Improving pediatric care access and outcomes through value-based Medicaid contracting, technology, and a prevention-first model | Chris Johnson & Michael Glazier, MD (Bluebird Kids Health)

When I was a middle school teacher, on particularly refugees, we put Whitney Houston's greatest love of all on. Number one, because it's a jam, but also as a reminder that children are, in fact, the future. From a health care policy and financing perspective, it seems we're not doing a terribly good job investing in that future. A recent JAMA article found that the health of US children has worsened across a wide range of health indicator domains over the last 17 years. Today, I'm welcoming Chris Johnson, founder and CEO, and Michael Glazier, chief medical officer of Bluebird Kids Health, to share their views on what good would look like in terms of stemming this tide, but also more generally, providing excellent health care experience to future generations. Chris and Michael, welcome to HCN Radio. By way of introduction, can you talk about your paths to Bluebird Kids Health? Absolutely. It's great to be here, Martin. Thanks for having us. My name's Chris Johnson. I'm the co-founder and CEO of Bluebird Kids Health. I've spent most of my career in health care, really at the intersection of technology, care, delivery, and value-based care before joining and starting Bluebird Kids along with Michael. It's been about a decade in an organization called Landmark Health, providing in-home primary care for seniors with serious illness in value-based care arrangements. That organization, over time, became part of United Health Group in Optum Health. It's been a number of years. They're helping to integrate the organization and left in 2024 to join Michael and start Bluebird Kids Health. Michael, over you. Thank you, Chris and Martin. Thank you for having us super excited to be here today. I am a practicing pediatrician. I have been a pediatrician for 20 plus years. I have had the privilege of working in leading teams in small private practice group settings up to large multi-specialty clinics. I left as the chair of Pediatrics H.A.S. Health, which was acquired by Optum and Massachusetts as the chair of Pediatrics two years ago. At that point, we'd had 17 locations under pediatricians and 125,000 kids. And I jumped at the chance and the opportunity to work with press and the team that we've kind of developed. I think I understand Martin, you were a middle school teacher at one point. I think there's nothing no greater responsibility than privilege than caring for kids, teaching for kids, falls in the category two. So super excited for Bluebird Kids, super excited for what we're doing, what we're developing and what we're building, and super excited for our clinical model. Where I want to start is setting the table for folks who are maybe not as tuned into Pediatric Health, which I think gets less attention than it ought to. I talked about, you know, I showed a recent JAMA study, semi-recent JAMA study with YouTube before we got started, but YouTube are in the sort of day-to-day trenches of Pediatric Health Care. What's the current state of Children's Health in the US? And maybe if you could shine a brighter light on specifically for Medicaid populations? Yeah, absolutely. So I think at a high level, this was shocking for me. I showed most of my career in health care. One in two children in the United States is covered by the government health insurance program, either Medicaid or the Children's Health Insurance Program Chip, which is just shocking. And it's gone up dramatically over the last several decades. In the 90s, it was kind of mid-team that believe and now in the 2020s, it's gone up to about one in two children, about 50%, 50%. And so, and I think as a lot of folks know, Medicaid historically has kind of reimbursed it at lower rates, at least for certain physician services, than commercial insurance. And what that's, it's really created kind of a dichotomy in terms of kids' health, where if you have commercial insurance, you tend to have better access to pediatric primary care and other specialty care for, for pediatrics. And if you have, if you're, if you're covered by Medicaid, you have a much, much harder time accessing care. That it's much harder to find a pediatrician that will accept Medicaid, who doesn't have their Medicaid panel full. Oftentimes, we see a lot of pediatricians limit the amount of children they have to, you know, 15 or 20% of their panel on Medicaid. Not because they're, I think, ruthlessly profit-seeking, I think because it's already a low margin, it can be a very challenging, a run of pediatric practice, when you have really low rates on the Medicaid data, it just becomes even that much harder to make the, the economic work as an independent pediatrician. And so, that's just driven a real shortage of access to high-quality pediatric care. And what we see is that as a result of that, children who are on Medicaid tend to use acute care facilities, emergency medicine and inpatient medicine, at rates that can be three to four times children in that same community who are covered by commercial insurance. And that's because they're locked out of the system. They don't have access to routine care. They have to go to acute care facilities for that. And then in those acute care facilities, they're not getting longitudinal care. If you have asthma, if you have a behavioral health condition, you're really not getting the ongoing support that you need, either as the patient or the family caregivers to provide care for those children. And so, it's a really interesting, because this is happening in front of us. And I think a lot of us aren't aware of this, like really, really significant challenge that exists in just about every community across the country. We've looked and mapped nationally. We see the same kind of pediatric care desert shortage in every metro area. I live up in Boston. It exists in Boston. We have many of our clinics down in Florida. It exists in every metro area across Florida, where if you look at the higher income zip codes versus the kind of lowest quartiles at income zip codes in a community, there's a 75% differential and the number of pediatricians per child. And that's the mission, really what started our mission to ensure that we provide exceptional care so all children can thrive. There's really like the macro things that we're seeing around children's health. But I'll let Michael share what that means in terms of like actual individual care for a child. Dad, and I'll piggyback on that. In addition to the access struggle, Martin, as you mentioned, and as the JAMA article was citing, we're seeing an increased prevalence and increasing yearly incidence of childhood diseases and childhood issues for lack of a better word. So we see that I can spin on a chair wherever that chair stops spinning. I can point, look in that direction. And there's an increased prevalence of a childhood disease. Look at obesity. Obesity is defined right now as having a BMI over 95%. And one in five children meet the criterion. In addition, we're seeing an increased incidence in type two diabetes. We're seeing an increased incidence in metabolic syndrome, redibedes from a behavioral health standpoint. We're seeing an increased incidence. And this is over 10 years of anxiety, depression, as well as diagnoses like EDHT and autism. And again, this has been kind of a slow increase over the last 10 years, much of which was accelerated during the pandemic, but hasn't yet leveled off. So we are globally, or you know, nationally seeing an increased need, based on increased prevalence of disease. I want to learn a little bit more about the the Bluebird Kids model. So imagine I'm a parent or a particularly precocious potential patient. Can you give us the pitch for Bluebird Kids, what your approach is and what it looks like from the patient perspective? The more precocious the better. Michael, what are you coming to this? So Martin, I love that question. So as a pediatrician and a parent, so I've got three daughters, you know, I don't think there's anything, you know, better, more exciting than being a parent. I think, you know, it's just an incredible opportunity, but it also comes with an incredible amount of anxiety and stress, because obviously, the first child you've never done it before. And with Bluebird Kids, like we've realized that, and we want to be a partner and a coach with you on this journey of parenthood. And the way we do that is we practice, you know, what's really paramount to our model are really two things. One is it has to be, you know, evidence-based high-value care, it can't be anecdotal, it has to be actually based on science, because we do believe in science. But it also has to be a high-quality experience. And I think somewhere along the way in a lot of medical organizations, that second part kind of fell short or became less of a priority. You know, it's not just about the quality of care. It's how you're treated as a person. And in Bluebird Kids, since we are focused on children and family, that's how we treat the children and how we treat the parents. Additionally, we're here. We are a patient-centered medical home. We want to be here for everything. And as Chris mentioned, our mission is we provide exceptional care so every child can thrive. What's really important is what that mission says, but also what it doesn't say. It doesn't limit it to medical care. Absolutely, there's times when kids come into my office with horrible fever and sort of throat. And the best thing I can do is diagnose them with strap and give them a prescription of a moxacelin to make them feel better. But probably as important, if not more important, is the relationship that we develop with the families and with the kids so that we guide them along the way. for other things that are perhaps just as meaningful. So if a child feels comfortable coming to me for their care and admits that they're being bullied in school, I can have an incredible impact there that is far longer lasting than just treating this or throw. And so inherent in our model there is cold child health. We're treating not just the issue or the injury you come in with, but we're actually assessing you and helping you along all domains. And that's quite frankly how I want my children to be cared for. And you know, Mark, I think I add to that, that's kind of the consumer, you know, patient experience with the practice, which is, you know, the beginning and the end of any great health care, health care delivery organization. What we're overlaying on that is I think we're seeing technology starting to change health care. It's starting to change a lot of industries in pretty profound ways, maybe for the maybe we've always been saying that before it's actually starting to do it right with a lot of these new AI tools and other types of process automation tools that are existing. So we've really we're designing our model thinking about well, how is pediatric is going to continue to evolve over the next couple of decades. And we all we believe still that the pediatrician and family patient relationship needs to be at the heart of that. But I think we do think that over time that experience as a consumer is going to look different because of what technology can do. And so we are we we've built and continue to innovate on technology that allows for easier access to the practice so that you you really do have like Omni Channel 24/7 access to the practice. We're investing in new approaches that will allow us to will allow us to use virtual care. So that's a really seamless hybrid physical to virtual experience when you're in the practice. Not because we have telehealth offering, but because sometimes when you need sick care, it's 830 in the morning, you can't get to the practice. How do we make sure that that actually is convenient for the caregiver and the patient. And then on the back office side, really looking at how do we use automated AI workflows that make scheduling more efficient, that make care coordination more efficient, that allows us to build tech enabled care pathways and Michael and the team of Bilba, as my care management pathway, which is one of the big conditions for children. It takes that care plan that's in the practice. You know, if you have a child or those less than have children, you have a great conversation with the pediatrician to explain everything to you about asthma, what you need to do. And then you walk out and you forget the difference between the two inhalers and when to use it and when do you call it actually goes home with you. It subtly nudges you when like a care manager would normally be nudging you to check in on make sure you got your your your prescript filled, ask you if you remember how to use the inhaler and then shows you how to use the inhaler on kind of a digital footprint. It checks in with you every month to make sure that your your asthma is controlled. And so like we see the potential of technology. We've helped Uber, OS to really transform the practice operation and help our pediatricians deliver that exceptional care that Michael is just talking about. I'm curious on the the Bluebird OS question. You know, one of my next questions was going to be how you're seeing technology impact the operations of the clinic. It feels to me like a lot of the conversation right now around AI is still theoretical. And when I listen to earnings calls from the big hospitals, they have a very compelling story about how it'll impact. You know, it'll make the hospital more efficient or improve the user experience. But they they're sort of shy about sharing any results yet. And I'm curious. You you both have experienced working in medical groups in a landmark of like what's different about this technological era that we're entering right now than some of the past things that we've seen. Yeah, I think what we're seeing is that it's actually going to be able to provide efficiencies of scale that have I sometimes jokingly say I think every health service organization always build in like a scale factor of their central operations. And they say it's going to grow at like 0.6. And the reality is that historically, I bet it almost always grows at like one point something because you start to need to increase the number of folks and then you build management layers and then regional layer. It actually it's a little bit like bamboo. It's think you can't you can't like fight it back kind of some of the that that like central ops managerial levels that build that I really do think and we're seeing it already that there's actual technology now it's not going to get rid of humans. Like humans just to play a very, very important role in managing the back office. But it actually is increasing the productivity of the individuals that we have. They're able to handle more schedules. So it's like, hey, do we have processes that allow us to hire more people and keep the scheduling consistent? It's about taking the individual who's going to be doing the scheduling, doing the care coordination and say, hey, can we actually have you focus on the most complex complex tasks? Let's have the technology handle a lot of these more simple, simple tasks that we see is like really probably being able to increase like employee productivity by a factor of like three or four as we continue to scale. And the exciting thing when you're building an organization is you don't have the kind of current operations. I think it will be interesting to see are incumbent able to make like pretty big ships in how they think about their labor forces to evolve to that future state. And again, that doesn't necessarily mean like reducing head count, but I think it means having people do dramatically different roles and not needing to think about, hey, if I want to serve more patients, I need to add more to my head count as I grow. So we're excited because we really have a blank canvas to be able to continue to roll these things out and having been part of large organizations previously. It's really hard once you get to a certain size to really radically rethink it's impossible, but it's a really big ask to start to like rewire operating workflows once you get to a, once you have a couple thousand people. So value based care and value based care payment models have been mostly concentrated in the Medicare world. It sounds like both of you based on your experiences have had pretty extensive experience within these value based care contracts. I'm curious to hear what it's been like building this in a pediatric context and working with Florida's CMS and structuring contracts with MCOs. Are they receptive to this? Are you having to sort of write these contracts from scratch? Like what does that look like for on the contracting side? Yeah, it's certainly to use the baseball analogy like earlier innings in I think Medicaid, value based care, then say Medicare advantage or for that even Medicare fee for service with some of the things that like the innovation center has done. But I think at the end of the day, the outcomes that we're trying to achieve are very, very similar. So absent risk adjustment, which obviously is important for a lot of the Medicare, value based care, value creation. In Medicaid, it's really focused on improving and reducing avoidable utilization of acute care facilities. And what that means is getting better primary care to patients so that they are proactively remaining healthy. When they have an issue, they call you first. You can quickly triage and intervene before something exacerbates into a more of a crisis mode. And so we're very focused on can we have emergency room rates reduced around 50% in our population that we that we manage versus bench community benchmarks in the population in the areas that we we service. And the same thing on inpatient, we like to see our inpatient rates come down close to 50% relative to community rates. And that's the big value creation. And that's good for the plans, the plans, I get to have, you know, contracted higher higher profit members in their relationship that they have with us. We close more of their quality gaps for them. So we typically perform like the top desial across the heat as measures that these MCOs are held accountable to by the states. And you know, the other big difference on Medicaid is it really is driven state by state. And so there are these procurement processes. And I'm sure some folks listening are even more of an expert on this than I am. But you know every every few years there's a procurement for the at the state level for who's going to provide services for their Medicaid beneficiaries. And the states increasingly are pushing for outcomes that that feel more like Medicaid is not just build me a network and administer claims anymore. It's a build me a network guarantee me a certain level of quality. I want to see you move my membership into the future. value-based care arrangements. And so we see that there's like very nice tailwinds in terms of it, for a practice that wants to be in value-based care to align with MCOs that are trying to be competitive in these in these state-based procurement processes. And in some states like Florida and Texas, they're actually withholding premium dollars from the MCOs if they don't achieve certain quality outcomes. And so it's going to become more and more important to actually be able to achieve wellness visit rates, lead screening rates, other vaccination, combination rates, in order to unlock full payment for these plans from the state. Michael, one thing that I think is fascinating about pediatrics and sort of echoes of by Tire as a teacher is you have a kid who's their own human being developing, you know, but still their own human being. And then you have the parents who obviously have a tremendous impact on whether a care plan gets implemented and how all of these things work. I'm curious to get both of your perspectives. Michael, maybe starting with you on what that relationship looks like and how you're sort of going about, like it strikes me as challenging to take risk for a population of people, but that also have a third party, their caretaker who you need to work with. Martin, I love that question because it gets to the hardest. What being a pediatrician is and you know, shows a reflection into what the workspace is like much like, you know, when you have a child in the classroom and then all of a sudden there's parents teacher conference day and you start to realize, wow, the autism fall far from the tree. In many cases, and it helps you understand the child a little bit better. You know, as a pediatrician, that child obviously is our focus. But oftentimes they're coming into us on like day three of life. And so they're obviously not talking to us. So everything that we are doing and implementing outside of a physical exam relies partnership with the parents. And so we have the privilege of getting to know not just the infant growing up into the adult, but the parent and the entire family unit as well because grandparents come in. And so early stage, it's always relying on those the bond that we form with the caregivers. But then as that child ages, we get to that point where we actually have to kick that caregiver out. Because it's our mission and part of our job to teach that child to develop autonomy, you know, to start taking responsibility. And that is a journey. It's not a one visit thing. But it is as a clinician, super exciting to watch them go on that path. And, and, you know, have these kids who come in at such a young independent age then start to assert independence, which is always an interesting, you brittle struggle. But then actually become independent. I had the chance to speak with Chris Cogel who is CMO in Florida, for Florida Medicaid. And one of the things he pointed out is that Medicaid is this great building ground for companies. Because if you can make it work on Medicaid rates, like you've built a really great business. And I'm curious as a new parent, I have a nine month old. I'm curious if you've thought it all about moving or, you know, moving up market or seeing not just Medicaid patients. Like I would love something like Bluebird from my kid. If you want to expand to Washington DC, I would, I would welcome it. I'm curious how you're kind of bouncing that. Like there's this mission, obviously. But then there's also this you've built a business that works for this population with lower reimbursement. And like if I want to come to you and say, hey, I've got, you know, commercial commercial rates, is that ever interesting to you all? Oh, it is. We actually, we're pay our agnostic Martin. So we see any child who has the ability to pay today. So that for us, that means you have Medicaid insurance, chip coverage, exchange, commercial, or your cash pay. And you get the same experience regardless. So we don't, you know, I don't think of us as a like Medicaid provider. I think of us as a provider who delivers great care to children, regardless of what your insurance card says. And like I love what you just said, if we want to deliver experience that like regardless of your ability to pay for premium, you would come to our, you come to one of our clinics and you say, wow, that's, that was a great experience. The care was incredibly high quality. The our care facilities are bright. They're modern feeling. They're not, they're not luxury dayspos, but they're probably the nicest pediatric clinics you've ever stepped foot into. And we've made it just easy to be a part of our practice. But I don't think a lot of people identify as like, hey, I'm in healthcare. I think we identify like Medicaid, commercial. I don't think that people want to identify themselves as like I'm Medicaid or I'm commercial. And we try and take as much of that, that away in the care model. And I'll just say the other great thing is the care model is in pediatrics. And this is a little bit different than senior medicine. What we do is the same. Pediatrics is actually built around preventative medicine. It's like the only we always say in the in the air country like I wish we had more preventative medicine. We actually did design pediatrician very, very prevention focused. And so I think we just try and do that really, really well. Regardless of who the payer is, who the construct is, and we try to make that invisible to our frontline provider. So they don't have to say, oh, this is, this person has blue cross blue shield, you know, Cadillac plan or this person has, you know, United healthcare Medicaid plan. I need to think differently about them. We want you to treat everyone the same, have the same resources. And we try to build very intentionally a business model that allowed us to have a super consistent clinical model from the start. On that question, like obviously a huge believer in preventative care, I my my senses in pediatric populations, there's sort of similar dynamics where you have, you know, small number of people driving a lot of the spend. I'm curious, you know, Michael, maybe you can jump in here a little bit when you, how do you think about the this sort of quarterbacking that needs to happen when you have a super medically complicated patient or, you know, like high medical needs and thinking about like a spark pediatrics type patient who has multiple comorbidities, maybe as a feeding tube and something like that. What's Bluebird's role when it comes to those, those patients? So Panart core we are for all its definition of meaning a patient center, Pentechle home. So, you know, we try and do as much care in Charlie's, we can, but obviously it takes more than a home, it takes a village. And so we partner with families and we partner with the external network. And as the gana the parent, parents are selfs, we know it's like it's difficult to make appointments like even when things aren't complicated. And then you start to talk about complexity of children and multi specialty visits. That gets to be near impossible. So we rely heavily on our team and our care coordinators to not just provide a phone number and actually make those appointments for them and help coordinate. And I just, I know as a parent a gamut that's like super important. Yeah. Where I want to land this before I sort of ask you what we should be looking for next from Bluebird is a step back and a look at the policy landscape. So on the one hand, we have all of this stuff going on in the expansion population, one big beautiful bill. It doesn't, I think that the sort of first order effects are are not directly impacting the population of kids you work with, but no doubt there will be second order effects with the financing changes. So that on the one end and then on the other end, like we seem to have a very creative group at CMS right now with Abe Sutton and Dan Brillman. And so I'm curious, you know, what are you seeing as operators in this space, both on the policy landscape side and what recommendations would you have for the folks in Washington, like Abe and Dan, who are thinking about how we can encourage more models like Bluebird? Yeah. You know, I think it's it's been a busy time right at the health health care policy level, both in terms of funding as well as, you know, how how the government thinks about their role in mandating back vaccination policies, etc. I think when I step back that the one of the things that I think is most important for us all to understand is most of the, you know that there's that chart that health care wonks like myself love where it's like OECD countries, like life expectancy versus the US life expectancy. And we're like, oh, like it's so we're so much worse and we spend so much more money. Yeah, there's a lot of research that showed like the vast majority of that divergence happens before 18 years of age, right? We put a lot of resources at like people who are 70 years and older. It's really interesting. If you actually look at the pop, if you make it to 70 years old in this country, your life expectancy is like almost the same as the rest of the OECD countries, right? So like if you're 70, you've made it like it, but we've We put a ton of resources against it as though that's where we're missing out. Where we're missing out is early, earlier interventions, making sure that children are getting access to care, making sure that they're getting ice-creams so that if they're having trouble seeing the chalkboard that we can get conglasses so they don't drop out of school because they're so frustrated. Those are the types of interventions that I think I would want folks in Washington to be thinking about and making sure that we create the incentives for more access points to pediatric primary care. We certainly need to manage the high needs population in pediatrics, but we also need to remember that that's a very, very, very small population. We're talking about a quarter of a percent of children, maybe even lower the really, really, really high needs children, and they need a lot of support and we need to continue to innovate around them. But unlike adults where there's 20% of the population that's complex and chronic, most children are and should continue to be relatively healthy or have one condition that they need to manage. We need to make sure that those kids have a longitudinal relationship with pediatricians. We need to make sure that there's enough resources being invested there, whether it's through reimbursement rates, other creative quality incentive based programs to drive more folks into pediatric care and ensure that they're opening their doors to what probably over the next decade will be maybe 60% of the population that's covered by Medicaid or CHIP and not creating kind of a two tier program for kids where Zibko drives your destiny in terms of your health outcomes. So that was a super, like specific policy ask, but I think one that's been really eye-opening for me is just how important actually getting more innovation, more resources and higher quality care to our children in this country can dramatically change the prospects of the country and actually close that gap that we all look at as health care wonks and say, how do we do that better? We've got to start with kids to close that gap. Martin is Chris Seton in earlier answer and especially at Pediatrics, like we are built some first day of training on for preventative care, not just acute care and you probably see you've seen this when you're now nine month old when you go in for visits. It's not just a physical exam, it's not just treating earings actually. We're talking about developmental stages, we're talking about nutritional support and what to expect next and we do that through every visit, you know, and I mean, it's an overuse expression, but an ounce of prevention is worth a pound of cure and like Pediatrics is the time when we would get the most benefit for the buck in terms of prevention. And that prevention obviously has short term horizons, but it has long term horizons too and adult care is really good with the reactive care of those long term horizons. We just want that opportunity to reduce that burden on them. It's a really compelling vision and I think folks are going to be very interested in watching the Bluebird Kids Story develop. Can you give us, you know, a sort of little preview on what we should be looking out for or keeping an eye on for what 2026 has in store for you all? Yeah, absolutely. You know, I think what you're going to see from us is just continued growth. Today we're in Florida. We'll continue to grow our Florida footprint through new new clinic openings, so we're very focused on organic growth as well as continued development of a lot of our Bluebird, OS operating system. And then as we go into 27, we'll see some expansion into new states. Most likely, we really we really want to see this become a national platform. We're starting in Florida. We're very focused on getting it right and then being able to unleash that innovation across the kids, like I shared earlier in every metro area across the country. We know there's a need for more high quality care. We want to get to each and every one of those as soon as we can. Might I recommend Washington DC. Thank you both so much for your time today. It's been been hugely informative and it's just a great story to watch. Yeah, have a nice rest of your day. Thanks for having us, Vernon. Thank you, Martin. Super appreciate it.