000 to keep Brian Sharpe healthy for the year, and you're able to do it for 800, then the practice or the doc would split some of that savings with the government.

And so but then the other thing I was like, well but okay, so cardiologist he can say change your diet, get on an exercise routine or get this stent.

Mike, there's some patients who might be like, I don't want to do all that other work.

Give me the stent.

Give me this.

How do you get people to follow through?

And the more I looked into it, they said, you know, the other thing is carrying fewer, carrying fewer patients means that you can have more regular contact with that patient, follow up more regularly with that patient.

That's the other thing of bringing the cardiologist in and everything.

And that patients are more likely to follow through if they know, you know, just like think of all the times when we go to the dentist.

We brush and floss super good.

And that maybe a few days.

Before a patient all the way through.

But it's that I think it's sort of that kind of mentality.

If, you know you're going to see the doctor on a more regular, having more regular contact and follow up, you're more likely to do the thing that's going to keep you healthy.

Okay, Doctor Mendoza, what do you say to that?

I think that's great.

I think when you present a question to most patients, they just want to have the information that we can provide that they can get, you know, through other sources that helps them to make the best decision for them and their circumstances.

Some people will say, yes, give me the stent right now.

Some people will say, replace my knee right now, but not everybody will.

And I think if we can educate people on their options, frankly, a lot of people will say, I'd rather just, you know, learn how to be more healthy in terms of diet or exercise, because, newsflash, you're going to have to do all those things after your knee replacement anyway.

So when you present the options to patients, I think people will generally make the right choice for them.

And if we can help them to make that choice better for them and save the system money, I think then that's a good thing all around.

I do think Brian is me.

I think the dentist office is a really good comparison.

I mean, everybody can understand that.

So if you're at 500 patients per doctor and the average primary is 2000 patients per doctor, can this ever work on a broader scale?

Well, that begs the question of what does the workforce have to change in order to meet the demands of, in Monroe County, 7 or 40,000 people?

How do we are you talking about bringing down the number of patients per doctor or what are you talking about?

Well, I'll say this and this will be controversial, but not every 25 year old needs the same access to a primary care doctor that every 85 year old does.

So when I put my public health hat on and I say that that caring for a 25 year old is primarily about prevention, you don't necessarily need a family physician in the same ratio for that population as you would for an 85 year old population, but then how do we invite public health to the conversation so that we keep those folks healthy because there aren't enough doctors to go around.

So I think it would be more rational to have the doctors go where they're needed the most, where there are more chronic illnesses, where there are higher stakes outcomes that we want to prevent, like preventing a stroke or a heart attack.

Those things are much less likely in a 25 year old.

So deploying that same family medicine physician resource to a 25 year old is not going to get to that benefit, as it would deploying them to an 85 year old.

All right, one more question then we're going to turn it back to Daniel.

To Daniel on the line with us here.

So I was telling Doctor Mendoza before the program of the scenario that I'm dealing with right now.

And I want you to describe for me how in your office this might be different.

So I need a colonoscopy.

I'm over 45.

I should have had it by now.

I get it, okay?

No one needs to tell me.

I should have gotten it by now.

I need I'm getting myself set up to get it.

So I called my doctor's office a couple of weeks ago and they said, you haven't had contact with us for more than three years.

We've dropped you as a patient.

And I said, okay, what do I do?

And I said, well, you're going to have to like restart the process.

Your old doctor's full.

We can get you on with a different doctor in the office that you haven't met yet, but you got to come in first for basic, you know, routine visit.

And then we'll start the process of getting you down the line.

The referral.

So I'm doing that later this month.

It's like starting from square one.

So I had to go all the way in there, meet new people I don't know, give them all the new information, meet a new doctor.

Hopefully I get a referral.

Eventually I'll figure out when I get a colonoscopy, probably months from now.

And then it finally happens.

So what happens to you?

How do you what do you make of that?

And then how do you did your office?

So did they explain to you what was magical about three years?

No.

So three years is the point at which, if I see you in a traditional setting, I have to build you as a new patient again, or I can build you as a new patient again, because the insurance policy is after three years, you're no longer an established patient.

So the billing rules change.

The reimbursement changes a little bit.

But this all comes back to the reality that if you're a doctor in that kind of a setting, you have a panel size that if you go beyond that, you just make more work for yourself.

And so this is a way for primary care practices to keep things manageable.

You know, there's nothing magical about three years.

You know, that's just a billing circumstance.

But in our model, we want to take care of people as long as they want to be taken care of.

And we're not going to discharge people because it's been some artificial billing rule.

When they've been healthy, right?

When they've been incompetent.

We want to have them.

Absolutely.

Because in my in my understanding, you want your patients to be healthy.

You're in a preventive care mindset.

Why would you penalize them if they haven't seen you in three years?

Because it means they're doing what you wanted them to do.

Well, we.

Want we never want to get to the point where we don't see somebody for three years, because we believe that prevention is an act of skill, okay.

And so we we want to actively help to prevent things, which means doing a lot of surveillance, like making sure that your, you know, your balance and all of those things are where they should be.

Your cognition, your memory, your ability to manage your medications, all of these skills take work on the part of the patient, and we don't want to take that for granted.

So we want to bring people in as much as necessary to help them to do the things that we we know they will need to do to prevent those outcomes.

Okay.

And then the other side to that is this idea that people are often now going to their primary going through some kind of a meeting, check, etc., and then on a different date, getting assigned to a specialist for a different set of circumstances.

You're trying to get everything together.

How do you do that?

Well, we won't be able to get everything together, so we will never have a surgeon necessarily in the near future.

So what's.

Something?

What's one example of something you think you actually can sort of consolidate and have people come one time.

So you know, from a specialty standpoint.

Yeah.

So so take endocrinology.

Highly specialized field endocrinologists have a level of knowledge that is beyond my scope of practice.

I will need endocrinologists to help to take care of my patients.

Right now, we often need to tell our patients, go to the endocrinology office to see that specialist and get care what we want to be able to do is bring them into our office.

And, you know, in person is a lot to hope for.

So we want to use telemedicine.

We want to use technology because many times the endocrinologist doesn't necessarily have to see the patient, at least on the first time, you know, we can get a consultation, figure out what labs or studies need to be done, any kind of education that we need to provide to that patient.

And we can do that in a way that doesn't require the patient to have to get to a physical, a different physical space.

On a different day.

Right?

So if we can do that in the office, leveraging technology, get the expertise of that specialist, at least for the first however many visits.

And then if they have to see the specialist in person, that's fine.

But let's get that stuff out of the way, because not everybody will have to see that specialist the first time later.

And Brian story, you mentioned the use of artificial intelligence.

And can you explain a little bit there.

And we're going to talk to Daniel about that.

I think the way I understood it is it's essentially this is again looking to drive efficiency.

And as Doctor Mendoza said, you know, it's not that other physicians and everything aren't already using this, but I think the idea is to really deploy this in, a much more, don't know, a holistic type of way where it could, you know, digest the patient notes and, and make suggestions on things.

I think, you know, Doctor Mendoza said, I'm not not an expert on everything and reading the latest on everything, but I can and raise these things about, well, what about this?

What about that?

It can also, if the patient elects help, inform them so they ask better questions.

It can tell the doctor, hey, this person is about to turn 45.

You should bring this up and do that.

And then, I mean, it still comes down to the doctor, you know, taking the advice or the information or the prompts or whatnot, and the patient, doing that.

But it handles I think it sort of is a, you know, another tool to help with, streamlining some of those efforts and making it so the doctor isn't, you know, spending all the time doing the notes and, and such.

Doctor Mendoza fair.

I think that's fair.

I think I think, first of all, our patients are coming to the table with a lot more information.

You know, we were all around when Google started and the fear was, well, will patients come in and, sort of have the answer in mind, before they come and see us.

And the answer is sometimes, yes.

And that's generally a good thing.

I would rather a patient come in with a, with a question than a blank slate.

Okay.

And so, you know, as I get older in my career, you know, at the beginning, I was mostly worried about what I knew.

And now I'm worried about what I don't know.

And I think AI is is good at helping me to identify those areas that I don't know, so that I can make sure that I'm taking comprehensive care for that patient.

And and that's where society is going, you know, to say that we're going to push back on AI.

And, you know, I understand all the controversies around, but it's here to stay.

And let's leverage that technologies to do a better job.

I will argue with you on a different day, good, about how possible I should be on a societal level.

But where I am the most optimistic is medicine.

And I want to ask Daniel Marino how you see it.

He's a principal DCG management consultant.

So let's start with AI and then we'll talk more broadly about the work and maybe some of your reactions to the model that Doctor Mendoza has been talking about.

How do you see the use of AI in medicine?

Daniel, I think it's really exciting as to what AI is bringing to the healthcare industry, the healthcare community, and particularly for our physicians.

You know, Doctor Mendoza said the historical model of healthcare is really episode based episode, you know, based driven care, if you will.

And it's very reactionary.

So a lot of times physicians will know they'll do their evaluation of the patient.

They may look at the labs, that had occurred, you know, maybe a couple days ago or a month ago and, and try to draw some conclusions going forward.

Well, with AI, we have an opportunity to change the care paradigm.

We're able to incorporate a lot more information, information about that patient, information about similar patients with those types of of, diagnoses, if you will, and information about their social conditions, the social determinants of care, and taking all that information and being able to pull it together to tell a different type of story, a different type of narrative, and really shift the care model from being episode based, driven and reactionary, to more integrative and more proactive.

And as we all know, with AI, you know, it's able to it's much more robust.

It's much more it's there's a greater opportunity for us to understand, some conclusions coming out of that level of information.

If it's done right and, you know, it's validated and everything else but the power of that to be used as a tool to change the clinical paradigm and the care model, I think is really what's exciting.

And and I would assume Doctor Mendoza, that's a lot of what you're incorporating into your care model as you start to advance a lot of the work with your patients.

Mike, you want to add to that?

I mean, physicians are using AI now, you know, many of us are familiar with open evidence, which is an AI model that's available to people who have a medical license.

And it allows us to leverage, artificial intelligence to change or impact our decision making.

I would never ask it for the answer.

I would ask it a question that will help me to get at the answer.

But this is happening right now.

And I think if if to to Daniel's point about integrating the social, you know, impacts, I mean, this is this is my public health, you know, dream where we can understand the patient not just from their personal circumstances, but from the circumstances of the community that they come from, or the family that they come from.

You know, what can we learn about the patient and their circumstances that we wouldn't necessarily know in a traditional, you know, medical model?

Okay.

Daniel, any privacy concerns with all of this?

Well, of course, you know, I think we have to be careful as to how we use it, the level of information that is incorporated into it and a lot of times what we're looking for is the insights coming out of this information that we can apply to specific patients to really help support the patient and their needs.

So if we're looking at sort of the learnings coming out of what I can generate and use that to provide more proactive, more prospective care, that's where it becomes really powerful.

We don't want to get to the point, doctor Mendoza is absolutely right.

We're not going to be basing AI on clinical decisions, right?

The physician, the health care provider still still has to be the end all, be all that is going to make that clinical decision.

However, if I can be used as a supporting tool to help inform, to help provide a greater context, to help deliver more patient driven, patient needed care, then the opportunities to really evolve that care model are are incredible.

And that's, I think, how you want to begin to look at it, how you want to begin to use it.

And so, Daniel, before we let you go and I know your time is limited and we appreciate you joining our program today.

Can you describe some of the maybe the the broader view of how you see the model that Doctor Mendoza is describing, what they're going to attempt to do here?

And in general, if you think in your experience, this kind of model can be sustainable at at least at the smaller scale, and whether it even is scalable, larger.

Yeah, and that's a good question.

I commend Doctor Mendoza and what he's doing because he's really forcing the paradigm shift of care as well as then reimbursement, in the care delivery model, really moving from episode based care to more integrated, integrated, care model, if you will.

But there's a couple of important points, and I know Doctor Mendoza is working through this.

It's not going to be enough just to establish a level of reimbursement on a per patient or what we would call a per diem basis.

There has to be some level tied to clinical outcomes into clinical performance.

If Doctor Mendoza can show that he's able to drive down what the cost of care would be for similar patients, his model has a less cost structure than what the typical cost structure is.

Doctor Mendoza and the Surance plans are going to share in that.

Right, because he's doing, you know, so he's changing the paradigm of reimbursement that's going to create a lot of reimburse, a lot of opportunities, to lower the cost of care.

The other piece that's going to be important, and I love the way Doctor Mendoza, positioned this, we have to focus on quality, quality and focusing on the outcomes related to the care that's being delivered has to be part of the equation.

You know, if if anybody remembers the 1990s when HMOs were here, we had these full risk, these capitation based models that physicians were just paid a pmpm.

And there was incentives for the physicians not to see the patients because they were getting paid anyways.

And if they didn't see.

Oh, boy, we lost.

More money into their own.

Pockets.

We lost you for a. Yeah.

Go ahead.

I'm sorry.

Go ahead.

Sir.

That's okay.

So what it did was it created a lot of dissatisfaction by patients because when they couldn't get in to see their, their physicians.

But second, they just didn't feel like they were being heard or their care was really being addressed.

So in order for them, for us not to not fall into the to the same mistake that that we did in the 90s, we have to have quality as part of this.

We have to be able to show that the clinical and performance outcomes of patients and the care that we're delivering is at the highest level, and that reimbursement has to be tied to that at a certain level.

And we have to show that the care that we're providing is driving more efficiencies than the alternative historical model.

I think if Doctor Mendoza can show that he's got a real opportunity to be able to grow it, I think if if the outcomes become a little challenging and the payers come back and say, we don't see that you've been able to reduce the cost of care, I think it will be a bit of a challenge for him.

I don't know if you have comments to that respect, Doctor Mendoza, I'd love to.

That's what we often see around the comment around the country.

Okay, Doctor Mendoza, it's.

True, it's true.

And, part of the reason why we're focusing on the Medicare, age group is that that's where a lot of the expenses occur.

A lot of procedures, chronic illnesses, things of that sort happen in our sort of later years.

It's also there's a lot of opportunity to show improvement, you know, to show improvement for a 30 year old, it's going to take many, many years just because of the risk of a 30 year old's a lot lower than the risk of a 60 year old.

But if we can demonstrate better outcomes, we can show that we have a decrease in the incidence of X or a decrease in the prevalence of Y, or a decrease in the number of procedures that don't necessarily improve their quality of life, then we not only demonstrate an improvement in quality, but we can also also demonstrate to the payers and the community that we can lower the cost of care.

We can take care of somebody at least as well, if not better, for less money.

And I think that's a proposition that everybody can get behind.

Well, I appreciate the time from Daniel Marino who's principal, DCG Management Consultants.

Thank you for making the time, Daniel.

And I know we will have plenty more to talk about in this field going forward here.

We will look forward to welcome you again.

Thanks for your time.

Appreciate you having me.

On.

Daniel Marino EAG Management Consultants.

And again, they're not working directly with Doctor Mendoza's group.

But you can hear the experience they've had around the country looking at attempts to do exactly the kind of thing that Townsquare Health is doing.

If you're just joining us, Doctor Michael Mendoza is a familiar name and face to many of you, former public health director from another county, his new role as senior medical director for Townsquare Health and the Rochester office.

Brian Sharp, investigations and enterprise editor for Sexy News, brought the story of this different kind of a model to what Townsquare Health is trying to do.

Ingrid in Penfield will take your call on the other side of this.

I've got several emails to share, questions for Doctor Mendoza and just in general, thoughts about trying to do health care differently.

Listeners, if you want to weigh in on that in our remaining time, you can do that by calling toll free.

844295 talk.

It's toll free (844) 295-8255.

Or you can email the program.

As always, connections at Borg.

If you're watching on the WXXI news YouTube channel, you can join us there and join the chat right there.

We'll come right back.

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This is connections.

I'm Evan Dawson, Ingrid and Penfield.

First high.

Ingrid.

Go ahead.

Hey, thanks for this program.

This question may not be quite appropriate.

And then I hope you know I won't lead you too far astray.

So I'm in that the age group that Doctor Mendoza is trying to help, and I appreciate that.

It's been a little bit frustrating.

I didn't need a doctor for a long time.

I waited a year and a half to get in with a PCP.

Then I actually got her nurse practitioner, and I'm not really with the PCP.

I don't know why.

When I did get in, I've, you know, long story short, I have two knees, bone on bone.

One doesn't hurt at all.

The other one has a hormone is good meniscus.

It hurts.

I advocated hard for myself to get in with the person I thought was a renowned surgeon.

Knee surgeon in town.

And at the end of that appointment, he was wonderful.

At the end of that appointment, it turns out he doesn't do what's called the clean out surgery.

The only thing he does is a total knee replacement.

And I am seeing I don't know if it's I, I don't know if it's trustworthy.

Some of them are coming out of Stanford, some out of Yale.

It looks good that within two years we'll probably have a shot which will allow me to grow more collagen in his home.

So I wrote all these questions to my PCP on my chart, and she wrote back and said, I don't know about this stuff.

You should ask the knee surgeon.

I have a feeling that since he doesn't do the clean out surgery and just full replacement, this is this isn't his purview either.

His home.

Should this kind of question be addressed?

Is there anyone.

Thanks.

Yeah.

Thank you.

Ingrid.

Doctor Mendoza.

Well, those are complicated questions, and I would want to know more about all of the things that you're trying to accomplish in in your day to day life and what what solution makes the best sense for you?

You know, I'm not the one to be able to weigh in on whether the injection versus the knee replacement versus the clean out surgery is the right thing with that, more information that's at specialty level, consideration.

So yes, to some degree, this is a question for a specialist.

But as a primary care doctor, I would want to at least understand your values, your preferences, the things you're trying to accomplish, and then help to steer you toward what is the best outcome for you.

You know, at the end of the day, if your goal is to be more active and more fit and to be able to do the things that you want to do, we're on the same page.

So the question is, how do we get there?

How do we get there in a way that makes sense for you?

How do we get there in a way that that overall across the population decreases the cost for the whole system?

Because if you have a complication from a fall resulting from your knee pain, well, that's not a that's not an expense.

And everybody wants.

So, you know what is you know, the end goal here.

And I think everybody's end goal is a little bit different.

But you know in our model we would want to take care of you.

We would want to understand those preferences and, and then steer you in the right direction and hopefully get you the right answer.

Who should you be talking to next?

I mean, I'm going to assume that you have a strong primary care provider, a primary care physician who can help guide you to the right places.

If you definitely want treatment a and that's not available in this community, then the question is, how do we get you to the community that can provide that that level of care?

I think that would be the next step.

All right.

I see the phone's ringing.

Ingrid.

Thank you.

We're going to move right along.

And I've got Steve in Rochester next.

Hey, Steve.

Go ahead.

Good afternoon, everyone, and hello, Doctor Mendoza.

In listening to this, this is a great discussion.

And I'm just thinking about really what is what is now or what had been old is now once again new.

And I must say, as a physician myself, who's now retired, I participated in primary care capitation models in the early 90s in our community.

And I'm just trying to understand why this is different.

And I'm also concerned that there's even greater challenges today.

Challenges.

And I think it's has been raised the number of primary care physicians.

And I think we're in a situation not only from primary care as well as the, there's practitioners and Pas that might be in their offices.

The greatest shortage, I think we have seen, at least in my, experience.

And then also, given the fact that almost all the primary care physicians and most of the specialists are employed by one of our two health systems, you know, how are you?

What are your ideas about trying to meet?

And are we going to be successful in meeting, John Berwick's old triple and now the quadruple aim with patient satisfaction, total cost of care, quality of care in the population survey and provider experience.

What are your thoughts about how is this going to be different compared to what we have been doing over the last essentially 35, or 40 years?

Thank you.

Steve, thank you.

Go ahead, Doctor Mendoza, first.

First of all, Steve, it's good to hear from you.

I think I know what Steve, this is.

So you raised some of the most, you know, pressing questions that healthcare has been trying to address for many, many years.

Let me start with a the last point that you made, which is the quadruple aim, the the experience, you know, getting back to the the notion that that my colleagues, I think, want to provide good quality.

I think let's start there.

If we have a system that aligns the incentives around providing quality, not just providing volume, I think that will that will improve the experience that physicians have.

I think when you do the math, I think we can all agree that the way to solve a physician workforce shortage is for every physician to have more patients, which is counter to what I've been talking about for the last 44 minutes.

So the question really is, how do we deploy that physician workforce to where the need is the greatest?

Because that's where the greatest improvement in cost of care will result, and potentially where the greatest improvement in quality can be found.

So we need a fundamental realignment of where the the physician and the provider workforce go.

And we need a fundamental realignment in how the incentives pay for all of that.

Judy in Pittsford, hang there for a second before we take this next call.

My follow up to what Steve's talking about, what I think you're talking about.

I go back to a question that Brian had raised.

Brian, tell me if my mind is going in the same place yours did.

So when you hear Doctor Mendoza describe why the system hasn't been as effective as he and his colleagues have wanted for decades.

He's not saying, well, because everyone knows it's profit based, and so everyone wants you to have a knee replacement.

You don't need it or have the most expensive treatment when you don't need it.

What he's saying is the reality is when those options are on the table and there is money in the system like that, you know, it's not malicious.

It ends up, you know, going that way.

It tilts in a direction that's not meant to be bad for patients, but sometimes it gets away from preventive and it gets toward the more expensive options.

And what I'm hearing about the new model that you're attempting is to say it's kind of the opposite, that, okay, we're going to take a patient and we're going to try our best to make this an efficient way to treat and to prevent.

And if that patient does need a knee replacement or another procedure, okay, now we're in charge of the cost of that.

So you're actually going to try to avoid those things.

And when Brian was asking what does that mean.

You're going to cherry pick healthier patients who won't need those things.

Is that where your mind was to to say, okay, now, now the systems reverse.

Will they cherry.

Yeah, I'm sort of the you know, I come from the print side.

So I'm a numbers geek on a lot of different things.

And I was trying to figure out how this works.

And it works as I understand it.

And Doctor Mendoza can correct me, but in two ways.

One, it incentivizes the the fact that you're for the physician.

You're not going to get, you know, 10,000 for this.

You're going to get 2000 for the way you treat this patient by incentivizing it by then some of that savings coming back.

But then it also incentivizes not avoiding the expensive thing because, you know, to the earlier caller, if if we don't do the knee replacement and then you fall, you know, you ultimately want to be reducing the expenses.

So you don't want that patient to wind up in the hospital.

So you are doing the things that need to be done.

You're just trying to, you know, do more prevention and also avoid the most expensive thing.

So you're not going to, put off care just to drive down the cost.

Okay.

How do you see that?

It's true.

And and when we look at, decreasing costs, we're not looking at decreasing costs just for one person.

We want to look at a panel of patients.

So the 500 that I start out with, you know, there's going to be somebody there who might need a kidney transplant.

Well, that's a really expensive procedure.

And if they need a kidney transplant, we will do everything we can to get them that kidney transplant.

But, you know, that's why we can't do this on 1 or 2 patients when we need a panel of patients to have a contract around, that's when you start to balance out like insurance.

You have a shared pool of people.

The pool.

Yeah.

So that's where we're going with with all this.

But if we can deploy tools that will steer everything toward more efficiency, toward more patient centered decision making, toward more access, then I think those principles will ultimately improve quality on that whole pool.

Bottom line, you don't foresee being in a spot where, just based on the reality of the numbers, you are avoiding bringing on patients who have the highest need.

Well, I think if you if you really want to dig into how insurance companies get paid.

Yeah, taking care of a healthy person gets them less reimbursement than taking care of a sicker person.

So from our standpoint, we're going to have contracts that are sort of agnostic of that.

But my goal is to help to improve quality and to decrease unnecessary outcomes.

It's easier to do that from my perspective, on somebody who's got a lot of risk factors to begin with.

So in some ways, I to want to cherry pick people who have more complications because I can I can show an improvement much more effectively for somebody who's got issues compared to somebody who didn't have issues in the first place.

And I was just going to this other consultant that I had spoken to in preparation for doing the story, had said that they they work.

They're just sort of the tech folks, and they work with 3000 physician offices across the country.

They're most profitable, are in the Mississippi Delta region because of the lack of health care that's existed, the number of folks who who don't just health care in general, there is and the co-morbidities that exist, the lack of access to care, the number of folks who maybe haven't been routinely seeing a doctor and such.

The highest profit opportunity for also for improvement.

Right.

So that's why I'm so yeah, that's why they're most successful.

Okay.

Judy and Pittsford been waiting.

Hey, Judy.

Go ahead.

Hi.

Yes.

So I'm not sure I'm asking the right question, and I. I got in a little late on this discussion, so just let me know.

My husband was by, the guy who did his implants.

The surgeon told him he had a collapsed sinus because he couldn't breathe, so he was referred.

He had to go to the doctor.

The doctor said, you need to go to an EMT person.

And this has been going on since last November.

He has never seen a doctor.

And I'm wondering how anything you've said would change.

And if maybe you can explain why people don't get in to see doctors.

He's only seeing PA, he's not seeing a doctor.

He never, never.

And he has.

And even that appointment, he had to wait the first one three months to get into a Q and then they put him on steroids.

And basically it's been unresolved.

And so you have and we're both on Medicare.

I'm wondering if because we're on Medicare, is that a reason we're not getting to see a doctor or what is the reason we're just not seeing a doctor.

I think it's time for him to.

But, it's not happening with the caveat.

Let me just jump in and I'll let Doctor Mendoza try to weigh in.

So hang there for a second with the caveat that it's difficult for Doctor Mendoza to describe exact needs of care for patients he hasn't met personally.

But go.

Ahead.

Well, and and I'll say it's also hard for me to comment on the particulars of how the practice that you are seeing currently runs.

And there are very there are a lot of excellent PRS in this community that provide excellent care, and I don't want to start to just assume that there are if there are Pas, they're not as good as a doctor or whatnot.

That being said, if your desire is to see a physician, you know, make your needs known and more importantly, make your needs known as to what you're expecting from your care.

And if that's not being met, whether it's by a physician and peer a Pas, that's important to know no matter what.

Will our model of care change that necessarily?

No, not right now, because we're not employing specialists.

We're going to rely on the very same specialists that you're seeing to provide high quality care for our patients.

What I will say, though, is that when we have nurse practitioners, NPS in our practice, they will have a panel of patients and we will take care of you as a team.

So if there's a physician perspective that's important, then I'll weigh in.

If there's an NP perspective that's important, then that person will weigh in.

But to say that NPS and we're all different, we have different perspectives.

But in Townsquare Health, our goal is to improve quality any way we can.

If you had a patient in your system who said, look, this has been going on for a long time and we don't feel like we're getting the right answers, or we don't feel like we're even getting direct access to medical, the medical professionals that we want.

That's a problem, right?

Problem.

And we'll want to advocate for that patient, you know, within our office.

Absolutely.

But then outside the office, if we have to, that's that's important too.

So number one, I suspect you would say they've done this, but be direct with who you want to see and when and push for that.

Right.

And and try to understand what the circumstances are at play.

I have no idea the details in this practice, but, you know, absolutely if you've got if you've got concerns, you know, raise them, voice them, you know, we can't deal with whatever we don't know.

Judy, good luck to you guys.

I'm sorry you're going through that.

Sy writes to say simply being able to see all the specialists I might be referred to from primary care in a single location or in a single visit, sounds like an absolute dream for someone like me with multiple disabilities and conditions, with transportation issues, and who struggles with making and keeping appointments on time instead of planning multiple days around getting to a single appointment, people can plan a single day around all of their appointments.

Being able to have one doctor speak directly, face to face to the person you just saw would also be a benefit.

But he's saying this sounds really good.

And it the potential is immense and we will have to try to change the way things are enough to make it possible, because the notion of having a cardiologist in the room virtually with me in the room at the same time with the patient, will take some coordination.

And that's something that's new to most people.

But I think it's worth trying for for all the reasons that the caller just mentioned.

So I'm going to ask one more question.

Then we'll see.

What doctor does that sound.

We'll ask Brian if he's got other outstanding questions here.

But for me, we're going to see how soon.

Well, I mean, this is a two parter.

How soon will you know if this model really is working the way you want?

I think growth is the most important, measure of our success in terms of our ability to attract new patients and, and then be able to show that we can help to, to improve their quality of care.

You know, there isn't a number per se, but if we have continued growth and if we can keep up with that patient growth, if we can continue to demonstrate improvements in quality, then we will be able to transition from where we will start, which is traditional fee for service, to move toward a value based contract with one of our payers.

And I think that's the first sort of gate.

If we can demonstrate that quality beyond, you know, a handful of patients, when you have, you know, 500 patients, a thousand patients, then then I think that's the first measure of our.

Success will, you know, in a year, three years.

Maybe.

I hope so, definitely.

I think in a year, I think within a year, you know, if we can grow, at the rate that we anticipate, I think within a year, 18 months, we should know.

Okay.

Are you full at 500 now?

Not right, not right now.

We haven't started seeing a single patient.

September 1st.

We start seeing patients.

But how many patients?

I mean, how many people someone's gonna email me like.

So they're openings.

What do they.

Yeah.

We are.

We are accepting appointments for for new patients.

Absolutely.

New patients.

Okay.

How do people find you?

You go to TownsquareHealth.com.

And, at the top of the website is a phone number.

There's a link we can reach out to you.

If you leave your name, number and email address, we'll we'll find a way to to reach out to you.

Okay.

What stands out to you, Brian?

What's unanswered here?

I don't know about unanswered, but I think, you know, Doctor Mendoza's point is just how this goes once it starts.

This is, we have a very.

You have.

Unique.

Community in terms of health care, given that it's dominated by two health systems, there are few, if any, independent primary care offices.

One of the reasons that, as I understood, Drew Town Square to here was we also have a very limited number of insurance providers that allows them to negotiate with fewer people.

They don't have to go out and talk to 17 different, different folks.

But, I think that's my question as to his point of growth and, and sort of breaking through in that environment.

Okay.

But last 45 seconds thoughts.

On I mean, that is the that is the the main question is, is to what extent can we demonstrate the improvements in quality that we believe are possible, that we know are possible given the outcomes that we see today, given the status quo of access that we have today?

I think we but it's on us to figure out how to improve access, to improve quality.

And so to the payers and to the community that we can do this in a way that lowers costs and therefore makes it sustainable for all of us in Rochester.

Do you have like this really ambitious dream that sometime in the future are two major dominant health systems are going to be like, we're going to have to do what they're doing.

You know, I'll leave it up to them to decide what is the best path forward.

But I do think the primary care, regardless of what side of the fence you are, is under, under reimbursed, undervalued, we don't get to show how much in primary care we do improve quality and decrease costs.

I think of the systems and and the payers can see that.

Then I think we will have a brighter health future in this community.

David, writing from Vancouver, Canada, formerly of the Finger Lakes region, says, I agree with your guest.

Sadly, that incremental reform like this is currently the best that can be done in America.

I will note, though, that a friend of mine in Ontario is working under a similar flat rate patient centered model.

It's more efficient, even under single payer, and saves him from doing the visit per billing.

That is common there.

But he wishes you well.

I want to thank you for coming in, and I'm sure you'll be talking to reporters like Brian.

You're welcome any time to tell us how things are going.

You see, the phones ring and people want to know some things.

So come back sometime.

We'll do.

Doctor Michael Mendoza is now the senior medical director for Townsquare Health.

They're accepting new patients in Rochester.

Brian Sharp Investigations Enterprise Editor great job.

Thanks as always.

Thank you.

Thanks for popping in here.

More connections coming up.

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