A Conversation With SCAN's Joe Kimura, M.D., M.P.H.

Joe Kumura, M.D., M.P.H.

Joe Kimura, M.D., M.P.H., was named chief medical officer of the SCAN Group in Long Beach, California, in April 2025. Before SCAN, Kimura was the chief medical officer at Somatus, Inc., a value-based care company for kidney and cardiovascular disease, and at Atrius Health, a multispecialty medical group in Massachusetts, where he led a number of value-based care initiatives, clinical analytics and digital health solutions. Kimura has an M.D. from Washington University School of Medicine and an M.P.H. from Harvard University. He completed his primary care internal medicine residency at the University of California, San Francisco (UCSF).

The SCAN Group operates SCAN Health Plan, a prominent Medicare Advantage plan with more than 300,000 members in California, Arizona, Nevada, Texas and New Mexico.

Peter Wehrwein, managing editor of Managed Healthcare Executive, conducted this interview. The transcript has been edited for clarity and length.

In broad strokes, your career has been on the East Coast, in Massachusetts — Harvard Vanguard, back in the day — and more recently, Atrius Health and Somatus. What have you discovered about the difference between how healthcare is organized and delivered in Massachusetts compared with California?

I did my clinical training out here, right at UCSF, but I also actually practiced at Southern California Permanente down in Irvine, so I do have a sense of how medicine is practiced on the West Coast versus the East Coast. Although I think we like to think of ourselves in Boston as progressive, there is a very high utilization of specialty care in Massachusetts. In California, there is a very strong sense of the role of primary care and the fact that primary care is the foundation. I think primary care clinicians [in California] — pediatricians, internists, family medicine —we prided ourselves a little bit more on being able to provide really outstanding clinical care and leveraging our specialists when needed, when

Boston's Longwood medical area

things obviously did get complex or super complicated. In Boston what I discovered is that there is an almost reflexive utilization of specialists that happens. I remember, literally, maybe my first or second month practicing as a PCP [primary care physician] in Boston, and we had our mentors that were assigned to us, and a senior clinician said, “Well, you know, some of these blood pressure patients, you should just send to nephrology.” And I turned to him and said, “Why would I send that person to nephrology? I mean, I know the guidelines. I know these medications. I could manage this overall. I don’t need to refer to nephrology.” And his response was, “Well, I mean, that’s OK, but that’s kind of what we do. That’s the community standard around here when you get to a certain level.” I think that told me a lot about the differences in medicine.

I’m biased. I am a primary care physician. I would say that primary care should be expected to do a great job with our patients around all those Barbara Starfield initial elements: first contact, comprehensive, patient-centered care.

But both the West and East coasts are now having challenges with — I hate to call it burnout — the administrative overload, all these things that are really making it challenging for folks to do outstanding care. That’s one thing that both the East and West Coasts have in common at this point in time.

Let’s just talk about primary care and managed care. In the first iteration of managed care, the primary care physician was supposed to be the quarterback. But then managed care became less managed. In the context of managing care— which is to say, efficient use of resources — where does the primary care physician fit in? In 2025, is he or she still the quarterback? And for people like me who experience healthcare as a patient, you’re really dealing with the physician assistants or nurse practitioners. You don’t necessarily see a doctor.

I think there is evolution. It’s being driven by many different forces: the human capital shortages, the administrative burdens, etc.

But I would make a distinction between capital P primary care and little P primary care. I think primary care physicians are critical to maintaining that really important function of trying to be sure that care is clinically knitted together, particularly for our seniors, when things get complex and the ability to thread the medicine with patient needs and wishes becomes really, really critical, because sometimes they do start conflict with one another. But from a little P perspective, I would say it’s back to those core principles that Barbara outlined for us.

As much as we’re trying to shift toward preventive care, to try to be proactive, to try to say, “Let’s get things going before they get bad,” we’re still in the middle of it, where probably the majority of care that most people receive, when they’re saying, “Uh oh, something doesn’t feel right. I don’t feel good. Something’s happening. I need to go and get reactive care.” [We need to make sure] that primary care is available and accessible to start to have the conversation.

There’s a lot of discussion around what technology can do. Maybe these AI [artificial intelligence] symptom checkers can start to jump in and do things. But one of the critical things that humans can do that computers still haven’t figured out how to do is tell when someone actually is not quite telling the truth — when the patient says, “Nope, I don’t smoke.” And yet there’s a sense of smoke in the exam room. All of those moments — how do I bring that together, recognizing that the patient is presenting in a particular way, and I need to maintain their autonomy, their dignity, while also trying to make sure I come up with the best clinical plan for that patient?

I think primary care is evolving in many ways to try to handle these things, but that core function that has been demonstrated again and again and again to create that value, particularly in fragmented, complex care — I think that is durable. I think it’s going to look different going forward, but the little P primary care continues to be a critical part of the healthcare system that we need to reinforce and make as accessible as possible to the population.

You said you think primary care is going to look different going forward. How so? We’ve been talking about team-based care for decades.

Tom Bodenheimer at UCSF has written a ton about this — the medical home, the different layers, who’s on the first floor, who’s on the second floor, etc.

I think there are a lot of new capabilities that one could argue should start to increase access to certain types of knowledge and capabilities. This is a co-evolution of both the provider side as well as the patient and population side.

I think patients are, for better or for worse, being forced to explore lots of different alternatives as access has been challenging. They need care, so they are jumping to different sources, as the medical profession is struggling to keep up with that demand. That’s forcing some really innovative thinking. How do you actually access the things that you need?

To your point, about seeing my PA [physician assistant] or my NP [nurse practitioner] rather than the physician: There should be a really good triaging capability that matches the clinical skill set and background with the needs that you have as a patient.

I’m the first to say that you can have a fresh physician coming out of residency, and you can have a nurse practitioner who specializes in geriatrics with 25 years of experience. I would submit that for 80% to 90% of the things patients need, that experienced geriatric nurse practitioner can pretty much handle most of those things. It’s not based on your title or necessarily your schooling but, definitely, your experiences and capabilities. We are still in the infancy of trying to match resources with the needs of patients to the true capabilities that providers have or the system has and matching them in the most resource-efficient way.

You’ve probably seen those classic papers. I always reference that Scientific American article by Sidney Garfield that had that diagram that said, “population needs,” and there is a computer in the middle that is figuring out what is needed and then is triaging to nurses, to dietitians, to nutritionists and to physicians to make the system more efficient.

To your point, that was, what, 50 years ago, and we’re still trying to make that model work. Conceptually, it makes sense, but I think we’ve stumbled a lot on the execution. I think that’s something that we’re really focused on at SCAN, trying to get that execution up to par, to really get the breakthrough outcomes that I think our membership and our seniors deserve. I am super excited to be on that mission.

Let’s pivot to SCAN. What does the chief medical officer at SCAN do?

I try to think about clinical issues across the realm. When we are thinking about the clinical needs of the population, are we putting together the right systems, programs, and capabilities to be able to achieve the highest level of outcomes we can? There are standard statistics that we use to measure some of these things. We still continue to have a high readmission rate for acute care hospitalizations. Why is that? Why are we stumbling around with transitions of care, and why are still one out of 10 or one out of five folks coming back to the hospital within 30 days? There are things that we, as clinicians and as a clinical enterprise at SCAN, are committed to really leaning in and figuring out what we can be doing differently and better to try to get those outcomes to best-in-class space.

I’m coming with the clinical [view] in mind. And of course, I’m biased. As a physician, I’ve got the medical side thinking, “OK, I’ve got to get timing, medications, things titrated,” but also, I fully know that some of it is around care coordination; some of it is the health-related social needs that are blocking my ability to execute on this stuff. Some of it is as simple as transportation. But how do you wrap all that stuff together? As a health plan, trying to be sure that we are providing that in a reliable fashion across our population is something that I feel like I am championing.

My chief financial officer and my chief experience officer — we need to be working together on this because I could spend a lot of money trying to chase things. I have to make sure this is a sustainable enterprise. I also can throw a lot of different things at the member or the patient. I need to make sure I’m titrating that with what that member’s experience is. We’ve got to try to figure out how we do that in the most effective way possible.

My role is to champion the clinical side, to try to drive those outcomes fully, knowing I am part of a great executive team.

Can you talk about — try to be nice and concrete — what you’re working on most immediately?

I am working on trying to figure out the best way to match our members’ needs, clinically and otherwise, with the portfolio programs that we’ve got currently available within the SCAN Group overall. I think there is a need for us to be sure that there’s a strong clinical voice prioritizing — I don’t want to call it triaging, because it’s not always the clinical side that dominates. We are fortunate. We have oodles and oodles of great programs that are out there, but sometimes getting our patients engaged and attached and introduced to these programs when they need them can still be a hurdle.

One of the big first things I’m trying to do is help organize our clinical team to make sure that the rest of the operations — the call center and everybody — has a road map to “when do I activate x for member y, and when someone’s eligible for multiple different programs, how do I make sure that they’re set up in the right way and I’m not picking the first one that comes up?” We’re trying to infuse and introduce clinical logic to try to make sure that’s being prioritized in the best way possible.

So that’s probably one of the first things, to be sure that we’re taking advantage and executing on these great programs that have demonstrated outcomes, but we have got to get the right patients into them.

When you say “program,” can you give mean example?

So two examples that are kind of classic are case management-type programs, and then there are the transitions-of-care programs — the things that we have to do reliably when people leave the hospital: make sure that their medications are OK and make sure that they’re following up with their provider. All that needs to happen, best in class, within three days. A lot of us settle for getting all that done within the first seven days post discharge.

But that program, in and of itself, if you try to do that for every patient coming out of the hospital, you would be overwhelmed at this point. So who are the patients that really need that? There is the ability to do that by telephone. There is the ability to do that by sending someone to the home. That’s a more resource-intensive intervention, and yet some people really need that kind of intervention. So we need to figure out how to sort through that population of people coming out of the hospital and identify the most efficient way to [use those resources].

Case management is similar. You’ve seen the classic population health pyramid. At the top are the highly complex patients. Where in that pyramid do you sort?

Overall, one of the big things that we’re trying to do more of is get to the vector of change. So who’s rising and elevating in risk because there’s something dynamic happening in their care or in their lives? When are the moments when we can jump in and really begin to help to be sure that new trajectory is as optimized as possible? How do you find that in the data and the information that we’re putting together working with our providers, and then how do you plug that patient into those kinds of programs going forward?

SCAN has been in the news because of this new partnership with Sutter Health. How has that partnership affected your role at the company?

I begin by saying it’s a super exciting evolution in how we think about providing this kind of outstanding care. I have known about Sutter for a long time, from my Harvard Vanguard days. We were at many conferences together, so I am very familiar with the leadership and capabilities that the system brings to bear.

Combining care and coverage in a more progressive way and trying to figure out how they can complement each other in a way that is better than how each individual company or enterprise has been able to do — that is super exciting. And I have found that just during my short time here, leaning in and working with my colleagues at Sutter, there is a lot of excitement about trying to break some of those barriers and create some really innovative new ways to go upstream, particularly around the member population that they’re trying to serve, to try to grab and implement a lot of the preventive care much, much sooner.

Sutter actually does a really great job with that top of the pyramid. They’ve got really great complex care management, and their performance and their statistics show that. But they say where we could work better together, it’s around that rising risk, and how do you engage the patient sooner, activate the patients, so that they, too, want to get some of that early preventive care that we know can make a difference? Those are the areas that we, as the health plan and working together with Sutter as a delivery partner, can really start to think differently about. That’s exciting to do. It’s a fun thing for me to think about as we’re jumping into this particular role.

Not everyone in the SCAN markets has [access to] Sutter. One of my jobs is to think about how I take those learnings and make sure that other membership geographies within SCAN are benefiting from that as much as possible.

At the federal level, much of the action has been in Medicaid and drug pricing; Medicare Advantage has been in a relatively safe harbor and there was a favorable rate determination. So I’m wondering what aspects of federal politics and policy are affecting SCAN and your role at SCAN.

I’m early in my tenure, so it would probably be premature for me to wax poetic too much on some of the headwinds that face us. Now, that being said, I think some of the things we’re working on have been somewhat ubiquitous. We’re thinking about the increase in total cost of care trends and, obviously, the increase in particular pharmaceuticals, such as Part B drugs.

I think that as Medicaid benefits are challenged going forward in our population, with our duals, we’re going to have a lightening, potentially, of some of the support services. Thethe state’s capabilities will also shift, undoubtedly, in those areas. What do we need to be able to support, given the criticality of supporting some of these things? Even with the world’s best clinical care plan, you can’t get to that if these barriers are not met.

We are continuing to aspire to drive the bar higher and higher, recognizing that some of these headwinds are continuing. I think SCAN is very bullish about what we can do and continue to differentiate ourselves to provide services that bring the member to the forefront, particularly our geriatric seniors, to try to make sure that they are supported to get the best possible health that they deserve. We’re leaning into that.

Yes, there are choppy waters all around, but some of the basic stuff we’re continuing to plow forward with, and we’ll focus on getting the blocking and tackling done really well to be sure that we are providing those services to our membership as best as possible.