Sept. 8, 2025: In this episode of MedCast, a podcast of the Maryland State Medical Society, Dr. Stephen Rockower speaks with Dr. Farzaneh Sabi, an obstetrician gynecologist at Kaiser Permanente and a member of the Health Services Cost Review Commission (HSCRC). They discuss the differences between integrated medicine and fee for service care models, utilizing AI-related technology, and Dr. Sabi’s work on the HSCRC. Listen in to learn more about Maryland’s unique all-payer model and how the HSCRC fits into our state’s health care system.
Dr. Rockower (00:05):
Welcome to Med Cast, the podcast from Med Chi, the Maryland State Medical Society. Each episode will be doing a deep dive into medicine and taking an insider's view on issues facing Maryland's physicians, patients, and healthcare more broadly. I'm your host, Dr. Steven Rockower. Today my guest is Dr. Farzaneh Sabi, an obstetrician gynecologist with Kaiser Permanente, and also a member of the H-S-C-R-C, and we'll talk about that in a little bit. Welcome Dr. Sabi.
Dr. Sabi (00:37):
Thanks, Dr. Rockower. I'm really happy to be here.
Dr. Rockower (00:39):
Well, we're glad to have you. Why don't we start by doing a little biographical stuff and tell us where you did your training and sort of how you got to Maryland and how you got into Kaiser.
Dr. Sabi (00:54):
Sure, I would love to. So I, as you noted, I am an OB GYN. I actually grew up in Montgomery County, went to Gaithersburg High School. I then went to GW for undergrad and medical school. I joined the Navy and I did my residency in San Diego. And then I came back to Maryland as an active duty Navy officer, as well as staff O-B-G-Y-N at the National Naval Medical Center in Bethesda, now known as Walter Reed to many people in the audience, but always will be National Naval Medical Center to me.
Dr. Rockower (01:36):
And to me as well.
Dr. Sabi (01:39):
Yes, our roots are deeply planted there. I had two of my children at that hospital. Within a year of coming back to Maryland after I finished my residency, this was right around the time of nine 11, I was deployed on the big hospital ship USNS Comfort. And so I served in the Persian Gulf, a great opportunity, professionally, hard opportunity personally. My husband was also in the federal law enforcement, and so I made the very difficult decision to leave the military in 2006, and I transitioned to Kaiser Permanente and have been here for almost two decades.
Dr. Rockower (02:25):
That's terrific. And how did you get, well, tell us, start with Kaiser Permanente. Many listeners may not understand how Kaiser is different from other medical systems here in the state. It certainly is different from what I practiced when as a private practitioner here in Montgomery County. So tell us more about Kaiser.
Dr. Sabi (02:48):
Sure. I would love to really, one of the things that I personally as a physician loved in my experience when I was active duty Navy was having all of my other colleagues, all of the other specialties be part of the same medical group as myself. And so in the military, it's an integrated delivery system. We share the same population of people that we care for in the same practice. And so when I was leaving active duty, I was really drawn to a system that felt familiar to me and that was a system of Kaiser and Permanente. And interestingly, it's taken me a while to figure this out. There actually is no such thing as Kaiser Permanente. It's actually a marketing moniker. Really, it is the combination of Kaiser Foundation Health Plan, which is in essence the insurance part of our organization and the Mid-Atlantic Permanente Medical Group who are the exclusively contracted physicians and clinicians who then provide the care to people who are insured through Kaiser Foundation Health Plan. And the unique aspect of Kaiser Permanente is the care and coverage delivered together. And so a lot of the other challenges and obstacles that people face when interacting separately between a medical group and an insurance company, we don't have those barriers and obstacles because we're essentially one organization working together with the same goals.
Dr. Rockower (04:38):
And how is that different from the traditional fee for service model that I grew up with?
Dr. Sabi (04:45):
Yeah, absolutely. And again, it's taken me a long time to really understand that and respect the value that that brings. So for traditional fee for service medical practices, the revenue, the sustainability, the practice model solely relies on the utilization and the people who are served one person at a time with the revenue generated from those individual interactions and so many physicians who have been part of traditional fee for service medicine, there's a lot of focus on productivity, RVUs and the revenue generated by each incremental interaction with patients. Kaiser Permanente's model is different in that we actually, in essence, are a prepaid model of care. And so our medical group on a yearly basis negotiates a rate with the Kaiser Foundation Health Plan Insurance Company, where we get paid by the population of people who we serve. And so it's a prepaid model of care. And so we know that we're going to get a specific allocation for the number of patients who we're responsible for.
(06:20):
And what that allows us to do is really hone in our focus on things that really help with prevention of disease management of chronic conditions, and taking care of each individual person within our population to keep them as healthy as possible and to meet their needs in a way that is most convenient to them. Because our practice model and sustainability does not rely on the individual increments of utilization to bring in the revenue into our practice. And so we can do a lot more innovative things. For example, when we have that relationship with our patients and they have a question, they need a medication refill, they have a concern, we can communicate with them through a secure message. We can address their needs, we can refill their prescriptions, we can answer their questions. And because our practice model does not rely on the billable activity of that interaction between us and our patient, we don't need to make that patient come and see us in order for us to bill for that communication and interaction. So it allows us to practice in a different way than traditional fee for service medicine.
Dr. Rockower (07:55):
Are you able to manage costs and ensure quality through all that? If patients are not coming in, you may be having problems with quality and patient satisfaction?
Dr. Sabi (08:12):
I'm so happy you asked that. So everything that we do actually starts with quality. And because all of our patient interactions are through our electronic medical record, we actually know when our patients are engaging with our delivery system. We know if and when they're picking up their medications, we know when they're getting their labs done, or if we ordered a lab, we get alerts if they did not get those labs done. So we're able to really care for our patients globally and as a population, and we use the technology from the information that we have available in our medical record to then proactively identify if someone is missing appointments, if they're not staying in touch with us, if they haven't had their preventive measures, if they're not getting their labs for their chronic conditions. And so we don't have to wait for an interaction with one of our patients to then have that as a trigger to know if they have care gaps. We have all of that information within our system, and so we're constantly proactively identifying either care gaps, missed opportunities, and we are outreaching to our patients to then bring them back in. And because of all of the systems that have been built to support our physicians, we actually have been number one in NCQA, HEDIS quality for Medicare, Medicaid, and commercial for many years in a row.
Dr. Rockower (10:00):
Okay. I'm curious about your electronic medical record system that is able to control all of this. Is this a commercial plan or something that you've developed in-house or something that came from the California Kaiser people?
Dr. Sabi (10:17):
Yeah, so we call it KP Health Connect. It is an epic based electronic medical record, But what we have done is we actually have sent many of our physicians to Madison, Wisconsin, and they have become epic super users. And we have hired people within our medical group who really understand how to leverage the modules and the tools that are available in Epic to help us continuously build the safety net alerts, workflows, order sets to then empower our physicians to function at the highest level. And it makes us look really smart when our patients come in and the computer system does all the work for us. And so instead of having to flip through pages of charts or go back and forth to see one was the last mammogram, one was the last immunization, what is missing? We look really smart because all of that is right there in front of us. And because we have this integration, our clinical assistants and nurses are also part of bridging a lot of those gaps. So we have outreach by our care team, and so all of the processes to support quality do not fall only on our physicians. It's a whole team effort.
Dr. Rockower (11:47):
Okay. Do you use what they call AI augmented intelligence in your systems? And I'll put in a plug now for a book that I reviewed in Maryland medicine called The Algorithm, We'll See You Now, which sort of takes that to an extreme, but that's a side note. Go ahead, and talk about ai.
Dr. Sabi (12:14):
Fascinating because everyone is interested in how AI is being used in medicine and in multiple industries. And for us, we actually consider the use of AI as more of an augmentation to the systems that we have in place. And so what is AI and AI can mean different things to different people. One part of AI is using data science and algorithms to identify people at higher risk for certain conditions to do an analysis to say if you have a person who is not showing up for their appointments, who is not refilling their medications, they may be at risk of something. And so using the data that is available to us and then having an algorithm that then helps escalate those people that may have more needs than others is an invaluable part of our practice. We also use a tool in the exam room with ambient listening. That has really helped us for especially those physicians who are typing with two fingers, really be more present in the moment with our patients in the exam room. And then through this ambient listening, a note is generated, and many of us were skeptical about how these notes would look. So it is not a transcription of every word as we said it, it actually helps collate the parts of our conversation to the sections that we're used to as physicians. So the parts that go into the history of present illness, the parts that go into past medical history, family history, as we're doing our exam, it is a little bit different than you normally do because you have to talk about the exam. I'm now listening to your heart and your heart sounds normal. I'm touching your stomach and I don't feel any masses. So you have to talk through that. But then through that ambient listening, a note is generated and it just helps us be more productive. And then one other area that we are looking at augmented intelligence and augmenting, what we normally do is having it as a second read for things like mammography, imaging studies, pathology. We always have a physician who is doing the actual read, but as a safety net, as a backup as that second read, we're using these techniques to really help us make sure that we're not missing anything.
Dr. Rockower (15:01):
That's terrific. The augmented listening that you're talking about, it reminds me of one time I was dictating something and I talked about her knee is, and it came out as a hernia. Her knee is, yeah. So I guess you have to go back and read what you're saying and to make sure that it picked up appropriately. How does Kaiser sometimes patients go to non Kaiser hospitals or physicians. Are you able to collaborate with other systems or providers? You don't have your own hospitals. I know you're seeing patients at Holy Cross and Suburban, but maybe there's others that I don't know about. How does that all work?
Dr. Sabi (15:55):
Yeah, so within our model of care, because we are in essence a multi-specialty group practice, it's important for us to really care for our members and our patients through the entire course of their care. Where it starts from at home to the clinic and outpatient setting into the inpatient setting, and most importantly, that connection back to home and the outpatient setting. And so we have certain hospitals where we have our own physicians who are providing the care in those hospitals and colloquially, we internally refer to that as what we call our core hospitals or our premier hospitals. And the value of having our physicians in those hospitals, for example, Holy Cross Silver Spring, is we have our own hospitalists who will be the quarterbacks and who will manage and coordinate the care for our patients. Our Permanente hospitalists will then stay very closely in touch with the outpatient primary care physicians, both as the patient is getting into the hospital and importantly as a patient is being discharged.
And then our hospitalists will also coordinate whether there's a medical specialty consultation that's needed with a Permanente physician, a surgical consultation that's needed with one of our surgeons, and we're able to then have all of this care within our coordinated medical group and have all of this care linked back to our robust medical record. So all of this is in one place, and that way when a patient is discharged from the hospital, they're not then having to navigate what to do next. And there isn't risk of what happened in the hospital not being translated to the outpatient setting. Like if someone goes in and they have heart failure, they have COPD and their medications are changed because we have our physicians working closely together, we have our own clinical pharmacists who are making sure that the outpatient medical record is updated to reflect what happened in the hospital. We're able to create those safety nets that help our patients navigate. We navigate on their behalf going in and out of hospitals.
Dr. Rockower (18:27):
And what happens if somebody say, gets in a car accident in Virginia and goes to a non Permanente hospital or in Ohio or wherever they might be?
Dr. Sabi (18:40):
That's right. And life happens and things like that happen all the time. The good thing is we also have Permanente physicians from Virginia, But let's say Ohio or somewhere, something that happens and a person has to go to a hospital where we don't have our own physicians. Always foremost, the most important thing is a stabilization and the immediate management of the needs of the patient wherever they are. And then we have a group of physicians who get alerts, especially if one of our members goes to a hospital within our geographic footprint between Maryland, DC, and Virginia. Our physicians will then call and talk to the physicians and the care teams at these other hospitals. Certainly in critical cases where patients are not stable, we continue to follow the care that they're receiving in these other hospitals and help when the time is right to coordinate the discharge of those patients, whether it's to home back into our delivery system, so then they're not left having to navigate that on their own. There are times when a patient may have something happen emergently, they go to a hospital that is not one of the hospitals where we have our own physicians when they are stable and we identify that they will have ongoing inpatient clinical needs, we do then transfer them to one of the hospitals where we have our own physicians because we want to be able to more closely help them manage their inpatient stay and help them with the coordination upon discharge to home skilled nursing facility or wherever they need to go next.
Dr. Rockower (20:39):
Okay. Do you have rehabilitation facilities? Some people might know that I spent some time at a rehabilitation facility in Rockville this past summer, so I was most impressed by the care I got there. Is that something that's available through Kaiser?
Dr. Sabi (20:59):
Yeah, absolutely. And I'm sorry that you had to go through that ordeal. I know a lot of times when you personally, we as physicians experience those things, it gives us just a different lens to what our patients go through and some of the challenges and also some of the great things that are available. So similar to the fact that we don't own and operate our own hospitals, we do contract closely with many skilled nursing facilities and rehabilitation facilities within the state. Even in those areas, we have our own physicians who are rounding on and caring for our patients in those facilities.
Dr. Rockower (21:41):
Okay. Let's take a quick break. We're speaking with Dr. Farzaneh Sabi, an obstetrician gynecologist with
Kaiser Permanente, and also a member of the H-S-C-R-C.
(21:56):
Welcome back to MedCast, the podcast from Med Chi, the Maryland State Medical Society. We're continuing our discussion with Dr. Farzaneh Sabi of Kaiser Permanente as she discusses Kaiser Permanente, and we'll be getting into the H-S-C-R-C. So I was talking about your other job of the H-S-C-R-C, the Health Services Cost Review Commission. Could you spend some time telling people exactly what it is and how you got there?
Dr. Sabi (22:31):
Sure, I would love to. So the H-S-C-R-C as we call it, is Maryland's Health Services Cost Review Commission. And this is an independent state agency that's designed to really help ensure Marylanders have access to high value affordable healthcare, although the commission really is set to regulate hospital rates. Part of what I love about the commission and my role on the commission is really the focus of taking the lens off of just cost and putting it on quality care experience in the lens of the total experience that people have in their healthcare that then eventually does translate to the total cost of care for a population rather than the individual increments of care.
Dr. Rockower (23:37):
And how did you get appointed to this and who else is on the commission?
Dr. Sabi (23:43):
Sure. So I've been with Kaiser Permanente for over 18 years, and as one of the associate medical directors, I've had the honor of leading a lot of our different operational areas, including hospital operations, perioperative services. I also have created a lot of our programs, including our home-based programs. During the pandemic, we had a group of physicians who were virtually rounding on patients receiving care at home because of the challenges of getting access to hospital beds. And so through the work of Kaiser Permanente, our model and the ability that we have had to innovate around how people get care, I was invited and encouraged to apply to be part of the H-S-C-R-C as a commissioner, really with the lens of bringing some of that experience and insights into the commission of what are other ways that we can care for patients and a high quality, accessible, great experience and affordable way.
Dr. Rockower (25:04):
How many physicians are on the commission and how many people are on there altogether?
Dr. Sabi (25:12):
Yeah, so the commission is composed of seven commissioners. I am proud to share the seats with two other physicians as well as other leaders from the industry.
Dr. Rockower (25:26):
Okay. And how does the H-S-C-R-C fit into the hospitals, the Maryland's hospital system? It's different here in Maryland and the rest of the country, at least for now.
Dr. Sabi (25:40):
That's right. And so the H-S-C-R-C oversees the all payer model and the rates that hospitals will charge for the inpatient care and also some outpatient care, but it's more than just a rate setting regulatory body. There's also a lot of focus on the quality of care that is provided in hospitals. There's a lot of effort and focus on sharing of best practices, really encouraging hospitals instead of competing with one another to gain market share, to have patients go to one hospital over another. In Maryland, the incentives really are based on similar incentives to Kaiser Permanente on focusing on quality on outcomes, looking at hospital acquired conditions if there are certain patterns, really having hospitals learn from one another, work together to solve those problems. Looking at things like readmissions or avoidable utilization to create the incentives and create the processes whereby the focus can be on the most appropriate level of care, venue of care rather than traditional fee for service medicine, which drives that care and that utilization to the hospital in order for the hospital then to meet its margins and create their financial stability.
Dr. Rockower (27:25):
If the hospital has a set budget and they're running faster than their budget, do they tell physicians not to admit and do surgeries or not to admit and do testing because they're going to lose money for that particular year?
Dr. Sabi (27:46):
Yeah, that's a great question, and thankfully that is not the case and now not how the hospitals operate within the system, within the global budgets, there are also different volume policies. There are also different relief valves that are built in to really make sure that if, for example, there are unusual circumstances, so something like a cyber attack or a storm or something that affects a hospital's infrastructure that has not been anticipated, is not part of their established global budget. There are things in place to make sure that the hospitals receive the funds to be able to account for those types of things. There are also different factors. So we have been watching the ebb and flow of respiratory illnesses and spikes in utilization where we are seeing unprecedented utilization of ED hospitalizations mainly related to respiratory flu type illnesses. And so when those things happen, there are mechanisms in place where hospitals can get additional funding to be able to accommodate changes in their volumes. They're also volume policy, so we know that, for example, during the pandemic, many people moved from the city out into the suburbs and beyond. And so as we see the changes in populations demographics with the growing older population, living longer, using more inpatient care, there are mechanisms in place to really understand and accommodate for those changes.
Dr. Rockower (29:50):
Okay. One of the other relatively new programs is this EQIP program that works with hospitals as well as physicians. Could you talk about that some?
Dr. Sabi (30:02):
Yeah. And so the EQIP program and many other similar programs are really meant to bring that value-based care to the inpatient setting and thinking about how do you care for a person for an episode of care rather than the increments of care. And again, when we talk about the differences between traditional fee for service medicine where each interaction has its own distinguishable billable activity,
Dr. Rockower (30:38):
The good old RVU,
Dr. Sabi (30:39):
The good old RVU, yes, the many physicians assistants and CPTs, instead of thinking about it in that lens, when you think about value-based care, it's what do you need to do in order to take care of an episode of illness and so orthopedic surgery, what are all of the steps that you need to have in place in order to care for someone who needs a hip replacement, knee replacement surgery? And instead of thinking about it as the individual increments of the pre-op visit, the assessments, then the surgery, then the aftercare, it's really the whole bundle of care around that episode of care.
Dr. Rockower (31:29):
Has the physician community taken up all this?
Dr. Sabi (31:36):
I think there are a lot of physicians who have been eager to really be able to practice in this type of model rather than the incremental RVU based models, because there's a lot of effort and administrative burden when you have to constantly chase after those RVUs, when you constantly have to worry about all of the different components of billable activity rolling up to the care that's provided. Because the risk is when you have the fragmented billable activities at any time part or all of them could be denied, not reimbursed. And so there is that financial and viability risk to physician practices if they don't enter into and have the security of value-based care models.
Dr. Rockower (32:35):
Yeah, I was always a private practice physician and I would make my money by what I did not on the rest of everything else. It made things make me want to do more and more and more, which wasn't always to the best interest of the patient, and I understood that. But it is sometimes very difficult when as a private physician, you have rent to pay, you have payroll to pay if you're malpractice to pay. There's a lot of competing interests for our time and resources. What other kinds of opportunities are there for specialists and independent practices to engage with the H-S-C-R-C?
Dr. Sabi (33:28):
Physicians absolutely need to play a much bigger role in just the care that's delivered to patients in the state of Maryland, and also through the H-S-C-R-C. Physicians are the largest stakeholders in what happens in hospitals, and we are the leaders of how that care is provided. And so we really need to engage in these important conversations. And one of the big aspects that is continuously coming up and becoming a bigger and bigger issue in the state of Maryland through the H-S-C-R-C and even MedChi and physician practices, is the growing pressures on physician practices to sustain and be viable as entities. And unlike 20, 30, 50 years ago where the referral patterns and the financial viability of group practices really relied on the care that started in a hospital where that's where referrals were generated, that's where a lot of the financial revenue came into a group practice by the work that they did in a hospital.
Now, many group practices, the majority of their work is in the outpatient setting. However, hospitals through the joint commission regulations have to provide access to a certain number of specialties, hospital-based care. And so private practices, people in small group practices find it really challenging to provide call and coverage in a hospital setting while trying to maintain their outpatient group practice. Hospitals are obligated that they have to be able to provide these call coverage and specialty services as part of their hospital functions. And so there comes this challenge of how do hospitals make sure that there is enough access to these specialties and specialists? How do the small group practices or even moderate group practices maintain a presence both in the hospital setting and the outpatient setting?
And so this is really coming to a head where I think we need to work collaboratively to figure that out because many group practices are then putting the burden on the hospital to pay them either stipends or additional call fees in order for them to be able to provide that care in the hospital that is not part of their traditional regulated budget or scope of hospitals. And so there is a lot of financial burden and just pressures on hospitals to navigate this space.
Dr. Rockower (36:33):
Right. The Trump administration has been changing a lot of the payment structure through HHS and CMS, and that's going to be hitting Maryland somewhat hard over the next few years. How do you see that shaking out?
Dr. Sabi (36:57):
I think it's too early to tell, and I'm not sure. I do know that things are not going to be the same as they always have been. And so it really puts the onus on us to work collaboratively and think about what types of services really need to be provided in a hospital setting. What more can we do to provide the appropriate level of care, the access that our fellow Marylanders, our neighbors, our patients need, and really think about how best to retain those relationships, the access, the quality in the lens of this constantly changing environment that we're a part of.
Dr. Rockower (37:49):
What kind of policy changes would you like to see in the future?
Dr. Sabi (37:55):
Hard question to answer. I think for sure, there needs to be a lot more acceptance of virtual and telehealth care delivery options for patients. Again, more people are moving to the suburbs, to rural areas, and in some places we have really rich physician density and access in some areas we do not. So really making sure that we acknowledge and give credit for virtual medicine, whether it's secure messaging, telephone calls, video visits, really understanding that the landscape of medicine has changed and telehealth and virtual health is here to stay, and making sure a lot of our network adequacy, a lot of other policies recognize that.
Dr. Rockower (38:56):
Okay. Well, that's really very fascinating stuff. Let's switch gears a little bit and do some other sort of off the wall kinds of questions. What would you be doing if you were not a physician?
Dr. Sabi (39:10):
I have four kids. It is a blur. I don't even know how they grew up. They grew up despite me, and many times when I think back to when they were little, I think I missed all of that, and I think many physicians probably feel the same, especially I trained prior to the 80 hour work week, I was active duty Navy. My husband was federal law enforcement, and so I don't know, my kids grew up despite my career, and so I would love to be able to spend more time just really enjoying my family and hopefully one day soon being a grandmother and really being able to explore that part of my life that I put on the side burner through my career.
Dr. Rockower (40:01):
Yeah, I'll tell you that having grandchildren is the best. What's, yeah. What's the best advice you ever received?
Dr. Sabi (40:14):
In medical school? And this really resonated well with me, and it's something that I keep in mind in all of my personal and professional dealings is surround yourself with people who are better than you, who are smarter than you, who are stronger than you, who know more than you, because that will then encourage you to rise up and continue to expand and develop. Versus a lot of times people will surround themselves with people who aren't necessarily as strong or optimistic as they are in order to make them things feel better. And in leadership, in life, really surrounding yourself with a diverse group of people who do argue with you, who don't agree with everything that you say, who push you and make you rethink some of your things. That is the most important thing that we can do in order to improve ourselves and also just be there and serve the people who we care for and who we are responsible for, and constantly rethinking and pushing ourselves to do better, think better, work harder.
Dr. Rockower (41:39):
Well, that's been wonderful. Thank you so much to Dr. Farzaneh Sabi who has been our guest on Med Cast, the podcast for Med Chi, the Maryland State Medical Society. Tune in next time as we continue our conversations with the leaders of medicine in Maryland to discuss the issues facing physicians and our patients. For all of us here at MedChi, I'm Dr. Steven Rockow. Thank you, Dr. Sabi, very much.