Lessons from Vivek Garg, Chief Medical Officer of Humana, on the future of primary care and selling to Medicare plans

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Welcome back to the Pear Healthcare Playbook! Every week, we’ll be getting to know trailblazing healthcare leaders and dive into building a digital health business from 0 to 1.

Today, we’re excited to get to know Vivek Garg, CMO and SVP of Primary Care for Humana. Vivek currently leads national clinical strategy and excellence, care model development and innovation, and the clinical teams for Humana’s Primary Care Organization (CenterWell Senior Primary Care and Conviva Care Center) as Chief Medical Officer (CMO), serving over 240,000 seniors across the country.

Vivek is a physician and executive dedicated to building the models and cultures of care we need for our loved ones and healthcare professionals to thrive. Previously, Vivek served as CMO and Chief Product Officer at CareMore. At Caremore, Vivek led their expansion into Medicaid and home-based complex care. Prior to CareMore, Vivek joined Oscar Health during its first year of operations as Medical Director and worked as national Medical Director at One Medical Group. Vivek graduated from Yale University with a BS in Biology, and earned his MD from Harvard Medical School and MBA from Harvard Business School.

Founded in 1961, Humana is one of the nation’s leading managed care insurers with over 95,000 employees and 8.7 million Medicare members.

In this episode, Vivek shares his incredible journey from joining as the first medical director of One Medical and Oscar Health to serving as the CMO and CPO of Caremore to leading Humana’s Primary Care group, technology’s role in combating burnout, and tactical advice on working with larger health plans like Humana and tips on how to sell your first pilot (hint: it is not to sell your product at freemium).

If you prefer listening, here’s the link to the podcast!

‎Pear Healthcare Playbook: Lessons from Vivek Garg, Humana, on the future of primary care and…

Vivek’s serendipitous career from residency to joining the early team at One Medical

• Vivek was coming out of internal medicine training at Brigham and Women’s Hospital and planning to move to New York where his wife was. He was introduced to Tom Lee, CEO and founder of One Medical, and had a panel interview with some of the PCPs there.

“A lot of my interest in healthcare and in medicine has been about the question of: Why don’t people get what they deserve in healthcare? Why don’t we get it as clinicians? When I thought about that question, it led me to leap to something that felt different, which was One Medical and then subsequently Oscar and now on to other organizations.”

• Vivek shares that he believes one of the most transformative aspects of new models of care is the activation of great clinician talent. In the last 10 years, many clinicians and other talented people with specialized expertise have been brought into the mix.

Vivek went from One Medical to being Oscar Health’s medical director in their first year of operation. Afterwards, he transitioned into the Chief Medical Officer and Chief Product Officer role at CareMore:

• Vivek shares that while he was attracted to working on different types of care models, as a physician, he wanted to focus on patients with more needs. He joined CareMore, one of the original payer providers in Medicare Advantage, and recognized that the organization was able to use the levers of being the payer and the clinical organization to change patient outcomes at scale.
• Vivek shares that the Chief Product Officer job wasn’t focused on technology. Their product was the people they put in front of their patients, and the clinical model was built and defined around that. The role crossed business development, product development/design, launch and implementation, and new market ownership. Vivek shares that it was an amazing experience to see the full cycle of building product lines that were care models and scale.

His career insights from working with companies from seed to growth / mature stages:

• Find a way to do the granular, but important work. He joined Oscar Health when they were around 50 employees and tens of new employees were starting every week — ”an amazing time of creativity”. During that time, Vivek got his hands dirty, learned SQL (structured query language), and built dashboards for real-time data points that some of Oscar’s care management programming was based on. Vivek shares that in Humana’s primary care group now, that real-time intelligence is very important to being a comprehensive home of care.
• Always keep the patient and member front and center. There are a lot of new joiners in the space, some folks who are not experienced in healthcare clashing with folks who have a career in healthcare. Vivek refers to the new healthcare landscape as “a really fertile and in some ways, volatile environment”, which happens in any organization going through a lot of change. If the member is front and center, a lot of the friction can die down.
• For any care model, you must design it to be cross-functional, highly specific, and highly adaptable. Vivek believes that any care delivery model must operate like this so that it can evolve as you learn what patients really need, how they really engage, and what outcomes you shift or don’t shift. Humana currently has more than 220 clinics serving more than 240,000 seniors in 11 states — they’re continuing refining, identifying, and adding to their care model to continue being the most effective and comprehensive care home for seniors.

What does a Chief Medical Officer do?

Vivek has worked as CMO across startups to larger payer provider organizations and now Humana, one of the largest organizations in the space. He recognizes a lot of variation in the role, but a few key responsibilities:

1. Be one of the stewards of patient care excellence. Vivek shares that while this is a shared responsibility of everyone in a patient care organization, the CMO has a unique platform to lead and inform non-clinical decisions with a clinical perspective.
2. Be the steward of the clinical team. Vivek is focused on finding the best talent for patients and supporting these practicing clinicians against burnout and fatigue. The goal is to make clinicians’ work sustainable so they can deliver the best care.

Humana’s Primary Care organization is made up of CenterWell Senior Primary Care and Conviva Care Center, serving more than 240,000 seniors as their community-based primary care home with a team of physicians, advanced practice clinicians, social workers, pharmacists and therapists.

• Humana has been a long-term enabler and category creator of senior-focused care within particular primary care. They’ve been long standing early partners with many existing medical groups and health systems around value-based care payment, data sharing, and care enablement. Vivek was drawn to Humana as a large organization with a big commitment to seniors focusing on clinical care and providers.
• Conviva came out of a set of practice acquisitions and integrations in Florida and South Texas and CenterWell sprung from a new clinic launch focus, but both were focused on a common goal. Two years ago, Humana joined the groups to form a common EMR, data warehouse, and leadership team. Vivek came on a year and a half ago as the first CMO for the national group.
• Humana’s primary care division is payer-agnostic. They work with multiple national and regional Medicare Advantage plans and traditional Medicare beneficiaries as patients. Vivek shares that the intention is to make the right decision for communities, the organization, and clinical structure, and that opening it up to all health plans serves patients best. Many care delivery organizations that are owned by payers are actually payer agnostic.

Vivek’s vision for Humana’s trajectory:

• As a primary care physician, Vivek has always believed that primary care is the single most impactful lever to improve population health, and at this point, it’s still massively underutilized and underinvested in.
• Humana Primary Care Org is growing rapidly, launching 30 to 50 new clinics a year across existing and new markets. They are payer agnostic as a primary care group, working with provider partners like Oak Street Health, Iora Health, ChenMed, and more. Humana Primary Care Org’s goal isn’t to solve the population health problem alone, but to support the ecosystem.
• The other dimension is that while Humana grows, CenterWell can look at improving patient experiences in care delivery within CenterWell Pharmacy and CenterWell Home Health. Vivek is working on establishing impact metrics and updating programs to connect home-based care to Humana’s comprehensive primary care.

Primary care as the center of the ecosystem

Time and comprehensive ownership are central tenets of great primary care.

• Coming out of residency, Vivek recognized that the primary care team can be the owner of your patients’ care over the entire care timeline.

“We do things in our model to equip our primary care clinicians and teams — to not just understand what’s happening with their patients over time but actually be a part of that care, whether it’s curating the specialist network or even embedding specialty care in our own model.”

• Vivek’s goal is to make Humana the one-stop, accountable, full ownership enabled, clinician-led primary care provider. There’s so much to incorporate: care management programs around care transitions, social work and behavioral health expertise, etc. Vivek shares that they incorporate a lot of geriatric care principles to define what their patients really want out of their care and help them best optimize it.

Perspective on opportunities in the primary care innovation:

1. Real time intelligence. Vivek believes there’s a lot more opportunities to make use of Healthcare Information Exchanges, aggregating useful insights from what’s happening outside the clinic and folding it into the model.
2. A value-based care hybrid specialty care framework. There’s a lot of activity around virtual care and specialty care, but Vivek recognizes that seniors often have health needs that require in-person care. He believes that the goal is to bring the right balance between virtual, in-person, and specialty care to the outpatient realm.

On primary care moving out of the hospital four walls:

• Based on his hospital practice experience, Vivek shares that there is a bias towards doing more in the hospital because of the acuity level of the emergencies and the resources available. In the chaos of the hospital environment, these actions might not be contextual to each patient and patients often struggle to adequately interpret what’s happening to them.
• This means that in many inpatient settings, there are a ton of interventions and referrals to specialists that can delay the care timeline; the sheer activity level can be damaging towards patients. The patient can often thrive more in an at-home care environment, which is why Vivek is focused on care moving outside of the hospital to ambulatory care and the home.

What Humana is doing to combat provider burnout:

Vivek believes clinician burnout is an enormous issue. The world of decision making in healthcare has gotten more complex. Vivek believes we’ve designed and created burden around documentation, billing, all these other things that make all the wheels turn that ends up burdening the clinicians.

1. Make sure that the hard work that clinicians signed up for is the hard work they actually do, not other work that gets in their way. For example, Vivek shares that they look at who’s using the EMR after hours on weekends and reach out to that person’s direct clinical leader to ask, “How can we help?” It could be EMR training, schedule updating, new call systems, referral management process… “things that will help make the day-to-day operations much more frictionless.”
2. Provide clinicians flexibility. Vivek shares that medical practice has traditionally been very inflexible — they’re investigating ways to trial alternative schedules to make sure downtime is actually downtime and the work is sustainable.

Technology’s role in combating burnout:

• Vivek’s perspective is that technology does have a role to contribute, the first point being communication. They’re often trying to have multiple people with different clinical backgrounds work with the same patient; putting them on a workflow platform where they can see each other’s work is a feature that EMRs don’t offer but would be extremely useful.
• Vivek also believes that technology can create respect for people. In his experience with seniors, they want to have control of their information and have a relationship with their providers. Technology can create more communication channels that help family members, friends, or caregivers get involved in a more meaningful way.

Advice to startups on working with larger health plan partners like Humana

1. Have humility and understanding. Everything in the Request for Proposal process is there for a reason.

Vivek has seen many people get frustrated by the RFP process for large organizations like plans or health systems. Companies that show up with a willingness to help their partners on the other side are able to be more productive.

2. Gather the right proof points.

Vivek has also seen that it can be valid for new entrants to go smaller first, creating relationships, delivering results, and proving their product or service before scaling. Taking financial risk is a serious issue, so Humana looks for partners that display depth about looking at outcomes.

3. An angle to working with larger partners: build out a specific nuance that they haven’t solved yet.

Vivek has personally found that organizations that have started focusing on a non-senior population are better served by building some seniors’ specific nuance before coming to Humana’s primary care group.

“Does your service or technology or engagement approach fit? Does it work or not? Why do you believe it would work beyond just telling us you think it would work? That’s why I look for depth of thinking and actual work and effort.

We’ve done and tried so many things ourselves, either directly ourselves or with partners, and we know that it’s really specific in terms of how you engage and care for seniors.”

Tips on landing your first pilot with a major health plan

1. Be clear about the scope of your pilot, and be open to starting narrower than you may think.

• Are you doing a test of a potential model that needs a few hundred patients or do you believe you have the final model that needs a thousand patients? Vivek believes you have to understand what stage you’re at and be clear about the patient targeting. Metrics can vary based on the background of the patient.

“Who are the specific people along all sorts of dimensions of their profile, their utilization, their conditions, their engagement patterns? How do you really profile your ideal patient?”

• Many people see the specific value of their product but want to work with a broader population. Vivek encourages being mindful and open to starting narrower at a higher acuity level, because there’s more opportunity for you to make a difference.

2. Build a chain of causality.

• Vivek looks for a chain of logic that proves what you’re doing is leading to inflection points and changes in health outcomes, utilization, and total cost of care. He looks for partners who have a strong thesis and level of specificity about clinical indicators
• Be honest about regression to the mean, given that you won’t be serving the same cohort over time. Come with a framework where you want a partner to build out analytical depth or build it out yourself. Have a plan to get to a comparison cohort whether it’s real or synthetic, so you can validate the impact of your intervention.

3. Interact with the right people.

• Vivek has noticed that many startups go straight for the board chair or the CEO, but they must pay equal attention to the people who actually do the day-to-day work.

4. Lead with the strength of your product, not its freemium model.

• Vivek is wary of pilot pitches in his inbox that are free for the first year or have other cost cuts. He’s not just looking at the financial contracting piece, but rather belief in the model and the track record of the people involved to ensure economic sustainability and impact.
• Vivek has seen models fail that he thought would succeed, and seen improvements happen that can’t be explained by the model.

“There’s a lot of ways to have the financial view disconnected, or the contracting disconnected from sustainability and long term value. Ultimately, the best partnerships are going to be sustainable with clear mutual value. For what I focus on, that comes from better patient care that materially not just shifts experience, but people’s actual health.”

5. Even if it’s a tech product, don’t forget to build out human connectivity.

• You need an outreach team or a care management coordination team — people who will pick up the phone when the clinical team needs to call you about something.

Vivek’s advice to early founders: Find the best clinician you can for the domain you’re working in. Hire them and make them a key partner for you from the beginning.

• Humana’s Primary Care organization has physician and clinical leadership partnered across every level of market leadership and across key functions like analytics and quality.
• Don’t treat clinicians like commodities. There’s often a bias to center on the technology or the business model, but it’s important to build a culture that focuses on supporting clinicians and avoiding burnout.

Interested in Humana or joining their team? Learn more on their website, Twitter, and LinkedIn.