'Rebuilding health care as it should be'

Care teams at Oak Street Health take a proactive and personalized approach to help older adults lead healthier, more fulfilling lives, says Dr. Creagh Milford, SVP and President, Oak Street Health.  

• Oak Street Health has 230 centers across 27 states, with most located in “primary care deserts” — geographic areas with a shortage of health care professionals relative to the population, Dr. Milford says. 

• By addressing a patient’s social determinants of health — non-medical factors that influence health outcomes, such as food security, housing and social isolation — Oak Street Health helps them better manage their chronic conditions and adhere to treatment plans, leading to their better health.

• “Oak Street was built long ago on this mission of rebuilding health care as it should be,” Dr. Milford says. “I think that we've demonstrated that this is the right model for these types of patients in these communities.” 

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Matt McGuire

A lifelong writer, editor and content strategist. Senior Manager, Enterprise Communications, CVS Health

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Matt McGuire
Oak Street Health is dedicated to rebuilding health care as it should be by shifting the focus from reactive treatments to proactive, personalized primary care.

Through this unique care-team model, Oak Street Health supports its patients with doctors, social workers, behavioral health specialists, nurse practitioners, physician assistants and more. This approach ensures that each patient has a personalized care plan that looks beyond clinical numbers to address behavioral healthcare, social determinants support and personal health.

On this episode of Big Questions Answered we’ll explore how Oak Street Health identifies the communities that would benefit from its support. We’ll learn how the care team at Oak Street centers personalizes care for their patients. And we’ll hear about what’s on the horizon for the company as it continues to help older adults stay healthy and live life more fully.

Welcome to Big Questions Answered, a podcast that helps us understand the important initiatives at CVS Health. I’m Matt McGuire from the Enterprise Communications team. I’ll be your host as we dive into the latest developments, breakthroughs and innovations that are helping us achieve our ambition to become America’s most trusted health care company. Thanks for joining me today as we get our big questions answered.

I'm here with Dr. Creagh Milford, the President of Oak Street Health. Dr. Milford is responsible for ensuring Oak Street Health provides unmatched care for its patients, and that it delivers improved clinical outcomes for them using its industry-leading care model.

Previously, he served as president of the CVS Retail Health business, which brought together MinuteClinic and CVS Health Virtual Care capabilities. He's a central part of the company's health care delivery strategy.

Dr. Milford, thanks for being a return guest on the podcast. I appreciate it.

Dr. Creagh Milford
Great to be with you again.

Matt McGuire
So, Dr. Milford, you became the president of Oak Street Health in May of 2025. What have you learned about the business since officially becoming an Oaky?

Dr. Creagh Milford
Yeah, I've had to learn the term Oaky, so hopefully I am one of the Oakies, as they say. To back up a little bit, you know, I'm an internal medicine doc. I've had a long career in and outside of CVS leading, you know, lots of different companies, many of which are primary care-focused and value-based focused. And for more than a decade I have looked at Oak Street and followed Oak Street, like many of us have. And it really, over the last decade and even today, serves as probably one of the best examples for value-based care. And I know we're going to get into personalized care and value-based care, but I really do think those two themes are closely, closely tied.

I do want to give a couple of highlights around what I've been up to. I've been in the role for about a year. And as I’ve taken on the role, most of what I've been doing the last several months is listening and learning about the great work and the model that the teams are engaged in, and that's through lots of listening channels as well as visiting a lot of our centers and seeing our care teams in action.

One of the things that we'll touch on, hopefully today, is these are very different models from when we kind of do an air quotes primary care. Oak Street is a purpose-built, care-team model. And really we're taking full accountability for patients and their health, ideally to keep them out of the hospital and healthier. And so, in order to do that, you'll hear me talk a lot about our care team. And well, who is that, right?

So, our care team largely is going to be led by an MD or DO, the physician. And we have, actually now, over half of our workforce are APPs [advanced practice providers], so that's your NPs [nurse practitioners] and PAs [physician assistants] that do tremendous work. But we have a lot of other parts of the care team that I think are relevant to highlight because they're going to help us go through some of our examples today. Those include nurses. That includes medical assistance, social workers, behavioral health teams. And then also actual specific teams to help patients navigate their particular diseases, whether that's diabetes or heart failure. So, we have a pretty robust care team model relative to others. It's a great patient-centered model, but it's also great for providers who actually get all those resources to help better engage their patients in the process.

And then finally, there are results are really driven through the outcomes of quality improvement, but also reducing costs. And I'd love to share a story with you, Matt, if that's all right.

Matt McGuire
Absolutely.

Dr. Creagh Milford
The patient's name is Linda. She's a real patient in Oak Street and she has a great video that brought tears to my eyes. And this is a lovely woman who actually came into Oak Street as a new patient. She had what's called the diabetic ulcer. So, this is where the skin kind of fades away and you have an ulceration on her leg in this instance, really because she had poorly controlled or uncontrolled diabetes. For all the doctors and providers out there listening to the story, you know her A1C, which is our lab test for how well or not well your diabetes is controlled, was 14. So, to put that in perspective, really less than 6-1/2 is normal. And, so, this was really poorly controlled diabetes. She comes in and she asks our provider, hey, I just need a surgical clearance for her ulceration of her leg to have the surgeon do surgery on her leg.

And credit goes to our, in this instance, our NP and the care team in our in our center. They really worked with this patient, built a trusted relationship, brought her back to the center over and over, week over week. And as a result of all that, her blood sugar level, that A1C number, went down from 14, which is very uncontrolled, to less than 7. And that's, frankly, miraculous and doesn't happen often enough in health care. The general health care story would have been, Linda comes into any PCP, she wants to get a pre-surgical clearance, the doctor says, “Yep, sure, you're good to go,” and she goes to surgery, right?

In this case, this was exactly the opposite. And what really our model is founded on, which is we worked with this specific patient, enrolled her in personalized care plans around managing our diabetes. And in this video that we shared with our teammates, she talks about her goal of walking further, walking with her grandkids, taking more time with them, feeling much better. And by the way, she avoided surgery altogether, right? And so that's kind of the power of the model that we have at Oak Street, and that type of story plays out across hundreds of thousands of patients that we serve every single day in our communities.

Matt McGuire
Wow. That is an amazing story, anchored, of course, by the amazing care she received at Oak Street. Thanks for sharing that. So, Dr. Milford, I live in the Chicago area, and I frequently see Oak Street Health clinics as I drive around the city. I’m curious, what factors does Oak Street consider as it determines where to open a clinic? And can you describe the typical Oak Street patient?

Dr. Creagh Milford
Yeah, we, uh, it's grown a lot. The headquarters are in Chicago. I was there a week or two ago. And, so, we have several Oak Street centers in Chicago to your point. But over the last decade it has grown tremendously. So, we have 230 centers, so those are clinics, centers, across 27 states. So, we are covering a lot of different communities. I think there's really important pieces. It goes to my comment of Oak Street as a value-based provider is very different from your kind of typical primary care practice. So I want to share with you a couple of the numbers that hopefully pulls that in a perspective for your audience.

The first is, almost two-thirds of the areas in which we operate are actually what I would call primary care deserts. What that means is that that is a set of communities in areas that for a whole host of reasons, they really don't have access to primary care. So, we intentionally go into those types of communities and serve as the primary care for those communities.

I think the second is around the patient population. So, largely, these are going to be patients who have multiple chronic conditions. Two-thirds, roughly, of our patients have more than two chronic conditions. And almost all of them, it's like 95% have at least one chronic condition. These are generally older individuals, so 69-plus years old. And our average patient has an average of nine medicines, right? If you think… I take a statin every day, that's one. And I have trouble remembering when to take my one medicine. Think about that times nine to manage multiple conditions.

The other component of our patient population we serve in these communities what are called dual eligible patients, and that means I'm qualified as a patient for Medicare and Medicaid. Generally, all the health literature and our own numbers would show that these patients are sicker and have more complex problems.

And I want to highlight a couple of aspects of kind of what we talked about in the care team model as it plays out for the patients we serve. The first is, almost half of our patients have a behavioral health condition. So, what does that mean? Anything from kind of depression to substance abuse, all the way to complex psychiatric conditions. And therefore we actually have integrated behavioral health support within our care team model.

The second, because we operate in these, what I would call underserved primary care desert communities, we find almost half of our patient populations have, we kind of generally bucket these as, air quotes, social determinants of health. Those include things like housing instability, food insecurity, social isolation, which we know now from all the literature, is a driver for not only poor health outcomes, but increased medical costs from patients going more into the ER and the inpatient setting.

And, so, therefore, we've integrated social work as an example to help manage and support not just the medical problems for these patients, but the social problems that actually helps lead to either better or worse outcomes if you can help that patient with things like food and housing stability. So, a lot of details there, but hopefully that gives you a sense of kind of both where we operate, which is nationally and then the complexity of the population that we serve.

Matt McGuire
Yeah, absolutely. And that’s a helpful breakdown on Oak Street’s patients and centers. So, I know a big focus at Oak Street Health is how it personalizes care. You’ve definitely touched on this. Now, many of us feel like we have a good relationship with our doctors, myself included, and we may feel like we’re receiving personalized care. How does the Oak Street model of personalization go above and beyond what a patient might experience elsewhere?

Dr. Creagh Milford
Yeah, I mean, you're right, right? Look to the credit of all the physicians and APPs in our country, by and large, you know, our providers want to personalize care for you, Matt and others. I think what happens in today's world is time and complexity of our health care model distract and fragment the personalization of that care.

And so how we're thinking about it at Oak Street is, number one, you know, each patient should have a personalized care plan. So, I'll pick on Matt, if you are a patient, what is Matt's actual goals, right? And it's beyond the numbers, right? We touched on a whole variety of other issues — whether it's mental health, social work coordination — that actually play directly into you accessing care the right way, being engaged in your care in the right way, and frankly, building a trusted relationship with your care team. So, the first is really honing in on that personalized care plan.

The second is making sure that we're seeing our patients and engaging them much more routinely than perhaps your primary care doc or other docs would be doing. So, on average, our most complex patients are seeing our care teams, on average, about once a month, so 12 times a year, right? And if you kind of juxtapose that against a normal PCP in our in our community, granted they're not taking care as complex of patients as we are, that they would not be seeing the patients as robustly or often as we do.

And then the final piece is, we are very intentional about leveraging the data that we use to understand how we can actually proactively manage patients like Linda, the one we just talked about and others. And so, we use a lot of data that could come from the payors, so claims data, it could come through our obviously our electronic health record, through labs, and imaging, and specialist visits, to understand deeply our population. And we call it risk stratification. All that means is we put all that data together and then understand who is most clinically and financially at risk for having a poor health outcome. And so we start with those folks and then we work our way all the way down the list to every patient that we serve. And within that, we actually specifically tailor our programs to your point of personalized medicine, around each patient's condition.

So, if you have diabetes, like Linda did, there's a whole diabetes team that works with her to control her plan for her diabetes. If you have heart failure, we have a team that works on what's called goal-directed medical therapy to make sure that you as a patient with heart failure gets the right medicines, has the right care plan to stay healthier and frankly out of the hospital.

And when I say that, you know, the health policy people listening to the call are like, oh, we're trying to, you know, just save on costs. Well, yes, that's true. But we're also actually creating healthier lives for the patients we serve. Because I've never met it — I've treated a lot of patients — I've never met a patient who has raised their head and said, yes, I really want to go to the hospital versus staying at home, right? So, our goal is to try to keep patients healthier and at home. And I think that proactive personalized approach helps in the way that we do that for our patients.

Matt McGuire
For sure. Between the personalized care plan, the frequency of seeing patients and then using data to help care for them, that’s definitely taking personalization to the next level. And then with all of this in place, does Oak Street Health track the impact of personalizing care? And if so, can you share what effect personalizing care has on patients?

Dr. Creagh Milford
Yeah, I think for myself and a lot of other leaders in health care, we throw around the term value-based care, and largely that was predicated or defined, you know, by the likes of Don Berwick, Tom Lee and others almost 15 years ago, right? 2010-ish. And what they came out with was we all need to be thinking about the triple aim, right? We've all heard that term. What is that? That is, we as providers, every provider in America, including Oak Street, should be focused on improving quality, improving access and improving affordability for our patients and the health care system. If I think about Oak Street and you know how we personalize care, we hit all of those themes.

And we think very deeply about quality measures. So, we track to your point — how do we track the outcomes? — we track our quality scores on each patient and how we end up improving the quality around three main dimensions.

The first is prevention, the second is chronic condition management, so those chronic conditions that we spoke about. And then the last is keeping patients healthier and out of the hospital, and how we're tracking on readmissions and really that's important and we do a lot of deeper tracking on can we see patients in follow-up in the timely way to keep them if they've been admitted to the hospital and now discharged out of the hospital again and ensuring that they have all that they need from a medication perspective, support perspective and primary care visit perspective to keep them back on their journey to recover to health. As a result of all that, you know, we've been able to reduce hospital admissions inside Oak Street by more than 40% against traditional fee-for-service. So, we're really proud of the work that we've done.

And, you know, that I use the term I've now that I've been CVS for quite a while, you know, NPS or Net Promoter Score is used in all the other industries across America and is relatively new to health care, and we track that on every patient. And our NPS or Net Promoter Score at Oak Street is 78. And to put that in context, anything really over 70 in health care is a world-class score. And, so, we're really proud of not just all the quality measures I just walked through or keeping patients healthier, but actually the patients themselves, what that means is they're very likely to refer and recommend their friends and family to Oak Street because they love the model. So, we're proud of all of those components and I think that, you know, it's a credit to all of our teams across the country that are doing this work, day in and day out for the patients we serve.

Matt McGuire
If Oak Street has a Net Promoter Score of 78, that preventive care, chronic condition management and work to keep patients healthy and out of the hospital is clearly working. So, Dr. Milford, as you approach your one-year anniversary at Oak Street Health, you and the Oak Street teams across the country have accomplished quite a lot, but I imagine you’ve put together a bit of a list. What does the near future hold for you?

Dr. Creagh Milford
Yeah, I think, you know, as one of the leading value-based, primary care, team-based models in America, you know, we're going to continue to lean in to value-based care and demonstrating the effectiveness of value-based care along those dimensions we just talked about. How do we improve quality? How do we improve access? And how do we reduce total medical costs?

You know, if I zoom out for a second, you know, we operate by and large, we do take on fee-for-service traditional Medicare patients. But by and large, we're serving Medicare Advantage. And if we just looked at the trends in Medicare Advantage, you know, over half of our country now is enrolled in a Medicare Advantage plan. So, patients, citizens of the U.S., they love Medicare Advantage, they love the benefits they get from it, and we, as a value-based provider have tremendous opportunity to continue to partner with health plans to deliver better care for the patients we serve.

I think a little bit more tactically, as I think about this year, and then you know three years out a couple things we're doing. We're redoing our entire tech stack, as they say. So, we're putting in a new electronic health record. We're moving to Epic like most of the other provider groups have done. We're really excited about that to provide more collaboration amongst care team members, leverage some of the other facets of Epic.

I think the second thing we're going to be focused on is the patient experience. And, you know, largely a lot of these centers have been built around a community room and being kind of the focal point in that community to serve not just your primary care medical needs, but also your social needs, having social events and so forth. And as we go to digitize and improve our tech stack, our ability to have a portal and have patients get their labs and message with their doctor, all of those components, will be a real unlock for our business.

And then I think the other piece that, you know, I as an internist and I think all of our providers out there, you know, we've got to continue to focus on our provider experience and leveraging the power of our care team model to reduce some of that administrative burden, as the doctors would tell you and providers would tell you in service of creating less friction for how we treat and see our patients.

I do think there's the question you're probably going to ask, which is like, what's the role of AI? We like everybody else are looking carefully at AI. We've rolled out AI in a lot of the different parts of Oak Street and really excited about the opportunity with AI. You know, we look at that as augmenting and supporting the care team but not replacing any of our providers or care team members. And I think that is really is going to afford us better insights into how we manage our centers, how we manage our patients all the way to some of the data complexity of how do we proactively start to get much better at predicting when a patient will be at risk for going into the hospital. So, a lot of opportunity I think with AI across our business.

And so, if I kind of sum all that up, you know, Oak Street was built long ago on this mission of rebuilding health care as it should be. I think that we've demonstrated that this is the right model for these types of patients in these communities. And I'm really honored and humbled to serve in this role to help push our mission forward over the next few years and continue to serve as the leading value-based provider organization in the country.

Matt McGuire
I really like the sound of that. Dr. Milford, as always, it has been a pleasure talking with you. I really appreciate you stopping by. Thank you.

Dr. Creagh Milford
Great. Thanks for having me.

Matt McGuire
And a big thanks to you for tuning in to this episode. Until next time, I'm Matt McGuire. I look forward to joining you again to get more big questions answered.