Relentless Health Value (Stacey Richter)

In this health care podcast, I talk with Brian Scott. Brian has a background which is perfect for the question of “Will employer health care costs go up or will they go down as a result of this pandemic?” First, Brian was an underwriter at United. Then he was in a dedicated complex claims group for Lockton that managed self-funded plans. And now he’s at Point6 Healthcare, where he works to put together the best-value plan for employers, including getting stop-loss. Brian works with TPAs (third-party administrators) across the country to this end.

So, this conversation that I had with Brian is a two-part affair: The first episode (episode 275) was mostly about the specific additions as a result of this pandemic used in cost models and also what some self-insured employers are doing or considering doing to address the underlying risk factors that might help drive up costs in a plan. This, however, is episode 276; and it includes Brian’s advice for self-insured employers, as well as a look into the fully insured market. Why there have been those estimates that costs will go up 4% to 40% when premiums are re-upped, Brian has some thoughts. 

You should definitely listen to both episodes (275 and 276), although you probably don’t need to listen to them in order if you just happened to hit on this show first.

You can learn more at point6healthcare.com and brian.scott@point6healthcare.com. You can also connect with Brian on LinkedIn. 

Brian Scott is an assistant vice president at Point6 Healthcare. He joined the team in 2019 to implement and lead a new type of ICU related to self-funded employers focused on implementation, consulting, and underwriting strategies on behalf of self-funded benefits plan sponsors. Point6 is an authority on employer-sponsored self-funded health care financing and risk transfer strategies in the United States and maximizes the value of interactions between those providing, receiving, and financing health care.

Brian has also worked as the strategic consultant for a major consulting firm specializing in employer stop-loss and cost-containment strategies, where he managed administrator and carrier relationships and opportunities, risk transfer strategies, and self-funding overall, while growing a team to ultimately handle stop-loss placements nationwide. Prior to that, Brian worked as a senior underwriting consultant for a BUCA managing stop-loss negotiation and placement, administration, and pharmacy pricing for large and complex self-funded, fully insured, and HMO cases.

Brian works to maximize employer strategies for managing high-cost claimant risk, focusing on opportunities to enhance plan designs, administrator-specific gap avoidance, and cost-containment processes. Brian has assisted with the formation of medical stop-loss captives, merger and acquisition risk coverage strategies, fully insured to self-funded conversion strategies, and reference-based pricing and alternative funding concerns as well.

02:48 What health care costs and revenue look like further out—2021.
06:13 Can and will employers meaningfully impact the price of care?
07:59 “A lot of it has to do with, ‘Who do I receive direction from?’”
10:54 The fully insured market vs the self-insured market.
14:15 The cost of care for COVID-19 cases and the cost of care for cases that turn out not to be COVID-19.
14:41 “Provider billing behavior is going to be impacted well beyond COVID.”
16:02 Covered California in the time of COVID-19.
17:15 Does a fully insured carrier have the incentive to cut costs?
17:40 What will happen to fully insured carriers who can no longer raise premium costs to cover COVID-19 costs.
19:13 What self-insured employers shouldn’t be doing right now.
20:07 Examining cost vs value of care.
23:42 “How can you create the best chance that you’re not going to have really big outlier costs on your plan?”
24:35 Where the name Point6 Healthcare came from.

You can learn more at point6healthcare.com and brian.scott@point6healthcare.com. You can also connect with Brian on LinkedIn. 

Check out our newest #healthcarepodcast with Brian Scott of Point6 #Healthcare as he discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

What health care costs and revenue look like further out—2021. Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

Can and will employers meaningfully impact the price of care? Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

“A lot of it has to do with, ‘Who do I receive direction from?’” Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

The fully insured market vs the self-insured market. Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

“Provider billing behavior is going to be impacted well beyond COVID.” Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

Does a fully insured carrier have the incentive to cut costs? Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

What shouldn’t self-insured #employers be doing right now? Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

Examining cost vs value of care. Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

“How can you create the best chance that you’re not going to have really big outlier costs on your plan?” Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

What’s the cost of care like for cases that aren’t COVID-19? Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing

Ashok founded Centivo in 2017 after observing the inefficiency in the health care system and the pain that has resulted for employers and employees.

Prior to Centivo, Ashok co-founded Liazon, operator of the nation’s industry-leading private benefits exchange for active employees. Liazon was acquired by Willis Towers Watson in 2013, and after the acquisition, Ashok served as managing director for Willis Towers Watson’s Group Exchange business. Prior to Liazon, Ashok was an associate principal at McKinsey and Co., where he served as a leader in the firm’s health care and private equity practices.

​In addition to his role at Centivo, Ashok serves as an independent Board director at Artemis Health as well as a senior adviser to Silversmith Capital, a growth equity firm.

Ashok received his undergraduate degree from Princeton University, a master’s degree from Stanford University, and an MBA from the Stanford Graduate School of Business.

Here’s a vital question, “How do you make sure that the physicians your employees or members are seeing are high quality in a given area of focus?” Getting to the right doctor matters when you consider that something like 70% of back surgeries are unnecessary and medical errors are the third leading cause of death in this country. And also because, as Suzanne DelBanco put it in EP224, if a payer simply cuts out the bottom performing 10% of practices, the returns are outsized from a cost and quality perspective. The challenge is how to actually accomplish this. How to measure quality in a sea of dirty data and noise and whatever the opposite of interoperability and aggregated data sets is. With the confounding factor also that outcomes are rarely if ever included in data sets, especially when you consider that the outcomes that matter to patients are really the outcomes that count.

Today I speak with Suzanne Clough, MD. In a former life, Suzanne was a co-founder of Welldoc, the first FDA-approved digital health platform and also featured on EP102 of this podcast. Now, Suzanne is the chief-medical officer over at ArmadaHealth, a company that aims to become a GPS for health care helping to get patients to the right doctor quicker.

You can learn more at www.armadahealth.com

Dr. Suzanne Sysko Clough, MD, is Chief Medical Officer of ArmadaHealth, a health and data science company that navigates consumers to quality health care providers using big data, AI, and proprietary quality algorithms that together produce 360-degree profiles of physicians. The platform enables precision matching of physicians with patients based on diagnosis/condition and nonclinical attributes. Before ArmadaHealth, Suzanne was a co-Founder and Chief Medical Officer of WellDoc, the first FDA-approved digital health platform. Dr. Clough completed her medical training in internal medicine and a fellowship in endocrinology at the University of Maryland Medical Systems and served as an assistant professor in the Division of Endocrinology as well as Medical Director and as the Founder and Medical Director of the Center for Weight Management and Wellness.

This episode is a tale of what happens when some employers decide to open up a few virtual front doors and when these virtual front doors lead only to referrals to providers who are willing to be accountable and offer financial predictability. That’s what these employers want, after all. They want accountability and financial predictability.

Many employers now have access to all claims databases and other data like the RAND 3.0 report. Therefore, employers can and are using this information in a big way to steer their plan member populations.

Given these goings-on, some slower-moving providers could easily find themselves on the outside looking in. So, who are those providers who are or will be getting shut out of referral flows? They’re definitely FFS-centric, but they could be a large health system, an urgent care center, or a hospital-owned PCP.

In this health care podcast, I speak with Jeff Hogan, the northeast regional manager for Rogers Benefit Group and also president of Upside Health Advisors. We talk in this episode not about what might be theoretically possible but about what is happening right now.

You can learn more at jhogan@rogersbenefit.com and connect with Jeff on LinkedIn.

Jeffrey Hogan is the northeast regional manager for Rogers Benefit Group, a national benefits marketing and consulting firm. Jeff has been with Rogers Benefit Group for 30 years. Additionally, Jeff operates a consulting firm, Upside Health Advisors, where he provides expert witness services on health care–related litigation, is a consultant to payers and large provider groups for product development and launch, and is a resource to employers desirous of implementing strategies to manage their health spend. Jeff is focused on health care payment reform, health policy, care coordination, value-based health care, health care quality, and precision medicine.

Jeff regularly appears on national forums focused on moving to value-based health care and is actively working to promote health care–related transparency measures in the market. He serves as the group’s liaison to the National Alliance of Healthcare Purchaser Coalitions. Jeff is the regional leader for The Leapfrog Group. He is also one of the coordinators of Connecticut’s Moving to Value Alliance.

01:43 What are self-insured employers doing right now to impact referral flows?
03:29 Are any virtual tech companies moving in on the local provider space?
07:46 “What we’re trying to do … is to help the member have the best outcome.”
10:32 “It’s a continuum, if you will.”
10:44 “There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence].”
11:13 “What is value for employers coming out of COVID? Accountability and predictability.”
13:40 What are second-order effects?
14:29 “People like and want better access.”
14:46 “Fee-for-service providers fear the informed health care consumer.”
22:19 “Many of the brick-and-mortar providers are realizing that they have to up their game.”
24:52 “Things will change.”
25:07 “People not only want convenience, but they want safety, they want data.”
26:11 “We are at an inflection point … After 35 years in the business, I really finally feel like we’ve broken through.”
27:31 “This requires people to really think; it requires employers to actually know what their biggest problems are.”
29:53 “We can’t go back to the fragmentation of fee for service.”
30:25 “Data is critical.”

You can learn more at jhogan@rogersbenefit.com and connect with Jeff on LinkedIn.

Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

What are self-insured employers doing right now to impact referral flows? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

Are any virtual tech companies moving in on the local provider space? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“What we’re trying to do … is to help the member have the best outcome.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence]” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“What is value for employers coming out of COVID? Accountability and predictability.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“People like and want better access.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Fee-for-service providers fear the informed health care consumer.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“People not only want convenience, but they want safety, they want data.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“We are at an inflection point … After 35 years in the business, I really finally feel like we’ve broken through.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“This requires people to really think; it requires employers to actually know what their biggest problems are.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“We can’t go back to the fragmentation of fee for service.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Data is critical.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

Stacey is co-president of Aventria Health Group, a marketing agency specializing in helping pharmaceutical, device and pharmacy clients gain access to patients by creating and leveraging partnerships with other health care organizations. For twenty years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders, and most of all the patient.

02:15 Tip #1: Think ahead of time about what unique expertise listeners want to hear from you.
03:00 “People like to buy, but they don’t like to be sold.”
03:15 Insights from Annette DuBard of CCNC, Josh Benner of RxAnte, Eric Grossman of NextHealth, Soheil Saadat of GenieMD and Friendly, and Lisa Erwin of Aventria Health Group
05:50 Tip #2: Tell stories.
09:15 Tip #3: Explain the Why.
10:00 To avoid confusion, take it one whole answer at a time - just talk about the problem, just talk about the solution.
11:20 Lessons learned from “Same Side Selling,” by Ian Altman.
12:45 Get to the problem first.
13:00 Tip #4: Make sure your back story is unique and meaningful.
15:00 Tip #5: Test your sound quality ahead of time.
16:20 The best places to find good sound quality.
16:50 Skype test calls.
17:30 Surprisingly noisy everyday-sounds that wind up in recorded audio.
19:45 Tip #6: Give actionable advice.
20:15 Tip #7: Make it a conversation.
20:30 The more often speakers switch, the higher the baseline interest level.
22:00 “Begin at the beginning, and go on till you come to the end: then stop.” - Lewis Carroll, “Alice’s Adventures In Wonderland”
22:30 Don’t read from a prepared statement - you’ll sound like you’re reading something.
23:15 Pause after each thought and leave a cliffhanger.
24:30 Tip #8: Tell the interviewer in advance what you want to talk about.
25:20 Tip #9: If the show is edited, feel free to pause.
27:15 Uh, um, sort of, sorta: Easy to edit, don’t sweat it.
28:45 Make sure to check out next week’s regular podcast episode, which airs on Thursday, July 7th.

David Perez is the founder and CEO of Seamless Medical Systems and the inventor of the innovative SNAP Practice patient engagement platform. He is a successful and creative entrepreneur who has been working in the Internet industry for 20 + years. Throughout his career David has been at the forefront of innovation and change. In the early ‘90s he started working in the new field of internet marketing, 1999 founded a digital Hispanic marketing company and 2011 saw the opportunity to bring medical practice waiting rooms into the 21st century creating SNAP on the iPad.

Prior to Seamless Medical Systems David started a number of New York City based businesses including: Lumina Americas a digital marketing agency serving the US Hispanic and Latin American markets; Latin Force Ventures a internet incubator and The Latin Force Group a US Hispanic focused marketing services company. He has worked with a variety of clients including: Kraft Foods, Nickelodeon Networks, MTV, The NFL, Nike, Wells Fargo Bank and others. Before entering the world of marketing David spent 10 years in the investment management industry with Dean Witter Reynolds and Wells Fargo Asset Management.

David has been a featured speaker at numerous industry conferences and recently spoke at TEDx Acequia Madre (http://www.youtube.com/watch?v=PkjPZB_lWdU) and IdeaMensch. He also gave the 2007 commencement address to the University of Vermont School of Business.

David is a graduate of the University of Vermont .

You can find out more at seamlessmedical.com or email David at David@seamlessmedical.com.

Three transparency rules have come out of CMS in the past months. My guest in this health care podcast, Jeff Leibach, calls these three rules three steps on a ladder. They build on each other.

The first rule was announced last year, and it was for hospitals to post their chargemasters. You could consider this a baseline step. It’s not really all that useful in practice as many discovered.

The next step on the ladder (which is coming out on 1/1/21): Providers (hospitals) for all services have to post a machine-readable file—all of their negotiated rates for all service categories. They also have to post a shoppable service file and/or some kind of patient estimator tool so patients can estimate the cost of the most shopped services.

Then there’s the payer rule. This is more comprehensive than the provider rule, and the payers have some extra time—actually, they have an extra year (till 1/1/22). But basically, payers have to comply at a higher level. They have to allow price shopping across all sites of care.

My guest in this health care podcast, Jeff Leibach, is a director with Guidehouse in the Healthcare Practice. He focuses on how health care services are priced and paid for, working with a lot of payers and providers. Thus, he is the perfect person to discuss these transparency rules with because of his deep knowledge of payers and provider contracting and also how pricing impacts patients, employers, and stakeholders across the industry.

Jeff and I get into these three transparency rules and their likely impact and also kind of their philosophical underpinnings. We also talk about what might happen with them under a Biden administration. After our conversation, I started to think about these transparency rules in the broader context of what’s going on in the health care marketplace.

There’s kind of a constellation of market factors, and these market factors increasingly seem to be necessitating hospitals and ambulatory practices to really differentiate themselves in ways that employers and patients/consumers care about. I mean, these CMS transparency rules for payers and hospitals are but one thing that is going on. But these rules ultimately mean that it’s easier for patients and employers to price shop. It also makes it easier for employers to narrow their networks and exclude providers.

Consider this impact and then think about how that fits with the ONC TEFCA (Office of the National Coordinator for Health Information Technology Trusted Exchange Framework and Common Agreement) rule. So, that ONC TEFCA rule means that it’s gonna be a less effective tactic to prevent network leakage by hoarding patient data. So, if patient data is portable, patients can seek out the best care provider without the friction of some kind of PHI (protected health information) transfer.

Okay … so now prices are available because of the transparency rule, and patients can walk more easily because of the TEFCA rule. So, these two together could be a forceful combination.

We also have the rise of consumerism. I just saw a study the other day kind of validating that consumers are voting with their feet if a provider does not meet the quality of care, the supportive patient experience that they believe could be found elsewhere. And add to that the at-risk PCPs (primary care providers) cropping up in various concentrations across the country.

But then also, you’ve got payers buying PCPs. And what that means is that you get these PCPs who control the referral flow, and they’re taking an active interest in the downstream costs and population outcomes of specialists in their referral networks. So, you’ve got specialists who maybe lack processes to minimize inappropriate care or who do not deliver consistently high patient experiences and outcomes. They could easily get excluded from those referral flows.

So, you take all these things together—the transparency, the ONC TEFCA rule, consumerism, and the disruption of certain referral flows—and, if you ask me, I think all of this together means that providers who are more commodity and less brand may need to consider ramping up their Triple Aim endeavors.

You can contact Jeff at jeff.leibach@guidehouse.com. You can also connect with him on LinkedIn and Twitter.  

Jeff Leibach, MBA, is a director with Guidehouse’s Healthcare Practice. Over the last decade, Jeff’s main area of expertise has been in developing and implementing managed care solutions for payers and providers. These solutions include development of several analytic solutions, alignment of clinical and financial models, and negotiation training and preparation. Jeff has significant experience building and leading teams to deliver complex analytical tools to quantify opportunities into business strategies for clients. Jeff currently leads Navigant’s Strategic Pricing and Revenue Rebalancing Solutions for Navigant.

Prior to his consulting career, Jeff led national nonprofit Camp Kesem, a summer camp for children affected by a parent’s cancer.

Additional information: Price Transparency White Paper and 2019 Massachusetts Attorney General Report

05:31 What are the two pieces to the new transparency rule going into effect on January 1, 2021?
06:58 “Any negotiated rate … is required to be disclosed.”
07:43 What’s the payer rule, and how does it differ from the hospital rules?
10:24 Where are direct comparisons going to come in most useful with transparency rules?
11:16 How does CMS intend these rules to be used?
14:34 “I anticipate employers having a newfound power here.”
17:27 Why is there opposition to transparency in health care?
18:27 “The administrative burden is real.”
21:03 “I think commoditized is a word we’re going to hear a lot more.”
22:55 Where is CMS headed under a Biden administration?
26:22 What barriers can tech help break down, and what other opportunities are there for tech right now?
28:49 What should payers be preparing for right now?

You can contact Jeff at jeff.leibach@guidehouse.com. You can also connect with him on LinkedIn and Twitter.

@jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

What are the two pieces to the new transparency rule going into effect on January 1, 2021? @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

“Any negotiated rate … is required to be disclosed.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

How does CMS intend these rules to be used? @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

“I anticipate employers having a newfound power here.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

“The administrative burden is real.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

“I think commoditized is a word we’re going to hear a lot more.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

Where is CMS headed under a Biden administration? @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency

Lauren Vela is back on the pod today with a summer short that originally was a section of episode 406 that, unfortunately, I had to cut. It was a little bit tangential to the “why with the employer inertia” theme that the original episode was about. But tangential does not mean unimportant. This clip has some really critical insights on a different topic that may or may not to a greater or lesser degree contribute to inertia. And I’m gonna call this other topic the benefit design that most employees might ultimately be the most satisfied with might not be the one that they are explicitly asking for.

Let’s start with three kinds of market research insights that Lauren Vela, my guest in this healthcare podcast, uncovered when interviewing friends and neighbors not in the healthcare industry about their benefits:

1. Nobody reads their benefit information.

2. They are unhappy with their benefits.

3. The most important thing for them is to have choice. They want to avoid the notion of “managed care.”

In thinking about this, I was reminded of a Henry Ford quote: “If I asked my customers what they wanted, they would have told me a faster horse.”

Or Steve Jobs famously said, “Some people say, ‘Give the customers what they want.’ But that’s not my approach. Our job is to figure out what they’re going to want before they do.” Jobs’s whole thing, after all, was that true innovation often comes from anticipating customer needs and desires before they can articulate them themselves.

So, let me reconcile Lauren’s findings when she interviewed people about what they want in their benefits and what Henry Ford and Steve Jobs have to say about the matter.

First of all, patients/plan members—most people have never experienced a comprehensive primary care situation where they are assisted in finding the highest-quality specialists or sub-specialists and have their care coordinated. They have never had someone worrying about them in their “in-between spaces,” as Amy Scanlan, MD (EP402), put it, between appointments. This is all just a fantasy. It is a reputed Shangri-la that almost no one has ever seen with their own two eyes.

But what many have seen—I have; you have—are narrow networks in which cost containment is wielded like a brute-force weapon, where, for example, the NCI-designated cancer centers are out of network as a way to make sure that people with cancer don’t sign up for your plan … or don’t last long on your plan if they do. (Did I say that out loud?)

Do I sound like I suffer from a brutal lack of trust? Yes, I do—and I was just role-playing there an employee probably pretty accurately.

Most of us remember the HMO a-go-go years when your PCP was an administrative gatekeeper and you had to see them to get a specialist appointment—except you never could see them. Wait times were weeks or months, obviously by design, right?

But this way-too-expensive PPO model is the devil I know because, even if it totally sucks, it’s better than the conspiracy theories and/or accurate or exaggerated recollections of other options.

Here are my recommended next steps. Listen to the shows with Vivek Garg, MD, MBA (EP407), and Scott Conard, MD (EP391), and Douglas Eby, MD (EP312), as a start. All three make it really clear that advanced primary care—maybe even direct primary care—can not only save money, but it also can produce better health and patients are super happy and usually clinicians, too. It’s like a quadruple aim home run.

But none of this can happen if we say “integrated care or advanced primary care and you have to go there to get a referral” and then leave whatever that means up to employees’ or plan members’ imaginations. Communication is really required here, as it is when rolling out most new things—not just cars or cellular telephones.

You can learn more about Lauren’s work by connecting with her on LinkedIn.

Lauren Vela is a passionate advocate for a more rational and sustainable healthcare system and recognizes the influence had by employers and other commercial purchasers through their oversight of employer-sponsored insurance plans. As an independent consultant, she partners with entities that are committed to changing the ineffective status quo.

Previously, Lauren was the director of health care transformation with Walmart, where she partnered with the Walmart Benefits team to identify solutions concerning low-value care, site of care, and vendor evaluation. Prior to her tenure at Walmart, Lauren led market strategy and member initiatives for the Purchaser Business Group on Health, where she cumulatively spent two decades working within various healthcare sectors, including health information technology, provider organizations, and pharmacy benefit management. Lauren also served, for seven years, as the executive director of the Silicon Valley Employers Forum, a trade association of high-tech employers collaborating on innovative delivery of both domestic and international benefits.

05:15 Do employees really understand what it means to have integrated care?

06:57 Why employees want choice and avoid the notion of managed care.

07:15 “I’m not sure that Americans really know what would be better.”

07:19 What would be a better way to do integrated primary care in America?

08:04 How do you fix it without disrupting what everyone thinks would be better?

You can learn more about Lauren’s work by connecting with her on LinkedIn.

@laurenvela1 discusses #employeebenefitdesign on our #healthcarepodcast. #healthcare #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon

Ram Raju, MD, brings vast executive leadership experience and a keen understanding of New York’s health care delivery system to Northwell Health. As senior vice president and community health investment officer, he evaluates the needs of Northwell’s most vulnerable communities and provides solutions for them by collaborating with community-based organizations. He’s responsible for promoting, sustaining, and advancing an environment that supports equity and diversity, and helping the health system eliminate health disparities.

Prior to Northwell, Dr. Raju served as president and CEO of NYC Health + Hospitals from January 2014 to November 2016. Dr. Raju also served as CEO for the Cook County Health and Hospitals System in Chicago, the nation’s third-largest public health system, where he improved cash flow by more than $100 million and changed the system’s financial health during his tenure from 2011 to 2014.

Dr. Raju served as vice-chair of the Greater New York Hospital Association and currently sits on the boards of numerous city, state, and national health care organizations, including the American Hospital Association, the New York Academy of Medicine, and the Asian Health Care Leaders Association.

Dr. Raju earned a medical diploma and Master of Surgery from Madras Medical College in India. He underwent further training in England, where he was elected as a Fellow of the Royal College of Surgeons. He later received an MBA from the University of Tennessee and CPE from the American College of Physician Executives.

James is the founder and managing director of Fitzroy Health, a leading international health care investment and commercialization firm. He has served as an executive, entrepreneur, and investor in health care firms across numerous international markets. James sits on the boards of RJ Health Systems, DosedDaily, Salute Safety, and Flex Health. He was awarded Entrepreneur of the Year at The Wharton School 2009 WEC Expo and has been profiled by the Financial Times. James holds a BA from The University of Melbourne and an MBA from Columbia Business School.

One way to spot a flash point is to notice when people are using different words to describe the same concept. Throughput is one example of this.

On one side of the table, you have those who grasp that if a provider organization is concerned about patient outcomes, with few exceptions, building relationships with said patients is essential. It’s not entirely clear to anyone anywhere how you manage to build relationships and trust without spending a certain amount of time with patients. These “we need time with patients” people will bring up the Quadruple Aim issues that arise from rigid 7-minute appointments or even 50-minute appointments really.

On the other side of the table, you have those who have built practice fiscal models on the backbone of however-many-minute appointments. They use different terminology for this whole concept, however. They call it throughput. How many patients can a physician manage to squeeze into a day? Some of these folks will tell you that throughput success is “more is more.” In other words, throughput is one of those things that you can never have too much of.

Let me back up for a sec and mention the mission of this show. It is to connect health care leaders together by helping everyone understand each other well enough to communicate effectively, which is rate critical numero uno for any collaboration. You can’t collaborate if parties don’t really grasp what anyone else is actually saying when they communicate their WIIFMs (their “what’s in it for me?”) or their organizational imperatives.

If we consider that the health care industry can only transform when multiple stakeholders collaborate, these little “language discrepancies” actually can have macro implications. In this respect, this throughput example—not in all cases but at a minimum—it’s an exemplar illustration and certainly something to contemplate. Consider people arguing against 7-minute appointments without mentioning the word throughput. They’re probably not going to even reach the headspace of those who just spent the past two decades in meetings to increase throughput. It’s like two ships passing in the night.

You could be sitting there right now pooh-poohing what I’m saying, but I’ve sat in enough meetings where people talk around each other using different terminology, think they’ve agreed on some collaboration or compromise or solution, except nothing happens because everyone got to walk out without addressing the elephant in the room. It sounds something like this:

DOCTOR OR NURSE: We need you to enable patients to have quality time with their doctors and the rest of the care team.

SOMEBODY ELSE: We need to get rid of inefficiencies, which means driving maximum throughput.

ANOTHER PERSON: OK, let’s compromise. Doctors should have quality time while maximizing throughput.

Don’t laugh. I’ve heard “action items” like this often enough, and so have you if you think about it. That’s why I originally started this podcast—because I can also guarantee you if this is the action item, no action will actually take place. The only way this conversation is going to net any change is if people around that table head-on confront that quality time with patients means less throughput. And how much less are we going to agree on and/or how are we going to creatively change the practice model so throughput is an archaic term (ie, asynchronous stuff, etc)?

I say all this to say that this throughput business also leaks into the technology space in ways that we should probably think about. Increasing throughput, after all, is one of the key ways to increase FFS (fee-for-service) revenue. FFS is all about the need for speed. The faster you can smack a billing code on a patient visit, the more patient visits you can pack into a day, the more billing revenue you can rack up. To some extent, throughput is code word for an addiction to FFS. You can always tell a tech vendor who is used to selling in an FFS environment because the second slide of their pitch deck is always one of two things: either how much faster the tool will get patients in and out of a doctor’s line of sight or what the billing code is for the tool (but that’s a whole different topic).

I just described the second slide in an FFS-centric technology vendor deck. The first slide in those “use our AI thingamajig to revolutionize your throughput” decks is always some mission statement about improving patient care. And this is where not everybody using the same language creates immense wiggle room for profit over patients under cover of mismatched terminology.

To add one point of context, when I say throughput here or increasing throughput, nobody is talking about making the front desk more efficient, minimizing faxing things around, or streamlining prior auths or duplications in the workflow (ie, fixing things that are in desperate need of a fix). What we’re talking about in this health care podcast are tools like the one I saw the other day.

This biz dev person of this company was up and about early promoting some AI diagnostic tool. With this tool, so their slide deck promised, a physician could see 50 patients a day. Even for this particular vendor, I guess a full-throated “Hey, let’s burn out all your doctors and make patients wonder if they imagined their doctor visit would happen so fast”—a blunt message like that—presumed a little too much avariciousness on the part of the practice. So, they tempered their message by stating the inarguable fact that there is a physician shortage in rural America and that this tool will help resolve that.

OK … that’s a worthy thing to fix. But, seriously, is the goal to get rural patients an automagical visit with a doctor that, in hindsight, they wonder if they hallucinated it was so fleeting? Or is it to actually help patients get better health? Also inarguably, health care that leads to better health requires less than pedal-to-the-metal throughput. If you think differently and want to change my mind, feel free but show me the study.

I say all this to say that I called up Arshad Rahim, MD, MBA, FACP, a little bit ago to see what he thought of my aforementioned burning premises (aka rants) about throughput; and he kindly agreed to come on the show again. Dr. Rahim is senior medical director of population health at Mount Sinai. He was last on Relentless Health Value on EP219 talking about population health for reals in the real world. Go back and listen to that show after this one if you want to hear more of Dr. Rahim’s sage advice. 

One more recommendation: For more insights into the impact of maximum throughput, read the awesome op-ed in MedPage Today by Brian Klepper, PhD, and Jeff Hogan. 

You can connect with Dr. Rahim on LinkedIn. 

07:37 When does throughput negatively affect patient care?
08:55 Why does diagnostic inaccuracy become a problem with throughput?
09:27 Do population health outcomes decline with less throughput?
10:20 “The way you can also be most financially successful is by taking care of sicker patients.”
10:53 What do patients actually want and need?
11:55 “The emotionality in a health care interaction is always there … [when] you’re focused on throughput, you can definitely lose the healing and calming presence.”
14:18 What do doctors need from their organizations to sustain a high level of care?
15:59 “The actions vary across the spectrum from very supportive to not very supportive at all.”
17:02 “There definitely is a challenge of competitive pay.”

The North Carolina State Employees Health Plan (SEHP) crafted a proposal called the Clear Pricing Project. The Clear Pricing Project proposed to pay network hospitals based on a transparent price schedule. Considering that SEHP purchases benefits for something like 720,000 people in North Carolina at a cost to taxpayers of billions of dollars, this seems reasonable. When you’re the fiduciary for thousands of dollars, let alone add six more zeros, it would seem to be non-negotiable to actually see the numbers and not write a check to a black box. Nonetheless, a few of North Carolina’s largest hospital chains disagreed. They want to bill whatever they want and to do so shrouded by a cloak of secrecy.

I don’t want to put words in anyone’s mouth, but it appears that the CFOs and CEOs of these hospital systems don’t believe that the treasurer of the state has a right to see what he’s spending taxpayer money on. And these CFOs and CEOs have expressed their position with a brutal onslaught of personal attacks against the North Carolina Treasurer’s office.

I feel like this episode needs a trigger warning. As David Contorno, also from North Carolina, has said on this podcast (EP186), the only way to pay less for health care is to pay less for health care. It’s hard to do that if you don’t know how much you’re paying. It just blows my mind when all across this country, financial toxicity is reducing health outcomes while nonprofit health systems—excluding some of the rural ones—are yanking in record profits, and employers and public entities are not messing around when they say that health care prices are an existential threat.

Let’s all get on the same side of this issue, please. Ultimately, it’s everyone’s responsibility to do the right thing right now. In this health care podcast, I am speaking with North Carolina State Treasurer Dale Folwell.

You can learn more at nctreasurer.com. 

You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell.

Dale R. Folwell, CPA, was sworn in as State Treasurer of North Carolina in January 2017. As the keeper of the public purse, Treasurer Folwell is responsible for a $100 billion state pension fund that provides retirement benefits for more than 900,000 teachers, law enforcement officers, and other public workers.

Kyle is the founder and CEO of PatientCrossroads, a provider of patient registry solutions to the rare and neglected disease community.  PatientCrossroads collects patient provided medical history and testing results in order to gain insight into disease progression and to recruit patients for inclusion in clinical studies and trials.  Kyle is a respected authority on rare disease patient registries and is a frequent speaker at research conferences educating the non-profit and research community on the need for universally accessible, de-identified patient information.   Kyle's passion is to change the economics of patient provided information from closed, proprietary access, to universally available self-funding programs that accelerate disease research.

You can find out more information at PatientCrossRoads.com.

A.J. Loiacono is the Chief Innovation Officer at Truveris, where he leads product development, strategic planning and enterprise partnerships. Prior to Truveris, AJ was a co-founder and Partner with SMS, a software development firm specializing in transactional software solutions for national realtors. He also founded enterprise resource planning company, Victrix, leading the firm to a successful sale. AJ previously served as a Partner with Artemis Venture Capital.

You can find out more at oneRX.com, and truveris.com.

Eric is established as a national expert on the impact of health care reform on health care providers and is a respected thought leader in the hospital health system industry. A consultant with deep experience in health plan strategy, design, prevention care, and productivity and behavioral economics, Eric serves as the national leader of direct provider solutions for Collective Health. A former executive at Evolent Health and principal with Towers Watson, he has worked in the employee benefits business for 30-plus years as an advisor to hospital and health system clients, developing health benefit and prevention care strategies that align with the health system’s population health business. Eric focuses on improving the poor health of health care workers and professionals as a first step to improving patient satisfaction and quality outcomes. He frequently speaks about the direct link between improving health care workers’ health and boosting patient satisfaction and quality outcomes.

Eric is a published author, including the book STOP!: 21 Stops to Reduce Stress and Enhance Joy, and has authored more than 20 articles on employee benefit topics, including "Fixing the Broken Triangle," "The Healthcare Benefit Crisis—Ten Years Later" in 2015, "Choice Architecture—A Tool for Ratcheting Up Benefit and Wellness Results," "eACOs—The Health Plan of the Future," and "The Healthcare Benefit Crisis." A member of several "Who’s Who" lists for business executives, Eric graduated from the University of Illinois with a BA in psychology and earned his MBA from the University of Chicago Booth School of Business.

Will the Health and Human Services (HHS) proposal materially impact Pharma’s ability to “pay to play” on pharmacy benefit manager (PBM) formularies? We have that HHS proposal that is now at the stage where they’re trying to figure out how to implement it. What’s at stake right now is that implementation flowchart and who exactly is involved in adjudicating the something like $186 billion in potential charge-backs.

Since any middleman who gets himself involved in any flowchart of this sort takes a buck, there is a massive land-grab opportunity that all these heretofore hidden players are battling over. My guest today, AJ Loiacono, CEO at Capital Rx, can shed light on the hidden complexity of what goes on in the dark middle of a pharma drug transaction and contracting—and that is very relevant right now.

Anthony J. “AJ” Loiacono is a successful entrepreneur, with over 20 years of experience in pharmacy benefits, finance, and software development. As the CEO of Capital Rx, his mission is to change the way pharmacy benefits are priced and administrated in the United States. Prior to Capital Rx, AJ was a co-founder of Truveris, where he served for 8 years as CEO, chief innovation officer, and board member, leading the company to record growth. 

Moore, is CEO of the health care IT analyst firm, Chilmark Research, which he founded in 2007. Chilmark Research was founded on the simple premise of conducting the best research possible that will ultimately lead to improvements in the quality of care a patient receives. Having spent many years in other industry sectors, Moore has seen the dramatic improvements possible through effective adoption and use of IT and is convinced that the same can occur in health care.

A core thesis for Chilmark Research is to help guide the industry in specific subsectors of the health IT landscape by focusing on those technology domains that will be truly transformational to the delivery of care. Current areas of research include: analytics, care management and coordination, interoperability, population health management, engagement, and most recently provider-payer convergence.

Prior to founding Chilmark Research, Moore led a diverse worldwide team at Dassault Systèmes, based in Paris. As head of corporate, worldwide industry and market intelligence, he worked with the executive leadership to define key global market opportunities, forecast growth, and develop critical paths to market for its numerous software products.

Moore has held a number of other senior positions during his career including: SVP at analyst firm ARC Advisory Group; Research Associate at MIT; VP of Marketing for an analytical instrument company; and policy analyst for the Commonwealth of Massachusetts. An accomplished speaker, Moore has made numerous presentations on current and future IT trends and their impact to markets. Widely quoted in numerous publications, he has also been interviewed by: AMA News, CIO, CNBC, Computerworld, eWeek, Health Data Management, HealthIT News, InformationWeek, Investors Business Daily, US News & World Report, The Washington Post, and The Wall Street Journal.

Learn more by going to chilmarkresearch.com and find a free copy of the 2017 Healthcare Analytics Market Trends Report during March!

“If operating on the wrong leg is called a ‘medical error,’ what do we call operating on someone who doesn’t need surgery?” That is a quote I have heard attributed to Jack Wennberg. It also crystalizes a theme I have been hearing a lot lately—the idea that quality metrics in this country today assess care from basically a patient safety standpoint but they don’t consider whether the patient actually needed the surgery or whatever in the first place. Or whether the outcome of the treatment matched an outcome the patient understood and had hoped for.

I get into this in depth, by the way, with Dr. Suzanne Clough (EP235); and I’m going to get into it again in my upcoming interview with Dr. Marty Makary (EP242).

In this health care podcast, I speak with Olivia Ross. Olivia has a reputation as a “rock star in the employer coalition world,” and I say this because it was a direct quote from an email I received after I mentioned that she was coming on the show. Olivia earned her rock star chops at the Pacific Business Group on Health (PBGH). Olivia is the associate director of the Employers Centers of Excellence Network, otherwise known as ECEN.

What Olivia has worked on at ECEN is to put together a network of centers of excellence (COEs), meaning provider organizations that have committed to prospective bundled care payments for services like orthopedic surgeries, oncology, and bariatric surgery. Not only do these organizations … well, not only have they demonstrated excellence, but they also have demonstrated that they only treat patients who are appropriate to treat.

Employers including Walmart, Lowes, and McKesson use this network. In my interview with her, Olivia discusses how the COEs are selected and exactly how employers intercept employees at the right waypoint along their patient journey, fly them or get them to travel to the COE, and then repatriate them back home with their local PCP (primary care provider) for follow-up care. I’m not sure if repatriate is the right word to use there, but I’m going to go with it.

You can learn more at Pacific Business Group on Health. 

Olivia Ross, MBA, MPH, is associate director of the Employers Centers of Excellence Network (ECEN) at the Pacific Business Group on Health (PBGH). Olivia oversees the ECEN program, a national, multi-employer initiative developed as part of PBGH’s commitment to value-based purchasing. 

“Dr. Google” has a bad rap in some health care circles. If you doubt my words, go on Instagram and do a search for “Doing battle with Dr. Google.” But let me give you a tip: Pretending Dr. Google doesn’t exist or telling patients to quit it with the internet—these are tactics that are always followed by #doomed.

The best way to help your health care brand, organization, and clinicians and patients is to ensure that patients can find credible, accurate content on the internet, which they will be searching whether you like it or not. Another way to help your health care brand, organization, and clinicians and patients is to help patients and their families better process and use the information that they do find on the internet.

Today I speak with Chris Cullmann, head of innovation and engagement at Guidemark Health. Chris offers up some key insights and practical advice to help you help patients and clinicians. Chris also curates a great Twitter and LinkedIn feed.

You can learn more at guidemarkhealth.com, or find Chris on
Twitter at @cullmann and LinkedIn at Cullmann.

Chris Cullmann is the head of innovation and engagement at Guidemark Health, a leading marketing agency. Chris is a veteran in digital marketing with more than 2 decades of experience. Health care has been a focus of his career, technology a passion, and strategy a craft. A career in professional communication has allowed Chris to explore emerging platforms, channels, and data to create industry-leading customer experiences. Chris is actively involved in the health care innovation space and is an evangelist for the adoption of digital in health care.

First, let’s talk about reducing administrative waste in the US healthcare system. There was a pretty famous 2019 study by Shrank et al. that estimated about 25% of the $3.6 trillion the US spends on healthcare annually is potentially wasteful. This is each person spending $2500 unnecessarily.

Robert Kocher wrote a really interesting article about getting rid of administrative waste and inefficiencies, and he said that it is the “safest form of health care cost savings; virtually no one argues that administrative costs should remain high. Reducing administrative waste should be the highest priority … [because] everyone, including patients and clinicians, would benefit from lower health care costs.” In my mind, “everyone” means payers, policy makers, and also providers who are or want to take some accountability for the total cost of care here.

To talk about the possibilities, I have the perfect guest: Gary Campbell, who is the CEO of Johnson Health Center, which is an FQHC, a Federally Qualified Health Center, in Lynchburg, Virginia. Why is the CEO of an FQHC a great person to talk about cutting out administrative waste with? Well, first of all, the patient population is what many would consider challenging at an FQHC. Second, they really have to cut out as much waste as possible because there is zero potential to cost shift. They do not have the option to charge their commercial lives 4x Medicare or whatever and effectively cost shift the impact of inefficiencies. There basically are no commercial lives. You either figure out how to be efficient, or the patient population does not get care.

As Gary and I were talking, however, it became clear that when you cut out administrative waste, you wind up actually with the potential to become a great place to work. One reason for this just has to do with the process of cutting out waste, which requires culture and process. And a by-product of a great culture and a great process means a great place to work.

You might be thinking, as I was thinking, that this show, which is supposed to be about cutting administrative waste, is going to be all about how to do lean and Six Sigma and pretty much go peak MBA. Spoiler alert: It’s not. When I asked Gary how to be operationally efficient, it all ladders up to organizational leadership: leaders who commit to putting patients first, to have core values with the expectation to actually achieve them (for reals—not just in the marketing). Because without effective, accountable, committed leadership, patient first, lowering the cost of care, removing administrative waste … it ain’t gonna happen. Leaders should be visible, have a vision, a strategic plan, project plans, and be inspirational. They also need to not be afraid to “move along,” as they say, people who are pulling the team down and holding it back—maybe even if a short-term revenue hit will transpire.

Before we get started here, let’s talk about FQHCs for a sec just in case you’re unfamiliar. Besides the acronym giving me fits of dyslexia—my brain always wants to invert the letters, so I have a Post-it Note here and I’m staring at it so, hopefully, I’ll be able to keep this straight—FQHCs (Federally Qualified Health Centers) are usually nonprofits that are oriented to take care of the underserved. Today they serve upwards of 30 million people in the United States, and that’s a growing number. There’s something like 1500 of them across all 50 states. They’re federally funded. They are a safety net really for individuals out there who may not be able to access care anywhere else. There’s generally bipartisan support for FQHCs and often a real purpose and passion to really care for people regardless of their ability to pay. They also tend to offer a lot of resources under one roof (eg, medical care, dental care, other things, mental health care), which can add substantially to the operational complexity.

Gary Campbell, my guest in this healthcare podcast as I said, is the CEO of an FQHC. Gary has a procurement and operations background, and this background informs how he approaches leadership and care delivery in ways that I find inspirational—and I hope that you do, too.

Some of the conversation that we had in this episode reminded me of the interview with Tony DiGioia, MD, in EP332; so if you want to dig further into this topic, go back and listen to that episode. That interview is very specifically about how to create a patient-centric value system, which Dr. DiGioia says should be the new OS for healthcare delivery. During this show, I also mention my conversation with Jerry Durham (EP297), where we talk about streamlining the front desk. 

I didn’t mention this in the show, but another episode that would be great to go back and listen to if this topic intrigues you is the one with Matt Anderson, MD, MBA, talking about how things get better when the scrubs and the suits collaborate (EP266).  

You can learn more at impact2lead.com. 

Gary Campbell is the founder and owner of Impact2Lead, LLC, and the CEO of Johnson Health Center (JHC), where he has enjoyed a career centered on leading for-profit/not-for-profit organizations and helping to unleash potential in others along the way.

In 2011, he left Bayer and came to JHC; and in 2013, he launched Impact2Lead to provide transformation-consulting services to other firms across the United States.

Since joining JHC, the center has enjoyed unprecedented success and growth by transforming the culture using his Impact Leadership model and becoming the first Federally Qualified Health Center to be recognized as an Employer of Choice by Employer of Choice International, Inc. The health center has achieved multiple workplace and community awards since that time and has enjoyed exponential growth during his seven years as the CEO.

Gary currently speaks and consults nationally on leadership, workplace strategies, and motivational topics.

05:15 Why is there no opportunity to cost shift in an FQHC?
05:46 What happens when an FQHC is operating inefficiently?
06:12 “Have you workflowed it out? … You can overstaff yourself in a way that your cost per patient goes way up.”
06:37 Why is taking a lean approach not an excuse to cut staff?
08:05 “The nurses are linchpins to everything.”
09:05 How does standardizing care lead to personalization of care?
10:28 “Our clinical teams see that we care.”
10:48 “If you don’t have a vision for where you want to be two and three years down the road, you’re struggling.”
11:03 “I want everybody to understand, What is their why?”
20:10 “They don’t teach leadership in most medical schools.”—Dr. Robert Pearl
21:19 “Get to know these clinicians … sincerely.”
23:11 “From a core values perspective, you can make every single decision … on core values.”
23:35 “We always start with those values. … They’re embedded in everything we do.”
24:16 “You have to project plan things out that you want.”
25:09 How does an FQHC or private practices that are patient-oriented attract talent?
30:45 “First and foremost, be visible.”

You can learn more at impact2lead.com. 

@Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Why is there no opportunity to cost shift in an FQHC? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What happens when an FQHC is operating inefficiently? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Have you workflowed it out? … You can overstaff yourself in a way that your cost per patient goes way up.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Why is taking a lean approach not an excuse to cut staff? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“The nurses are linchpins to everything.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How does standardizing care lead to personalization of care? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Our clinical teams see that we care.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“I want everybody to understand, What is their why?” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Get to know these clinicians … sincerely.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“We always start with those values. … They’re embedded in everything we do.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“You have to project plan things out that you want.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How does an FQHC or private practices that are patient-oriented attract talent? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“First and foremost, be visible.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell

As Chief Strategy and Chief Innovation Officer, Christopher Cornue leads Navicent Health's efforts to plan for the future and meet the organization's mission, vision and values. He collaborates with the organization's leaders, caregivers, physicians and community and other key stakeholders to establish and execute on strategy, operations and innovation across the system.

Christopher has more than 20 years of professional healthcare experience. He leverages his expertise in leadership, operations, strategy, physician relationships, thought leadership and clinical performance both domestically and globally. He has been a thought leader at Sg2 where he led the consulting practice, oversaw the Center for the Future, and served as a trusted advisor to healthcare organizations.

He was CEO of McKee Medical Center in Colorado, where he led the organization to strong financial performance and top decile performance in quality outcomes and patient satisfaction while creating an engaged workforce. He was vice president at Sinai Health System, where he held system and medical group leadership, operational and strategic responsibilities. He worked with major academic medical centers nationwide at University HealthSystem Consortium, and held several leadership roles at the University of Chicago Medical Center.

Christopher has collaborated with international partners to further global healthcare strategies and solutions, and serves as an expert and mentor with the International Society for Quality in Healthcare (ISQua). He is a fellow of the American College of Healthcare Executives and holds bachelor of science degrees in biology and chemistry and a master of science degree in health services administration from Gannon University.

You can find out more at www.navicenthealth.org, on twitter @navicenthealth, and on LinkedIn.

“Those who say it cannot be done are usually interrupted by others doing it.” That’s a James Baldwin quote to keep in mind while considering employers ginning up real change in the health care industry.

Generally speaking, employers who still don’t believe they could have an impact helping their employees get better health care at lower prices, don’t listen to this podcast. But if they did, I’d suggest this James Baldwin quote is apropos.

It’s probably also apropos for providers, carriers, Pharma … anyone who isn’t paying a whole lot of attention to the success of organizations like Catalyst for Payment Reform. Americans, meaning employees, can no longer afford their health care. Deductibles are higher than savings, basically meaning that employees have health plans they can’t even afford to use; and it costs as much as a midsize sedan—a new one every single year. Furthermore, we have employer health care spend chewing up raises. Employers and their CFOs are increasingly in a position where they have to act. It’s no longer an option.

I speak today with Suzanne Delbanco, PhD, executive director of Catalyst for Payment Reform. In one of her past lives, Suzanne was the founding CEO of The Leapfrog Group.

You can learn more at catalyze.org.

In addition, for a curriculum of podcasts to get you up to speed on what’s happening in the employer space, check out this blog post.

Suzanne Delbanco, PhD, is the executive director of Catalyst for Payment Reform (CPR), an independent, nonprofit corporation working to catalyze employers, public purchasers, and others to implement strategies that produce higher-value health care and improve the functioning of the health care marketplace. In addition to her duties at CPR, Suzanne serves on the advisory board of The Source on Healthcare Price & Competition at the University of California–Hastings and the Blue Cross Blue Shield Institute. Previously, she was the founding CEO of The Leapfrog Group. Suzanne holds a PhD in public policy from the Goldman School of Public Policy and an MPH from the School of Public Health at the University of California–Berkeley.  

In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable.

To Read The Show Notes With All Mentioned Links, Visit the Episode Page.

If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.

The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes.

This encore is very relevant after the shows with Cora Opsahl (EP452), Claire Brockbank (EP453), and Marilyn Bartlett (EP450). Getting better health for the 160 million Americans covered by commercial insurance is all about rates, rights, and power.

07:34 How did Rob get to his current role?

09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this.

10:27 Why economic consequences move the needle, and why sometimes they don’t.

12:26 Why the best way to address costs isn’t to re-shift costs but to address them directly.

13:22 Why compensation that isn’t dependent on outcomes is a problem.

16:23 “Strategy’s not what people say; it’s what they do.”

18:21 How do you operationalize saving money with better outcomes?

26:26 How do employers turn conflict into collaboration?

28:20 What is the win-win-win structure among employers, payers, and providers in Rob’s eyes?

30:53 To whom should the task of risk adjustment fall?

34:43 “Better contracts do improve outcomes.”

As one of our guests, Dr. Tony DiGioia (EP332), has said, healthcare has been pushed to its limits this past year; but that doesn’t mean that nothing good has come of it. Celebrating our bright spots and using our experiences to inform future innovations is really the key to more accessible, equitable, and higher quality of care. While the timing of the celebration could, in general, be better given the latest pandemic news, as they say, there’s no time like the present. So, let’s do this thing.

Also, it’s just definitely good from a mental health perspective to find bright spots and to be grateful for them. So, let me kick this off with all of the gratitude I can hold in my two hands for anybody listening who is on the so-called front line of healthcare. My appreciation cannot be expressed more fiercely. I wish, in fact, that there was more that I/we could do to address the systemic issues that plague our healthcare industry and really impact you directly.

Speaking of doctors as one of these frontline healthcare groups, in the Doximity Physician Compensation Report that was released for this past year, here’s four stats to know:  

1. Twenty-two percent of physicians are considering early retirement because of overwork.
2. Sixteen percent of physicians are looking for another employer because of overwork.
3. Twelve percent of physicians are looking for another career because of overwork.
4. Twenty-seven percent of physicians said they’re not overworked, so I guess there’s that—that’s a bright spot.

So, all you docs, nurses, PAs, social workers, therapists of all kinds, any other healthcare workers: Thank you for all that you do even in the face of these adversities and a bunch of seemingly shortsighted policy and/or administrative decisions. Take care of yourself first and foremost. We need you; we appreciate you. Thank you.

I’d also like to thank everybody who listened to Relentless Health Value this past year. Thank you for being part of an inspired and inspirational community of individuals who are trying hard to do the right thing and learn and connect with others on a similar journey—even in the face of all the perverse incentives and calcified status quo processes, the whole host of factors that add up to formidable barriers to positive change.

All of us—and I’m thinking that includes you—we continue to press forward. This is important because the more of us there are, the more of us who link hands and do some combination of educate, cajole, scold, guilt into, demand, lead, vote, wear down … the more of us who consider ourselves part of the change, the more effective we can be. So, recruit your fellow thinkers and let’s continue to make inroads.

I want to give a special thank you to the many of you who have reached out to me over this past year. You have encouraged, coached, and debated with me. You have added details and case studies. You’ve provided context. You have offered up topics to explore and introduced me and our team over here to some great guests. You have changed my mind. You have made me realize that there’s some maybe underlying reason for something that is, in fact, valid or a consequence that maybe hasn’t been thought through well enough by me and/or others.

I couldn’t be more thankful or appreciative to every single one of you.

For more information, go to aventriahealth.com.  

Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry.

In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.

03:36 Thank you to our listeners and the feedback you’ve given the show over the years.
05:10 “Good and bad is a matter of extremes.”
06:20 Thank you to Dr. Steve Schutzer, Dr. George Mathews, Dr. Ge Bai, Troy Larsgard, Dr. Hugh Sims, Vinay Eaton, Dr. Brian Decker, Jeff Hogan, Peter Hayes, Dr. Aaron Mitchell, Parker Edman, Andre Wenker, Doug Aldeen, Cristy Gupton, LynAnn Henderson, Chad Jackson, and Darrell Moon.
07:27 Thank you to our iTunes reviewers.
07:47 If you haven’t given us a review yet, please do here.
08:01 Thank you to Malfoxley, Jopo1234, and Teresa O’Keefe for your 2021 reviews.
08:19 Thank you to Dr. Nadia Chaudhri, who sadly died this past year of ovarian cancer but who did so much to advance the awareness of ovarian cancer and pursue better outcomes and better patient care. Look through her Twitter feed.
08:39 Thank you to Brian Klepper, who is a great writer but also runs what might be the largest Listserv for those on the innovative self-insured employer side of healthcare. What I most admire about Brian is his ability and dedication to fact-based and productive debate. Brian is featured on several RHV episodes this past year. You can check them out here: EP335 and AEE16.
09:09 I’d also like to thank Dr. Eric Bricker for his series called AHealthcareZ. Dr. Bricker is a guest on an episode coming up that I’m so looking forward to publishing.
09:45 Thanks to these writers for taking the time and effort to put out such worthwhile content: Brendan Keeler, Kevin O’Leary, Nikhil Krishnan, Olivia Webb, Joe Connolly, Christian Milaster (Telehealth Tuesday), Gist Healthcare daily/weekly newsletter and podcast, John Marchica’s newsletter and podcast, and Merrill Goozner.
10:10 If you don’t already, I’d also recommend following these individuals on LinkedIn: Darren Fogarty, Leon Wisniewski, and Christin Deacon (listen to Christin’s episode about the CAA this past fall).
10:26 David Contorno and Emma Fox, thanks so much for all of your work motivating collaboration and inspiring self-insured employers to wield the power they possess in meaningful ways. There’s a symposium coming up that anyone interested should check out.
10:42 I appreciate and periodically check out Julie Yoo from Andreessen Horowitz’s collection of resources on a Google doc.
10:55 Thanks to Rohan Siddhanti and Ezequiel Halac for organizing events in NYC.
11:03 People often ask me for podcast recommendations, so here’s a few I listen to regularly: John Lynn’s podcasts, Creating a New Healthcare with Dr. Zeev Neuwirth, Race to Value with Eric Weaver, Radio Advisory, Gist Healthcare Daily, The #HCBiz Show! with Don Lee, and Primary Care Cures with Ron Barshop (I was on the show released Thanksgiving week). There’s also the Pharmacy Podcast Network.
11:42 Also thanks to the following publications who have given us press credentials and passes to conferences: STAT News, NODE.Health, HealthIMPACT, and JAMA.
12:03 Lastly, we have a tip jar on our Web site which we don’t really publicize. I say this to emphasize that those who choose to donate are just simply kind and gracious individuals: Alex Dou, Linda Garcia, James Farley, Arthur Berens, Lois Drapin, James Cheairs, Robert Matthews, Lois Niland, Teresa O’Keefe, Richard Klasco, Hugh Sims, Matt Warhaftig, Meredith Fried, Chad Jackson, Vidar Jorgensen, and Brandon Weber.
12:38 Thank you ALL for your continued leadership in improving healthcare.
12:42 Christin Deacon has said, “What we need more of in the healthcare industry are leaders who are willing to take on legacy institutions and their lobbyists, in both public and private discourse. We need leaders that are willing to take on an industry that makes up about 20% of our GDP and is willing to go on record stating that the goal is not just to curb growth but, rather, stop it and rebuild this whole thing better for patients.”

For more information, go to aventriahealth.com.

From all of us at Relentless Health Value, THANK YOU for your listenership and support. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #podcast #digitalhealth

Did you know you can review our #podcast? https://relentlesshealthvalue.com/4-steps-rate-review-podcast-itunes/ Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth

In memory of @DrNadiaChaudhri, check out her Twitter feed for info on better #patientoutcomes and care. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth

Check out @DrEricB’s AHealthcareZ for in-depth industry information. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth

Thanks to @healthbjk, @olearykm, @nikillinit, @OliviaWebbC, @JConnol, @GistHealthcare, @DarwinHealth, @_GoozNews, and @HealthChrism for putting out great content. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth

We appreciate and recommend following @julesyoo for more #healthcareinsights. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth

Thanks to @RSiddhanti and @halac_ezequiel for their event organizing in NYC. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth

We love #podcasts! Check out some of Stacey’s recs in our show notes, including @techguy, @ZeevNeuwirth, @Eric_S_Weaver, @raemwoods, @Alexolgin, @The_HCBiz, @RonBarshop, and @PharmacyPodcast. #healthcare #healthcarepodcast

Thanks to the following #healthcarepublications as well: @statnews, @HITHealthIMPACT, @JAMA_current, and @nodehealthorg.

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen

Stacey is co-president of Aventria Health Group, specializing in helping employer, pharmaceutical, device and pharmacy clients by creating partnerships with other health care organizations. For twenty years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders, and most of all, the patient.

00:00 Incrementalism - Worth it?
01:51 “The CEO’s Guide to Restoring the American Dream: How to Deliver World-Class Healthcare to Your Employees at Half the Cost,” by Dave Chase.
02:25 What would Amazon do differently by building a System of Care?
03:15 Does our conviction about the current Healthcare System stop us from creating something better?
04:15 Divestiture Aversion - Why a Healthcare reboot isn’t such a bad idea.
11:00 “What are the ramifications if Amazon enters more deeply into that hybrid online-inperson space?”
12:45 How did we get where we are now? - Check out INBW13, INBW12, INBW10.
13:00 Only three stakeholders that have an invested interest in keeping Healthcare Value high: Employers, Taxpayers, and Consumers.
13:20 Large Employers as the only stakeholder with the power to make change in Healthcare.
16:50 Who is going to be behind such a reboot?
19:00 How onsite clinics might be the future and greatly benefit reducing healthcare costs.
20:00 The divorce of patient care and industry needs.
21:50 “Employers don’t just have skin in the game, they have entire bodyparts.”
22:50 “Employers have a larger call; healthcare is a means to an end for them.”

"What is this podcast?" 
It's a valid question that I've answered many times lately.

This podcast is about the people of the healthcare industry— the entrepreneurs, employee-preneurs, business leaders. Those of us who struggle, every day, to do what we can to make healthcare better. We all know the health industry is a tough place to drive results. It's highly regulated, enormous, chaotic and rife with vested interests. Implementation of almost anything involves navigating a very messy middle. 

Relentless Health Value is about us. It's about our successes and lessons learned. My guests share their stories. They talk about how they manage to stay strategic and focused when their days are chock-full of too many distractions, too much data, too little data, and triple-booked meetings. They talk about what they're currently excited about, what's inspiring them, what's troubling them. They offer advice and share an insight or two. They talk about their role and what they hope to achieve. And this is important.

It's important because in order to collaborate, we need to understand each other.

There are a number of health industry podcasts already out there and I'd like to give them a shout out. They make it easier to keep up with what's going on with the industry by covering news, current trends and topics:

• First Word Pharma - Daily podcast to keep you up to date on who bought who, who sued who and the general goings-on. A robot reads the copy.
• Pharma Marketing Podcast - Hosted by The Pharma Guy. His guests talk about their latest projects.
• Healthcare Informatics - Health IT focused.
• HIN.com - Episodes are short, usually teasers for a longer webinar but cover trending topics.
• AJHP Voices - Pharmacy-centric.
• Pharma Talk Radio - Sometimes clinical, sometimes not. Guests share their recent projects.
• Medical Sales Guru - Mace Horoff gives advice on how to sell medical/pharma products.
• (In the podcast, I neglect to mention the HIMSS podcast called "HIE InPractice.")

My name is Stacey Richter and I'm the founder and CEO of Franklyn Healthcom, a marketing agency specializing in communications to decision-makers at healthcare organizations. I'm your host. 

Take a listen and I thank you very much if you subscribe. Upcoming episodes feature Robert Herzog of eCaring, Kent Dicks of Alere, Leo Francis of LPF Solutions among other American entrepreneurs and business leaders you might want to get to know.

Visit us online at RelentlessHealthValue.com

Kyle Samani is a CoFounder and CEO of Pristine, a company pioneering the next generation of tele-presence through Google Glass.

Prior to founding Pristine, Kyle led design and development of a hospital electronic medical record (EMR) system. Kyle is an active writer who writes at the intersection of healthcare, technology, policy, economics, business, and entrepreneurship with an audience of more than 200,000 readers each month.

In addition to writing, he is also an active public speaker. In the past year, Kyle has spoken at HIMSS, SXSW, TEDx, Healthspottr, Rutberg and won the coveted DEMOgod award at the DEMO startup conference. He’s also a member of the Young Entrepreneur Council (YEC). Kyle studied Finance and Management at the NYU Stern School of Business.

Kyle Samani is CEO @ Pristine
Book an appointment with Kyle at calendly.com/kyle
Check out Pristine and its Healthcare and Engineering blogs.

In this healthcare podcast, I am talking with Dan Serrano; and we’re talking about payer/provider collaboration—blocking and tackling, I’m gonna say—from primarily a financial and revenue point of view. I’d classify this as, say, a 201-level discussion (ie, not entry level, but it’s also not super deep in the weeds). We mainly cover the ins and outs of why a provider organization should probably be looking to get paid to better take care of patients with chronic disease and drive better patient outcomes at lower downstream costs and, to some degree, also why payers should be helping provider organizations in their local communities to do so by providing some help and shelter on the journey from here to a capitated payment.

The focus today is really, I’d have to say, on the messy middle, where a provider organization does not have capitated contracts nor access to any premium dollars, which, by all accounts, is the holy grail here. The premium is where it’s at, and provider organizations might want to be aiming to get a piece of that action.

The why for this “get the premium dollar” prime directive is pretty self-evident when you look at the big bucks rolling around in the coffers of those who are collecting said premium dollars. So, this “get the premium” endgame is, for sure, a big piece of the why—why, if I am a provider organization, I might want to take the time and energy and spend the money to embark on a path that might lead me to be able to get compensated for the stuff that patients really want and need to do better, which includes all of the things that I spoke about with Eric Gallagher in episode 405. Also, Vivek Garg, MD, MBA, in episode 407 and Amy Scanlan, MD, in episode 402.

Spoiler alert: It’s not easy.

Now, I asked Dan Serrano, as aforementioned my guest today, to offer up his advice here in the context of CKD (chronic kidney disease) patients. Why did I ask Dan to use the CKD case study, as a touchstone? Well, first of all, talking about this topic in totally theoretical terms is not ideal. We need an actual example for a lot of this to kind of make sense, combined with the first step for most outcomes improvement programs, which is to study your data and pick a patient population to focus on where the data suggests that you can have a big impact. And speaking of impact, did you know that an underlying reason why heart failure patients get hospitalized and rehospitalized is because of underlying CKD? So, impact in the short term and longer term, which I’ll get to in a sec.

Another reason is—and I’m quoting John Rodis, MD, MBA, here, who is the independent medical director of QC-Health^®—Dr. Rodis said the other day, “I sure as heck hope I don’t get CKD, because if I do, chances are I’m not going to be diagnosed. And even if I am diagnosed, I won’t be treated properly.”

So, there’s that. And I can see why he’s saying that. Two out of five patients with ESRD (end-stage renal disease) don’t even know they have kidney disease at all. And the number of patients with progressing CKD on any kind of evidence-based treatment plan is stunningly low.

But also, here’s another reason I asked Dan Serrano to talk about CKD patient populations specifically as his example: I and Dr. Rodis and the team at QC-Health are not the only ones who have figured out that CKD patients are notoriously expensive and way underdiagnosed.

You know who else has figured this out? Payers. Also, private equity. In fact, I was in a meeting with a payer recently, and they stated they had to get CKD patients into point solutions.

This payer—and I’ve heard of others, too—none of these entities are waiting around. And I guess, fair enough, if you look at some of the population health data, that I’m sure these payers and others are looking at. But if you work for a payer and you’re listening right now, what I would say, “Okay, with the point solutions, one that you have carefully vetted, of course, because we have patients suffering right now and dollars being frittered away right now.” But I also would submit that those point solutions will perform a whole lot better if we are all gunning for synergies.

PCPs (primary care physicians) and traditional FFS (fee-for-service) models in this country need your help. The payment models and admin burden are decimating. Payers certainly are a group with some culpability here. (Sorry to be saying the quiet part out loud.) Instead of forgoing them, please help PCPs. Am I saying be altruistic? Actually, no.

Listen to episode 409 with Larry Bauer or episode 391 with Scott Conard, MD, or an upcoming show with Jodilyn Owen and what you will hear is the amazing ability for clinicians rooted in the community to actually drive change in their local markets. In fact, I’d hypothesize that these community-rooted organizations probably have a better track record for actually moving the needle on patient outcomes than any snazzy tech that I have seen, although I am sure that there are one or two very effective snazzy techs out there—the exception proves the rule and all that.

Bottom line: As I do so often, I am advocating for payers and provider organizations within communities to collaborate, regardless of whether there’s a third party also in the mix. I am reporting all of this in the spirit of being helpful but also with some degree of urgency for any care delivery organization because, I mean, really, forget about the holy grail of trying to capture a percentage of the premium if the money is already going elsewhere to too many point solutions who are already capturing a portion of the premium.

IRL, this is what’s already going on out there.

But where there’s a challenge, there is also opportunity. As I have said pretty repeatedly for the past four minutes, because the bar is so low and because CKD patient outcomes are bad news, in general, from a lot of angles, CKD is actually a great place for providers to work hard to improve care and quality.

From a financial standpoint, I think there’s also a great business case for payers to help provider organizations do so. Doing better than the local standard of care is not hard, sadly. And what that means is that there’s so much money that’s possible to save due to the expense of this condition.

And if you’re a payer, even a payer with a third-party CKD solution, if you can help local PCPs and others level up their care, then either you don’t have to pay for the third-party point solution for patients who can be managed successfully locally and/or there’s a more frictionless path for those patients to be identified and get into the point solutions that are available to them.

Let’s all keep in mind that patients at rising risk are falling through a lot of cracks. You can have the best point solution in the world, but if patients aren’t making it there, then, yeah, no outcomes will improve. No costs will be reduced.

Everything I just went through are also all of the reasons why we picked CKD as our focus for a national Groundswell Movement^™ that the benefit corp I am co-president of is kicking off to improve CKD patient outcomes. If you are also thinking about improving CKD patient outcomes, for sure, hit me up.

On to a few thank yous. Thank you so much to Carl Hansen, MD, a direct primary care physician, for a really generous tip in our tip jar. Also, thanks so much to Keith Passwater, who is CEO of Havarti Risk Services and Pasco Advisers, for a really nice donation to the cause over here. It was such an honor and a pleasure to moderate a panel at the Society of Actuaries’ latest meeting at Keith’s invitation also.

Additionally, may I extend thanks to Dffdgg, RKC2023, and Healthy economist for super nice iTunes reviews. The shout-outs are amazing, especially when public like this. Also much appreciated how you have shared Relentless Health Value with your colleagues.

Back on track, let’s hear from Dan Serrano, who is a consultant with COPE Health Solutions, where he works to help clients figure out the best way to make investments that drive better outcomes in a more cost-efficient way.

You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.

Dan Serrano joined COPE Health Solutions in September 2022 as principal and senior vice president. He supports Analytics for Risk Contracting (ARC) finance build and cost models in terms of drive and delivery with Great Lakes Integrated Network (GLIN).

He is a seasoned healthcare/finance professional with 20+ years’ experience and has held a number of roles across the industry and has primarily served as a senior finance leader with proven ability to drive strategy development and execution across multiple business lines for complex organizations in various stages of maturity.

Prior to COPE Health Solutions, Dan served as senior vice president of finance at CareAbout, a private equity–backed start-up focused on driving performance for primary care physicians. He also was the vice president of value- and risk-based contracting at Mount Sinai Health System, where he worked to align contracting, operational performance, and network strategy for employed and voluntary physician groups. Prior to his role at Mount Sinai, Dan served as vice president of commercial products at Healthfirst, market chief financial officer at ChenMed, and Mid-Atlantic Region chief financial officer at Aetna, where he focused on driving strategic financial decisions by analyzing the value drivers for each of the stakeholders across the industry.

Dan holds a bachelor’s degree in finance from the Peter J. Tobin College of Business at St. John’s University.

09:08 What is the importance of payer/provider partnerships in reducing costs with chronic condition care?

10:52 Josh Berlin, JD, of rule of three; look out for his episode in a few weeks.

11:19 What’s the endgame here with this payer/provider collaboration?

11:43 What advice does Dan have for providers who want to do better by patients with chronic conditions?

15:11 Who’s driving costs in the system?

15:50 Why is lowering the average cost of chronic condition care important?

17:03 Why is there a meaningful delta between well-controlled CKD patients and those who aren’t well managed or identified?

21:57 What does a realistic time horizon look like for addressing chronic condition care?

22:38 Why is it important to start in a shared savings place?

25:25 William Shrank, MD, of Andreessen Horowitz; look out for his episode in the fall.

26:35 Financially, what is the goal and how are we achieving a sustainable goal?

29:06 What is the balance between progress and risk here?

You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.

Dan Serrano of @COPEHS discusses #chronicconditions and #payer #provider #collaboration on our #healthcarepodcast. #healthcare #podcast

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249)

I have been on a mission to figure out why some health systems, particularly in the oncology space but not limited to the oncology space, could manage to mark up the price of infused specialty pharmacy drugs up to 6x. Some employers and patients are paying six times the cost of a specialty pharmacy drug in markup for some already incredibly expensive specialty pharmacy drug at some oncology centers. Read more about this in a study by Roy Xiao, MD, and colleagues.

Let’s not forget now or ever that financial toxicity is clinical toxicity. This 6x is exactly how financial toxicity is operationalized. Many patients are charged a coinsurance percentage based on their cost of care, after all; and like 20% of 6x is a huge number, it is a huge bankrupting bill for some patients—maybe many patients. That, plus their premiums go up because, of course, their employers are picking up the remaining 80% of that 600% markup.

Families are already, on average, paying I think it’s $22,000 in premium; and the trend line on that premium growth continues to go up steeply in the 2022-23 projections that I have seen.

Bottom line: This 6x is not a victimless modus operandi is my point.

But what I wanted to know is how they do it, these health systems. Charging 6x the cost of a super expensive specialty pharmacy drug in markup would seem to require some skill, right? And any time I see a Pandora’s box, I have a terrible habit of trying to get in there.

Autumn Yongchu and Erik Davis to the rescue. Today’s show digs into how some health systems and hospitals stack the odds that no one will notice their 6x markups and just pay the bills. Here’s the short version of the playbook, but you’ll need to listen to the show for a more robust explanation.

First off, keep in mind that while Medicare Part B tells hospitals to charge ASP (average sales price) + 6% (ish) when they buy and bill Medicare patients, there is no such guidance for commercial patients. Commercial insurers negotiate a fee off chargemaster rates, and as we all know, those chargemaster prices are, in general, based on absolutely nothing and are, in general, sky-high. So that’s the first thing.

The second thing gets into coding. Let me give you the general idea here, but we talk about this in some depth in the conversation to come.

As you likely know, hospitals get paid by sending bills with codes on them—procedure codes, for example. We the hospital did this procedure, and our charge for this procedure is $4000—so, here you go. Code followed by dollar amount is shown on somebody’s bill or explanation of benefits document.

These procedure codes are standardized across the industry for the most part. It’s not like every health system and/or payer is making up their own. This standardized set of procedure codes is called the Healthcare Common Procedure Coding System, affectionally known as HCPCS. So, if someone starts talking about a HCPCS code, all it means is that the code comes out of that standard set of codes.

Now, J-codes are one kind of code in this common procedure coding system. They are procedure codes that start with a “J.” These J-codes are for procedures involving (usually) specialty pharmacy drugs. A J-code identifies the specialty pharmacy drug that was used in the procedure.

So, you’d think it’d be pretty easy to audit a hospital bill, right? You look at the J-code on the bill; you find the ASP, the average sales price, or whatever of the drug; and then you get out your trusty calculator and you do the math on what the markup is.

And okay, maybe this works sometimes … but the problem is that so very, very often, the hospital doesn’t put the actual drug’s J-code on the bill. There’s this miscellaneous J-code that doesn’t specify the drug used, which is a quite common tactic, it seems. (I learned that in this episode.) Hospital just sticks “Miscellaneous chemotherapy” on a bill with a price after it, and nobody knows what drug was used.

Or the hospital will send a bill that just includes revenue codes. I think about revenue codes as the name of the section of the bill. It’s like on a menu: There’s that section, that headline, that says “Seafood” with a whole list of seafood dishes underneath it. In this example, the Seafood header is like the revenue code; and the J-codes are the actual dishes. Some bills come from the hospital, and all they have on them are the revenue code. There was some seafood. We’re not gonna tell you what dish or how much seafood, but yeah, seafood. The only thing we know about seafood is that there was some and it was very pricy.

Here’s a great example of a bill with some explanations.  

The main point here is that how health systems get away, in large part, with charging a whole lot for specialty pharmacy drugs is that their bills roll up charges into these very opaque codes that include lots and lots of stuff that is not broken out.

When I interviewed Marshall Allen (EP328) and we talked about his book Never Pay the First Bill, he said step one in getting an accurate and fair bill is to ask for the line item charges—and now that is totally making sense to me and also why this is so vital.

Just be aware, if you ask for these breakouts, you will likely get a huge box of hard copies. Check out this photo of a literally three-foot pile of printouts that one patient-turned-artist exhibited at an art show recently that I saw. If you don’t have the stamina to sort through all of those pages and pages and pages, you could be subject to 6x or more in markups or billing errors which are all too common and all too expensive. Hospital charges are a huge chunk of any employer’s healthcare spend, after all—over half of it in some cases. These are not small potatoes that we’re talking about. These are bills that bankrupt patients and make premiums go so high that patients cannot afford to get care.  

In this healthcare podcast, as mentioned earlier, we have two guests—Erik Davis and Autumn Yongchu—both from USI Managed Care Consulting and both having spent decades deep in the inner workings of the healthcare industry. And the topic of today’s show required that depth of knowledge, for sure.

You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.  

Erik Davis, AAI, CIC, CRM, is senior vice president and principal consultant, managed care and analytics, at USI Insurance Services. He has over 30 years of experience in the insurance and risk management industry. Erik works to create an environment that supports the healthcare risk management goals of an organization while maintaining focus on compliance and financial accountability. He is instrumental in vendor negotiations, data benchmarking, population health strategies, claims analysis, recommendations in plan design, and communication strategies.

In this capacity, Erik has been involved with development of rates, payment structures, and recommendations of changes in processes, policies, and procedures. He has a broad understanding of contract analysis, evaluating risk, auditing for correct payment, and structuring of excess loss and pharmacy programs.

Erik’s experience extends from overall employee benefits consulting to workers’ compensation, as well as managed care organizations in Medicaid, Medicare, and commercial contractual risk arrangements.

Erik earned his bachelor’s degree in economics from Oregon State University. He holds Accredited Advisor in Insurance (AAI), Certified Insurance Counselor (CIC), and Certified Risk Manager (CRM) designations.

Autumn Yongchu is a healthcare operational risk consultant at USI Insurance Services. Autumn works with multiple database platforms to examine data for trends and abnormalities. Using investigative querying, medical coding analysis, and report development, she provides resources that help identify cost control opportunities and assists organizations in strategic business decisions regarding the management of healthcare risks.

Autumn analyzes and interprets healthcare utilization data, allowing the development of initiatives regarding claim and risk management. This includes identifying fiscal and clinical strategies and providing necessary information to develop, design, and implement management initiatives. Autumn also analyzes trends, assists with insurance underwriting, and adjudicates stop-loss claims.

Autumn has an in-depth knowledge of Medicaid and Medicare billing guidelines and payment methodologies.

Prior to joining USI, Autumn was a claims auditor and trainer for a managed care organization which serviced over 100,000 commercial, Medicaid, and Medicare lives. Her responsibilities included contract analysis, claims adjudication, ensuring accurate payment, and identifying and recouping errors.

07:33 How do hospitals maximize inpatient bills?
08:05 How can hospitals upcode on specialty pharmacy products?
09:44 “It’s really not uncommon to be overbilled and overcharged.”—Autumn
11:11 Why do marked up bill charges actually affect the price commercial payers pay?
12:49 “If your payer’s not double-checking … how do you know that fraud’s happening?”—Autumn
12:52 “If the payer doesn’t have the detail to validate what that drug actually is, then are they really checking?”—Autumn
13:33 Why is it so hard to verify what you’re actually paying for on a hospital bill?
16:28 How do hospitals maximize profit with outpatients?
17:12 “Really it comes down to contracts and how [the] contracts are written.”—Autumn
21:54 “There are … silos within healthcare, and none of them actually talk to each other.”—Autumn
24:56 “There are these rules out there, but there are also big loopholes out there.”—Autumn
26:13 How can hospitals maximize payments for Medicare patients on drugs that have been out for a while?
29:30 “We just have a tendency to assume … that Medicare has a rate for everything, and Medicare doesn’t.”—Autumn
30:32: EP369 with Keith Hartman, RPh.  

You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.  

Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

How do hospitals maximize inpatient bills? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

How can hospitals upcode on specialty pharmacy products? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

“It’s really not uncommon to be overbilled and overcharged.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

Why do marked up bill charges actually affect the price commercial payers pay? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

“If your payer’s not double-checking … how do you know that fraud’s happening?” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

“If the payer doesn’t have the detail to validate what that drug actually is, then are they really checking?” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

Why is it so hard to verify what you’re actually paying for on a hospital bill? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

How do hospitals maximize profit with outpatients? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

“Really it comes down to contracts and how [the] contracts are written.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

“There are … silos within healthcare, and none of them actually talk to each other.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

“There are these rules out there, but there are also big loopholes out there.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

How can hospitals maximize payments for Medicare patients on drugs that have been out for a while? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

“We just have a tendency to assume … that Medicare has a rate for everything, and Medicare doesn’t.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong

Understanding Actuarial Risk Horizons in Healthcare with Keith Passwater and J.R. Clark

To read the full article and show notes with links mentioned, click here.

In this episode, Stacey Richter speaks with Keith Passwater and J.R. Clark, healthcare entrepreneurs and executives, about the importance of actuarial risk horizons in improving patient outcomes. They discuss how different risk horizons impact healthcare costs, benefit designs, and plan strategies. Keith and JR explain the key differences in risk management between short-term and long-term healthcare plans, such as individual exchanges and employer group insurance, and emphasize the significance of including the patient as a stakeholder in actuarial models. The episode highlights the complexities and challenges faced by actuaries in the healthcare system and the potential benefits of innovative, patient-focused actuarial practices.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

02:39 Why is it a problem for actuaries to ignore the patient as stakeholders in benefit design plans?

04:37 What is a risk horizon for actuaries?

05:38 “What’s the time interval over which we hope to impact healthcare costs?”

07:25 What is a risky investment from an actuary’s point of view?

08:05 How do you keep premiums down when the time horizon is short in an actuary’s point of view?

10:31 How do actuaries assess risk horizons or health insurance, and why do they choose those risk horizons?

14:05 What options are on the table when the risk horizon is longer?

16:06 How does the length of risk horizon affect benefit design?

So … let’s start here. Mostly this whole episode is about the so-called “Big Three” PBMs that provide between the three of them pharmacy benefit services for 95% of insured Americans. PBM stands for pharmacy benefit manager, and the Big Three PBMs being ESI, otherwise known as Express Scripts; OptumRx, which is a part (a big profitable part) of United Health Group; and then also CVS. Yes, CVS is not just for your retail pharmacy needs; they are also a huge pharmacy benefit manager.

Now, we get to the GoodRx part of our story. If you don’t know how GoodRx works, I would strongly encourage you to go back and listen to “An Expert Explains” with Dr. Ge Bai from last year (AEE13). That said, here’s the super short semi-reductive version to keep us all level set here. If you already know how GoodRx works, you can skip forward about four minutes. 

So, first of all, let’s all understand that GoodRx’s business model only exists because the pharmacy supply chain dominated by these three big PBMs that we just talked about is such a cluster. GoodRx profits from that dysfunction. So, as I said, here’s the short version of how they do that. It all hinges on so-called spread pricing, and this is what I mean by that.

Patient goes into pharmacy with a prescription for generic drug X. The patient has insurance—good news! Pharmacist checks the computer and sees that this patient should be charged, I don’t know, $50 for drug X. The patient’s insurance carrier picks up, say, $30 of the $50 cost; and the patient is left with, say, a co-pay of $20.

Who did that little math there in the computer? The PBM (the pharmacy benefit manager) did that math. That’s their thing, these PBMs. They adjudicate claims. That’s what this math is called. Anybody who goes into a pharmacy with a prescription, it’s the PBM on the back end who figures out how much the patient owes and how much their insurance will pay and what the patient responsibility is, etc.

Goodness, you might say. How much are the PBMs being paid to perform this useful service? Turns out, it’s free. That’s right … the Big Three PBMs do all this adjudication for free. No charge to plan sponsors. Isn’t that nice?

Except it’s actually not free if you dig into it. The PBM is certainly getting paid by means of arbitrage. They’re taking a little something something out of the middle of every single transaction. Here’s what that looks like in the example aforementioned. Recall the patient’s insurance paid $30, and the patient themselves paid $20.

The question is, how much did that drug cost the PBM? Remember, that’s commerce: Buy low, sell high, and all that. You buy something, and then you sell it for more than you bought it for.

OK, so we’re talking about a generic drug here. They’re cheap (usually). So, let’s just say drug X costs, I don’t know, $5. The PBM pays the pharmacy $5 for that generic script—and you can see how much money the PBM just made right there. The patient and their plan sponsor got charged $50, and the PBM’s cost of goods was $5. Multiply that profit margin by the billions of generic prescriptions in this country that run through insurance, and you have a tidy little business model there. UHG, the parent company of OptumRx, made $24 billion in profit in 2021. Not all of that was from generic drug arbitrage (ie, taking advantage of spread pricing), but some of it was. And $24 billion is an awfully big amount when you consider whose paychecks all those pennies were lifted from.

PBM services are anything but free. PBMs are collecting massive windfalls in the so-called spread between what the patient and the plan pay and what the PBM is actually buying those drugs for.

Here’s another wrinkle: When a PBM contracts with a pharmacy, part of their contractual terms is that the pharmacy’s list price for drugs cannot be lower than a certain amount usually having something to do with the PBM’s rates. So, pharmacy list prices become artificially high as a result, meaning that cash-pay patients who just wander into a pharmacy and try to pay cash pay an artificially high price.

Into this mess swoops GoodRx with a killer idea. They see all that money on the table that PBMs are cleaning up in that spread. They want a piece of that action. And in the beginning, PBMs were fully on board with this. They were fully on board because the market GoodRx was going after was the uninsured market, meaning untapped turf for PBMs. And because PBMs make so much money off of each transaction, PBMs are always hungry for more transactions (the Big Three PBMs, anyway). They love more transactions. The more more more with the transactions, the more more more with the money.

So, GoodRx goes to the PBMs and says, “Hey … if a cash-pay patient shows up in a pharmacy, what price would you charge them for you to adjudicate that claim? You know how much money you have to pay the pharmacy, so what can the patient price be? What spread are you willing to accept? GoodRx will take a little off the top, but you can keep your spread on this new frontier of patients that you haven’t historically had access to because … uninsured. Oh, by the way, we, GoodRx … we’re gonna go around to all your competitors, too (just saying)—the other two PBMs—and we’re gonna show their prices, too, in our GoodRx app at different pharmacies. So, you’re gonna have to compete with other PBMs in this model.”

This is why GoodRx cash prices for generics are so very very often less than what the patient will pay if they use their insurance. In the GoodRx app, PBMs have competition. So, by not using their insurance, patients often pay less for generic drugs—which, by the way, are 90% of the scripts written in this country—and also, as an added bonus, patients don’t have to jump through all the weird and arduous prior auths or step therapies or other hurdles that a PBM might toss in the mix. So, from a patient perspective, using GoodRx could save money, save time, and you could get your drugs faster because you don’t have to wait around for some prior auth to go through.

But this was not what PBMs had originally thought they were signing up for. They were working with GoodRx to gain new market share from the uninsured market, not lose market share to more and more patients forgoing their insurance, meaning forgoing shelling out to the PBM their spread on the transaction.

Cue my conversation today with Dr. Ge Bai. Ge Bai, PhD, CPA, is a professor of accounting at Johns Hopkins Carey Business School and a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health.

In this healthcare podcast, Ge Bai and I discuss the reactions of the Big Three PBMs to consumers getting all consumer-y when it comes to buying their generic drugs—despite the fact that, in my interview with Dr. Sunita Desai (EP334), she said that studies have shown that 67% of patients are unaware that they might be able to get a better price by not using their insurance and shopping around on GoodRx or Amazon or at a cost-plus pharmacy like Blueberry in Pittsburgh or Mark Cuban’s new thing. Despite that, it means 33% (one-third) of patients are aware that they can price shop and potentially get a better price not using their insurance on generic drugs; and apparently, it’s making some people at some PBMs nervous.  

Check the ESI (Express Scripts) blog post about their new prescription benefit that automatically applies discounts. Hmmm … sounds like a defensive play to me? What do we make of this? That’s my first question to Dr. Ge Bai in this episode.  

Also, if you’re really intrigued by generic drug goings-on, go back and listen to the show with Dr. Steven Quimby (EP344) when you have a chance. It’s about the high cost of generic drugs, and we go deep into supply chain machinations. 

You can learn more on Ge’s Web site at Johns Hopkins University. You can also connect with her on LinkedIn.

Ge Bai, PhD, CPA, is professor of accounting at the Johns Hopkins Carey Business School and professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on healthcare pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies.

08:45 What is ESI doing by automatically applying discounts to generic drugs?
10:00 Why are PBMs losing money when consumers don’t use their benefit?
10:46 “GoodRx disrupted the ongoing game.”
11:04 How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits?
12:13 Amazon pricing versus GoodRx pricing.
12:50 How much money is a PBM really making?
14:00 EP344 with Steven Quimby, MD.
14:29 EP334 with Sunita Desai, PhD.
14:43 How is future fear playing into the PBM business model?
16:55 Is there a negative consequence to subtracting from the bottom line in a PBM model?
17:50 “I think to have strong PBMs does not mean necessarily bad things for patients.”
19:39 What happens if everyone uses Amazon for drugs?
22:40 If every PBM gets their own discount cards, what will happen?
25:38 “We are actually witnessing a potential sea change.”
26:25 How do cost-plus pharmacies factor into the current market?
29:16 Is a profit shortfall inevitable?
29:35 “PBMs have to give a slice of their profit back to consumers. That’s just reality.”
30:11 Can anything be done on the PBM side to generate a higher margin in the generic space?
31:41 “Naive plan sponsors are a big problem.”

You can learn more on Ge’s Web site at Johns Hopkins University. You can also connect with her on LinkedIn.

@GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

What is ESI doing by automatically applying discounts to generic drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

Why are PBMs losing money when consumers don’t use their benefit? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

“GoodRx disrupted the ongoing game.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

Amazon pricing versus GoodRx pricing. @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

How much money is a PBM really making? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

How is future fear playing into the PBM business model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

Is there a negative consequence to subtracting from the bottom line in a PBM model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

“I think to have strong PBMs does not mean necessarily bad things for patients.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

What happens if everyone uses Amazon for drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

If every PBM gets their own discount cards, what will happen? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

“We are actually witnessing a potential sea change.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

How do cost-plus pharmacies factor into the current market? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

Is a profit shortfall inevitable? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

“PBMs have to give a slice of their profit back to consumers. That’s just reality.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

Can anything be done on the PBM side to generate a higher margin in the generic space? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

“Naive plan sponsors are a big problem.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335)

The reaction of some hospitals and health care systems to the COVID-19 pandemic has been truly breathtaking. Doctors, nurses, first responders, other staff at hospitals and elsewhere have worked hard—so hard—to support the national effort. The same can be said to some tech entrepreneurs and other businesses who have snapped into action in order to provide PPE (personal protective equipment) and artificial intelligence to the frontline health care workers.

In this health care podcast, I’m talking again with Marty Makary, MD, MPH. Dr. Makary is a surgeon at Johns Hopkins, professor of surgery and health policy and management at Johns Hopkins University, and the author of The Price We Pay and Unaccountable. So, this is episode 268. In this particular episode, Dr. Makary and I discuss the situation that will likely play out after the “reactive” phase of this COVID-19 pandemic (ie, March, April, May). 

After about June, the pandemic, according to Dr. Makary, will start to wind down a bit; and at that juncture, there’s going to be a backlog of patients who had their elective surgeries postponed and their care journeys potentially interrupted if they required an in-person visit or a lab test or an imaging study that did not happen. There will be a need to prioritize them, something that we have never really done in this country before. This is what we’re going to talk about in this episode: this second phase.

Potential point of interest: Episode 267 (the one right before this episode) is about the here and now, prior to the peak, if you want to go back and listen to that when you have time. 

You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary. 

Martin “Marty” Makary, MD, MPH, is an American surgeon, New York Times best-selling author, and Johns Hopkins health policy expert. He has written for The Wall Street Journal, USA Today, Time, Newsweek, and CNN and appears on NBC and Fox News. He has written extensively on organizational culture, the science of measuring quality in medicine, and health care reform. Dr. Makary is the author of two best-selling books: Mama Maggie, a book about a Nobel Prize nominee, and Unaccountable, a book about health care transparency. He also recently released The Price We Pay: What Broke American Health Care—and How to Fix It. This book offers a road map for everyday Americans and business leaders to get a better deal on their health care and profiles the disruptors who are innovating medical care.

Dr. Makary is principal investigator of a Robert Wood Foundation grant to lower health care costs in the United States by creating physician-endorsed measures of appropriate medical care and directs the national “Improving Wisely” project to reduce waste in medicine. He speaks nationally on disruptive innovation in health care. Dr. Makary is a frequent medical commentator of NBC and Fox News, commenting on the health care cost crisis, the impact of new technology, and interpreting the latest medical research for everyday consumers. Dr. Makary is director of the Center for Opioid Research and Education and founder of solvethecrisis.org, a Web site that shares expert opioid prescribing recommendations for common medical procedures for clinicians and patients. 

At Johns Hopkins, he has served as the endowed chair of gastrointestinal surgery, director of surgical quality and safety, and founding director of the Johns Hopkins Center for Surgical Outcomes Research and Clinical Trials. Dr. Makary is a surgical oncologist specializing in minimally invasive surgery and teaches health policy and management at the Johns Hopkins University School of Medicine. He currently serves as the chief of the Johns Hopkins Center for Islet Transplantation and director of the appropriateness in medicine project.

02:23 What “normal” will look like in June.
03:46 Why people who need basic medical care right now aren’t getting that care.
06:13 “For the first time, we’ve got to think now about prioritizing which patients need to get in line first.”
07:51 “We see gaming of the system.”
08:05 “We don’t do a good job of prioritizing.”
10:07 Why teamwork and team building are a problem in medicine.
12:57 The incredible heritage of the medical profession.
13:52 Will there be a decrease in outcomes?
14:33 Why lowering insurance deductibles will be key in making successful strides on the other side of this pandemic.
17:23 The great things to come out of the pandemic.
21:41 “Everybody’s right … [they’re just] looking at it from their point of view.”
21:56 What’s in store for pharmacies coming out of this pandemic.
24:53 What hospital executives should be doing, looking and planning months out from now.
25:48 “We’ve never asked ourselves, ‘What would take priority?’”

You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary. 

Keeping up with #covid19 news, check out our second-part episode with @MartyMakary as he talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech

What will “normal” look like come June? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

Why aren’t people getting basic #medicalcare right now? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

“For the first time, we’ve got to think now about prioritizing which patients need to get in line first.” @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

“We see gaming of the system.” @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

“We don’t do a good job of prioritizing.” @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

Why are teamwork and team building a problem in health care? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

What is the incredible heritage of the #medical profession? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

Will there be a decrease in #healthoutcomes come June? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

Why will lowering insurance deductibles help ease the coming months? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

What positive changes might be coming after #covid19? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech

“Everybody’s right … [they’re just] looking at it from their point of view.” @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

What’s in store for #pharma coming out of #covid19? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech

What should hospital execs be planning for in the upcoming months? @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

“We’ve never asked ourselves, ‘What would take priority?’” @MartyMakary talks #healthcare, #hospitals, and #coronavirus in the upcoming months. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19

In this episode, Stacey Richter explores how the demands of shareholders influence the actions of publicly traded health insurance companies with guest Wendell Potter. Drawing from Milton Friedman’s assertion that a business’s primary responsibility is to its shareholders, we examine the implications of this philosophy in the healthcare sector. The discussion highlights concerns about fraud allegations among major insurers and the lack of open competition due to market consolidation. 

We delve into the concept of the “medical loss ratio,” a key metric for investors, and how it pressures insurers to prioritize profits, often at the expense of patient care. Our guest, Wendell Potter, a former health insurance executive turned advocate for healthcare reform, provides insider insights into these dynamics. He discusses the challenges insurers face in controlling costs, the impact of rising premiums, and the broader consequences for patients and the healthcare system. This episode offers a critical look at the intersection of corporate interests and patient care, shedding light on the systemic issues that arise when profit motives drive healthcare decisions.  

All mentioned links can be found in the show notes. 

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08:31 What is the medical loss metric?

11:33 “The reality is, insurers have been jacking up premiums … for a long time.”

12:48 “It’s a short-term game.”

15:39 “You’re seeing that these companies are not doing a very good job … of controlling costs because they don’t have the incentive.”

20:19 EP366 with Kevin Schulman, MD.

22:45 How do payers ensure that they’re controlling utilization?

25:53 “It’s death by a thousand cuts.”

31:51 “Just like independent practice physicians are endangered, so are community pharmacists.”

33:17 Who runs our healthcare system?

There is a lot going on with digital health tools these days. Which ones are the good ones and which ones are nothing burgers packaged up in beautiful marketing? That’s a good question, and it would be nice to have a go-to source for such information.

Some parties — mainly PBMs [pharmacy benefit managers] and to some extent payers and providers — recognize that this actually would be nice, and they see that creating digital formularies could be an opportunity to grow revenue for their shareholders by meeting a market need potentially and offering additional services to the marketplace. But the term formulary implies more than just some kind of health technology assessment. It implies, at least at some level, the promise of reimbursement.

But given how local health care tends to be, especially when considering patient populations and the “bottom-up” nature of the doctor-patient relationship, here’s the question I have for you: Is it even possible for a third party, disconnected from the care setting and the patient, to “top-down” select the technology which will be used and reimbursed … especially in the age of consumerism?

For more on the intersection of patients and provider digital tool selections, listen to episode 250 with Vicky Tiase from NewYork-Presbyterian. 

In this health care podcast, I am speaking with Randy Vogenberg, PhD. Randy suggests that a more crowdsourced approach to digital health tool selection might be in order here. He says that those who are using the tools really need to have a seat at the table. He says that possibly the “formulary” within any given organization should be more of a consensus among stakeholders and less of a mandate from on high.

But there are a lot of wrinkles … like, lots of wrinkles.

Randy Vogenberg is board chairperson at the Employer-Provider Interface Council. He is principal over at the Institute for Integrated Healthcare.

You can learn more at iih-online.com, epicouncil.org, and hope.rutgers.edu. 

Randy Vogenberg, PhD, is principal at the Institute for Integrated Healthcare, co-leader for the National Employer Initiative on Specialty Pharmacy, and cofounder of the National Institute of Collaborative Healthcare (NICH). He is a health care expert on health system delivery and economics as well as health-related solution innovation research. Most recently he partnered with the Hospital Quality Foundation in developing the Employer-Provider Interface Council (EPIC). His broad hospital and managed care expertise includes current or future trends around financing, market excellence, and benefit management or design.

A leader and highly requested speaker on applied health systems research, he has authored programs or books on self-funded health benefits, managed markets, hospitals, and integrated medical-pharmacy benefit management. His academic relationships include Rutgers HOPE Center and former senior fellow at the Jefferson School of Population Health. Currently, he is an adjunct professor at the University of Rhode Island College of Pharmacy and Presbyterian College School of Pharmacy as well as the University of Illinois College of Pharmacy.

02:51 What a digital formulary is.
03:52 PBMs and digital formularies.
04:41 The changing landscape of PBMs and digital health.
06:00 The intersection of PBMs and digital health tools.
10:18 “Arbitrage, full on.”—Mark Blum, from America’s Agenda.
12:21 The inherent differences between a health plan and a PBM.
15:58 The original purpose of a pharmacy/therapeutics committee.
16:58 “There’s a lot of change happening, is the bottom line.”
18:18 The risk assessment behind medical software.
18:29 Harm vs digital therapeutics and digital medicine.
18:52 Cybersecurity in digital therapeutics.
19:08 Reimbursement in digital therapeutics.
19:43 The question of “how” in reimbursement.
20:37 “How do we reset health care in just one state, let alone the whole country?”
22:13 Taxpayers, patients, and employers vs the health care industry.
22:56 The slow move away from fee for service, and why.
24:13 The timeline for incorporating digital tools into the health care system.
24:33 “It’s a real problem for the consumer side.”
25:09 “What’s really going to be worthy of reimbursement?”
25:50 “There’s only two major payers in the health care system … that’s the government, and it’s the private sector employers and state programs or unions.”

You can learn more at iih-online.com, epicouncil.org, and hope.rutgers.edu. 

Robert White is a healthcare administrator who has been working in medicine for over 25 years. He has managed physician groups and practices in Anesthesia, Pain Management, Dentistry, Oral & Maxillofacial Surgery, Retina Surgery, Rehabilitation Medicine (with Primary Care/Hospitalists), Obstetrics & Gynecology, and Primary Care/Family Medicine. This wide array of medical specialties provides an ideal background for someone to understand the nature and utility of the GoGoHealth Environment for providers and patients.

Robert has been responsible for workflow design and optimization and enhancing the patient experience. He joined GoGoHealth in August of 2013 and has been working to develop the workflow integration model for product rollout. He has also concentrated on speaking with physicians and determining modifications to the product to meet the needs of the market.

Once the solution has been completed, Robert’s primary role will be to generate customers and implement GoGoHealth into their practices and workflows. He will be the primary trainer for staff and providers to insure successful rollout. Robert will also continue his role as CFO, managing the financial and revenue systems for GoGoHealth.

Robert will commit 100% effort to this project for the entire project period.

Twitter: @rwhite020 and @gogohealthllc

Facebook: gogohealthllc

Delivering Better Care and Getting Paid: A Value-Based Healthcare Guide with Justina Lehman

To read the full article and show notes with links mentioned as well as a full transcript, click here.

In Episode 414 of 'Relentless Health Value,' host Stacey Richter interviews Justina Lehman to explore practical strategies for healthcare practices to provide coordinated, high-value care while achieving financial growth. The discussion covers the detailed steps for developing and implementing value-based care models, including assembling a committed team, defining ideal care pathways, navigating payer relationships, and engaging with self-insured employers. Lehman emphasizes the importance of close collaboration between physicians, clinicians, and payers to enhance patient outcomes and reduce costs. The episode provides actionable insights for healthcare professionals aiming to transition from fee-for-service to value-based care.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

07:35 What has Justina been up to, and why is it relevant to this conversation?

08:23 What is high-value care, and how do we figure out what it is in reality?

08:59 EP412 with Robert Pearl, MD, on the art and science of medicine.

10:08 “What is the clinical design of … high-value care?”

10:21 Care as usual vs ideal care.

11:11 Summer Shorts 8 with Larry Bauer.

12:23 How does Justina figure out what the benchmark is for high-value care?

12:36 Meeting patients where they are at, not where we want them to be.

17:42 EP402 with Amy Scanlan, MD.

18:28 “What is the story as a group to the payer? What is the story as a group to the self-funded employer?”

19:19 How do you align business operations and the financials?

20:16 What are the four avenues for getting paid for high-value care?

21:58 What are highly engaged payers most intrigued by in high-value care?

24:11 What are the different ways a practice can get compensated?

28:52 Are there programs that have advanced without payers leading the way?

29:37 What’s the “hook” for payers?

31:12 What’s a winning message to payers and employers?

33:04 Summer Shorts 4 with Eric Gallagher.

34:13 “Not everyone needs to participate.”

38:24 Can a program be successful even if a physician is a passive participant in the program?

Let’s just start here: As a general construct, insurance carriers have every incentive for health insurance premiums to go up every year. If you’re an employer, that is a material fact. Is it counterintuitive? Maybe.

Except if you’re an employer and your premiums are going up year after year, it begs the question why, every single year, the already-extravagant amount you pay continues to go up way more than the inflation rate.

You’d think that if your broker and your plan administrator were so great at their fiduciary responsibility over your self-insured plan that this wouldn’t be happening. Oh right, whosever PPO network you’re using, they don’t have any fiduciary responsibility over your self-insured plan. You do, all you CFOs and CEOs and benefit professionals out there. Wait, I misspoke. Plan administrators do have fiduciary responsibility—to their shareholders. The CEO of CVS/Aetna made $36 million in 2019. He’s clearly very good at that job. The rest of them are, too. I’m not singling anyone out here. And also, this podcast is not investment advice.

In short, as previously stated, most major insurance carriers and the brokers they pay commissions to have every incentive for your premiums to go up every single year.

That’s where we’re at, folks. It’s an open secret, yet so many are just getting so wildly taken advantage of by carriers and brokers whom they have really put their trust in. If you work for a self-insured employer, tell your CFO/CEO to listen to this show. Or if you are a CEO/CFO or a benefits professional in charge of healthcare benefits, welcome. I hope this information is helpful.

My guest in this healthcare podcast, David Contorno, has been in the benefits industry longer than he hasn’t been in the benefits industry. I think he started working in a benefits brokerage when he was 17 or something. Currently, he’s the founder of E Powered Benefits. In this episode, we talk about the keys for self-insured employers that lead to better health for their employees at something like 20% or more lower costs. Here’s some of the imperatives for employers that David digs into in this episode:

1. Advanced primary care—really valuing primary care providers who do not work for hospital systems and, therefore, are not subjected to the ball and chain of perverse incentives that David talks about at some length.
2. Getting cost and quality data so you can make prospective choices and not get hit in the back of the head with an after-the-fact “gotcha” in the form of an overpriced bill that you are now obligated to pay.
   Let me bring up all the articles lately in the New York Times and elsewhere … people paying hundreds of thousands of dollars for something that should cost a fraction of that. Most of them have “good” insurance (keep that in mind) from their employer. Also keep in mind that most of these stories that hit the news are the ones where some poor employee got stuck with a bill—not the metric ton of other examples where the self-insured employer was on the hook. If you’re an employer, you can get ahead of these “gotcha” moments. It’s textbook risk mitigation if nothing else.
3. Create benefit designs to help employees find and incent them to use the highest-quality providers charging a fair price. Listen to EP334 with Sunita Desai for more on the topic of incenting consumerism.
4. Know how your broker gets paid. If someone is paying your broker a commission and it isn’t you, then your broker makes more money when your premiums and rates go up. They are a sales rep getting paid to make someone else money off of you.
5. Get a handle on your pharmacy spend. David gets into some nuances here which are super interesting.

You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn.  

David Contorno is founder of E Powered Benefits. As a native of New York, David began his career in the insurance industry at the age of 14 and has since become a leading expert in the realm of employee benefits over the last 22 years.

David was Benefits Selling magazine’s 2015 Broker of the Year, and in March 2016, Forbes deemed him “one of America’s most innovative benefits leaders.” More recently, he received the 2017 Leadership Award at ASCEND, the annual conference of The Association for Insurance Leadership, which recognizes those whose leadership in support of improving the value and performance of employee benefits has significantly advanced the industry.

David is a member of the board of directors for both the Charlotte Association of Health Underwriters and HealthReach Community Clinic. He served on the NC Insurance Commissioners Life and Health Agent Advisory Committee, as well as participated in the Technical Advisory Group that helped with the market reforms required under the Affordable Care Act in North Carolina. He is a longtime member of the Lake Norman and South Iredell Chambers of Commerce as well as the National, North Carolina, New York, and Long Island Associations of Health Underwriters. David contributes to numerous publications, including Forbes, Benefits Selling magazine, Business Leader magazine, and Insurance Thought Leadership.

David is committed to giving back to his community and actively participates in the membership drive for the United Way, assisting the local chapter of Habitat for Humanity, and supporting The Dove House Child Advocacy Center. When he is not working, he enjoys boating and traveling.

04:20 How do you ensure better care for patients?
05:10 “What’s required to correct those things is not really a massive degree of intellect or even innovation.”
05:38 What’s the road map for self-insured employers who want to take control of their healthcare costs?
10:06 “Higher costs equal more profit and more revenue.”
14:03 “The problem with devalued primary care is … that most people pass over the primary care provider and go right to the specialist.”
19:41 “Every employer should have every broker sign a compensation disclosure form.”
20:06 “If you think there’s perverse incentives on the medical side … it gets even worse on the pharmacy side.”
21:01 What changes do employers find when they follow the road map to taking control of their healthcare costs?
21:44 “It’s not uncommon for us to reduce total healthcare spend for an employer by between 20% and 40% at the end of the first year.”
22:09 “I can’t change [the] outcome without changing the path you walked to get there.”
22:41 “Going self-funded is where the journey starts, not where it ends.”
24:47 “If most employers truly understood how badly these carriers and health systems are taking advantage of them … [it’s almost like] Stockholm syndrome.”
27:09 “The only legitimate fear that employers should have is, How do they message these changes … to the employees?”
29:21 “This has to happen, and if it doesn’t happen, the system’s going to break and … be picked up by entities that are, I think, only going to make the situation worse.”

You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn.  

@dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

How do you ensure better care for patients? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“What’s required to correct those things is not really a massive degree of intellect or even innovation.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

What’s the road map for self-insured employers who want to take control of their healthcare costs? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“Higher costs equal more profit and more revenue.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“The problem with devalued primary care is … that most people pass over the primary care provider and go right to the specialist.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“Every employer should have every broker sign a compensation disclosure form.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“If you think there’s perverse incentives on the medical side … it gets even worse on the pharmacy side.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

What changes do employers find when they follow the road map to taking control of their healthcare costs? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“It’s not uncommon for us to reduce total healthcare spend for an employer by between 20% and 40% at the end of the first year.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“I can’t change [the] outcome without changing the path you walked to get there.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“Going self-funded is where the journey starts, not where it ends.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“If most employers truly understood how badly these carriers and health systems are taking advantage of them … [it’s almost like] Stockholm syndrome.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“The only legitimate fear that employers should have is, How do they message these changes … to the employees?” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

“This has to happen, and if it doesn’t happen, the system’s going to break and … be picked up by entities that are, I think, only going to make the situation worse.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316)

I was thinking about this when reading that Forbes article that came out the other day that 44% of Americans skip doctor visits or medical care due to cost. Here's my point: There could be 2 prongs to this. One of them is that the costs are too high. And yep, they are. Even more distressing when you consider that only a dime on every dollar spent on health care goes to the physician or nurse or person actually providing the care. So much is chewed up by invisible middle people adding questionable value to patient care.

But here's another prong that you might not have thought of. I remember in one of my marketing classes ages ago the case study about classified ads. Classified ads that listed the price were something like 50% more successful than those that did not. If there's no price, consumers just assume the price is too high. Consumers are consumers whether they're buying a used lawnmower or medical care, and they simply assume the cost is too high when the price tag is turned under. Buying something and being obligated to pay for it even if you don't know what you're getting yourself into... that's a risk that might be a factor in that 44% not bothering to show up for care they need.

Today, I speak about the hidden costs and frictions in health care with Joe Murad, President and CEO of PokitDok. Costs and frictions that make being a health care consumer a less than optimal experience.

Joe most recently served as Managing Director and Head of Individual Exchange Solutions for Willis Towers Watson where he was responsible for the largest private health insurance exchange. Prior to WTW, Joe was the COO and a founding team member of Extend Health, Inc. from its inception until its $435MM sale to Towers Watson in 2012. Before Extend Health, Joe was part of the initial team at eHealth (IPO: EHTH) where he served as the Director of Business Development and was instrumental in building the company’s early overall success. Before eHealth, Joe held numerous market facing roles at Informix Software, Inc. (acquired by IBM in 2001) by way of its acquisition of Illustra Information Technologies in 1995.

You can learn more at pokitdok.com

I wanted to talk with Dr. Lee because so many RHV (Relentless Health Value) listeners are trying to figure out how to sustain primary care as a stand-alone entity when the most obvious and most common way to make enough money in primary care is to drive and maximize the dollars from downstream volume of high-priced service lines, which, if you think about it, undermines the entire point of primary care.

In Episode 445 of Relentless Health Value, Stacey Richter interviews Dr. Tom Lee, founder of One Medical and Galileo, about the sustainability of standalone primary care practices in 2024. Dr. Lee also was a founder at Epocrates

They discuss the paradox of primary care, the economic challenges of running an independent practice, and the importance of enlightened leadership with a value-focused mindset.

Dr. Lee emphasizes innovative service operations, cutting hidden waste, and balancing human-centered care with efficient processes. The conversation explores various facets of primary care, including access, longitudinal patient care, and the role of technology.

Tune in to understand how primary care can thrive amidst economic and systemic challenges.

07:02 What is the paradox of primary care?

09:19 Why is it hard to run an independent primary care practice?

10:01 What are the barriers to running an independent primary care practice?

10:41 Can you have fee for service and value?

12:25 “Value is more about a mindset.”

13:22 What hidden waste is there in a primary care practice?

15:11 What do you need to have a value-focused mindset?

17:14 Why does access precede quality?

18:20 Why have retail clinics failed in being longitudinal primary care destinations?

20:29 What is a longitudinal primary care destination and why does it matter?

23:48 What are the nuances of a service business that make them challenging for managers?

24:35 How do you find the balance between fee for service and value?

31:17 EP438 with John Lee, MD.

32:14 How can you invest in quality without a value-based contract?

34:19 How do you address the trade-off between fee-for-service finances and investing in value-based care?

35:36 Where is the “productive middle”?

36:27 Dr. Tom Lee’s message to payers.

39:55 Dr. Tom Lee’s message for policymakers.

The Financialization of Health Benefits: A Boardroom Imperative

To read the full article and show notes with links mentioned as well as a full transcript, click here.

In episode 419 of Relentless Health Value, Stacey Richter interviews Andreas Mang from Blackstone on the financialization of healthcare benefits for corporate boards and C-suite executives. The discussion highlights the transformation of healthcare benefits into a significant business aspect, emphasizing the importance of C-suite involvement to combat waste and financial exploitation by vendors. Andreas offers practical steps to save companies up to 10% on healthcare costs while improving employee satisfaction, including self-insurance and careful selection of brokers. The episode underscores the need for enhanced purchasing discipline and strategic alignment among company leadership to manage healthcare expenses effectively.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

04:19 Why Andreas starts every conversation with the question, “How’s your healthcare company?”

07:04 Why is it important, as a self-insured employer, to treat your business as a small healthcare company?

08:42 Why is it unnatural for companies to be providing health insurance?

10:13 What can be achieved when there is alignment between employers and insurers?

12:07 What things can a company do to reduce spend by 10%?

13:40 Why is it better to have CFO engagement in the benefits plan throughout the year?

15:51 Why does self-insurance save 5% to 9% for companies automatically?

17:41 “The funding isn’t a healthcare thing; it’s a CFO thing.”

17:54 Why is it vital to have a reliable, trustworthy broker?

24:38 When is the last time your company has RFP’d their health plan?

27:06 Why does changing a health plan feel scary but is necessary?

27:58 What is a dependent eligibility audit?

30:48 Why are employers better together?

34:02 How do employers truly get a flat-fee model with brokers?

Jeff Scott is the VP of Business Development for DHS Group, a health, wellness and population health software company with offices in Houston, TX, and Cleveland, OH. He has over twelve years of corporate and business development experience spanning financial services, healthcare and software verticals

Prior to DHS Group, Jeff was CFO of Movable, a health and wellness software startup that was acquired by DHS Group in 2015. Before Movable, Jeff was VP of Strategy and Business Development for KeyBank, where he developed organic and inorganic growth strategies for all areas of the $90B financial institution, with a heavy emphasis on healthcare and B2B payments verticals.

Jeff’s experience includes managing P&Ls, building new sales teams, launching new products and developing & executing sales strategies. He has advised companies of all sizes on health, wellness, financial and technology strategies.

Find out more at www.DHSgroup.com.

In this encore episode of 'Relentlessly Seeking Value,' host Stacey Richter revisits a critically important conversation with ERISA attorney Paul Holmes about the complexities and hidden pitfalls in Pharmacy Benefit Manager (PBM) contracts.

Aimed at CFOs and employer plan sponsors, Holmes highlights how poorly reviewed PBM contracts can lead to companies paying 30-40% over market for pharmacy benefits, discusses the potential legal exposures under the Consolidated Appropriations Act (CAA), and suggests the essential need for independent reviews.

Holmes also delves into issues with Employee Benefit Consultants (EBCs) taking indirect compensation from PBMs and offers actionable advice for employers on how to mitigate these risks. 

07:41 What are Paul’s usual observations when a PBM contract crosses his desk?

08:34 “If you just sign … one of their model contracts …, you’re probably gonna pay 30% to 40% above market on your drug spend.”

12:11 What is a PBM lawyer? And why is it important to find an ERISA PBM lawyer?

17:12 EP379 with AJ Loiacono.

17:40 Who is on the hook for the cost of the PBM contracts?

21:05 What’s the problem with most ERISA lawyers today?

22:56 Lawsuit about PBM contract.

27:43 What’s Paul’s advice for benefits consultants?

31:40 How much might a plan sponsor be paying their consultant versus what a consultant might be making from a PBM?

PCPs (primary care providers) are really important to population health. Primary care is the foundation of any well-functioning health system, I am sure many listening to this podcast know well. For the Triple Aim to happen, patients really need access to robust primary care. This has been affirmed by almost anyone who looks into it. And yet, in this country, our system sort of anemically supports our primary care colleagues.

As a general statement, poking and prodding and procedures are compensated at a far higher rate than anything requiring cognitive services. What a PCP or a pediatrician mainly does all day is really cognitive. It’s listening and thinking and counseling and coordinating.

But here is maybe an underappreciated point: If we’re going to measure PCP performance, then we need the right measures to measure that performance. You might be doing this measurement as a basis for incentives or maybe for continuous improvement programs. Either way, if you don’t have the right measures, then maybe great primary care is under-rewarded or your continuous improvement process is counterproductive—you’re incenting the wrong things, you get the wrong activity. And to add to that, PCPs (ie, practices) can spend upwards of $40,000 a year of uncompensated time trying to add and subtract and tote up the difference in all these varied and potentially inapplicable measurement standards coming at them from all manner of directions.

My guest in this health care podcast is Rebecca Etz, PhD. Dr. Etz and the team over at The Larry A. Green Center have worked hard to create a set of 11 performance measures for primary care. These measures went through the wringer as far as their creation and validation. These 11 measures take into account what patients want, what primary care clinicians (including pediatricians, nurse practitioners, and others) think is most important and possible to provide, and what payers want to pay for. These 11 measures are aligned across the three stakeholders, and they are actionable. Neither of these descriptors is anything to take for granted.

Rebecca Etz, PhD, is associate professor of family medicine and codirector of The Larry A. Green Center, which is in Richmond, Virginia, at the Virginia Commonwealth University.

You can learn more at green-center.org.

Rebecca S. Etz, PhD, is an associate professor of family medicine and population health at Virginia Commonwealth University (VCU) and codirector of The Larry A. Green Center—Advancing Primary Health Care for the Public Good. Dr. Etz has deep expertise in qualitative research methods and design, primary care measures, practice transformation, and engaging stakeholders. Her career has been dedicated to learning the heart and soul of primary care through three main lines of inquiry: (1) bridging the gap between the business of medicine and the lived experience of the human condition, (2) making visible the principles and mechanisms upon which the unique strength of primary care is based, and (3) exposing the unintended, often damaging consequences of policy and transformation efforts applied to primary care but not informed by primary care concepts. As a member of the VCU Department of Family Medicine and Population Health and previous codirector of the ACORN practice-based research network, Dr. Etz has been the principal investigator of several federal and foundation grants, contracts, and pilots, all directed toward making the pursuit of health a humane experience. Recent research activities have included studies in primary care measures, behavioral health, simulation modeling, care team models, and adaptive use of health technologies. Dr. Etz currently leads the fielding of a weekly survey regarding the response to and impact of COVID-19 on US primary care practices. She also serves on the National Academies of Medicine consensus study, “Implementing High-Quality Primary Care.”

03:41 Why is primary care one of the “best-kept secrets” of better health outcomes?
08:38 “Measures are a form of communication.”
08:51 “If the way that you are assessed does not actually match up with the work you do or what you find to be important, it’s pretty demoralizing.”
11:41 “It is the outcome of health care, but it is not the same thing as quality.”
16:31 “It creates a financial incentive to hit a target by any means necessary.”
18:06 “We incentivize people to have good outcomes, and what that means is that electronic medical records are no longer simply databases that tell us what the health of the population is. They are databases that tell us what is the optimal picture that a clinician is able to paint of their patients.”
21:07 “Primary care is a relational field.”
22:14 “How does this relate to cost and utilization?”
26:43 “I think we all know that fee for service is death.”
27:11 How has the measure of PCPs in the time of COVID held up?
27:32 What measure performs worse in the time of COVID?
28:17 “Primary care is the place that everybody goes.”
31:16 EP270 with Dave Chase and EP272 with Guy Culpepper, MD. 

You can learn more at green-center.org.

Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

“Measures are a form of communication.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

“If the way that you are assessed does not actually match up with the work you do or what you find to be important, it’s pretty demoralizing.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

“It is the outcome of health care, but it is not the same thing as quality.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

“It creates a financial incentive to hit a target by any means necessary.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

“Primary care is a relational field.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

“I think we all know that fee for service is death.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

How has the measure of PCPs in the time of COVID held up? Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp

David Contorno the other day posted the life expectancy chart comparing the US to comparable countries. Spoiler alert: It’s horrifying.

You see Japan; you see Switzerland, Israel, Spain, Italy … basically everybody else in a cluster of pretty darn vertical lines: increasing life expectancies year over year without much cost increase at all. And then—wow!—off to the right, all by itself, you see the USA, costing nearly double the worst of the other countries with a life expectancy that is years lower. We pay a whole lot, and despite all of the advances in medicine and how much we pay, we don’t seem to be getting the value for our dollar.

We could dig into those poor outcomes that we pay for. If we were going to, I might mention our truly beyond-upsetting maternal mortality rates and also infant mortality rates, which are way above other comparable countries. We could talk about all of our issues with diabetes and obesity. But let’s save all that for another day and just take one example that is really the quintessential example of what’s going on. Let’s chat about heart failure for just a sec. Here’s some stats for you. They come from Dr. William Bestermann’s Substack newsletter, and if you don’t subscribe to it, you might want to. It’s free. 

Dr. Bestermann wrote: “Twenty-two percent of heart failure patients who are admitted to the hospital are dead within a year. Patients with [heart failure] generate a third of Medicare spending and 40% of Medicare fee-for-service deaths. Overall, heart failure patients have a mortality of 22%, compared [to] 4% for Medicare patients without heart failure. They are responsible for 55% of Medicare readmissions.”

But here’s some good news: In Denmark, investigators proved that using optimal medical therapy reduced heart failure admissions by 70% compared with usual care.

Here’s some more good news: There was a small, impoverished town near the coast of the Carolinas that had very few heart failure admissions. How did they accomplish that, you might wonder? Well, there was a nurse—one nurse—who was working under a grant. She was very dedicated. She had a list of all the heart failure patients in the area, and this was her job: making certain that every patient was on the best treatment for heart failure. She called the patients. She spent time with them. She had a trusting, caring, long-term relationship with them. That’s it! That was the secret sauce.

As Dr. Bestermann says, “Every poor community in our country could do that, but they don’t.”

So, this leads us to care gaps—dare I say, this country’s seeming care gap fetish dealing with care gaps retroactively.

In this healthcare podcast, I’m speaking with Carly Eckert, MD. It’s kinda funny, actually. I originally wanted to get Dr. Eckert on the show to talk about care gaps and how to close them, but this show did not wind up going how I thought it was going to go because Carly Eckert is a physician by training who got really interested in the upstream causes of what she was seeing in clinical practice. Despite my best efforts, she refused to be lured into my closing care gaps conversation. So, instead, this conversation is about the construct of care gaps and thinking about them in context. Closing care gaps is a model of care and maybe not a particularly great one, relatively speaking. In fact, here’s another name for the model of care called closing care gaps: care gap whack-a-mole. Care gap pops up … we whack it. Care gap pops up … we try to close it. Another care gap pops up … we try to close it. Another care gap … you get the idea.

Carly Eckert has worked in epidemiology and public health and also clinical informatics for health systems and payers. She is currently leading a team at Olive AI working on network data analytics and machine learning algorithms.

I recorded this show with Dr. Eckert prior to EP359 with Dan O’Neill. In that interview, which you should go back and listen to when you have a sec, Dan O’Neill cleared up a couple of things that I struggled with during this interview. 

Here’s the big one that I could not figure out: Why with the whack-a-mole? Why do we still insist as a nation on waiting for someone to show up in clinic to retroactively and reactively address a missed preventative care opportunity?

Why don’t so many more provider organizations create pop health programs that consider the whole person proactively? Why don’t they take the time to operationalize whole-person care in a meaningful way? Why don’t they do what that nurse was doing in the Carolinas?

Ah, yes … to the surprise of exactly no one, it’s all about the Benjamins.

As Dan O’Neill put it, if all a provider organization is doing is slapping a sheet on a doc’s desk every morning with a list of care gaps for all the patients that he/she will see that day, it’s highly likely that incentives, or penalties to do anything else, are very weak. It’s a sign that, from a paying for value perspective, we’re not paying enough for value that it’s worth it or maybe even feasible for any provider organization to take the time and capital expense to switch up their business model in any meaningful way. So, the provider gets a little bump or a little knock if they don’t meet some quality standard. OK, great … so then they’ll minimally tweak their workflow and have doctors within their 7- to 15-minute visit suss out and try to close care gaps.

I don’t want to say this is entirely negative. It’s known that when provider organizations do close care gaps, patient outcomes do tend to get better—so, not arguing that. But there’s opportunities that get left on the table with all this reactiveness. Bottom line: You insurers, you purchasers of healthcare, get to it. Pay for value, for real. If you’re still just kinda paying mostly FFS with an icing of quality measures, maybe think a little bit harder about what’s next that’s really gonna end the whack-a-mole and bring about a more proactive and in-context mindset.

But you provider organizations, if you don’t fix this stuff yourself, you’re gonna get doctors and other clinicians (as we’re seeing) burning out and quitting because there’s only so much you can jam into a 7- or 15-minute visit, number one. But number two, doing population health reactively like this is suboptimal—and everybody knows it. So, what winds up happening is dedicated doctors and nurses desperately want to do the right thing but simply do not have the time. And they watch patient after patient suffer for it. That sucks. So, fix it. Maybe find a nurse like they did in North Carolina. At the end of the day, it’s probably cheaper to stand up a program like that than having to recruit all new doctors and hire traveling nurses when all of the current staff quits due to burnout and/or moral injury.

You can learn more at oliveai.com.

You can also connect with Dr. Eckert on LinkedIn and follow her on Twitter.  

Carly Eckert, MD, MPH, is a product leader at Olive AI, the automation company creating the internet of healthcare. As a trained physician, epidemiologist, and informatician, Dr. Eckert brings a tremendous amount of clinical experience and relevant healthcare industry knowledge to her work. In her role, Dr. Eckert combines her expertise, data understanding, and deep passion to impact healthcare for all patients. Prior to her role at Olive, Dr. Eckert led product for multiple AI start-ups with a particular interest in socially responsible technology and community impact.

06:59 What is the true goal in making population health successful?
07:26 How does the clinical pathway need to manifest in population health?
08:00 How do we get a nonfragmented state of care?
08:25 What is the best model of care?
10:08 “Identifying and addressing care gaps is an important element of population health.”
13:01 Closing care gaps vs creating a nonfragmented system of care.
17:11 “I think you have to take small steps with people.”
18:18 “There’s a lot of power in peer support.”
18:52 Why should provider organizations connect with peer groups?
20:39 “The key is that it’s not going to be the same for everybody.”
24:43 Why is diversity of the workforce key to closing care gaps?
25:07 EP322 with Monica Lypson, MD, MHPE.
25:11 EP347 with Ian Tong, MD.
30:09 Where can providers improve transparency to help close care gaps?

You can learn more at oliveai.com.

You can also connect with Dr. Eckert on LinkedIn and follow her on Twitter.  

@md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

What is the true goal in making #populationhealth successful? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

How does the clinical pathway need to manifest in #populationhealth? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

How do we get a nonfragmented state of care? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

What is the best model of care? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

“Identifying and addressing care gaps is an important element of #populationhealth.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

Closing care gaps vs creating a nonfragmented system of care. @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

“I think you have to take small steps with people.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

“There’s a lot of power in peer support.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

Why should provider organizations connect with peer groups? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

“The key is that it’s not going to be the same for everybody.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

Why is diversity of the workforce key to closing care gaps? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

Where can providers improve transparency to help close care gaps? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King

Maybe you’ve already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worries—here's the deal: I decided to split this deep dive into the 340B program with Shawn into two parts. So, feel free to jump into one or both—it’s totally up to you.

To Read The Full Article Including Links Mentioned, click here.

If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.

These episodes don’t have to be listened to in order, so you’re good to start here with Part 2. Let’s get into it!"

Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place.

As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med.

Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors.

After you listen to this show, if you want to drill in a little deeper on the “what the what” and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering.

If you want a summary of the points Shawn makes for why employers should care, it is your lucky day, because here you go. Here’s the four distortions in the market that Shawn talks about which impact employers:

To continue reading, please view our show notes/full article.

09:11 Why do employers care about 340B, which is a Medicaid program?

11:30 Why do I care as an employer, even if I’m not Pharma?

12:44 Why is 340B causing employers to pay significantly more for healthcare?

14:36 Study by Zack Cooper, PhD.

15:06 Why are there distorted pricing models at 340B hospitals?

21:22 Why do employers need to stop playing the blame game?

Episode 422: The Financial Struggles and Unexpected Insights of Independent Pharmacies with Benjamin Jolley

To read the full article and show notes with links mentioned as well as a full transcript, click here.

In this episode, Stacey Richter interviews Benjamin Jolley, a multi-generational pharmacy leader and consultant, who discusses the financial challenges faced by independent pharmacies. Jolley reveals that a significant portion of a pharmacy's profits comes from a mere 10% of prescriptions. The conversation dives into the detrimental impact of Pharmacy Benefit Managers (PBMs) on pricing and reimbursement, the inefficiencies in the system, and explores potential models like direct pharmacy care to create more sustainable business practices. The discussion also touches on the broader implications for local communities and the healthcare system overall.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

04:47 Benjamin Jolley’s recent revelation.

06:14 What are the 10% of drugs that provide all the profit for pharmacies?

09:21 What’s happening with the other 90% of drugs that pharmacies are filling?

11:05 What is the breakdown of costs when fulfilling prescriptions and running a pharmacy?

18:50 EP379 with AJ Loiacono.

21:42 What is the “cost savings” within the “insane system” of PBMs not sharing profit with independent pharmacies?

23:00 What is one of the things that PBMs and pharmacies don’t often talk about?

26:39 What can employers do so that patients aren’t getting overcharged by PBMs?

27:51 “How do I make the PBMs irrelevant?”

33:30 What’s the difference between an independent pharmacy delivery service and a service like Express Scripts?

34:36 What’s the other potential solution in solving the problems independent pharmacies face, and why does Benjamin Jolley feel that it’s not the best solution to pursue?

Tomas Gregorio is the Senior Executive Director of Healthcare Systems Innovation at the NJ Innovation Institute. In that capacity he has overall managerial responsibility for program development and execution of NJII’s activities organized under the Healthcare Systems i-Lab. Mr. Gregorio brings a rich and diverse background to the job having served various roles as a senior executive in regional hospital systems as well as with allied consulting and software industries. He was most recently the Sr. Vice President & COO for HealthEC, LLC, a leading provider of best-in-class data connectivity and consulting solutions for the healthcare industry. Prior to that he served as President and CEO of Meadowlands Hospital and before that, at Newark Beth Israel Medical Center was the Vice President Administration and Vice President & CIO. Mr. Gregorio has also been a principal advisor in NJIT’s efforts to establish and build both NJ-HITEC and the Highlander Health Data Network (HDN).

Tom spent seven years of his career as a management consultant with PricewaterhouseCoopers where he worked in over 23 hospitals around the country, hundreds of affiliated and independent practices, and several insurance companies and TPAs. The types of projects he worked on included vendor selection for financial, billing, and clinical systems, system implementation, support operations development, and healthcare business operations management. He also contributed to early HMO models in the Northeast and overall quality and process improvement initiatives. Having developed a deep understanding of hospitals and physician practices’ technology capabilities, he comfortably applies technical solutions to clinical and business problems to accomplish meaningful results for his clients.

As a hospital executive, Mr. Gregorio further developed his ability to oversee complex healthcare operations. Mr. Gregorio’s extensive experience in managing new and existing hospital operations was showcased during the change of ownership of Meadowlands Hospital Medical Center in 2010. As the CEO, he led the team responsible for contract conversions and systems implementations during the transition. He also made key organizational decisions including hiring the executive team, determining which staff members were retained, and negotiating new collective bargaining agreements.

In his roles as CEO, he ensured that senior management and administrative functions of the hospital were in compliance with state and federal regulations, rules of accrediting bodies, and licensing standards. His method of maintaining and improving quality is based on a systems approach: recognizing the value of measuring each aspect of an operation, down to the cost per unit of service. As a result, he instituted control systems for the maintenance of financial, human and capital equipment assets resulting in oversight of all financial affairs and ensuring that services are produced in a cost-effective manner. Tom has proven his ability to identify the root cause of an organization’s problems and make the necessary adjustments to resources and processes. In doing so, he cultivates environments that function effectively, efficiently, and produce results in a timely fashion.

Tom’s commitment to the delivery of quality and compassionate healthcare extends far beyond his administrative experience. Some of his innovations include a project to monitor the health of senior citizens with Diabetes and high blood pressure, and a physician house call service that tracks senior citizens’ health remotely and generates referrals to the hospital, physician or family members; a technology that was unheard of in the US at that time. During his time as VP of Administration and CIO at Newark Beth Israel, he brought his innovations across cultural and international lines with a Bloodless Medicine program and an initiative which brought patients from the Middle East to Newark Beth Israel. His diverse background provides a unique perspective rarely seen in traditional hospital executives.

Mr. Gregorio’s firsthand knowledge of healthcare technology and operational excellence span the entire healthcare landscape. Over the last two years, Mr. Gregorio had the opportunity to begin an Accountable Care Organization (ACO) service line with HealthEC. The population management software and services developed under this project are directly in-line with the new reimbursement models facing the healthcare industry today. HealthEC’s products and services helped one of their clients manage over 100,000 lives and save 6 million dollars through the Medicare Pioneer ACO program. With this project as well as Health Information Exchange technologies like the Highlander Health Data Network, Tom uses his knowledge of hospital operations to promote a change in hospitals from being a revenue source to a cost center. In addition to creating ACO and HIE infrastructures, he has contracted with community physicians and created the value propositions needed to work in a population management based operation. Outpatient services are the future and population health and ACO's are the vehicles currently in place to make that transition.

Mr. Gregorio is also a professor of Health Information Technology and Management Information Systems at NJIT in Newark NJ. Tom has a BS in Organizational Management Nyack College and an MBA in Management of Technology from NJIT.

You can find out more information by calling 973.642.4500, emailing tomas.gregorio@njii.com, or visiting www.njii.com.

A 27-year veteran of managed-markets marketing, David is the President/CEO of Pinnacle Health Communications. After working in consumer marketing with AT&T and healthcare publishing with Elsevier, David made the move to medical advertising and communications at K.I. Lipton, Inc. Subsequently, he became a cofounder of Pinnacle. David is an accomplished strategist, providing innovative customer marketing, access, quality, and health intervention solutions for large clients and has directed the development of numerous industry-leading campaigns in primary care and specialty markets. He has supported clients in disease areas that include oncology (Bristol Myers Squibb [BMS], Novartis, Eisai), virology (BMS, Merck & Co.), pharmacy (American Pharmacists Association, Merck, Novartis), and blood disorders (Novo Nordisk), to name a few. David has helped more than 15 clients achieve top rankings in their respective categories. He is also an active member of the Pharmacy Quality Alliance.

00:00 Dave discusses the three success factors that Steve Case has created.
00:30 Policy, Partners, and Perseverance.
02:30 Understanding where the market is going and who is driving that.
03:00 Dave talks CMS.
03:30 “No policy is static or stagnant; there’s always unintended consequences.”
06:30 Dave and Stacey discuss payment models and the changing landscape of reimbursement in healthcare.
08:00 “Are you only managing to the next quarter?”
13:00 Having a forward-looking strategy.
13:45 “There has to be organizational vision, commitment, determination and activity to pursue objectives.”
14:45 “Do you serve an immediate need, or do you build opportunity over time?”
18:20 The two related emerging dynamics in healthcare.
23:00 The big advantage of having a long-term partnership.
28:00 Change and the rapidly evolving marketplace.
29:00 “You need to see where the market is going; you need to develop a plan for both today and tomorrow.”
29:30 “This is a journey, not a destination.”

Let’s talk about one aspect of health care that’s not talked about possibly often enough: big national health care players siphoning money out of local communities—potentially a lot of money depending on where you are and considering that health care is inching toward about 20% of the GDP. But besides the money leaving the community, another downside of large national players is that sometimes problems—even kind of seemingly simple problems—can be totally intractable and unsolvable because there’s just so much diversity of need and intricacies if you’re trying to come up with a broad-stroke solution that works for everybody across the land. On the other hand, by thinking and acting locally, these same problems can be solved. Besides, at a local scale, community and relationships within the community can become powerful forces for good.

In this context, I was super thrilled to have had the chance to interview Dan Strause from Hometown Pharmacy and Drew Leatherberry from Avergent about a collaboration model they put together pairing up local PCP teams hired by self-insured employers with their local hometown pharmacy. Together, they’re similar to a team-based advanced primary care model that also has a level of navigation built in. Considering that patients visit their local pharmacy something like 35-ish times a year, it’s the expertise right in front of your face to help manage patients with chronic conditions. Add to this equation a pharmacist’s education and a local pharmacy’s position as a member of the community. Local pharmacies who are patient first and entrepreneurial could be a great way to keep health care local and solve for the needs of their communities at the same time.

This episode is the first-ever simulcast between Health Rosetta and the Relentless Health Value podcast. It was recorded live at the recent Health Rosetta Summit. Thanks much to the Health Rosetta team, including Dave Chase, for inviting me and Relentless Health Value to be a part of the summit.

In this episode, the CPESN Pharmacy Network comes up. Should you wish to learn more about the CPESN Pharmacy Network, listen to the Relentless Health Value interview 129 with Troy Trygstad. 

You can learn more at hometownrxpharmacy.com and avergent.com.

Dan Strause is a partner at Hometown Pharmacy of Wisconsin, a group of 70+ independent pharmacies focused on personalized patient care. Hometown Pharmacy educates and empowers patients and communities to make informed decisions about their health.

Drew Leatherberry is founder of Avergent, a Wisconsin-based benefits advisement firm serving employers around the country, guiding them to 20% to 40% cost savings on top of next-gen benefits and patient experiences. He has spent over a decade leading employers to restore health care to sustainable levels for their team members.

05:02 What has Avergent’s collaborative care model accomplished?
06:07 How did Drew and Dan connect?
07:08 “We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care.”—Drew
07:31 Why would a pharmacy make it their goal to get their patients off their medications?
08:20 “Prescription medicine is the most expensive, most dangerous form of a plant.”—Dan
08:39 “We believe we can help people by giving up prescription medicines.”—Dan
08:45 Is a pharmacy equipped to create a personal relationship with their patients?
12:50 “It’s a spin on traditional navigator-advocate-type roles.”—Drew
16:15 What does helping the patient look like through this partnership program?
19:18 “We’re really unifying the patient health record … and then … cross-referencing all those different data points … on a micro level [and] a macro level.”—Drew
20:53 “Everyone is onboarded into the collaborative care model.”—Drew
21:05 How does this collaborative care model cross the spectrum?
22:13 “Pharmacists are one of the unique professions that doesn’t get paid for time and knowledge [but rather] because of the product they dispense.”—Dan
23:06 “We can see the day where … patients will get a prescription from mail order but still need us.”—Dan
25:46 “We would love to get paid to keep you healthy.”—Dan
27:15 Why are pharmacists wanting to get patients off prescriptions, and how are they involved?
27:36 “In some cases, we are misapplying expertise that’s sitting right in front of our face that can help us deliver a better patient outcome.”—Drew

You can learn more at hometownrxpharmacy.com and avergent.com.

Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

Why would a pharmacy make it their goal to get their patients off their medications? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“Prescription medicine is the most expensive, most dangerous form of a plant.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“We believe we can help people by giving up prescription medicines.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

Is a pharmacy equipped to create a personal relationship with their patients? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“Everyone is onboarded into the collaborative care model.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

How does this collaborative care model cross the spectrum? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“Pharmacists are one of the unique professions that doesn’t get paid for time and knowledge [but rather] because of the product they dispense.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“We can see the day where … patients will get a prescription from mail order but still need us.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“We would love to get paid to keep you healthy.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

“In some cases, we are misapplying expertise that’s sitting right in front of our face that can help us deliver a better patient outcome.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

William Heisel is the Director of Global Engagement at the Institute for Health Metrics and Evaluation (IHME). In this role, Heisel is responsible for IHME’s media relations, digital outreach, events and marketing, publications, scientific communications, and external relations, including government engagements and policy translation. He also is leading IHME’s internal community-building initiatives and manages the organization’s advancement efforts.

As Director of Global Engagement, Heisel oversees the publication of Population Health Metrics, the scientific journal administratively housed at IHME, and advises on the Institute’s publication strategy. He and IHME’s Chief Strategy and Operations Officer oversee communications and coordination with the growing Global Burden of Disease collaborative network, currently at more than 1,000 researchers in more than 100 countries.

In addition, his team administers the Roux Prize, one of global health’s highest honors.

Heisel, who joined IHME in 2009, has a BA in Journalism and Spanish from the University of Montana. Prior to joining the Institute, he was a reporter at the Los Angeles Times.

IHME was established at the University of Washington in Seattle in 2007. Its mission is to improve health through better health evidence.

You can find out more at healthdata.org.

So, a few things to remind everybody. First of all, don’t forget EHRs (electronic health records) were purpose built originally for billing. This is no secret. People quite openly have called EHR systems glorified cash registers. If I want to be generous, maybe I would restate this to say that EHRs were designed to document patient interactions. This is what their core architecture was built to achieve.

But today, there’s a lot that goes on that isn’t a traditional patient interaction. First of all, me even calling it, frankly, a patient interaction should give longtime listeners a clue where this is headed. I mean, say you’re sitting at home on your couch. I don’t know. You’re probably not considering yourself a patient. You’re considering yourself a person sitting on your couch.

However, say you’re sitting on your couch and you haven’t taken your COPD maintenance therapy. Potentially that is something of clinical significance that maybe should get figured out and noted somewhere—potentially prior to the acute event going down.

Or, still talking about things that are relevant to patient health but which don’t naturally tuck into an EHR system’s native architecture, maybe we have social workers and nutritionists and all kinds of people who are not doctors or nurses or PAs (physician assistants) in this mix. Most of the time, these people don’t even have access to the EHR. I mean, what percentage of things that are going to impact a person’s health outcomes can be classified as traditional patient encounters that EHRs were designed to document? I mean, you’ve got your scheduler who wants to tell the transportation company something about a patient. Anything RPM. Where’s the caregiver or the family in that garden-variety patient interaction?

In sum, what is happening between codes getting written in patient health records? Where’s all that information going? I mean, what order set are you gonna use to get all that in and out of the system?

Am I saying anything revolutionary that many of you don’t already know extremely well? No, I am not. But I am shining the spotlight on it to challenge what might have become a sort of default position at provider organizations today, which is to make the EHR the one ring to rule them all, which might be something to consider revising strategically.

My guest in this healthcare podcast, Emily Kagan Trenchard, makes a super point about all of this that I haven’t heard made so succinctly or so eloquently. Emily puts it this way: She says just integrating into the EHR as a reflex without contemplation is kind of the olden days. She talks about identifying the core functionalities, the centers of gravity that are needed to bring together providers and patients and everybody else in the mix. Then you find the best systems—call them platforms if you want. But if, at a fundamental level, you have a technology designed for one thing and you’re trying to shoehorn it to do something else and this something else is a critical business function, maybe this is something to think about at the highest levels.

Of course, it goes without saying that these platforms have to work together (obviously); but you kind of gotta get the right platform for the right job.

Now, to make one point clear as glass, what we are not talking about here is cobbling together a bunch of point solutions. What we are talking about is getting the fundamentals, the core architecture here, solidified. Pam Arora talks about this at length in episode 246. She’s the CIO at Texas Children’s. Pam Arora says that if a health system doesn’t get its technology infrastructure rock solid, if that infrastructure is janky in any way, then everything built on top of it will require duct tape and workarounds and probably not go as well as planned.

On the show today, Emily Kagan Trenchard continues that theme. She talks about the four platforms that she feels are very necessary to underpin or be the chassis to best support helping providers and others help patients and people in and out of the clinic. She calls each platform a tentpole. These four platforms are:

1. The EHR
2. A CRM (customer relationship manager). And, by the way, when Emily says CRM, she’s talking about more than software. It’s more like a philosophy or a whole approach around relationship building with patients/people/customers.
3. A cloud platform for data and analytics
4. A data exchange

One last takeaway, for me at least. Emily has talked about two basic facts that inform her thinking: (1) Providers and patients alike are increasingly not tolerant of friction. (2) What is easiest is the most likely to happen.

Something that we don’t get into in this show but certainly bears considering is the larger context here. Yeah, we got Amazon, we got Google—not only what they are doing alone but also what they are investing in. They have platforms that are purpose built to remove friction and to be really, really easy … one-click easy.

So, let’s talk about the WIIFM (the “what’s in it for me?”) here for health systems to get a move on. When Merrill Goozner was on the show a few weeks ago (EP388), he says that when patients and employers and taxpayers start crying uncle on both healthcare prices as well as just bad friction-filled experiences and also when, at the same time, technology and new competitors move in on the supply side, he says what’s gonna happen then is older incumbents like hospitals could find themselves getting their lunches eaten. So, probably intuitively as well as intellectually, health systems really getting their technology clearly optimized to support their communities, their patients, and their providers might seem to be mission critical, especially as we contemplate the stuff that Mike Thompson was talking about in episode 389 about how there is increasingly data out there which identifies hospitals who are very inefficiently run.

And so, if at a very basic level a hospital has misaligned tech that’s requiring a lot of workarounds and stuff, which is another way to say wasting a lot of staff time, having the right technology deployed in the right way will certainly ground efforts to be effective and also help compete with some of these lurking entities who are looking to take a piece of the $3 or $4 trillion healthcare industry in this country—of which hospitals account for something like $1 trillion. And as Eric Bricker, MD, says in episode 351, this is why hospitals have a big red target on their back.

Also, I would be remiss not to mention that non–purpose-built, dare I say bad, technology causes bad clinician burnout, which causes bad turnover, which is really expensive. Arshad Rahim, MD, MBA, FACP, talks about this in episode 323.

By the way, I interviewed Emily Kagan Trenchard at NODE.Health’s Annual Digital Medicine Conference in New York City this past December—always a great conference. Emily is SVP and chief of consumer digital solutions over at Northwell Health. Northwell, in case you haven’t heard of this health system, is very large: 21 hospitals, 850 outpatient clinics, 300,000 patients a year. Yeah, it’s big.

Emily Kagan Trenchard offers a unique perspective from within the American medical system: A spoken-word-poet-turned-healthcare-executive, she is on a mission to remix the human in healthcare, challenging entrenched assumptions about what it means to give and receive care in the digital age.

As senior vice president, chief of consumer digital solutions, for New York State’s largest health system, Northwell Health, Emily leads teams that push the limits of how we use technology to make healthcare seamless and steeped in humanity while keeping the company competitive at a time of radical change. She is a big believer that innovation is an ongoing process, not just a box to check, and launched Northwell’s first UX department to ensure that patient perspectives and needs drove the design of digital tools and systems.

Prior to joining Northwell, Emily led Web systems for New York City’s Lenox Hill Hospital, where she drove the development of many early consumer health tools, including the first-ever implementation of the Zocdoc scheduling platform for a hospital.

Emily holds a master’s degree in science writing from Massachusetts Institute of Technology and a bachelor’s degree from the University of California at Berkeley.

07:55 How does customer digital solutions fit into the larger technology infrastructure in healthcare?

09:54 “Where else do you have centers of gravity that you should respect in the architecture?”

10:11 “There is a constellation of need here.”

11:51 “We interact with way more than just patients.”

14:28 “We have to be able to understand the network of relationships in a population.”

15:11 How do EHRs and CRMs interact as two tentpoles in healthcare?

17:32 “The question is, where does a human being work?”

19:54 How are patients staying on a nonfragmented care journey in a proactive way?

23:46 “Anybody who’s a consumer of our digital offerings has a relationship with us.”

29:33 “The medicine is being practiced not only on our physical bodies but on our digital bodies.”

@ektrenchard of @NorthwellHealth discusses #EHRs and #CRMs on our #healthcarepodcast. #healthcare #podcast #EHR #CRM

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373)

Somebody wrote on Twitter the other day that he was gonna give a talk on the use of evidence in drug policy, and Barrett Montgomery replied, “That’ll be a short talk then!”

So, let’s talk about the IRA (Inflation Reduction Act) for a moment, specifically the “CMS can negotiate for drugs for Medicare patients” part of the IRA. There’s one topic I don’t hear discussed what I would consider maybe often enough.

Will these negotiations result in pricing that is evidence based? Will good drugs that companies developed using less taxpayer money for R&D, drugs that positively impact the patient lives or have spillover benefits for society or save downstream medical costs, drugs that have solid comparative evidence data, drugs that are a meaningful therapeutic advancement over competitors ... will these drugs be priced in line with that value? Everything I just mentioned, by the way, are things that CMS is supposed to take into account during its negotiations.

So, that’s what this show is all about. To have this conversation, I invited Dr. Peter Neumann on the podcast because Dr. Neumann (along with his two coauthors, Joshua Cohen and Daniel Ollendorf) just wrote a book about pharmaceutical pricing entitled The Right Price. I convinced Dr. Neumann to come on the show and talk about what the likely impact the IRA will have on these right drug prices. And short version, Dr. Neumann told me that “presumably drugs that offer more therapeutic advances will do better under these negotiations.”

Here’s a really, really top-line summary of the negotiation provisions that are in the IRA:

CMS will negotiate prices on the highest gross spend top 10 Part D drugs in 2026, 15 Part D drugs in 2027, and 15 drugs from Medicare Part B and D for 2028.

Small molecule drugs become negotiation contenders after 9 years, and biologics after 13 years.

Once a generic or biosimilar comes out (ie, the patent is well and truly expired), then this negotiation provision is no longer in play.

Now, CMS is given some discretion over how it’s going to do things, and they will issue guidance and figure out how to implement the law over the next couple of years. As with so many things (and Chris Deacon talked about this recently on LinkedIn), it’s how that law is operationalized that actually determines if it achieves this “right price” goal and/or—and Dr. Neumann, my guest in this healthcare podcast, makes this point really clearly, too—maybe the point of the law is as much about cost containment, frankly, as it is about achieving value-based “right” prices. And cost containment and value-based pricing are not the same thing. I’m gonna do a show on this coming up.

So, what are the likely effects of the IRA pharma price negotiation provisions? And not talking about the whole IRA here and the cadre of other stuff like patient out-of-pocket caps and inflation caps. This show is complicated enough just talking about the negotiation portion and just talking about its potential to achieve pricing based on “value.”

Here’s a summary of likely impact of Medicare drugs being negotiated, some of which we talk about in this episode. There’s “seven-ish” main implications:

1. “Some Medicare patients will benefit substantially from negotiations …, as a reduction in the drug’s price will result in lower coinsurance and liability during the deductible phase.” Okay … this makes sense.

2. “Overall, negotiations are projected by the CBO [Congressional Budget Office] to reduce premiums, resulting in lower costs for all Medicare beneficiaries.”

References:
CBO estimates drug savings for reconciliation. Committee for a responsible federal budget. Accessed April 11, 2023. https://www.crfb.org/blogs/cbo-estimates-drug-savings-reconciliation 
Congressional Budget Office. Estimated budgetary effects of Public Law 117-169, to provide for reconciliation pursuant to Title II of S. Con. Res. 14. Published 2022. Accessed April 11, 2023. https://www.cbo.gov/system/files/2022-09/PL117-169_9-7-22.pdf

Okay … so, this #2 here is kind of thought provoking, especially when it’s unclear at this time whether the negotiated price will refer to the list price, the AWP (average wholesale price), or the rebated price (ie, the price after rebates are applied). There are many, many implications if the negotiated price is before or after rebates, just given how “addicted” plans are to rebates and use the rebates, and cost shifting to patients, in a convoluted and super-inefficient way to try to keep premiums down. Listen to the show with Chris Sloan (EP216) for more on this.

3. There’s more incentive to go after biologics than small molecule drugs—obvious, due to the 9-year versus 13-year thing. There’s additionally some incentive for rare-disease and orphan drugs, most of which are biologics, in other parts of the IRA.

4. More interest in drugs for non-Medicare markets (ie, drugs for diseases of younger populations, perhaps)

5. Possibly less pharma innovation, fewer drug launches

Oh, boy, with this one. Listen to the show with Mark Miller, PhD (EP380), for many, many nuances here. But let me give you a few things to think through, and I’d start with four words: We are chasing Goldilocks. There are two ends of the spectrum, and neither are good. On one end, Pharma charges way too much and the system gets bankrupted while pharma shareholders get rich. On the other side of the spectrum, there’s not enough returns for any investors to invest in new drug development. It’s all about moderation—finding the sweet spot in the middle—something the healthcare industry has a super hard time with.

Bottom line, we want to incent meaningful innovation, drugs that actually work. If we pay a ton of money for drugs that don’t work particularly well, then what’s the incentive to find good drugs? As per my earlier point, if this legislation does as was intended, then good drugs should get rewarded and less comparatively effective drugs should be less rewarded. Let’s cross our fingers, shall we?

6. Will Pharma raise its launch prices because the negotiations center on discounts? A higher price times the discount means a higher discounted price, after all. This one could be exacerbated by the part of the IRA that mandates inflation caps. There is some evidence that higher launch prices are already happening.

7. Manufacturers wait to launch until they have all their indications ready to go. If you didn’t understand this, we explain in more detail during the interview.

8. There are incentives for Pharma to jack up commercial prices. Because they’re making less money in Medicare, they try to make more money in the commercial market. But as Dr. Neumann says, you’d think that if Pharma could do that, they already would have done it. Or let me say that a different way: You’d think that if Pharma could have raised their commercial prices more than they already have been raising their commercial prices, they would have already done it. So, I think whether cost shifting actually increases here is a sizable question mark.

9. There’s also less incentive for Pharma to innovate me-too kinds of drugs. If a drug in the same class for the same disease is being negotiated, then a new drug coming out in that same category might sort of have to charge a price similar to the negotiated price of the other drug.

Dr. Peter Neumann, my guest in this episode, has a background in health economics and currently directs a research center that’s focused on health economic issues. His group does a lot of work trying to understand the cost effectiveness of drugs and other health interventions.

Other shows you should, for sure, listen to here are the ones with Mark Miller, PhD (EP380); Anna Kaltenboeck (EP303); Bruce Rector, MD (EP300); Scott Haas (EP365); and Chris Sloan (EP216). These shows offer context and adjacencies that are extremely relevant right now if you’re gonna understand the potential impact of the IRA.

Here’s a quote from the book The Right Price (written by Dr. Peter Neumann and his coauthors, Joshua Cohen and Daniel Ollendorf) that I thought summed up some of the issues here very nicely:

If there existed a Rorschach test for drug prices, it might conjure one of two images. Some people might perceive prices as a compass directing companies to invest in products that people value most. Aligning prices with value is akin to a “true north” orientation of the compass’s arrow. Failure to link prices with value sends misleading signals to drug producers.

Others might regard drug prices as a wall preventing patients from accessing the drugs they need. For them, the barrier should be as low as possible. But aligning prices with value might have little effect in lowering the wall. How then to accomplish that goal?

You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.

Peter J. Neumann, ScD, is director of the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center and professor of medicine at Tufts University School of Medicine. He is the founder and director of the Cost-Effectiveness Analysis Registry, a comprehensive database of cost-effectiveness analyses in healthcare. Dr. Neumann has written widely on the role of clinical and economic evidence in pharmaceutical decision-making and on regulatory and reimbursement issues in healthcare. He served as co-chair of the 2nd Panel on Cost-Effectiveness in Health and Medicine. He is the author or coauthor of over 300 papers in the medical literature and the author or coauthor of three books: Using Cost-Effectiveness Analysis to Improve Health Care (Oxford University Press, 2005); Cost-Effectiveness in Health and Medicine, 2nd edition (Oxford University Press, 2017); and The Right Price: A Value-Based Prescription for Drug Costs (Oxford University Press, 2021). Dr. Neumann has served as president of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). He is a member of the editorial advisory board of Health Affairs and the panel of health advisors at the Congressional Budget Office. He has also held several policy positions in Washington, DC, including special assistant to the administrator at the Health Care Financing Administration. He received his doctorate in health policy and management from Harvard University.

09:33 Is it imperative that drugs whose patents are expiring have their prices negotiated?

10:50 “We need innovation; we want to encourage innovation.”

11:01 Does this new law strike a balance between innovation and price regulation?

11:21 How are we assessing cost effectiveness and innovation in the drug space?

12:29 What’s the problem with the current drug markets?

13:14 Why can’t you rely on the drug market for the cost effectiveness of a drug?

14:13 Why very expensive drugs do not equate to poor value.

15:06 What are the likely outcomes of the IRA?

18:33 How does pharmacy budget factor into high-value drugs?

19:26 “Value-based pricing doesn’t mean necessarily lower spending overall.”

22:59 What are the types of drugs that will be excluded from the IRA?

23:22 Who will the law create problems for?

24:44 What have pharmacy benefit managers (PBMs) been doing to move forward with the new law?

26:04 What are plan sponsors doing right now?

28:32 What are the most important value metrics according to Dr. Neumann?

You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.

@PeterNeumann11 discusses #drugprice #negotiations on our #healthcarepodcast. #healthcare #podcast

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein

So, let me just cut to the chase here with very little preamble, and all of this is a setup to the interview that follows, although it is not really what the interview that follows is all about. A mentor of mine used to say, you can’t legislate the heart. Let me also suggest you can’t give someone in finance financial incentives and then expect them to not prioritize financial incentives.

It stands to reason that if the healthcare industry is found to be quite attractive to those who are money focused, then do I need to say this? The money focused amongst us will, of course, do the whatever to the extent that they can make money. They aren’t gonna be throwing their backs into quality or cost effectiveness or taking care of patients. They are throwing their backs into making money. Is anyone shocked?

Now, don’t get me wrong; I’m not a Pollyanna. And in this country, in order to run a healthcare business, you have to make money; otherwise, you’ll go out of business. So, do well by doing good and all of that. But how much money is too much money? This is an important line to figure out because that’s where you are doing well but you’ve stopped doing good—you’ve tipped into financial toxicity. You are taking more than the good you are doing, and the net positive becomes a net negative.

But complicating fact of current life, it’s becoming increasingly obvious that in order to stand up a practice that can take advantage of value-based care payments—payments where primary care docs mainly at this time can get paid more and likely more fairly to care for patients well—you need a lot of infrastructure. You need data, you need tech, you need a team. Translation: You need money, maybe a lot of money, to invest in all of this. And let me ask you this: Who has a lot of money in this country?

Here’s the point of everything I just said: These are the external realities that hit anyone trying to do right by patients from every direction. But on the other hand (or maybe different fingers on the same hand), as Amy Scanlan, MD, says in this healthcare podcast, physicians are the backbone of this system. Dr. Scanlan talks in the interview today about the opportunity, and maybe the responsibility, that physicians have here for patients; but also the Eric Reinhart article comes up again about rampant physician moral injury (unpaywalled link with my compliments).

Right now might be a great time to read something from Denver Sallee, MD. He wrote to me the other day. He wrote, “Like many physicians, I did not have much understanding of the business side of medicine, as I mistakenly thought as long as I helped take great care of patients that I was doing my job. More recently, it became apparent to me that by ceding the management of medicine to nonclinical administrators and to companies interested primarily in value extraction for the benefit of shareholders that I needed more education in order to truly help patients.”

Today as aforementioned, I’m talking with Amy Scanlan, MD, who is chief medical officer of the clinically integrated network (CIN) that is the new joint venture between Intermountain Health and UCHealth in Colorado.

We talk about what it’s like to be in the kind of messy middle of transformation to integrated care in a clinically integrated network, trying to figure out how to help physician practices and the CIN itself navigate the external environment in a way that empowers different kinds of practices at different points in their transformation journey that empowers physicians to be in charge, and considering clinical and financial outcomes (ie, the business of healthcare).

Dr. Scanlan brings up four main factors to consider when plotting strategy from here to there:

1. Give practices the tools that they need to succeed—not what you think they need but what you’ve discerned they actually need because you’ve listened to them.

2. Many times, these tools will consist of some combination of data, tech, and also offering the team behind the scenes to help doctors and other clinicians help patients through what Dr. Scanlan calls the “in-between spaces”—the times between appointments.

3. Medical culture really has to change, and in two ways: doctors learning how to be part of and/or leading functional teams and building functional teams. Because there are teams, and then there are teams. Well-functioning teams can produce great results. Nonfunctioning teams, however, are, as Dr. Scanlan puts it, just a series of handoffs. And don’t forget, handoffs are the most dangerous times for patients. The DNA of team-based care—real team-based care—for better or worse, are the relationships between team members, between physicians who work together, between doctors and patients, between clinicians and clinicians. So, fostering relationships, creating opportunities to collaborate and talk, is not to be underestimated. How do you re-create the doctors’ lounge in 2023?

4. Getting out from underneath the long shadow of fee-for-service incentives, specifically the paradigm that only patients who get mindshare are the ones in the exam room. Value-based care, integrated care is as much contemplating the patients who don’t show up as the ones who do. This is a really big mind shift, much bigger than many realize.

You can learn more by reaching out to Dr. Scanlan on LinkedIn.

 Amy Scanlan, MD, serves as chief medical officer for the new joint venture CIN between UCHealth and Intermountain Health—a physician-led, clinically integrated network of more than 700 primary care providers from UCHealth, Intermountain Health Peaks Region, the University of Colorado School of Medicine, and multiple independent practices along the Front Range.

Dr. Scanlan trained as a family practice physician and has continued to practice for the past 25 years. She has worked as a physician-owner in a small independent practice and has held multiple leadership positions as part of large health systems. She has served on numerous health system committees spanning quality, innovation, recruitment, and credentialing. She is very familiar with value-based care models, having been part of an accountable care organization (ACO) practice for the past 15 years, as well as participating on an ACO Practice Performance and Standards Committee and serving on a local ACO board.

She received a bachelor’s degree with honors from Wesleyan University in Connecticut. She obtained her medical degree from Case Western Reserve University in Cleveland, where she received the Kiwala Award for Research in Family Medicine. Her residency was completed at St. Anthony’s Family Medicine Residency program in Denver. She is currently board certified by the American Board of Family Medicine and NCQA (National Committee for Quality Assurance) certified in diabetes.

06:33 How is Dr. Scanlan thinking about the transformation process and the shift to value?

09:14 “It is really trying to think about, how do we help practices get there?”

11:46 “The hard part is the in-between spaces.”

14:10 “Team-based care done badly is really just a series of handoffs.”

15:50 “We have to get to that point where the culture of collaboration is more pervasive.”

19:57 “How do we as healthcare providers step in and solve this problem?”

20:04 Why do providers have a responsibility to step in and try to fix the healthcare system?

20:20 Article (unpaywalled) by Eric Reinhart, MD, PhD.

21:50 Why do physicians need to be accountable for the cost of care as well as outcomes?

23:37 Why does physician burnout give Dr. Scanlan hope?

24:25 What is the solution to changing fee-for-service incentives?

25:42 What are some of the challenges facing changing incentives?

27:14 Why is data so important?

28:53 EP393 with David Muhlestein, PhD, JD.

30:11 “It’s important to understand that we are in the middle of this change.”

31:16 Dr. Scanlan’s advice for those trying to stand up a CIN.

You can learn more by reaching out to Dr. Scanlan on LinkedIn.

Amy Scanlan, MD, of @uchealth discusses real-world #clinicalintegration on our #healthcarepodcast. #healthcare #podcast

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber

If you are a forward-thinking specialist right now, alarm bells may be going off, given COVID and/or the prospect of another COVID-style pandemic. Also, all of the capitated and advanced PCP (primary care provider) practices popping up. Also, virtual care models.

FFS is a cushy status quo revenue model until it isn’t. One underappreciated point might be that FFS is not only a revenue/payment model. It’s also a business model. And as a business model, FFS very much drives how practices structure themselves to realize that FFS revenue.

Consider that to earn a fee for a service, someone (a human person) has to physically do the service. So, all FFS-style businesses have an inherent incentive to add labor and not use technology in any way that actually reduces the amount of billable human hours involved in providing care to patients. But if that top-line revenue line goes down—wow!—you’ll find yourself as many did with way too many employees.

An FFS business model has zero flexibility when it comes to revenue that isn’t consistently going up or, at a minimum, a flat line. If revenue plummets and payroll is big—big so as to power a way higher revenue number than is possible for whatever reason—you have a major financial problem on the quick.

That is what I talk about in this health care podcast with Alan Kaplan, MD, MBA. Dr. Kaplan is assistant professor of urology at Georgetown University, and he is a practicing urologist. He recently cowrote a paper with Dan O’Neill in the publication NEJM Catalyst Innovations in Care Delivery. The article discusses COVID-19 and health care’s “productivity shock,” as they call it. Dan O’Neill, by the way, was on the show. Also, he was on EP287 and part of EP292. But in the article that Dr. Kaplan and Dan O’Neill wrote, they give some advice to specialists and hospitals who are looking to evolve with the changing marketplace. Spoiler alert: Conceptually, it’s a shock to move from a place where, every year, you can count on your billings going up and up and move to a model instead that assumes that this is not the case.

So, yeah, there’s a little talk for sure about the joys and challenges of transitioning to value or a value-based payment model. But that’s only the very first consideration. It’s also about reconsidering the operating model and the strategic use of digital technologies.

We talk about all of the above in this health care podcast. Quick sidebar: My interview with Dr. Steve Schutzer (EP294) might be a good follow-on for a very actionable work plan for specialists to implement some of the advice that Dr. Kaplan gives in this podcast.  

You can learn more by contacting Dr. Kaplan via LinkedIn.

Alan L. Kaplan, MD, MBA, is a practicing surgeon, innovator, and health services researcher. After finishing his urology residency, a health care administration fellowship, and an MBA, all at UCLA, Alan helped build a multispecialty medical group in a highly underserved area of South Los Angeles. Alan is currently an assistant professor of urology at Georgetown University; an attending physician at the Washington, DC, VA Medical Center; and a physician advisor at IDEO, a human-centered design firm. Alan’s work over the past 10 years has centered on value-based care redesign, aiming to transition to a more just, equitable, and sustainable health care system for all Americans.

03:51 Who are we actually discussing when we use the term specialist?
05:58 How does the PCP taking on more risk affect the specialists’ path to value-based care (VBC)?
09:42 “Technology leads to … a reduction in labor burden … but in health care, that really hasn’t been the case.”
11:36 “Technology … in health care … has never really been about making the bottom line more efficient. It’s been about expanding the top line.”
13:39 What do specialists need to be considering if they want to stay relevant in the next 5 years?
14:27 EP292 with Brian Klepper, PhD.
16:53 Is there a future where specialists can transition from FFS to VBC while skipping the messy middle of a transition?
18:37 “The way we always did things is not the way that we have to always do things in the future.”
25:20 “When all is said and done, the relationship between [PCPs] and the specialists that they refer … those relationships are really, really important.”
26:14 EP219 with Arshad Rahim, MD, MBA, FACP.
28:13 What’s going to be a big driver for providers to become more independent in the next 5 to 10 years?

You can learn more by contacting Dr. Kaplan via LinkedIn.

@ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #ffs

Who are we actually discussing when we use the term “specialist”? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

How does the PCP taking on more risk affect the specialists’ path to value-based care? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

“Technology leads to … a reduction in labor burden … but in health care, that really hasn’t been the case.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

“Technology … in health care … has never really been about making the bottom line more efficient. It’s been about expanding the top line.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

What do specialists need to be considering if they want to stay relevant in the next 5 years? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

Is there a future where specialists can transition from FFS to VBC while skipping the messy middle of a transition? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

“The way we always did things is not the way that we have to always do things in the future.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

“When all is said and done, the relationship between [PCPs] and the specialists that they refer … those relationships are really, really important.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

Dr. Hunt graduated from the University of Osteopathic Medicine and Health Sciences, Des Moines, Iowa and completed his residency in Pediatrics. During his military service, Dr. Hunt’s held key leadership positions. As Chief Medical Information Officer, he has implemented ‘Epic’ and ‘Cerner’ EMRs. He is Board Certified in pediatrics and received a Master of Science in Medical Informatics.

In April 2013, Dr. Hunt was appointed CPHO (Chief Population Health Officer [CMO/CMIO]) for St. Vincent’s Health Partners, Inc., a Physician Hospital Organization with more than 400 providers, and St. Vincent’s Medical Center. Dr. Hunt provides physician leadership and direction for the planning, design and implementation of clinical information systems at St. Vincent’s Health Partners, Inc. and oversees quality and utilization for its provider network. Under the leadership of Dr. Hunt, St. Vincent’s Health Partners, Inc. was the first organization in the country to become accredited and re-accredited by URAC as a Clinically Integrated Network and is leading the charge in changing the face of healthcare in CT. Currently, working with organizational leaders, Dr. Hunt is engaged to develop information system infrastructure to support a super clinically integrated network. As Chief Executive Officer (2016), he is now focused to develop additional opportunities for medical management with employers and payers, enhance network contracting, and continue to support organizational transformation to value reimbursement.

Dr. Hunt joined St. Vincent’s Health System (SVHS) as CMIO in August 2014. He is working closely with clinical and information technology associates to transition to ongoing operations after the Cerner EMR implementation. Additionally, Dr. Hunt participates with the Valued Care Alliance [VCA] (a newly formed six hospital consortium in Connecticut in which St. Vincent’s Medical Center is a founding member) to establish system-wide population management infrastructure. The VCA has been recognized as a leading advanced network by Connecticut and participates with the Community and Clinical Integration Program, and awarded the Accountable Health Communities (AHC) model grant by CMS.

Alex Lickerman, MD is a primary care physician, author, speaker, entrepreneur, and founder of ImagineMD, a direct primary care medical practice headquartered in Chicago. ImagineMD works with self-insured and fully-insured businesses and their benefits consultants to help lower health care costs and improve the access to—and quality of—health care for their employees. This enables businesses to attract and retain top talent, as well as increase productivity and reduce absenteeism—all to increase the value of the business itself.

You can learn more about DPC and ImagineMD at www.imaginemd.net.

You know back in the olden days when a foot of measurement was actually the measure of your own foot? So, I might measure something and it’s, like, 19 feet. And then you measure the same exact thing and it’s 38 feet because you have tiny feet. This is the analogy that kept running through my mind as I was talking with Anna Kaltenboeck in this health care podcast about QALYs to measure the value of drugs. In this metaphor, QALYs are the ruler so that 1 foot of drug value is the same for everybody and all drugs. It’s very civilized as a concept if you think about it.

QALY stands for quality-adjusted life year. The goal of a QALY is to figure out how much any given drug is worth to a society so that we, as a society, have a benchmark to evaluate the price of pharmaceutical products. QALYs are an apples to apples or a foot to foot way to compare the value of drugs for we the people. I mean, is this drug amazing and we should all pay a lot for it? Or is the drug more expensive than the current standard of treatment and it doesn’t confer any added benefit to patients? It’d be good to know that as a patient and as a payer and, frankly, as a pharma company.

QALYs offer a framework for levelheaded discussions. It’s complicated. I’m gonna take the risk of oversimplifying, but here’s how I’d explain the three parts in a QALY measurement, which combines measure pharmaceutical value.

The first part is, if relevant, how much additional survival can be expected with this drug? So, if it’s an oncology drug, for example, how much longer will the patient live? The second part of a QALY is, how does the drug make the patient feel? So, in an ideal world, survival is long and the patient feels super great. So, some economists and scientists get together and they do some math and they come up with the sum of these first two factors. Then the third part of a QALY calculation is the cold hard cash. How much is society willing to pay for this improvement in survival, in quality of life? This last part will depend based on the society (ie, the country) and also the condition. We’re willing to pay a lot for a drug that helps blind people see. We might be not so willing to pay a whole lot for a drug that lowers blood pressure marginally, for example.

My guest in this health care podcast is Anna Kaltenboeck. She is a health economist and program director for the Drug Pricing Lab at Memorial Sloan Kettering. She knows a lot about QALYs.

One last thing: ICER is the Institute for Clinical and Economic Review. It is an independent and nonprofit organization who creates a lot of these QALY assessments. Whether they succeed or not is something that is sometimes questioned, but the team over at ICER prides themselves in not working for Pharma and not working for payers in an effort to be as impartial as possible.  

You can learn more at drugpricinglab.org.  

Anna Kaltenboeck is the senior health economist and program director for the Center for Health Policy and Outcomes and the Drug Pricing Lab at Memorial Sloan Kettering Cancer Center (MSKCC). She focuses on the development and application of reimbursement methods for prescription drugs that reduce distortionary incentives in the supply chain and encourage pricing of treatments based on their value. Her work centers on developing an unbiased evidence base that characterizes the effect of federal policies on coverage and reimbursement decisions for branded specialty drugs and cell and gene therapies and identifying opportunities for policy changes that encourage affordability and access while maintaining incentives for innovation. Her current research interests include global comparisons of reimbursement policy and supply chain regulation, game theory in innovation decisions, and the effect of market concentration on pricing decisions.

Ms. Kaltenboeck’s research and policy work is informed by her experience as a consultant for pharmaceutical clients. Prior to joining MSKCC, Ms. Kaltenboeck spent 10 years working for Analysis Group and IMS Consulting Group, where she conducted health economics and outcomes research and developed pricing and market access strategies for pharmaceutical and diagnostic products.

She has published numerous articles in peer-reviewed journals and other press, including JAMA and Morning Consult, and speaks frequently on the topics of value-based pricing, economics of the supply chain, and reimbursement models. Ms. Kaltenboeck holds bachelor’s and master’s degrees in economics from Tufts University.

3:56 What is a QALY?
05:28 “You don’t get marks; it’s the treatment that gets the marks.”
09:13 What is willingness to pay?
10:52 “What we pay for drugs should be reflected in societal preference.”
12:29 Does Pharma fear the QALY?
15:38 “At the end of the day, the ideal here is simply to be able to quantify ‘This is what we’re going to pay for this additional benefit that we’re going to provide for patients.’”
17:09 “When you meet that price, patients should be getting access to that product.”
19:27 What are the significant advances being seen with QALYs and drug development?
21:23 “The challenge is when the price is so much higher than those benchmarks.”
22:27 How do we use the QALY as a tool?
25:56 Where does value-based pricing fall in the world of QALYs?

You can learn more at drugpricinglab.org.  

@a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

What is a #QALY? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

“You don’t get marks; it’s the treatment that gets the marks.” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

What is willingness to pay? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

“What we pay for drugs should be reflected in societal preference.” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

Does Pharma fear the QALY? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

“At the end of the day, the ideal here is simply to be able to quantify ‘This is what we’re going to pay for this additional benefit that we’re going to provide for patients.’” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

“When you meet that price, patients should be getting access to that product.” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

How do we use the QALY as a tool? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

Where does value-based pricing fall in the world of QALYs? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue

In a career, being new to any industry especially healthcare isn't easy. In June of 2004 Todd Eury left an eight year career in the telecommunications industry and entered the pharmacy technology sector as SoftWriter's (FrameworkLTC pharmacy software for institutional pharmacies) first business development oriented employee. "It was a gamble for me", Eury recounts, "being part of a national fortune 500 company like AT&T Business felt comfortable and making the jump to pharmacy software sales with a little privately owned company made me nervous, but excited." Within Eury's first year with SoftWriters the company doubled its customer base and within the next 3 years SoftWriters was positioned as the most innovative LTC Pharmacy Software company in the industry. "From there I wanted to do more, I wanted to help pharmacy owners leverage technology and understand other facets of their business which seemed mysterious. Marketing, drug purchasing, and new patient development were all parts of the business of pharmacy which seemed undefined. I wanted to help with more than just technology."

Eury has worked with several pharmacy system developers like KeyCentrix, Inc., headquartered in Wichita Kansas and SuiteRx, Inc., with offices in Chicago and Fort Worth Texas. In March of 2009 Eury founded the Pharmacy Podcast Show, the first audio blog about the Business of #Pharmacy. The podcast is dedicated to the pharmacy profession. The Podcast is about good useable content, information, and innovative ideas that Eury believes will advance the pharmacy profession.  The podcast's programming is developed Independent Retail, Compounding, Long-term Care, Specialty, Hospital Systems, and Small Chain Pharmacy Businesses. There's a new podcast segment dedicated to patients, specialty pharmacy, and the business law of pharmacy too. The podcast is the only digital health audio blog dedicated to the business of pharmacy and assists its sponsors with business lead development from a myriad of digital strategies including html embed code which places the podcast audio player into the web-environment of the sponsor's website.

"No other advertising tool or magazine in pharmacy uses this technique to drive business leads to an organization focused on pharmacy. Retail Management Solutions, Vuca Health, McKesson, Live Oak Bank, RxSafe, and dozen's of other companies have benefited from the digital content through the Pharmacy Podcast Show."

Based on healthcare analytics researcher Symplur, Eury is ranked as one of the most influential voices in the pharmacy space with a Twitter presence @PharmacyPodcast which is also about the Business of Pharmacy.  "Our followers respond to our tweets and links on aveage more than any other Twitter handle focused on the work "Pharmacy" and the hashtag #Pharmacy is tracked by Symplur and shows the effectiveness of our popularity and influence. Symplur is fascinating."

Eury is the founder of LinkedIn Networking Group: "Pharmacy Professionals Network" reaching more than 25,000 participants discussing different topics centered in pharmacy. In 2011 Eury created a firebrand pharmacy buying group called PharmacyGPO which didn't reach its potential before being sold in 2014 with partnership difficulties. PharmacyGPO experienced explosive growth of $144M sales and had search engine domination when the term pharmacy gpo was searched for by a operations director or owner. The pharmacy buying group also assisted its nearly 100 members with strategic marketing, technology consultancy, and different creative ways to develop new patients. Eury served 2 terms with the Pennsylvania Pharmacist Association as Board of Directors Industry Association Chair and has been published in Pharmacy Times through the podcast content engine since January 2015.

Eury's newest venture is with Colonial Management Group which focuses on supporting physicians with all marketing, administrative, staffing, and business development with patient care services through their American Practice Support division which Eury will be leading as Director of Strategy. "I'm excited about this new venture and its ties into specialty pharmacy with different medications helping patients overcome the disease of addiction. Supporting the patients with HUB-like services is critical to sustainability and Colonial Management Group has over 25 years experience in helping clients suffering with addiction. I am proud to be a part of this national initiative."

You can learn more information on LinkedIn and at pharmacypodcast.com.

Leela Barham is a Health Economist by training with an MSc Health Economics from the University of York and BSc Economics from the University of Nottingham. Leela has over a decade of experience in consulting, working with clients from across the world.

Leela focuses on policy and health economic issues from pharmaceutical pricing to Health Technology Assessment and more. Leela has worked with patient organizations, the NHS, a health insurer, think tanks, the pharmaceutical industry, and the medical device industry and has been an expert reviewer for the Department of Health to support on issues on innovation.

Leela has also worked for the Royal College of Nursing and NERA Economic Consulting, and has been a member of the Department of Health's External Advisory Group on Payment by Results and the HFMAs Costing Special Interest Group.

Leela's work has been published in a number of journals and she also regularly contributes to pharmaceutical industry magazines. She has also been a peer reviewer for journals including the European Journal of Health Economics and The Patient.

You can learn more on Leela Barham’s Facebook and her blog.

The discussion to follow is probably a 400-level class in payviders. If I just said the word payvider and you’re scratching your head wondering where you may have heard that term before, this show is probably not the best place for you to start. I’d go back and get some context by listening first to the episodes with Steve Blumberg from GuideWell (EP304) and/or the one with John Moore from Chilmark (EP172); and for a really retrospective lookback, check out the one episode with Dr. Kris Smith from Northwell (EP127) from back when they were still trying to become an insurance carrier. It’s like a time capsule into their ambitions.  

OK, if you’re still with me, in this episode I’m looking forward to digging into payviders with Jeb Dunkelberger, who is the CEO of Sutter Health | Aetna. Sutter Health | Aetna is the payvider joint venture between, you guessed it, Sutter Health and Aetna. Not only is Jeb one who would obviously know a whole lot about payviders and how they operate given his role, but he’s also super articulate and thoughtful in terms of the potential impacts that this type of entity can have on patients and the surrounding healthcare ecosystem.

I started to get really curious about payviders and what they’re up to because the term keeps coming up in conversations, number one. And the more it came up, the more it started to become really obvious that payvider is one of those terms that everybody tosses around and may or may not define it the same way. Jeb refers to a payvider as an entity that delivers care but also writes insurance products and takes risk for them—not just taking capitated payments or doing direct contracting. While it’s the employer who actually takes the risk, this is the definition of payvider that we explore in this healthcare podcast.

Two kinds of interesting points that Jeb makes, which I’ll just underscore here: One is “demand destruction.” I like the idea of the term because it brings a really obvious point into stark focus. Bottom line, taking on risk or value-based programs is easier if you are a smaller percentage of the healthcare spend. The bigger a percentage of the healthcare spend that gets cha-chinged into your cash register, the more you destroy your own demand by creating value-based programs that minimize downstream costs. Those downstream costs are your revenue, after all. Value-based care is all about demand destruction at its core.

In the last question of this interview (so, this is the second thing I’m underscoring here), I ask Jeb if he thinks payviders will ultimately lower healthcare costs; and he comes back with a reframe of my question. He says if we take costs out of the system, will hospitals close? And if the hospitals close, then people get laid off. Fair point, since in many places the health system is one of the biggest employers in town if not the biggest—and also a political tour de force. So, there’s more nuances here; but you’ll have to either get to or skip to almost the end of the episode to hear them.

Jeb Dunkelberger began his career as a health economist and consultant. He became the CEO of Sutter Health | Aetna to focus on alternative reimbursement models and value-based care. Jeb also wrote a book called Rich & Dying.

You can learn more at sutterhealthaetna.com.  

You can also connect with Jeb on LinkedIn and follow him on Twitter.  

Jeb Dunkelberger, MSc, MHCI, currently serves as CEO of Sutter Health | Aetna (SH|A), a commercial insurance plan serving Northern California. The health plan aims to combine the value of retail, provider, and payer via its partnerships with CVS, Sutter Health, and Aetna. Prior to SH|A, Jeb led growth for two bay-area healthcare start-ups: Cricket Health and Notable Health. Jeb has also held executive roles at Highmark, McKesson, and EY. Jeb holds healthcare-related degrees from Virginia Tech, The London School of Economics, Cornell University, and University of Pennsylvania.

03:58 What all does Sutter Health | Aetna entail?
04:31 What does it mean to be a “performance network”?
04:48 What does it mean to be a payvider?
06:35 How common are payviders?
07:31 “We are writing direct risk.”
09:21 How does the fully insured product work?
12:30 “You want to hold their feet to the fire, from a value-based perspective.”
12:42 What’s the incentive for providers to partner with payers?
15:25 “It’s just math. It’s the amount of lives times the amount of utilization multiplied by your unit costs.”
20:58 “You have to have a day of reckoning, and that only comes from financial incentives creating that gateway out.”
24:55 How do we think about reform and taking money out of the healthcare system?
26:58 “We also have to talk about repurposing the workforce.”
27:27 “We need to upskill our workforce.”
30:14 “Can a health system survive as the largest employer, year over year, if they give unit cost concessions, year over year? … The answer is no.”

You can learn more at sutterhealthaetna.com.  

You can also connect with Jeb on LinkedIn and follow him on Twitter.  

@Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What all does Sutter Health | Aetna entail? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What does it mean to be a “performance network”? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What does it mean to be a payvider? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How common are payviders? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“We are writing direct risk.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How does the fully insured product work? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“You want to hold their feet to the fire, from a value-based perspective.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What’s the incentive for providers to partner with payers? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“It’s just math. It’s the amount of lives times the amount of utilization multiplied by your unit costs.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“You have to have a day of reckoning, and that only comes from financial incentives creating that gateway out.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“We also have to talk about repurposing the workforce.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“We need to upskill our workforce.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Can a health system survive as the largest employer, year over year, if they give unit cost concessions, year over year? … The answer is no.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham

In this episode of Relentless Health Value we dive into the concept of Cognitive Dissonance in the healthcare industry with Dr. John Lee, an ER physician and chief medical information officer. We explore how healthcare professionals navigate the conflict between their beliefs and actions, especially in large healthcare organizations. Dr. Lee shares practical advice on celebrating small wins, incremental improvements, and fostering a supportive culture among colleagues.

This conversation sheds light on the challenges and solutions for those striving to deliver better patient care despite systemic obstacles. 

To read the full article and show notes with links mentioned as well as a full transcript, click here.

Dr. John Lee is an ER (emergency room) doc by training, who is also an informaticist and chief medical information officer. I can tell you from personal experience that Dr. Lee is one of the most creative and pragmatic problem solvers that I have encountered. He says he’s dedicated to trying to help move the ball forward and changing our healthcare system using information technology and using our ability to be far more transparent with the things that we try to do in a positive way in healthcare.

Join us for an insightful discussion on balancing ideals and realities in modern healthcare.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

“Scientists Announce Successful Experiment to Bankrupt Mouse That Can’t Afford Cancer Drug.” That’s a recent headline from The Onion, which is, by the way, a funny satire newspaper, if you haven’t heard of it. You could swap out “Cancer Drug” in that headline with “a Trip to the ER”—or pretty much any aspect of health care in this country.

No matter what health care service you stick in there as the potential cause for a mouse’s bankruptcy, it’s a pretty LOL headline, right? But the reason why it became a headline is because obviously it’s based on a truth that resonates with your regular citizens in this country. Think about that. A critical mass of people around here believe that health care will bankrupt you. This is one of those sociological signals that has implications to health care leaders.

Here’s another signal with implications. In this health care podcast, I’m interviewing the incomparable Marshall Allen. That’s not the signal. His book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, a book with that title being on the New York Times best seller list, is the signal. Marshall’s book is an instruction manual for patients on how to fight back against unfair and/or egregiously inaccurate bills. 

This interview with Marshall Allen is different from others that you may be hearing. Marshall wrote a book to motivate patients, a critical mass of patients, to get empowered relative to their health care bills. Because listeners of this show are health care executives, I wanted this interview to be relevant to you. What does this book mean for you? Doug Aldeen told me one time, unless something has a direct impact on the CEO or leadership team at a health system or insurance company, they’re just bored. Let me sum up this interview in one sentence: This is not boring.

If you want to skip to the exact examples of “not boring,” you can skip ahead to about the 30-minute mark. We go through the ways that health systems can and probably will be hurt by the financial toxicity that they create. Here’s the three-ish ways that Marshall and I talk about:

1. Doctors who no longer trust their employers (ie, the health systems they work for) leave and then you have to recruit new doctors—#problematicandexpensiveonanumberoflevels, but I don’t need to tell you that.
2. Reputational damage. When the slogan on the door becomes a joke, that’s a problem.
3. Employers and taxpayers reading best-selling books like this one and Marty Makary’s (which also is or was just recently on the best seller list) and learning how to not be basically passive suckers anymore. 

You can find Marshall’s book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, anywhere that books are sold.

Marshall Allen investigates why we pay so much for health care in the United States and get so little in return. He is the author of the new book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. He is also the founder of Allen Health Academy, which produces a curriculum of short on-demand videos to equip and empower employees to navigate the health care system. Marshall has investigated the health care industry for 15 years, including a decade at ProPublica. He has also spent a decade as an educator at the Craig Newmark Graduate School of Journalism at The City University of New York. His work has been honored with many journalism awards, including some of the top business reporting honors, the Harvard Kennedy School’s Goldsmith Prize for Investigative Reporting, and twice as a finalist for the Pulitzer Prize. Before he was in journalism, Marshall spent 5 years in full-time ministry, including 3 years in Nairobi, Kenya. He has a master’s degree in theology. 

03:35 What’s the point of view that Marshall is coming from with his investigative reporting?
04:06 “How does this affect the people who are paying for it and the people who are undergoing the care?”
04:58 “There’s a lot of good people working within this very messed up system.”
05:12 Why are patients considered outsiders in the health care system?
05:55 “What’s happened in health care is that the stakeholders treat each other more as the customer.”
07:54 What is upcoding?
11:27 “These are schemes that have been created within the industry to increase revenue.”
11:56 “This system is not set up for the benefit of the patient.”
12:22 “On the financial side, the industry is actually oppressing the American people.”
12:39 Can a critical mass of patients force health systems to become more accountable?
16:02 “We have been expected to pay whatever aggregate sum is thrown at us.”
17:09 Why have patients been so passive toward this crooked health care system so far?
18:04 “They’re violating the trust of the American people when they don’t treat us fairly.”
19:28 “It’s totally legal to do that, [but] is it ethical?”
20:11 What’s the difference between making a profit and profiteering?
21:43 “It’s hard to argue against your own paycheck.”
29:57 “The things that matter most to people are their health and their money.”
33:51 What are the first-order and second-order consequences of what’s happening in health care right now, and which of these consequences will actually drive change?
34:56 “When you tell the truth about what’s going on … they become so ashamed … that they change their behavior.”
36:10 “The patient … is not their most important customer.”
39:03 “The sleeping giant is the employers.”

You can find Marshall’s book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, anywhere that books are sold.

@marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“How does this affect the people who are paying for it and the people who are undergoing the care?” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“There’s a lot of good people working within this very messed up system.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

Why are patients considered outsiders in the health care system? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“These are schemes that have been created within the industry to increase revenue.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“This system is not set up for the benefit of the patient.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“On the financial side, the industry is actually oppressing the American people.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

Can a critical mass of patients force health systems to become more accountable? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

Why have patients been so passive toward this crooked health care system so far? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“They’re violating the trust of the American people when they don’t treat us fairly.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“It’s totally legal to do that, [but] is it ethical?” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

What’s the difference between making a profit and profiteering? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“It’s hard to argue against your own paycheck.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“The things that matter most to people are their health and their money.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

“The sleeping giant is the employers.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

So much of this episode (and this podcast as a whole, really) is about one consistent theme: How do we reset or redesign our healthcare industry, including hospital chains—mostly talking about the big consolidated ones that have a lot of money here—but how do we redesign these leviathans to be more consistent with our values as a country and the values of the doctors and other clinicians and others who work in these places and who went into the healthcare profession for a reason that had, you know, something to do with patients? And I mean something to do with patients that doesn’t involve dressing up for Halloween as a giant cardboard dollar sign, like some finance department guy did at one large nonprofit hospital in the spirit of shaking money out of poor patients (see article here). Or listen to previous episodes about hospitals raising prices way higher than the rates of inflation.

Not to belabor this because we’ve already talked about it so very often, but you also have the whole thing with big, well-funded, nonprofit hospital chains going on cost-cutting extravaganzas and, at least in one case, basically creating their own staffing crisis.

Do these activities have a familiar ring to them? Do they strike you as a page out of a playbook you may have seen elsewhere? I don’t know about you, but they remind me of things that private equity or financial folks run around doing. I mean, the classic stepwise for how to maximize the financial value of an “asset” from a financial industry standpoint is to cut costs and raise prices.

Piling on this “kind of sounds like a B-school group project” thesis, what about the thing with a bunch of these big, consolidated hospital systems with rich endowments crying crocodile tears about how much money they lost last year? Except … in a whole bunch of cases, the money they lost—some of which came from the COVID CARES relief act funds they got, by the way—but this money was lost when their risky stock market investments tanked. Those are their losses. Stock market losses. From speculative investments. Are you kidding me?

But hospitals are charities, right? They are nonprofits. They aren’t owned by private equity. They aren’t owned by an investment bank or a team of financiers, so you wouldn’t expect them to be acting like they are owned by Wall Street.

But … oh, wait … how weird.

You know who is on the boards of some of these very well-known nonprofit hospitals? If you don’t, I’m not surprised, because in too many cases, if you ask me, you have to dig around in tax filings and other bureaucratic paperwork to unearth the names of these members who have quite a large amount of power (it turns out) over what goes on in the hospital. But you know who is on these boards? Yeah … almost half of board members tend to have a financial background. Almost none of them are nurses. And what about doctors? Are physicians on these boards? Well, almost one-third of hospital boards did not have a single physician member. So, there’s that.

Here’s a quote from a STAT news article written by my guest in this healthcare podcast, Suhas Gondi, MD, MBA, and also Sanjay Kishore, MD, about a study that the two of them coauthored about who is on hospital boards. Here’s the quote:

Our findings are cause for concern. If hospital executives are largely held accountable by finance professionals and corporate leaders, instead of by clinicians and patients, might they focus more on revenue and expenses than the needs of their communities or staff? While some argue that margin facilitates mission, the measure of a nonprofit organization is how these priorities are balanced by leaders who ultimately answer to their board.

So, I get there’s balance. You have to be financially sustainable. But I also get that, apparently, tigers don’t change their pinstripes. The pin-striped suit remains even when the finance tigers become the board members of a charitable organization that’s supposed to be serving the surrounding community paying its freight in the form of its tax exemptions.

This is what this conversation is about today: Who is on these hospital boards? How much power do these hospital boards have? And what might be done to switch it up some so that we can get hospitals that are reflective of our values as a nation and what we want for ourselves and our families?

Today, as aforementioned, I’m speaking with Suhas Gondi, MD, MBA, who, along with his coauthor Sanjay Kishore, MD, wrote a paper on this exact topic. Check out some great Tweets and comments. Following are some suggestions that Dr. Gondi makes in this podcast interview that follows to help us get a little less misaligned.

Here’s one mandate and three suggested models for current hospital boards, which (let’s get real) are currently comprised a lot of times of a group of people making decisions in closed boardrooms that impact a whole lot of people.

First of all, there should be transparency about who is on the board and what they are doing in those closed rooms—what decisions they are making. Second of all, the IRS could surely mandate that for anybody looking to get tax-exempt status, certain requirements are in order for the boards of said organizations.

Then here’s three suggested models to consider:

1. At other kinds of charities and even healthcare organizations with clear missions, like Federally Qualified Health Centers (FQHCs), the composition of the boards is mandated; and for FQHCs, 50% of the board has to be patients who are patients at the FQHC, for example. And, yeah with this. Hospitals are tax-exempt entities. That means that others in the community are paying more in taxes so that this hospital isn’t paying taxes. This hospital, therefore, is in debt to the community. Having a board that is reflective of the community could be one way to ensure that this hospital has an accountability to that community and can serve its needs adequately.

2. NASDAQ requires that two members of every board have some “under-represented” diversity, so that could be a thing. You could add to that professional background diversity. I was looking at a Web site the other day featuring a team photo with the caption something like “Here’s our diverse team,” and the entire photo was of, I’m going to say, literally 30+ white men. The caption clarified that they all had different experiences … in the pharmacy benefit administration space. So, nothing against white men, but … yeah, it might be a good idea to align as a community on a broad definition of diversity and what “reflective of the community” means.

3. Accountable capitalism. This was originally suggested by Senator Elizabeth Warren, who argued that 40% of boards should be elected by workers. So, not the majority of the board but enough of the board that it becomes accountable to frontline workers and others.

You can learn more by connecting with Dr. Gondi on Twitter and LinkedIn.

Suhas Gondi, MD, MBA, is a resident physician in internal medicine and primary care at Brigham and Women’s Hospital.

As an EMT in his hometown in Virginia, he saw how structural barriers impact access to healthcare for vulnerable patients. He dedicated himself to studying medicine and policy together with the goal of building a healthcare system that delivers better outcomes and prioritizes equity.

His academic work focuses on incentives in our healthcare system and how they shape the behavior of providers and payers. His work on healthcare payment and delivery system reform has been published in the New England Journal of Medicine, JAMA, and The Lancet and has been cited by the Medicare Payment Advisory Commission. His advocacy and writing have been featured by CNN, NPR, New Yorker, and USA Today.

He graduated from Harvard Medical School and Harvard Business School and previously served on the White House Health Equity Leaders Roundtable.

05:26 What’s a hospital board, and how much power do they have over goings-on?

06:51 How big is a hospital board typically?

07:45 How powerful is a hospital board actually?

09:12 What percentage of these board members have roles within the finance industry?

10:04 What percentage of these hospital board members are health professionals?

10:47 How do these hospital boards work?

12:44 Have hospital boards always been made up of financial board members, or is this a recent thing?

18:12 “The private equity model … fundamentally changes the incentives of the organization.”

23:21 Are hospital boards a potential place to create change within the healthcare industry?

25:16 “It’s about who has power.”

30:55 What’s the hope with diversifying hospital boards?

You can learn more by connecting with Dr. Gondi on Twitter and LinkedIn.

@suhas_gondi discusses on our #healthcarepodcast who is on #hospitalboards. #healthcare #podcast

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293)

Summer Shorts: Knights, Knaves, and Pawns in Healthcare

To read the full article and show notes with links mentioned as well as a full transcript, click here.

In this episode, Stacey Richter speaks with Larry Bauer about the societal perceptions of physicians as knights, knaves, or pawns, inspired by a 2010 JAMA article by Dr. Sachin Jain and Dr. Christine Kassel. They delve into how these perceptions influence healthcare policies, the moral dilemmas faced by physicians, and the need for greater integration of doctors in policy-making processes. Throughout the episode, they stress the importance of understanding physicians' motivations and the significant impact of involving medical professionals in discussions about healthcare reform.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

07:36 Are physicians knaves or knights?

10:05 “Most of the people … that [I’ve met], I would actually put under the cap of knights.”

10:21 “By and large, the healing community is quite ubiquitous.”

10:38 What is more important than accountability in the healing community?

13:42 Why is it important to recognize our own biases in how we view physicians and the medical community?

18:10 EP266 with Matt Anderson, MD, MBA.

18:16 Is it “the suits” versus “the scrubs”?

19:08 Why is it important to get doctors on committees and get policymakers on the ground?

Stacey is co-president of Aventria Health Group, a marcomm agency helping employers, payers, pharma and pharmacies develop and leverage partnerships with other health care organizations. For twenty years, Stacey has used her expertise to innovate inspiring collaborative health solutions benefiting all stakeholders, and most of all the patient.

00:00 Elisabeth Rosenthal, “An American Sickness: How Healthcare Became Big Business.”
02:25 Look at the bills your insurance company is paying.
02:45 “All of your out-of-pockets are a function of how much your insurance is paying on your behalf.”
03:20 “If no one is questioning what those costs are, then providers will fill in whatever they think they can get.”
04:05 Is your practice owned by a hospital, or licensed as a surgery center?
04:35 Ask your physician to only refer you to other physicians in your network.
05:00 Request that labs be in-network.
06:15 Ask in advance how much a procedure will cost.
07:30 “It’s up to us to inform our Physicians about costs.”
07:50 “How will this test or exam change my treatment?”
08:20 Ask which blood test or exam they’re taking and why.
09:00 “Where will this test or surgery be performed, and how does that place affect the price?”
10:00 “Who else will be involved in my treatment, and will I be getting a separate bill?”
11:25 “Watchful Waiting,” - the Value in waiting to seek treatment.
13:30 Price Transparency.
14:45 Fight back on Gag Clauses.

Like many of us, Asif Khan worries about the health of his parents. Unlike many of us, Asif took that worry and leveraged twenty years of experience within the technology and global healthcare realm to create a revolutionary cloud-based communication and care coordination platform that streamlines collaboration among health care providers, non-clinical staff members, residents and their families.

Caremerge offers HIPAA-compliant secure messaging, shared care plans, real time risk management and proactive quality measures designed to increase quality of life. Designed specifically to meet the needs of a growing market, the platform is easy to launch, simple to use and highly impactful across multiple care settings.

Caremerge is funded and backed by Cambia Health, GE Ventures, Ziegler LinkAge Longevity Fund, Generator Ventures (Formation Capital) and Arsenal Venture Partners.

Asif holds a B.A. in journalism & history and a B.S. in computer science. He earned his MBA from Booth School of Business – University of Chicago. He is also a Lean Six Sigma Black Belt.

You can find out more at CareMerge.com.

Exploring Effective Payer-Provider Collaborations: Insights and Key Strategies

To read the full article and show notes with links mentioned as well as a full transcript, click here.

In episode 417 of Relentless Health Value, Stacey Richter engages in a detailed discussion with Josh Berlin from Rule of Three consulting firm about the dynamics and strategies behind successful provider and payer collaborations in the healthcare industry. They delve into the historically adversarial relationship between these entities and explore five distinct types of collaborations, ranging from data sharing to risk-bearing partnerships. Berlin outlines five crucial 'must-haves' for these collaborations to succeed, including scalability, sustainability, flexibility, effective collaboration, and compatible risk profiles. They further examine real-world examples of both successful and failed healthcare collaborations, emphasizing the importance of mutual goals and adaptive strategies to enhance patient outcomes and improve market competitiveness. The conversation offers practical insights for healthcare executives aiming to foster stronger, more innovative partnerships in a complex and evolving industry.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

06:06 Why should payers want to collaborate with providers?

09:46 “Collaboration … is bilateral. … Both sides, plan and provider, should be equally as interactive with the individual populations they work with.”

12:37 What are the must-haves for collaboration between providers and payers?

13:10 What are the five different types of collaboration?

16:03 What are the five characteristics you want to be focused on in partnership?

21:35 EP359 with Dan O’Neill.

22:16 In order to collaborate, do you have to be collaborative?

26:11 Ochsner as a great example of collaboration.

27:46 Episodes with David Carmouche, MD, and Eric Gallagher.

28:51 A collaboration failure in Haven.

Frazer Buntin has worked in strategic and operations leadership positions for the past 17 years and currently serves as the president of value-based services for Evolent Health. Evolent Health partners with leading provider organizations to achieve superior clinical and financial results in value-based care, actively managing care across Medicare, Medicaid, and commercial and self-funded adult and pediatric populations. Frazer is responsible for managing the operational performance of Evolent Health’s partners.

Prior to Evolent, Frazer served as CEO for WhiteGlove Health, a population health management firm providing primary health care services to self-insured employers and health plans. Previously, Frazer was co-founder, president, and CEO for Silvercare Solutions, one of the largest providers of primary care and health care management services to the senior population in the United States. Prior to Silvercare, he served in several senior-level roles for Healthways Inc. and Dollar General Corporation. Frazer currently serves on the board of Leadership Health Care and holds an MBA from Vanderbilt University and a BS degree from The University of the South.

As Senior Vice President in the Office of Population Health Management, Dr. Smith provides clinical leadership for all of Northwell’s population health activities. He is also the Medical Director for Health Solutions, Northwell’s care management organization and is the Chief Medical Officer for CareConnect, Northwell’s insurance company. Prior to these responsibilities he led system-wide care continuum initiatives in the post-acute setting as medical director for Post-Acute Care Services.

Dr. Smith is board certified in Internal Medicine as well as Hospice and Palliative care. He maintains an active clinical practice as a house call physician in Northwell’s nationally recognized home-based primary care program.

Dr. Smith, an associate professor at Hofstra Northwell School of Medicine, has published a number of papers on advanced care models for the frail elderly and has been a co-investigator on a number of grants investigating the outcomes of high-intensity primary care programs. He has been invited to give regional and national talks on health policy, the frail elderly and the intersection of payment reform and clinical redesign.

Dr. Smith has worked with regional and national associations such as the Greater New York Hospital Association, the American College of Physicians, Center to Advance Palliative Care, the Coalition to Transform Advanced Care and the American Association of Home Care Medicine on health care reform. He is the executive sponsor for a number of governmental demonstration projects including Medicare’s Independence at Home, Bundled Payment for Care Improvement and the New York State Health Home.

Dr. Smith graduated with a degree in sociology from Princeton University and received a Master of Public Policy in health policy from Harvard University, JFK School of Government. He received his Medical Degree from Boston University School of Medicine and completed a residency and chief residency in Internal Medicine at the Mount Sinai Medical Center. Prior to joining Northwell he was an assistant professor at the Mount Sinai School of Medicine and an assistant program director for the Internal Medicine Residency Program.

First of all, a shout-out to all of you listeners who have shared this show with colleagues and LISTSERVs—really appreciate it. It’s because of you and your efforts to share that Relentless Health Value maintains its spot as one of the top podcasts reaching health care executives, executives who take the insights shared by our guests to drive actual change and transformation across our industry. So, thank you. Leaving a rating and/or a review on iTunes is also the bomb and really helps our RHV team stay motivated and keep it going. Weekly shows take a ton of work! Feedback is super appreciated.

On to the topic this week: Who has read that white paper put out in February by the University of Pennsylvania, specifically, Penn’s Leonard Davis Institute for Health Economics? It’s called “The Future of Value-Based Payment: A Road Map to 2030.” I mentioned this paper last week, too. So, if you still haven’t read it, go back after this show and take a look. There’s links in show notes. 

As with every interesting white paper, while you’re reading it, you start thinking of more questions. That’s why I was thrilled to get a chance speak with Mai Pham, MD, MPH. She is one of the paper’s authors, a physician, and a trained health services researcher. Dr. Pham is a former chief innovation officer at the Centers for Medicare & Medicaid Services (CMS). She also spent time at Anthem doing value-based care (VBC) work for the enterprise on a national level. Further, she’s the parent of an autistic child and founded the Institute for Exceptional Care to transform health care for people with IDD (meaning intellectual developmental disabilities), which I’ll get to in a second.

Here’s some highlights from my discussion with Dr. Pham:

• Markets get distorted when insane quantities of dollars rush in. I’m thinking about Medicare Advantage and all of its attendant suppliers right now. Think about all of the amazing brainpower captivated by figuring out how to upcode at scale, which, by the way, only a minority of the time corresponds to actual spend. Dr. Pham has some words on this.
• Attaining value-based care results and adoption has a big problem. As a policy maker, you can’t just keep trying to sweeten the value-based care pot. You don’t want to plow even more money into the system. So, at a certain point, we all have to get real and realize that for the cost-driving entities in this country—those IDNs (independent delivery networks) with huge market clout—to get on the VBC bandwagon, value-based care probably has to be a mandate; and it also will mean making FFS (fee for service) much less attractive.
• Thirdly—and here’s something I never considered—commercial prices drive up Medicare prices. You have hospital systems pointing to growing disparities between commercial rates when they negotiate for higher Medicare rates, when the hospital systems themselves created those deltas with their private-sector negotiations.
• Lastly, we chat national versus local health care reform and about indie doctors and the “why” behind consolidation. It aligns quite a bit, our conversation in this health care podcast, with the insights from the show last week with Nicole Bradberry and Kelly Conroy (EP324). 

The last 6 minutes of this podcast is Dr. Pham’s insight about the scope and impact of not caring adequately for people with neurodevelopmental disabilities. We’re talking about somewhere between 10 and 16 million people, as Dr. Pham notes for perspective. That’s the number of new cancer cases each year. Collectively, we spend as a country somewhere between 1% and 2% of the GDP all in on this patient population.

You can learn more at ie-care.org. 

Hoangmai (Mai) H. Pham, MD, MPH, is a general internist and national health policy leader. She was vice president, provider alignment solutions, at Anthem, Inc., responsible for value-based care initiatives at the country’s second-largest health insurance company. Prior to Anthem, Dr. Pham served as chief innovation officer at the Centers for Medicare & Medicaid Services, where she was a founding official, and the architect of Medicare’s foundational programs on accountable care organizations and primary care. She was co-director of research at the Center for Studying Health System Change and has published extensively on provider payment policy and its intersection with health disparities, quality performance, provider behavior, and market trends. Dr. Pham serves on numerous advisory bodies, including the National Advisory Council for the Agency on Healthcare Research and Quality, the Maryland Primary Care Program, and the National Business Group on Health, and was a member of the Board Executive Committee at the Health Care Transformation Task Force. Dr. Pham earned her bachelor’s degree from Harvard University, her MD from Temple University, and her MPH from Johns Hopkins University, where she was also a Robert Wood Johnson Clinical Scholar.

04:22 What are the nuances within the promises of value-based care?
05:34 “For the first 10 years of … value-based care, it was right in order to generate momentum and get as much participation as possible.”
06:41 “When you leave yourself open to tackling prices, now you open up a whole world of possibilities in terms of how you could redirect sources.”
08:00 “Not all providers are the same.”
09:24 “It’s time to stop tracking the phenomenon and actually pay for change.”
10:29 “We haven’t done our best to actually make the alternative to value-based payment as bad as it could be.”
12:14 What’s the path forward in value-based care, especially for specialists?
15:43 “There has been tremendous business opportunity in Medicare Advantage, not to the benefit of the trust funds.”
17:13 “As a citizen, I gotta ask, ‘How much is enough?’”
19:03 “It’s not like we’re talking about replacing a really superlative gold standard.”
19:34 EP263 with Andrew Eye from ClosedLoop.ai.
22:02 “It’s not just about taking dollars away from certain subsectors; it’s about reallocating some of those dollars.”
23:34 “Policy making itself tends to be siloed.”
25:02 “This is about paying some people in health care modestly less.”
25:35 “Most of the costs are driven by fixed costs.”
29:25 “Value-based care is not what has driven consolidation.”

You can learn more at ie-care.org. 

@HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

What are the nuances within the promises of value-based care? @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“For the first 10 years of … value-based care, it was right in order to generate momentum and get as much participation as possible.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“When you leave yourself open to tackling prices, now you open up a whole world of possibilities in terms of how you could redirect sources.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“Not all providers are the same.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“It’s time to stop tracking the phenomenon and actually pay for change.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“We haven’t done our best to actually make the alternative to value-based payment as bad as it could be.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“As a citizen, I gotta ask, ‘How much is enough?’” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“It’s not like we’re talking about replacing a really superlative gold standard.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“It’s not just about taking dollars away from certain subsectors; it’s about reallocating some of those dollars.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“This is about paying some people in health care modestly less.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

“Value-based care is not what has driven consolidation.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

Here’s a hot take for you. I just learned what a hot take was last week, so, of course, I needed to get me one on the quick. The thing with hot takes, from what I understand, is that they are open for discussion. What I’m talking about today is something I’ve been thinking about for a while, and I would be interested in your thoughts, since probably some finesse is needed here.

I want to talk about the imperative of collaborating with organizations across the care continuum, even the ones you may have a problem with.

Let us begin by discussing why collaboration is so vital if the intention is to improve patient care, quality, and lower costs. The story really begins with fragmentation. Turns out, the US ranks last among 10 other countries in a recent study on healthcare systems. One of the reasons why is the fragmentation of professionals and patients and siloed health information. This is from a Commonwealth Fund study.

In fact, according to an AJMC article I found the other day—or do a Google search for any number of others—fragmentation is associated with increased costs of care, a higher chance of having a departure from clinical best practice, higher rates of preventable hospitalizations … Even among patients with the same chronic condition, lower quality happened and costs were higher in patients who received more fragmented care.

So, nothing for nothing, but it’s kinda self-evident that to fix American healthcare, we need to fix fragmentation. But to fix fragmentation, stakeholders along the care continuum have to—God forbid!—collaborate and work with each other.

For more information, go to aventriahealth.com.  

When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specializes in helping pharmaceutical, employer, pharmacy, and health system clients improve patient outcomes by creating and leveraging collaborations with other health care organizations. For more than 20 years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders and, most of all, the patient.

00:12 What’s Stacey’s hot take on collaboration in healthcare?
00:43 Why is collaboration so vital, and how does fragmentation play into that?
01:38 “To fix American healthcare, we need to fix fragmentation.”
03:23 “Nobody gets to be holier than thou.”
04:38 What is the bottom line on collaboration in healthcare?
05:20 What’s the difference between collaboration and collusion?
05:35 “More is not usually better.”

For more information, go to aventriahealth.com.  

Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth

Why is collaboration so vital, and how does fragmentation play into that? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth

“To fix American healthcare, we need to fix fragmentation.” Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth

“Nobody gets to be holier than thou.” Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth

What is the bottom line on collaboration in healthcare? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth

What’s the difference between collaboration and collusion? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth

“More is not usually better.” Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry

For more than 25 years, Patricia has chosen the “road less traveled” in building her career, focused on breaking new ground in order to solve hard problems. She brings executive operating experience from both early stage and mature companies in the medical device, diagnostics, life science companies, including Life Technologies, T Cell Sciences and Sigma Aldrich Corporation.  She has brought multiple new products to market in the areas of HIV monitoring; cancer diagnostics, pharmaceutical drug discovery. Prior to founding ActualMeds , Patricia founded RedTail Solutions, a Software as a Service (SaaS) company serving middle-market manufacturers in the global supply chain. While serving as its CEO (2000-2008), she established a new revenue and business model in this segment and built a capital-efficient business that achieved profitability in 2007. Armed with lessons learned in the retail supply chain about the value chain of information, Pat has returned to healthcare at a time when interoperability is one of the keys to its transformation, and she expects ActualMeds to play a major role in it. Patricia holds a B.A. degree in Biology from Kenyon College, an M.S.  in Biochemistry and an M.B.A. from Case Western Reserve University.

If you want to learn more about Actual Meds you can visit their website at http://www.adheretx.com/.

It’s rare you read an article about health tech and not see the word "interoperability" at some point, probably more than once. If that were a drinking game, we’d all be really drunk by now. Today I speak with Don Lee, a fellow podcast host about how Health Information Exchanges, otherwise known as HIEs, can assist us in the short term to get our data integration act together. This is a little bit of a reality check— blockchain and more elegant solutions might be coming, but today, right now, we need to meet quality measures. And you can’t meet quality measures without having a handle on the trips to the ER, eye exams, and specialist visits that are transpiring outside the four walls of any given provider office. 

Don is an accomplished Health IT expert with a 20-year track record of driving value with technology.

Don began his career as custom software developer and eventually built and lead a team of more than 30 engineers.  Later, he was the subject matter expert, product manager and head of sales and marketing for a digital health startup that launched a SaaS-platform focused on administrative simplification in healthcare.

Today, Don is President of Glide Health IT, LLC, a consulting firm that helps forward-looking organizations align their Health IT and business strategies. The firm specializes in business and product development with a focus on data aggregation, interop, analytics and quality measurement.

Don is also the founder, co-host and Executive Producer of The #HCBiz Show!, a podcast dedicated to unraveling the Business of Healthcare.

You can learn more by going to glidehealthit.com or don.lee@glidehealthit.com or by going to thehcbiz.com to listen to Don’s podcast.

If you go to the Sage Transparency dashboard Web site, you get a really graphical representation of the prices that any given hospital actually needs to charge so that they break even. You can see precisely which hospitals are operating on thin margins and which ones are not.

You might be thinking, “Okay, so ... what’s the big deal about this? Why is the Sage Transparency information so meaningful? Aren’t hospitals (most of them) providing their financial statements already?”

Well, let’s discuss. First of all, we have the main hospital lobbying organization coming out with press releases such as this one saying (here’s some quotes): “Hospitals have incurred serious losses …” “The vast majority of America’s hospitals [are] in serious financial jeopardy …”

Combine quotes like these (and there are many) with some of the funny stuff going on in some (not all) hospital financial reporting—like counting investment losses from their venture funds, not counting endowments or their big trusts in the math, paying C-suites way more than the average doctor or worker, or all of the varied things that get counted or overcounted as charity care or community benefit—yeah, these hospital balance sheets are too often as much of a PR campaign as the PR campaigns. When you dig into them, you find some very wealthy organizations dressing up in Tiny Tim Cratchit pants and leaning on a crutch … at least whenever the cameras are rolling.

So, where are patients in all of this? Chris Deacon linked to a Qualtrics study recently. It seems that in 2020, 48% of people deferred care as a result of the pandemic. In 2022, 43% deferred care because of cost—48% from the pandemic, 43% deferred due to cost this past year … wow!

There are patients saying, “Hey, I have this giant thing growing on my arm. Is it melanoma? I don’t know, but I do know if I go to the doctor, I’ll be $600 in the hole … so I’ll wait.”

It doesn’t matter how many medical advancements are made when almost half of the patients are making decisions like this, including patients with so-called “good” insurance.

Look, no one would or is arguing that hospitals aren’t vital. They are essential. Hospitals can be amazing places where lives get saved. Amazing doctors and clinicians work in hospitals. But putting everything I just said together, let me summarize a textbook hospital chain one-two punch.

The halo effect many hospitals enjoy is massive, and those administrators who choose to can take advantage of that halo for financial gain. When hospitals’ administrators cannot manage to curtail their own spending and then demand that their communities foot the bills, then the good that a hospital can do starts to go bad.

If you are a legislator, you might want to be paying attention to all of this. And when I say might be wanting to pay attention, I mean pretty much you want to be paying attention to all of this. With all of the data that is now available to especially more sophisticated employers, some companies are not building offices or plants in areas which are known to have healthcare prices that are multiples over what they should be. That might be in your legislative district or state.

Healthcare prices can be the largest cost for employers after payroll. Starbucks famously spends more on healthcare than they do on coffee beans. Nearly 8 of 10 employers considered healthcare costs a significant threat to affordability.

So, too high hospital prices are a community problem at the chamber of commerce as well as at the family and the patient level.

After you listen to this show, go back and listen to the one last week with Mike Thompson (EP389) if you haven’t already. It adds some context that you might want to have. Also stay tuned for a show coming up where we talk about just all of the anticompetitive stuff that some of these hospital system administrators have decided to subject their communities to.

In this healthcare podcast, I have two titans of employer coalition building on the episode. Gloria Sachdev from the Employers’ Forum of Indiana, who was instrumental in standing up the Sage Transparency dashboard that we talked about last week and we’ll discuss a little bit more this week. Gloria is a pharmacist, which I did not know. She also sits on the board for the National Alliance of Healthcare Purchasers Coalition and Hoosiers for Affordable Healthcare.

Also on the show is the one and only Chris Skisak, who leads the Houston Business Coalition on Health. He also speaks for the state of Texas through his role with Texas Employers for Affordable Healthcare.

Gloria Sachdev, PharmD, serves as president, CEO, and board chair of the Employers’ Forum of Indiana. She also serves as adjunct associate professor at Purdue College of Pharmacy. Forum initiatives focus on hospital price and quality transparency, value-based health benefit and payment strategies, and health policy. She serves as a member of the Board of Governors for the National Alliance of Healthcare Purchaser Coalitions and as board vice chair for Hoosiers for Affordable Healthcare.

Dr. Sachdev received her bachelor of science and doctor of pharmacy degrees from the University of Oklahoma and completed a primary residency at the VA in Madison, Wisconsin. Thereafter, she practiced in primary care physician offices managing patients with chronic diseases for 12 years, followed by consulting in the space of incorporating clinical pharmacists into team-based care for 6 years. She retired from Purdue College of Pharmacy after 15 years but still teaches a few classes for fun.

Chris Skisak, PhD, is the executive director of the Houston Business Coalition on Health, a multi-stakeholder but employer-centric 501(c)(3) focused on improving the cost, quality, and consumer experience in healthcare delivery. He is also the executive director of Texas Employers for Affordable Healthcare, a legislative advocacy organization focused on creating a competitive healthcare delivery ecosystem. Dr. Skisak also serves on the boards of directors of the National Alliance of Healthcare Purchasing Coalitions and Texas Business Group on Health. He serves on the leadership councils for Houston Cities Changing Diabetes, Houston Health Equity Collaborative, and Center for Houston’s Future. He had previously worked 25 years with Houston Fortune 50 energy companies in a variety of population health management positions. He is originally from Chicago and attended the University of Illinois. He received his master of science degree and PhD from the University of Texas School of Public Health.

06:04 How could the healthcare market correct itself?

08:27 EP334 with Sunita Desai, PhD.

09:38 What strategies are needed to make changes in the healthcare market?

10:13 What can be done with respect to market forces?

12:33 What needs to happen in regard to healthcare legislation?

13:03 Gloria’s ideas for legislation.

15:44 Why is it important to allow physicians to be independent again?

17:41 EP373 with Cora Opsahl.

18:21 Chris’s thoughts on legislation.

22:51 Why is it important that employers become present in the legislative process?

26:48 What has been immensely helpful to better understand hospital financials?

31:08 EP385 with Dan Mendelson.

31:16 EP379 with AJ Loiacono.

32:11 Why is transparency foundational for healthcare market change?

@GloriaSachdev and @ChrisSkisak discuss #hospitalpricing and #legislation on our #healthcarepodcast. #healthcare #podcast #healthcarelegislation

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308)

I was at the PanAgora Pharma Customer Experience (CX) Summit earlier this summer. Let me tell you one of my big takeaways. Many at pharma companies who are trying to convince their organizations of the need to be provider- and/or patient-centric are having a tough go of it. Heard that coming from every direction. Seems there are quite a few pharma organizations out there who are not actually customer/patient-centric. Say it isn’t so. Turns out, they continue to be pretty darn brand-centric whether or not anyone besides the CX team and the most successful KAMs (key account managers) realize this hard truth.

This matters because, from a provider organization, physician, or patient standpoint, it’s not what’s written on the walls … it’s what goes on in the halls. It’s what a company actually does in their interactions with the rest of the healthcare ecosystem that matters and that builds their reputation.

You see this lack of customer centricity and, et cetera et cetera, there are certainly other things going on here; but you see the lack of customer centricity manifesting, right? You see the pharma reps that get kicked out of hospital systems because the perception is they add little if any value and “waste doctors’ time; all they do is shove detail aids in our faces.” Heard that recently. You see manufacturers in the news getting fined, very publicly, by the OIG (Office of Inspector General) or the DOJ (Department of Justice) for doing stuff that is not really patient-centric by a long shot.

For those of you working at pharma companies looking to do the right thing by patients, looking to be patient- or customer-centric for reals, a couple of reality checks here which you might be able to use to spark transformation at your organization. You saw, for the first time ever, legislation allowing Medicare to negotiate for drugs to pass into law, as well as the inflation rebate. Listen to the show last week with Mark Miller, PhD (EP380), for the “why did that happen right now” full story, but the short version is this: People, voters, patients, physicians, taxpayers, policy makers … all of them are questioning the value that Pharma brings for the money being spent. I am being blunt, I know; but so is this here referendum that just happened. If you’re trying to spark change and you need a story arc that has a carrot and a stick to inspire transformation at your organization, I’m just dropping this here for you.  

In today’s environment, bottom line, being brand-centric instead of customer-centric diminishes trust. Look, this doesn’t just pertain to Pharma; this is a message for the whole industry. But there is certainly a way to do well by doing good, and how that starts is helping provider organizations and patients improve patient outcomes as the primary goal. Being innovative to that end.

It’s about supporting the best-practice standard of care and bringing resources to bear that are truly helpful. That is how more of the right patients can get the right treatment/drug at the right time or take their meds as per the A1A clinical guideline. It’s probably also the way to sustainable business success.

I’ve said it here a thousand times: People trying to do the right thing by patients all need to work together. If there’s a party in the mix that nobody else wants to deal with because they are deemed not a team player or they don’t listen … yeah, that’s what I call a competitive disadvantage, beyond just squandering their ability to achieve their mission statement and improve patient care and lives, that is.

Today’s conversation is with Karen Root, who was a speaker at the aforementioned PanAgora conference. In this healthcare podcast, we are talking about how to make transformation and innovation actionable at a large organization—maybe a pharma company but pretty much any large organization with lots of people, lots of human beings with different motivations and goals. As we all know, for every early adopter, there are (it feels like) five laggards who will fight you tooth and nail because they do not want to transform. They like being brand-centric, and it’s been working out fine … well, up until this year, at least.

Karen Root is currently director of experience strategy at Boehringer Ingelheim, which is a pharma company. For many years prior to her current role, she was an enterprise head of brand and culture at WL Gore & Associates. What we talk about in this show is how to break down the historical “brand is king” mentality so that people want to follow with the awareness, courage, and determination to do so. Everything that we talk about in this episode can also be applied to pretty much any organizational transformation or the rollout of any innovation or new capability.

Here’s the key things that Karen talks about which are essential for an organization to transform, maybe (again) in a way that is customer-centric and/or to roll out new innovations or capabilities:

1. Leaders must communicate a compelling vision that also includes a realistic assessment of what it’s gonna take to reach that vision and offer hope and the promise that the hard work and inevitable problems will all be worth it.
2. Systems thinking—a consideration of the systems and the people who will need to be a part of the transformation, thinking through what is likely to go wrong and proactively planning for it
3. Identify the right entry point. This should be a micro-journey or a quick win so that the team can score a victory and get through the messy middle that exists in any transformation or rollout. Triple points if you can find a micro-moment that has some emotionality connected to it from your customers’ perspective or patient perspective. If you can fix a so-called moment that matters, it really matters. Consider starting by looking into call center logs, finding a common complaint, and fixing it. Do it this way and it’s harder for anybody to complain that the status quo is so super amazing and tell you to talk to the hand.
4. Determine how you are going to measure what your quick win accomplished, as well as your whole larger transformational effort.
5. Ensure you have a full story arc here that shows the before and the after that clearly articulates that the before (the status quo) is problematic and that we have to, with urgency, get to the after.
6. Never forget that we’re working with human beings here and not, as they say, rational economic actors.

One heads-up: In the conversation with Karen today, we talk a lot about the so-called J curve. As Karen says (and you can look this up), whenever you introduce a new anything into an organization, at some point, there’s gonna be a mess-up. And when something messes up, the whole team will spiral into a so-called “trough of disillusionment” or a “trough of despair,” sometimes it’s called. This is the rock-bottom hook of that J in the J curve. The thing is, if a leader’s vision isn’t sufficient or their will to continue isn’t sufficient, then the organization quits at this low point instead of working through it and coming out in a better place on the other side of the J.

And you know what happens then. From that point forward until eternity, everybody who brings up implementing an innovation or a transformation will definitely hear the lecture about the time we tried that and how it failed miserably. So, the J curve … Check it out. Don’t underestimate it.

One very last thing: If you are working for a large organization (like Fortune 500 large) and you have succeeded in moving a transformation forward (like being actually patient-centric or customer-centric, for example), hit me up. I would certainly love to hear your thoughts on how you did it and why you think you were successful and the impact that you had.

Last week’s show was an encore episode with Dr. Aaron Mitchell (Encore! EP282), and we talked about buy and bill. To continue our exploration of specialty pharmacy intrigue, let’s talk about so-called “bagging.” I wanted to get an overview of all of the different kinds of specialty pharmacy bagging. Bagging is a big deal. If you have anything to do with trying to control pharmacy costs or the clinical outcomes of specialty pharmacy patients, you too are going to want to understand what’s going on here with bagging.

I was thrilled to have a chance to chat with Keith Hartman, who is my guest in this healthcare podcast. He is the CEO of ContinuumRx. He’s a pharmacist by education and has been in the pharmacy space for over 25 years now, touching just about every aspect of pharmacy from retail operations to long-term care and now, most recently, home infusion. This makes him an ideal person to chat with about this topic. And FYI, it was not easy to find someone to do so to clearly see the actions and reactions going on here because that’s what this is all about: actions and reactions—how any self-respecting market distortion is going to cause a cascade of equal and opposite market distortions.

So, let’s cruise through the whole infused/injected specialty pharmacy historical play-by-play, shall we? It’s like a “Who’s on First?” routine—except very, very not funny. So, here we go. This is, of course, the semi-reductive abridged version; but let’s do this thing.

Once upon a time, the bagging story starts in ye olden days, meaning more than ten years ago, before specialty pharmacy drugs really became the massive profit centers for any party who can manage to get their fingers in the specialty pharmacy cookie jar. In these ancient and halcyon times, brown bagging was kind of a modus operandi. Don’t forget, we’re talking about infused or injectable drugs here, especially ones that need to be infused or injected in the provider’s office.

So, brown bagging means and meant when a specialty pharmacy drug is shipped directly to a patient, or a patient goes and picks up the specialty pharmacy drug at the pharmacy. Doc takes out prescription pad (this is in ye olden days, remember) and writes out the Rx. Patient picks up the drug from the pharmacy, which may be handed to them in a brown bag. Get it? But then they take that “brown bag,” as it were, to their doctor’s office. The doctor takes the drug out of the brown bag and infuses or injects it. I say doctor’s office because many times, in the olden days, that’s where this went down.

And this brown bagging had some issues, for sure; but specialty pharmacy drugs really weren’t all that big of a thing either dollar-wise or frequency-wise.

At some point in our story here, pharma manufacturers start seeing just exactly how much money the market will bear for specialty pharmacy drugs, and the prices of these specialty drugs go through the roof. At the same time, for a bunch of reasons I actually discussed with Dr. Bruce Rector (EP300), a whole bunch of these specialty pharmacy drugs start hitting the market all at once. So, these drugs have skyrocketing prices—and there’s lots of them.  

At that point, some (certainly not all, but enough) CFOs at provider organizations were like—wowza, epiphany, light bulb moment—there’s a lot of money that can be made here because buy and bill. In buy and bill, which I talked about last week with Dr. Aaron Mitchell, provider organizations get reimbursed the cost of the drug plus some percentage when they administer it—meaning the more expensive the drug, the more money a provider can make because a percentage of a bigger number is, of course, a bigger number.

Add to that a party-sized container of other provider shenanigans to maximize revenue on specialty pharmacy patients—and that revenue got bigger every single year. A recent report just came out that, on average, for oncology drugs, some providers are making six times the cost of the drug. Six times the cost of a drug that can cost lots of zeros! Just wow—6x! That’s real money. This is winning the lottery every single time a patient needing a specialty drug shows up on your doorstep.  

Continuing the tale here, this buy and bill health system extreme greed hits employers in their pocketbooks. And, of course, plan sponsors start desperately seeking relief. Who rides up on a white horse? PBMs (pharmacy benefit managers), of course.

PBMs say that they will negotiate with drug companies and buy the drugs on behalf of the plan sponsors for much cheaper. Then they will ship the drugs purchased to the provider organizations. Thus, the plan sponsor only needs to pay providers to administer the drug, not that and some crazy markup on the drug itself.

Ladies and gentlemen, white bagging has entered the building. White bagging is when the drug is not shipped directly to the patient à la brown bagging. It is when the drug is shipped to the provider.

But wait … there’s more to the story than a grand PBM gesture of goodwill. They see how much money the employers are used to paying providers for these drugs and realize that the PBM only needs to come in with a price that’s less than that, at least at the beginning.

So, over the years, weird stuff starts happening with rebates on the specialty drugs. Listen to the show with Scott Haas (EP365) for more on that. But bottom line, white bagging becomes not exactly a mecca of cost savings. PBMs are, as we all know, not known for their ability to moderate their profitability, after all.

At this point in our story, let’s just pause to say that provider organizations are very, very, very not happy with this whole white bagging intervention. Not only did a piece of the provider’s specialty pharmacy cash cow get snatched by the PBMs, but there are also clinical issues with white bagging that we talk about on the show today. And some of these issues are not BS. Do not get me wrong. They are very real, and I do not want to minimize them.

And so, provider organizations start to stand up their own hospital specialty pharmacies because then at least they can get some of the white bagging cha-ching. See what I mean? Plan sponsor, health plan mandates that the drug be filled in a pharmacy, hospital owns the pharmacy or part of the pharmacy … and now they have so-called clear bagging.

Clear bagging is when one organization owns the pharmacy and the provider who will administer the drug. Clear bagging solves some of the clinical issues with white bagging, and the hospital also gets to take a cut. I’d be remiss not to mention here that some hospitals have worked very hard on their clear-bagging programs and definitely have tried to improve the quality of service here.

You’re going to have to listen to the show to hear about gold bagging and also the latest developments in this whole war employers and patients and taxpayers are fighting with PBMs and hospitals who are fighting with each other over who gets the money. Also, the continuing trend of brown bagging, especially as “in the patient’s home” gets tagged on the end of lots of care delivery like “in bed” gets tagged on the end of lots of fortune cookies.

Next week’s show will dig into how exactly some providers are managing to get the up to 6x the cost of specialty pharmacy drugs when Medicare Part B at least says that they’re only supposed to get ASP [average sales price] + 6% (ish). I just could not figure out how they were managing to get 6x just given that Medicare Part B rule, but yeah, they are—and we’ll learn about that next week.

You can learn more at continuumrx.com.  

Keith P. Hartman, RPh, is chief executive officer of ContinuumRx and an experienced operating entrepreneur and pharmacy business owner spanning two decades. Keith founded and grew a chain of retail pharmacies, a compounding pharmacy, and two specialty pharmacies along with a long-term care pharmacy. All were built and grown under the guise of operational excellence and produced great results. Some were sold, while others he still owns and provides limited strategic guidance as a member of the board of directors.

Keith graduated from the University of the Sciences with a degree in pharmacy. Today he is still involved mentoring future pharmacists and pharmacy owners.

08:09 What kinds of patients and/or drugs is the concept of bagging relevant to?
08:53 What is brown bagging, and what are the issues with it?
10:28 What is white bagging, and how is it different from brown bagging?
11:30 Who are the key players in pharma bagging?
12:25 Why does a PBM want a specialty drug to go through them?
12:49 From the physician’s perspective, why is buy and bill ideal?
16:46 How does white bagging impact patient clinical care?
22:12 Encore! EP216 with Chris Sloan.
23:05 What are the two main reasons patients might not continue their therapy?
23:29 “We’ve got to leave some authority with our prescribers to be able to make a clinical decision of what’s best for that … patient.”
24:41 What is clear bagging?
26:51 How does a hospital specialty pharmacy get in network with a PBM?
28:57 What is gold bagging?
30:11 “Outlook really needs to be what’s best for the patient.”
32:10 EP337 with Olivia Webb.  

You can learn more at continuumrx.com.  

Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

What kinds of patients and/or drugs is the concept of bagging relevant to? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

What is brown bagging, and what are the issues with it? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

What is white bagging, and how is it different from brown bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

Who are the key players in pharma bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

Why does a PBM want a specialty drug to go through them? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

From the physician’s perspective, why is buy and bill ideal? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

How does white bagging impact patient clinical care? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

What are the two main reasons patients might not continue their therapy? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

“We’ve got to leave some authority with our prescribers to be able to make a clinical decision of what’s best for that … patient.” Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

What is clear bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

How does a hospital specialty pharmacy get in network with a PBM? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

What is gold bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

“Outlook really needs to be what’s best for the patient.” Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider

So, this is a 400-level episode in specialty pharmacy options for plan sponsors, meaning here are your prerequisites: You gotta know what buy and bill is, and you gotta know what pharmacy bagging is, meaning white bagging, for example. If you do not, I would listen to Encore! EP282 with Aaron Mitchell, MD, MPH, where we go deep on buy and bill. And then listen to EP369 for the skinny on pharmacy bagging. If you already know what buy and bill is and you already know what white bagging is, then not only do you know more than 98% of the people in the healthcare industry, but also, you’re going to get as much out of this conversation with Erik Davis and Autumn Yongchu as I did.  

Last week’s show was also with Erik Davis and Autumn Yongchu. Last week, we talked about how some hospitals and cancer centers are managing to ring up up to six times the cost of an expensive-already injected or infused drug through buy and bill. This is why pharmacy bagging became a thing, if we want to talk about this in historical perspective. It’s a direct market response to buy and bill. Hospital systems start making egregious amounts of money marking up drugs that already cost hundreds of thousands of dollars, and their markups are hundreds of thousands of dollars on top of that. Hospital starts making a fortune off of drug markups. Plan sponsors need an alternative, and … enter pharmacy bagging (ie, carving out specialty pharmacy drugs to a PBM [pharmacy benefit manager]).

In this show, we compare the potential benefits and problematic loopholes and/or patient concerns for plan sponsors who are trying to figure out whether to carve out specialty pharmacy benefits to a PBM or grin and bear it with the buy and bill. Or, as another option, whether to steer patients to specific infusion centers or specific provider organizations that might have more favorable contract terms for the plan sponsor. Or, hooking up with a home infusion company, again, who is willing to negotiate terms that might be far better for said plan sponsor than just letting some hospital have their way with employees and the health plan. As another alternative, of course, plan sponsors could consider medical travel, which some certainly are.

My biggest takeaway from this whole conversation and from the episodes that we have had in this, dare I call it, series about pharmacy benefits, starting with the show with Scott Haas (EP365) where we talked about PBM contracts, moving to the show with Dr. Aaron Mitchell (Encore! EP282) where we talked about buy and bill, then going to the show with Keith Hartman (EP369) where we talked about pharmacy bagging, then last week’s show how hospitals manage to buy and bill at 6x the price of these expensive pharmaceuticals … my takeaway from this whole specialty drug extravaganza is that specialty drug procurement is very different than retail drug procurement. Retail drugs, you worry about them en masse at scale almost at the population level. Specialty drugs? You can have one patient on a specialty drug, and that one patient costs as much as the entire rest of the member population combined. So, managing specialty drugs and their administration becomes almost a case-by-case operation. What drug is it? Where is the patient? What options are available? It’s possible to save hundreds of thousands of dollars on that one patient, for that one patient’s care, and get better patient outcomes by getting the right patient on the right drug that is administered in the right setting.  

You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.  

Erik Davis, AAI, CIC, CRM, is senior vice president and principal consultant, managed care and analytics, at USI Insurance Services. He has over 30 years of experience in the insurance and risk management industry. Erik works to create an environment that supports the healthcare risk management goals of an organization while maintaining focus on compliance and financial accountability. He is instrumental in vendor negotiations, data benchmarking, population health strategies, claims analysis, recommendations in plan design, and communication strategies.

In this capacity, Erik has been involved with development of rates, payment structures, and recommendations of changes in processes, policies, and procedures. He has a broad understanding of contract analysis, evaluating risk, auditing for correct payment, and structuring of excess loss and pharmacy programs.

Erik’s experience extends from overall employee benefits consulting to workers’ compensation, as well as managed care organizations in Medicaid, Medicare, and commercial contractual risk arrangements.

Erik earned his bachelor’s degree in economics from Oregon State University. He holds Accredited Advisor in Insurance (AAI), Certified Insurance Counselor (CIC), and Certified Risk Manager (CRM) designations.

Autumn Yongchu is a healthcare operational risk consultant at USI Insurance Services. Autumn works with multiple database platforms to examine data for trends and abnormalities. Using investigative querying, medical coding analysis, and report development, she provides resources that help identify cost control opportunities and assists organizations in strategic business decisions regarding the management of healthcare risks.

Autumn analyzes and interprets healthcare utilization data, allowing the development of initiatives regarding claim and risk management. This includes identifying fiscal and clinical strategies and providing necessary information to develop, design, and implement management initiatives. Autumn also analyzes trends, assists with insurance underwriting, and adjudicates stop-loss claims.

Autumn has an in-depth knowledge of Medicaid and Medicare billing guidelines and payment methodologies.

Prior to joining USI, Autumn was a claims auditor and trainer for a managed care organization which serviced over 100,000 commercial, Medicaid, and Medicare lives. Her responsibilities included contract analysis, claims adjudication, ensuring accurate payment, and identifying and recouping errors.

04:45 Can you actually save money by carving out specialty infused drugs and making them a pharmacy benefit?
06:28 How can plan sponsors use white bagging as leverage to reduce costs from markups?
06:47 Does white bagging save money compared to buy and bill?
07:42 “You also need to understand that with some of these drugs, you’re dealing with very vulnerable people.”—Erik
08:41 EP369 with Keith Hartman, RPh.
11:10 “When your insurance carrier is married to your PBM, it doesn’t matter where the money goes.”—Autumn
11:33 EP365 with Scott Haas.
12:00 “You need to have a collective understanding of every variable … when you’re making those … decisions.”—Erik
14:53 How can comparison shopping save plan sponsors money when it comes to specialty infusion costs?
16:51 How can comparison shopping be a vicious circle in the wrong setting for plan sponsors?
18:43 “That’s part of the problem: It’s not just the plan sponsor not being educated enough; it’s also the consultant … that they believe is supposed to be that isn’t.”—Erik
19:03 How has transparency been used by healthcare systems to keep buyers’ eyes off the ball?
26:55 “It is very case by case, but it comes down to your risk appetite.”—Autumn
28:19 “It’s something that you have to, as a plan sponsor, really continue to monitor throughout the plan year.”—Autumn
28:38 “The more you know, the better equipped you’re gonna be.”—Autumn
29:27 What can employers who are feeling aggressive do?
31:19 “The dollars circle, whether people realize it or not.”—Autumn

You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.  

Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

Can you actually save money by carving out specialty infused drugs and making them a pharmacy benefit? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

How can plan sponsors use white bagging as leverage to reduce costs from markups? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

Does white bagging save money compared to buy and bill? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“You also need to understand that with some of these drugs, you’re dealing with very vulnerable people.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“When your insurance carrier is married to your PBM, it doesn’t matter where the money goes.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“You need to have a collective understanding of every variable … when you’re making those … decisions.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

How can comparison shopping save plan sponsors money when it comes to specialty infusion costs? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

How can comparison shopping be a vicious circle in the wrong setting for plan sponsors? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“That’s part of the problem: It’s not just the plan sponsor not being educated enough; it’s also the consultant … that they believe is supposed to be that isn’t.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

How has transparency been used by healthcare systems to keep buyers’ eyes off the ball? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“It is very case by case, but it comes down to your risk appetite.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“It’s something that you have to, as a plan sponsor, really continue to monitor throughout the plan year.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“The more you know, the better equipped you’re gonna be.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

What can employers who are feeling aggressive do? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

“The dollars circle, whether people realize it or not.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger

The World Bank had a revelation a few years back. Some very smart people working there realized that countries that were easy to do business with thrived. Within these countries’ business ecosystem, the best and the brightest entrepreneurs and investors grew not only their own businesses but also positively influenced other businesses and the community around them.

Brian Van Winkle and Rishab Shah, both executives at Johns Hopkins, had their own revelation: Health systems who are easy to do business with attract and enable the best and the brightest start-ups or other entrepreneurs who are able to do great work within their walls, with their patients, and with their clinicians.

It’s becoming fairly axiomatic at this juncture that provider organizations—along with payers, by the way—cannot be good at inventing and innovating absolutely everything that’s possible to conceive of and develop. It is impossible for any group, no matter how dynamic and forward thinking and awesome, to be better than everybody else at everything. For this reason, the idea of health systems and payers becoming great aggregators of amazing tech and services is definitely gaining traction. This would include internally developed as well as externally sourced technology and services. Listen to Rahul Dubey in episode 259 for more info on this evolution in the payer space.

But back to Brian and Rishab. They spotted this trend in its early days and also saw the issues that health systems face and will face as the ease of doing business becomes more and more of a rate critical of success. Thus was born the Ease of Doing Business Initiative, health care–style, based on the World Bank’s Ease of Doing Business model.

In a nutshell, what the World Bank did in their Ease of Doing Business Initiative is they came up with a set of measures and hived those measures into categories and then they ranked countries against those measures. Brian and Rishab decided to do the same thing. They created a list of questions for health systems to self-rank (at least initially) themselves on how well they did within these seven categories of measures. Twelve to fifteen of the leading health systems agreed to participate. Most are members of NODE.Health, where Brian is the former executive director. And this Ease of Doing Business Initiative is under the NODE.Health umbrella. 

In this health care podcast, Brian and Rishab speak only for themselves during this interview. They do not speak for their employer or anybody else. (Note: I also interviewed Brian and Rishab at the NODE.Health Digital Medicine Conference.)

You can learn more at the Sibley Innovation Hub (@SibleyHub) on Twitter or by connecting with Brian and Rishab on LinkedIn.

Brian Van Winkle, MBA, is the executive director of innovation at the Sibley Innovation Hub. His focus is on transforming the health care system by being a conduit between passionate clinicians and some of the most advanced solutions emerging around the world. Brian brings more than 10 years of experience helping some of the most complex health care systems in the world with transformation, process improvement, and strategy design.

Brian has a dual degree in economics and English from the University of Virginia and earned his MBA at Fuqua School of Business at Duke University.

Rishab Shah, MHS, is the head of digital innovation and strategic partnerships at the Sibley Innovation Hub. He leads the Hub’s charge in development, implementation, and oversight on driving innovation through strategic partnerships with emerging technologies around the world as senior manager of tech innovations.

Rishab is a strategist inspired to innovate while empowered to create. He has helped companies around the world with corporate strategy, business operations optimizations, and large-scale technology transformations—primarily within the health care and life sciences industries.

Rishab has a bachelor’s degree in biomedical engineering from Virginia Commonwealth University and a Master of Health Science from Johns Hopkins University.

03:46 Focusing on “outside-in” innovation.
04:09 The downside to hospitals and health systems not being easy to work with.
05:17 “You have to acknowledge that we’re in a crisis state.”—Brian
06:56 “Are we putting ourselves at a disadvantage by not … being easy to interface with?”—Rishab
08:25 Why hospitals might not be so easy to work with right now.
09:11 The correlation between a partnership strategy and health outcomes and metrics that matter.
09:42 The gap between health care players’ workload and collaboration.
12:04 “Who is putting the focus on the requirements?”—Rishab
12:44 What the Ease of Doing Business Initiative is.
14:56 The opportunity for entrepreneurs to be involved in this process.
16:07 Ecosystem-based work groups.
17:22 “What box do you exist in?”—Brian
18:29 The seven success factors an organization needs to be good at to improve their ease of business.
18:53 Customer support and governance.
19:02 Contracting and legal.
19:11 Patient safety and clinical research.
19:21 Integration and technology.
19:27 Data security and availability.
19:32 Commercialization support.
19:39 Industry perceptions.
21:04 How health care systems view their own ease of doing business.
25:20 The intent of the Ease of Doing Business Initiative.
28:39 Outside innovation vs comprehensive innovation strategies.

You can learn more at the Sibley Innovation Hub (@SibleyHub) on Twitter or by connecting with Brian and Rishab on LinkedIn.

Everybody’s been talking about the surge in telehealth usage—how it would have taken, like, ten years to get as far as we’ve gotten in the past ten days. I wanted to talk to somebody who has been ramping up their telehealth capabilities for a while to get a sense of what it takes to do it well. As has been said by many, doing telehealth isn’t just about technology. It’s about training—clinicians and patients and accounts receivable and other staff. It’s about rearranging workflows and processes. So, super pleased to have had the opportunity to talk with Jonathan Thierman, MD, PhD. Dr. Thierman is an ER doc. He’s also the chief medical information officer for LifeBridge Health systems and the medical director of the LifeBridge virtual hospital.

So, this show has two parts: episode 273 that you’re listening to; but the second part, episode 274, is where we’re going to get into some of the operational aspects of telehealth, like what EHR integration actually means and what it looks like. In this health care podcast (episode 273), however, Dr. Thierman and I discuss what telehealth can accomplish, maybe better than a face-to-face patient encounter, and what it’s not so good at. One thing that dawned on me as we were talking is that the technology isn’t just, you know, a video system. There’s apps, there’s AI, there’s minivans full of lab equipment … there are other innovations that expand the capability of a remote patient visit.

Here’s another point to ponder that Dr. Thierman and I explore a little bit. What is the impact of telehealth in a value-based care environment but also in an FFS (fee-for-service) reimbursement model? It’s likely, if you think about it, there will be more patient visits because the barrier to getting care has diminished. And that might be a good thing if we’re talking about chronic care, if we’re talking about ensuring follow-up after a surgical procedure. There’s any number of examples where patients getting help prior to some sort of acute event would be considered a good thing by most. But does improving access to care increase a patient’s chances of getting inappropriate care? You know, 25+% of care is some variation of waste, fraud, and abuse; and additional services rendered always have the risk of negative consequences. Or do we figure that bad actors are doing a pretty good job behaving badly anyway, so the net positive for the rest of us is worth it?

You can learn more at lifebridgehealth.org. You can also follow Dr. Thierman on Twitter at @techie_doc or connect with him on LinkedIn. 

Jonathan Thierman, MD, PhD, is physician executive in the LifeBridge Health system and president of the medical staff at Northwest Hospital. He started his career as an engineer and inventor, earning his PhD at MIT and then training in emergency medicine at Harvard Medical School and Johns Hopkins Hospital. In the past, he has worked to bring real-world clinical experience to the engineering and design of medical devices.

Currently, he is the chief medical information officer for the LifeBridge Health system in Baltimore, where he leads a team of physician informaticists to interface between the 180+-person IT department and the 3000+ affiliated physicians across five hospitals and in community practices on matters of the EMR, CPOE, and other health IT systems.

Dr. Thierman is passionate about applying technology to improve health and outcomes. To this end, he helped to establish the LifeBridge Health Virtual Hospital, with affiliated clinical call centers in Jerusalem and the Philippines, to provide telemedicine services across the continuum. He also created the LifeBridge Techbar to offer in-person IS assistance to LifeBridge providers. In addition, he developed a patient “Digital Front Door” to help direct patients to the right care center with the least wait time, improving patient experience and load-balancing the emergency departments and urgent care centers in the LifeBridge Health system.

03:26 What was happening with telehealth pre-COVID-19.
04:50 What’s happened to telehealth and primary care practices post-COVID-19.
06:28 How quickly telehealth medicine appointments are growing.
07:30 What percentage of patients are doctors able to see via telemedicine?
08:24 Are patients getting adequately cared for?
10:20 “The vast majority of medicine, except for surgical services, really is a mental game.”
14:15 “If you have a window into the home, you probably have a better view of the social determinants of health.”
14:25 How AI plays into telemedicine right now.
16:52 Where telehealth visits will land after the pandemic.
18:40 “When you improve access, you also improve demand.”
19:22 Is telehealth consumer driven?
20:48 “For the most part, patients are most connected to their actual physician.”
21:37 Why more frequent touch points via telehealth will benefit health care quality and costs in the future.
28:20 “It’s about the patient, and it’s about really keeping them well.”

You can learn more at lifebridgehealth.org. You can also follow Dr. Thierman on Twitter at @techie_doc or connect with him on LinkedIn. 

Check out our #healthcarepodcast with @techie_doc as he discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19

What was happening with telehealth pre-COVID-19? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

What’s happened to telehealth and #primarycare practices post-COVID-19? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

How quickly is #telemedicine growing right now? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

How many patients can a doctor see via #telemedicine? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

Are patients receiving adequate care from #telemedicine? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

“The vast majority of medicine, except for surgical services, really is a mental game.” @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

“If you have a window into the home, you probably have a better view of the social determinants of health.” @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

How is #AI playing into #telemedicine? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

Where will #telemedicine visits land after the pandemic is over? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

“When you improve access, you also improve demand.” @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

Is #telemedicine consumer driven? @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

“For the most part, patients are most connected to their actual physician.” @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

“It’s about the patient, and it’s about really keeping them well.” @techie_doc discusses #telehealth post-#pandemic. #healthcare #podcast #digitalhealth #coronavirus #covid19 #healthcarepodcast

For the past few shows and in a few coming up, we are circling our wagons around a theme: In healthcare in this country, there are two teams. One team is employers, taxpayers, patients … those trying to keep healthcare prices down. Then on the other team, we have those looking for healthcare prices to continue to go up, meaning, as just one example, some health systems and some hospitals.

There was a New York Times article recently, and Peter Hayes wrote an interesting comment about it on LinkedIn. He wrote:

“This article is troubling on so many levels and clearly demonstrates that patient health and well-being are not the top priority of many in healthcare leadership in our hospitals. Unfortunately, it is much more about patient revenue than patient health. … The non-profit status of our health facilities is a huge hidden tax and wealth transference from every taxpayer that is estimated to be about $39 billion annually.”

Look, for sure, not talking about everybody in healthcare leadership here, and increasingly I’m kinda thinking we need to maybe have more than one word for hospitals and their leadership because lumping them all together into a homogenous blob is really unfair to those rural and safety net organizations contending with all kinds of adversities—which is very, very different in circumstance to those so-called “well-resourced” hospital chains in suburban markets really raking in the cash and virtue signaling in very well-resourced press campaigns.

And the irony of this whole thing is that a reason hospitals (that want to) get away with doubling down on profit-centric business models is actually their nonprofit status.

This is a major loophole. If you are a nonprofit, you get to be excluded from some of the powers of the FTC (Federal Trade Commission), for example. But then there’s also the lack of financial discipline, as Mike Thompson puts it in the show today.

These nonprofit organizations have never had to run efficiently. They have never been asked to justify the new building or the other adds to their infrastructure that ultimately increase their costs of doing business in ways that, on the whole, might not benefit patient care.

And I say “might not benefit patient care” fairly confidently because there is absolutely no correlation between high prices and high quality in healthcare. In fact, it can just as easily be the opposite.

But if you overbuild and you buy too many MRI machines or whatever, then you gotta feed the beast. And then the downward spiral starts, and the anticompetitive, financially toxic behavior really kicks into high gear—which, again, is tough to regulate because our laws and legislation expect nonprofits to, you know, behave like nonprofits.

In this healthcare podcast, I am thrilled to speak with Mike Thompson, who is the CEO and president of the National Alliance of Healthcare Purchasers. Interestingly, Mike is an actuary by background; and I am sure that that has come in handy as more and more data is becoming available for purchasers and also regulators.

The National Alliance has created a playbook to help employers get a fair price from hospitals.

In short, the playbook’s five strategies to do so include (1) looking up what the fair commercial price is for your local hospital, which is really easy to see if you go to dashboard.sagetransparency.com. This Sage Transparency dashboard was created by the Employers’ Forum of Indiana. Not to drown you in acronyms, but the Sage Transparency dashboard very elegantly combines RAND data showing what hospitals are actually charging employer plans and compares that to what’s called the NASHP commercial break-even price. NASHP is the National Academy for State Health Policy, who crunched a lot of numbers to figure out this commercial break-even price.

Once you know the fair commercial price for hospitals in your area, then one way to go could be (2) using an RBP (reference-based pricing) strategy and paying based on the fair commercial price plus a markup.

Another strategy is to (3) start monitoring your ASO/TPA (administrative services organization/third-party administrator) carefully and see that they are paying this fair price and getting performance guarantees to hold them accountable to do so.

Yet another strategy is to (4) gang up with other employers in coalitions, which is often necessary, given how much market power some of these hospitals have consolidated and all the anticompetitive practices they’ve managed to tuck into their FTC-exempt quiver.

And last is to (5) regulate through legislation.

One point that Mike makes very clear is that if nonprofit hospitals cannot remain true to their mission and if they are also not subject to market dynamics, that’s a lose-lose for their communities. At that point, a very viable option is to regulate them like utilities. This is also what I talk about next week with Chris Skisak and Gloria Sachdev.

The sad part about this whole thing is that hospitals and communities really should be sitting on the same side of the table working together to improve the health and well-being of their communities. And that should include—according to me, at least—keeping financial toxicity in check, especially just given everything we know for sure about how financial toxicity negatively impacts patient health.

Oh, hey, here’s a thing: Turns out I had a fever when I recorded this show, so yeah, Mike deserves a little extra kudos for very eloquently just going with it when occasionally my questions sort of ended without, you know, actually asking a question.

Michael Thompson is the president and CEO of the National Alliance of Healthcare Purchaser Coalitions (National Alliance), the only nonprofit, purchaser-led organization with a national and regional structure dedicated to driving health and healthcare value across the country.

Prior to joining the National Alliance, Mike was a Principal at PricewaterhouseCoopers (PwC) for 20 years. He is a nationally recognized thought leader for business health strategies and health system reform. Mike has worked with major employers and other stakeholders on sustainable cost reduction, integrated health, wellness and consumerism, retiree health, private health exchanges, and health reform. Known for developing and promoting collaborative cross-sector health industry initiatives, Mike participated on the steering board of the World Economic Forum’s “Working toward Wellness” initiative and co-founded the Private Exchange Evaluation Collaborative. Prior to PwC, Mike served as an executive with diverse roles with Prudential Healthcare for over 17 years.

Mike is a Fellow of the Society of Actuaries, serving on the Health Practice Council, and chairs the Medicare Sub-Committee of the American Academy of Actuaries. He is board president of the Innovation and Value Initiative. He is also widely recognized as a leading national advocate for mental health and well-being and was past president of the New York City chapter of the National Alliance for Mental Illness.

05:37 Check EP372 with Cora Opsahl; EP358 with Wayne Jenkins, MD; EP388 with Merrill Goozner; and EP346 with Peter Hayes for a deep dive.

05:48 Why should an employer health plan be concerned about how much area hospitals are spending?

07:01 How are hospitals quantifying their prices?

08:10 “I think we’re not paying a fair price is the end game.”

10:45 How do we bring rigor back into the market?

11:12 What is NASHP?

15:10 What does the NASHP commercial breakeven take into account?

18:24 Why are hospitals conflicted when it comes to building a health system based on value and health?

20:17 Why is the onus on hospitals to defend the way they’ve spent the money they have?

21:58 “Where there are market dynamics, we typically see prices in that fair price range.”

25:06 What can employers do from a market standpoint, a program design point, and a policy standpoint?

27:11 What is the National Alliance of Healthcare Purchaser Coalitions playbook?

30:15 Why is changing the dynamics in the press important to changing hospital pricing?

33:02 How fundamental is the employer’s role in making sure that they’re paying a fair price for the healthcare services their employees are receiving?

@IWLMikeT of @ntlalliancehlth discusses #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #hospitals #healthcarepricing

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371)

Laura Adams is the President and CEO of the Rhode Island Quality Institute (RIQI), a center of collaborative innovation that advances health and healthcare transformation. RIQI is the only organization in the nation to win all three of the major HITECH health IT grants which funded CurrentCare (the statewide health information exchange), the RI Regional Extension Center and the RI Beacon Community, bringing in $27M in funding.

She was recently appointed to the Governor’s Workgroup on Healthcare Innovation.Laura served on the ONC’s HIT Policy Committee’s Governance Panel for the Nationwide Health Information Network. She is a member of the Health Information Management and Systems Society (HIMSS) Center for Patient and Family Centered Care Advisory Group and chaired the Institute of Medicine’s (IOM) Planning Committee for the “Digital Infrastructure for Population Health and a Learning Healthcare System” workshop series.Laura led the governance consulting for the Improving Performance in Practice (IPIP) Initiative, a RWJF-funded collaboration among the American Board of Medical Specialties, and the Boards and Societies of Internal Medicine, Family Physicians and Pediatrics. She traveled in the U.S. and Europe with W. Edwards Deming in the study of statistical-based quality improvement.

She was Founder, President and CEO of Decision Support Systems, a New York-based company specializing in Internet-based healthcare decision support.Laura has been a faculty member of the Institute for Healthcare Improvement (IHI) in Boston since its inception. She directed the IHI Idealized Design of the Intensive Care Unit project and served as faculty in the VHA’s ICU improvement collaborative. She was among the first to bring the principles of healthcare QI to the Middle East, in conjunction with Donald Berwick, MD and the Harvard Institute for Social and Economic Policy in the Middle East. She served as IHI faculty at the inaugural IHI Middle East Forum on Quality Improvement in Healthcare in Doha, Qatar in 2013.

You can find out more at www.RIQI.org or by emailing Laura directly at LAdams@RIQI.org.

In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJUnion. 

The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating health care complexities.

To Read the full article which includes mentioned links visit the episode page.

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Real-world examples underscore the financial impacts of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services. The episode aims to empower employers with tools and insights to negotiate effectively and ensure their health plan contracts align with their strategic goals, ultimately paving the way for better population health management and cost-effective care delivery.

As but one example—and Cora Opshal spoke about this last week and Claire talked about this today—it’s about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent around $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200 on behalf of the plan sponsor.

So now the plan sponsor is paying $200 for a $100 bill. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor?

So it's understandable why the team at 32BJ pushed back and pushed back hard. We all can see why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today.

For an open-source contract and some other free tools, please do head over to the 32BJ Insights Web site.

05:36 How does the initial contract writing affect how events in your healthcare plan will go?

06:56 What happens if a plan sponsor or employer doesn’t do the contracting right?

10:42 How much could be saved by doing contracting right?

11:01 EP433 with Justin Leader.

12:22 How do you start an RFP process with your own contract?

14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that’s best for you.

19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract?

21:11 Open-source contract available from 32BJ.

21:57 Why it’s important to really probe brokers, despite loyalty to your broker/consultant.

24:30 Who are the reliable agents and experts when carriers are looking to start this process?

26:24 EP428 with Julie Selesnick.

27:56 What’s the silver lining to this effort?

29:17 Why is it important to make it clear why you’re doing what you’re doing for your lawyers and any other support team you need?

31:39 What does “good” look like in this process?

34:15 Why is it important to continue to hold your ASO accountable?

Medicare Advantage (MA), otherwise known as the “money machine,” is often the most profitable parts of many payers’ business lines. Medicare Advantage plans can make a lot of cash if they are good at what they do. Look at any of these large, consolidated carriers’ financial statements to get the magnitude of that statement.

Also, in 2022, Medicare Advantage plans have enrolled 28 million participants between them, which represents 45% of all Medicare beneficiaries. This marks a three-point improvement in penetration over 2021 and a total program enrollment growth of 9%.  

All of this is not a secret.

So, what’s happening right now is that this administration is looking carefully at Medicare Advantage plans and what they have been up to. We have had an amping up of government oversight, including regulatory actions and program audits.

In this healthcare podcast, I am speaking with Betsy Seals, who is CEO and cofounder of Rebellis Group, which is a managed care consulting firm working with Medicare Advantage plans.

Betsy says (and this is what we talk about in the interview) that there’s three main areas that the government is currently scrutinizing:

1. Sales and marketing. There have been these third parties, it seems, these field marketing organizations who were hired to do marketing and sales for some of the Medicare Advantage plans. And because they were third parties, it seems that many of them felt themselves to be excluded from CMS (Centers for Medicare & Medicaid Services) regulations and able to basically mislead prospective members with sales pitches that were highly suspect. Betsy gives some examples of these, and when you hear them, you will see why CMS is cracking down.
2. Recouping improper payments is another area that CMS is all over. Interestingly, as Betsy Seals says in this interview, this might be one area where the government is actually ahead of private sector plans from a technology and analytic standpoint.

CMS seems to have better analytics capabilities and is better at detecting fraud schemes and improper payments than the plans themselves. These plans are not sophisticated enough to notice stuff that CMS detects when it gets ahold of the plan data.

But as unusual as this situation is where the government is ahead of the business sector, I can’t say I’m shocked. We have had one guest on this show after another talking about just how far in the past some of these health plans are lagging. Dan O’Neill probably said it most eloquently and notably (EP359).  

But I digress.

So, recouping improper payments has the eye of CMS. This means two things largely. It means finding “outlier” codes that some MA plan paid for but which are clearly errors and should not have been paid.

Another improper payment is when plans themselves do a little fancy upcoding so that they make more money than they should in their risk-adjustment payments. This has gotten some major attention lately. Let me quote from an OIG (Office of Inspector General) report:  

“Our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs [health risk assessments] to maximize risk-adjusted payments. We found that 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.”

The sneaky idea here to get more money than they should from taxpayers is that someone somewhere puts down that a member has major depressive disease because someone somewhere said they did. But the patient clearly doesn’t have major depressive disease because they aren’t getting any treatment for it and nothing anywhere would indicate that they are suffering from a major depressive disease.

So, the plan winds up getting more money from the government to care for a patient who is suffering from major depressive disease, but the patient doesn’t require any additional care because they don’t have major depressive disease. It’s a great way to make some dollars for shareholders that is coming right out of the pockets of taxpayers.

In sum, the #2 area of additional oversight is recouping improper payments either from paying claims that should not have been paid for or by wild upcoding.

3. This is just kinda like the general sort of compliance oversight that CMS does, meaning grievances and appeals and formulary administration and models of care for SNP plans (special needs plans), compliance program effectiveness—normal stuff like this—which will be interesting given all of the articles coming out right now about how patients on Medicare Advantage plans are less likely to get more costly diabetes treatments and how often there’s denials for cancer care or NCI cancer centers aren’t covered, etc.

One point of note here that’s kind of thought-provoking on a few levels: If you’re an MA plan, it is super important for you to get members in for their annual screenings. For one, CMS requires that you document diagnoses each year; and you need to do this to reduce the chances that CMS will question a treatment being paid for because there’s no underlying diagnosis to support it—and these diagnoses must be re-upped every year. Recall what I was just talking about re: improper payments and fraud schemes. If a patient isn’t diagnosed with something, then why are taxpayers paying for its treatment?

Also risk adjustment ... if you wanna upcode, it’s not a bad idea to have a diagnosis documented in multiple different ways so that when the OIG/CMS/DOJ comes knocking, you can have your ducks in a row. Getting patients in for their annual screenings is how you can safely upcode.

Further, one more reason why getting patients in for annual screenings matters to MA plans, member experience counts for an increasing piece of star ratings. Patients who never see their doctor and never interact with the plan don’t usually give the plan they have nothing to do with stellar marks—and besides that, these members are tough to retain.

Last big deal for an MA plan to get members in for their annual is this is when the doc gets into screening for care gaps, which is also part of star measures. All this about annual screenings is a bit of a sidebar, but it is kind of interesting to contemplate as we get into the conversation today about government oversight. (For a meme on this topic, check out this Tweet from Rik Renard.)

My guest, as I mentioned earlier, is Betsy Seals. Listen to our conversation about how MA plans are in the hot seat right now. Later in the fall, Betsy will be coming back to talk about trends in the Medicare Advantage marketplace.

You can learn more at rebellisgroup.com.  

Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience.

Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy’s expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations.

Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations.

Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs.

Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits.

08:15 What’s happening with sales and marketing in the healthcare industry?
11:04 What’s happening with the focus on recouping improper payments?
13:32 “When you look at the fundamentals of it, these are federal dollars. And what we’re talking about is federal dollars that were paid when they should not have been paid.”
15:39 Are improper claim payments an administrative problem, or something more intentional?
16:20 “The health plan has a responsibility to catch those issues.”
20:10 What are specialty pharmacy prescriptions being scrutinized for?
22:12 “If this is where CMS is headed … the health plan should’ve already been doing this.”
23:58 Why do you see a bigger focus on social determinants of health?
25:54 Do these health plan audits actually have any teeth?
27:01 What is the biggest penalty a health plan can face from an audit?
29:57 “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.”

You can learn more at rebellisgroup.com.  

@betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What’s happening with sales and marketing in the healthcare industry? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What’s happening with the focus on recouping improper payments? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“When you look at the fundamentals of it, these are federal dollars. And what we’re talking about is federal dollars that were paid when they should not have been paid.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Are improper claim payments an administrative problem, or something more intentional? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“The health plan has a responsibility to catch those issues.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What are specialty pharmacy prescriptions being scrutinized for? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“If this is where CMS is headed … the health plan should’ve already been doing this.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Why do you see a bigger focus on social determinants of health? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Do these health plan audits actually have any teeth? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What is the biggest penalty a health plan can face from an audit? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento

Now, I’m being pretty careful here because med schools are super sensitive about their curriculums. And I am sensitive to the fact there’s much to teach in four years. So, throwing no shade here, what do I know from the Krebs cycle? Choices of what to teach are tough. With that disclaimer, in this healthcare podcast I am speaking with Adam Brown MD, MBA, about an article he wrote entitled “Dear Medical Schools, Educate Students on the Business of Medicine—Without it, you are doing your students a disservice.”

Let me give you Dr. Brown’s list for the “why teach the business of medicine.” He says:

1. The role of physicians in medicine has changed, and we dig into this in the episode.

2. There’s an expectation mismatch. Docs are investing 10 years and, on average, $200K to $300K in real dollars to get that MD or DO. You don’t want those new physicians quitting on the quick because the reality is so different from what they thought it would be. Not being up front about the business of medicine is like hiding the reality of the situation instead of preparing them.

3. If you don’t understand the business of medicine, you do not know how to advocate for yourself or the profession or even patients in a way that is compelling to the current set of decision-makers.

As maybe a corroboration here, may I just report that I probably have gotten (conservatively) 100, 150 emails and LinkedIn notes from physicians who say basically some version of the same thing: Thanks so much for Relentless Health Value. I wish I would have learned even the basics of what you cover in med school. If I had, I would have been able to help myself and help myself help patients far better.

4. Docs are the ones with the prescription pads. Docs are just functionally the gang who are driving costs that patients and employers and taxpayers ultimately incur. Not knowing the how much or just the whole story here can inadvertently contribute to clinical morbidity, because patients who fear they cannot afford care do not follow doctors’ orders. We should get real about that. Or if they do follow doctors’ orders and go into debt … I mean, there’s just study after study in oncology and otherwise that shows patients who cannot afford their care have worse outcomes. We cannot hide from this any longer.

5. The last reason is that there’s lots of things that docs can do besides just be at the bedside. Not giving insight into these alternative paths seems unfortunate for any doc who maybe wants to mix it up some because they’re feeling burned out or in a different season of their life looking for something more aligned with where they are as a person.

So, now let’s think about this whole question from the standpoint of the system itself—from the standpoint of doing better by patients. Why is it important to teach docs the business of medicine? Let’s start here.

When physicians do not understand the business of medicine, it’s harder for docs to get into boardrooms and have their voices heard. Not teaching the business of medicine in med school might be one reason why there is such a shockingly small percentage of doctors on the boards of directors at major nonprofit hospitals (listen to the show with Suhas Gondi, MD, MBA [EP404]) and why there’s so little “dyad leadership” in the ranks of both clinical and payer organizations, etc. And even fewer nurses are in organizational decision-making roles, by the way, despite nurses actually being the most trusted profession—even more trusted than doctors by 14 percentage points, according to Gallup.

One way to interpret this lack of docs and other clinicians in the boardroom is simple cause and effect. Doctors are losing control and ownership—and I mean this in literal terms—of the organizations that run the business of medicine, which controls the medicine of medicine.

Chad Erickson wrote a comment about this on LinkedIn that I thought was great. He wrote, “Opportunities for physicians to really control or even impact the 86% of healthcare outside of their practice are being reduced every year. We expect doctors to make the decisions and be accountable for patients and outcomes, yet we are taking away their ability to do so.”

And going one level deeper here on how not having enough docs in admin roles becomes a snowball rolling downhill kind of downward spiral, I’m gonna quote Jeremy Granger, MD, FAAP. He wrote, “When you are a physician administrator, it can be very strange. There is tremendous pressure from administrators to think and act like one of them and give insight into how to best coerce physician behavior to align with administrator-determined goals without necessarily involving the physician with setting those goals. When you advocate instead with your physician hat, you can find yourself ostracized from that administrator clique. You realize that they view physicians as knaves and you as the Judas goat. You either pick a side or, if you’re lucky, you land with a team that has physician leaders equipped with equal power as administrators.”

So, you see what happens. Doc gets an admin role and either chucks their stethoscope and their patient-first mindset out the window to fit in, or they quit. And then we never get to any sort of critical mass of clinicians in leadership roles that would reset the organizational ethos.

So, here we are. Too few mission-driven and business-savvy docs in boardrooms mean patients get the kind of care they’re currently getting and at the prices we’re all currently paying. From the standpoint of doing better by patients, I hear story after story about some doc who was under the impression that, I don’t know, working with a private equity firm to do a roll-up of all the specialty practices in a local market was pretty cool and a totally victimless strategy. Or the surprisingly high number of docs prescribing drugs on that most wasteful spending list. There’s one on that list, for example, that costs taxpayers or an employer $2000 when that drug consists of basically two $15 over-the-counter meds mashed together—and yet there’s the impression that the $2000 drug is a better financial choice because there’s a co-pay card and the patient out of pocket might conceivably be less … until it isn’t, of course, because it’s not like that additional $1970 in cost suddenly becomes free.

Or what happens when a clinician is told to order largely unnecessary MRIs because workers’ comp covers everything and no one cares—so this kind of thing continues to just happen … all this stuff. It takes a broader understanding to get the why and create the intrinsic motivation and necessary insight and right language and arguments to make things better.

But all of this is about patients. If I’m talking to margin-driven people sitting around the conference room table with their calculators, are there any organizational consequences, meaning financial consequences, to not making sure doctors understand business and have a seat at the table? Here’s two (there’s probably more):

1. Staff turnover. If that’s a concern for any organization now, and if moral injury is cited as a reason for that turnover (which it often is), moral injury doesn’t happen when organizational demands are aligned with clinician values.

2. Successful value-based care isn’t gonna happen if docs don’t understand the business of medicine. Listen to the show with Eric Gallagher (EP405) or the one with Amy Scanlan, MD (EP402) or Larry Bauer (EP409). There’s like 10 guests who essentially say the same thing. Docs who are in the dark about how the world actually works IRL cannot be an aligned force helping move past the FFS (fee-for-service) status quo and the whole business model that underpins that.

Adam Brown, MD, MBA, my guest today, is a practicing emergency physician, board-certified ER doc. He recently founded ABIG Health, working with healthcare companies on communication strategies and advising investment firms. He’s also a professor of practice at the University of North Carolina, Chapel Hill.

Mentioned in this episode is a Tweet by Brendan Keeler. Also, Dr. Denver Sallee’s very inspirational predictive scheduling work.

I’ll leave the last word on this to Michael R. O’Brien, MD: “You don’t overcome the corrupting influence of money in medicine by ignoring its existence. … To slay the dollar-eyed dragon, we must be able to see like the dollar-eyed dragon.”

You can learn more at ABIG Health and by reading Dr. Brown’s bimonthly column.

Adam Brown, MD, MBA, is a board-certified emergency physician, entrepreneur, and accomplished healthcare executive whose professional journey traverses clinical practice to strategic leadership.

Having risen through the ranks at Envision Healthcare, Dr. Brown’s tenure there culminated in his role as president of emergency medicine, where he spearheaded the COVID-19 response and clinical communications. His impactful leadership led to his appointment as chief impact officer in 2021.

In 2022, Dr. Brown left Envision and established ABIG Health, a healthcare strategic advisory firm. Additionally, he took on the mantle of professor at the University of North Carolina, Chapel Hill, Kenan-Flagler School of Business (his alma mater), teaching healthcare operations and strategy to MBA students. He is the advisory board co-chair at the Center for the Business of Health and on the business school Board of Advisors.

A frequent media presence, Dr. Brown has been featured on CBS, Yahoo Finance, BBC, and local Washington, DC, outlets, speaking on various healthcare issues. His column, “Prescriptions for a Broken System” in MedPage Today, showcases his commitment to meaningful change in healthcare.

His passion for empowering informed health decisions shines through his roles as a communicator, leader, and strategist. A recognized thought leader, his ability to connect, envision, and lead underscores his impact on shaping healthcare.

08:49 What does it mean to teach the business of medicine?

11:04 The four Ps that are key within the business of medicine.

13:27 Why is it important for doctors to understand the business of medicine?

21:46 “Things don’t happen without a physician’s signature.”

27:27 Why physicians who understand the business side of medicine can broaden the view of outcomes for the business decision-makers.

28:30 Why is it important to make sure physicians are in the boardroom?

29:36 EP404 with Suhas Gondi, MD, MBA.

30:52 “We are getting what we designed.”

33:37 Dr. Brown’s advice for clinicians in the boardroom.

38:21 The work of Denver Sallee, MD, MMM, using artificial intelligence to do predictive scheduling.

You can learn more at ABIG Health and by reading Dr. Brown’s bimonthly column.

@ERDocBrown discusses teaching the business of #medicine on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #healthcare

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Rob Andrews, Justina Lehman, Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5)

My guest in this healthcare podcast is Nikhil Krishnan, who is the founder of the Out-Of-Pocket newsletter. I was talking with Nikhil, and we identified—or, more accurately, he identified—five business models of digital health. What makes each model distinct is a few factors. If you weren’t in the healthcare industry, you’d probably expect that I’m going to say that the biggest factor a business model must hinge on must have something to do with patient outcomes or care or something that has something to do with the hopes and lives of patients. Except no. Mostly, our models do not define themselves by attributes of their patients, except on one dimension: who is paying their bills.

Who is paying has enormous downstream consequences that I don’t think people outside of healthcare, or even people inside of healthcare, sometimes really appreciate. It’s because of all of the perverse incentives. It’s a tangled web we weave.

For example, let’s just say you’re a start-up founder trying to cook up your unique selling proposition. You can’t just decide you’re gonna lower costs and improve patient care as general constructs. Because let’s just say you do that—that’s your USP (lower costs and improve patient care)—and then you try to sell your thing to Medicare Advantage plans or large provider organizations.

Oh, right … Medicare Advantage plans or even commercial ones—they don’t care about the total cost of care. Neither do provider organizations unless they take on sufficient risk to care, and many do not.

In fact, as came out in that JAMA article the other day, it could be construed that entities such as these carrier health plans have a perverse incentive to see total costs of care go up. So right, you naively (you’re the start-up founder again in this case study, don’t forget) trot into some administrator’s office with a great something or other to reduce total costs of care—and you’ll get cast out upon your petard on the quick. 

Every single day of the year in my world, I see people make this same mistake over and over again: not tailoring their product market fit to any particular market, with the recognition that some in this healthcare industry have a vested interest to see costs going up and some have a vested interest in costs going down. Either way, if we’re talking about large organizations here and even some small ones, the money wins over patient care. So sad to have to say that, but listen to EP351 with Dr. Eric Bricker and you’ll get all the context you need on that point.  

Here’s the thing, though. I don’t know about you, but I can’t tell you how many digital health start-ups I run across where I look at their decks or have a conversation with a founder, and I ask who their customer is. Is it employers or health plans or … ? And they don’t know. They’re gonna figure this out later. I don’t get how to successfully do that. I’m indubitably wrong here given all of the pivots I hear about that seem to go OK, but the prospect of completely redefining my operational goals and operations and market positioning at some point in the future seems like a daunting and avoidable prospect.

I would be remiss not to mention, however, the number of really good mission-driven healthcare companies out there really trying hard to figure out how to create a sustainable business, a fair profit, while at the same time serving patients really well. There are companies adding value commensurate with the dollars that they come by, and I certainly applaud everything that they are doing.

At the same time, given all this, here’s a message for all of you VCs and private equity etc—people with money—out there. Let me quote Dr. Vivek Garg here (@vgargMD on Twitter): “If you’re financing care delivery without board-level focus on clinical outcomes, you’re part of the problem.”  

So, let’s talk about these five business models that health and healthcare start-ups eventually settle themselves into after they figure out who their customer is. Nikhil Krishnan, my guest today, and I discuss how they can be financially viable and if we think they’ll actually be able to provide superior patient outcomes.

[Trumpets play here] In no particular order, this is what we’ve got for our five business models:

1. Completely avoiding incumbents, creating a cash-pay ecosystem
2. Better middleware (being the pipes, as I’ve heard so many times these past couple of weeks)
3. Companies serving incumbents either by being a virtual front door for them or disrupting the competitive landscape somehow
4. Joint ventures
5. Old-school digital health who are now incumbents in their own space

My guest in this episode, Nikhil Krishnan, has a bunch of things going on. He might be best known for his newsletter, Out-Of-Pocket Health, which you should certainly subscribe to. He’s also working on a healthcare 101 crash course to teach newcomers about the Wild West we call American healthcare. Besides all of this, Nikhil does some early-stage investing. 

You can learn more at outofpocket.health and with Nikhil’s upcoming course. 

Nikhil Krishnan is the founder/thinkboi at Out-Of-Pocket, where he’s trying to make the business of healthcare more easily understandable and (hopefully) entertaining. He runs a newsletter (yes, yet another one) and an online healthcare community and does some digital health investing on the side. He’s “extremely online,” and you can find him firing off obscure healthcare memes plus the occasional insight on Twitter at @nikillinit.  

05:31 What are the different models of digital health?
07:17 What are the different motives for cash-pay digital health models?
13:08 “One of healthcare’s original sins is that every solution deployed has been a custom solution for the end user.”
13:31 How willing will these companies be to share their data with third parties?
17:20 “I don’t think selling tech to large incumbents is going to move the needle.”
20:27 “These companies, most of them are actually getting extra money for the more expensive stuff.”
22:11 How did joint-venture digital health business models come about?
25:50 Why do you see partnerships more on the payer/provider side?
26:41 Who are the old-school digital health companies that could be considered incumbents?
28:48 Why do so many digital health start-ups have a hard time pinpointing who will pay for their services?
31:22 “The ability to go through the idea maze is way faster now.”
34:08 “The field is wide open to help teach people how healthcare works.”

You can learn more at outofpocket.health and with Nikhil’s upcoming course. 

@nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

What are the different models of digital health? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

What are the different motives for cash pay digital health models? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

“One of healthcare’s original sins is that every solution deployed has been a custom solution for the end user.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

How willing will these companies be to share their data with third parties? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

“I don’t think selling tech to large incumbents is going to move the needle.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

“These companies, most of them are actually getting extra money for the more expensive stuff.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

How did joint-venture digital health business models come about? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

Why do you see partnerships more on the payer/provider side? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

Who are the old-school digital health companies that could be considered incumbents? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

Why do so many digital health start-ups have a hard time pinpointing who will pay for their services? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

“The ability to go through the idea maze is way faster now.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

“The field is wide open to help teach people how healthcare works.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai

Adam Sharp, MD is a founder at par8o and serves as president and chief medical officer. Adam oversees the development of par8o’s product offerings, ensuring that the clinical usability and ultimate value to the care delivery process are at the forefront of par8o’s development processes. Prior to launching par8o, Adam was a founding team member of SERMO, Inc., where he also served as the chief medical officer and focused on all aspects of the SERMO physician membership experience. In that role, Adam created positive peer-to-peer interactions and ensured that all physician-client engagements were mutually beneficial and rewarding.

Adam earned a Bachelor of Science in biology from Indiana University, completed medical school at Tel Aviv University and trained in emergency medicine at the Medical College of Wisconsin. Adam is board certified by the American Board of Emergency Medicine.

For more information, check out www.par8o.com.

Practical Steps for Plan Sponsors Post-J&J and DOL vs. BCBS Lawsuits

In Episode 428 titled 'Do It Now Advice From the J&J and the DOL versus BCBS lawsuits,' host Stacey Richter discusses the implications of two major legal cases on plan sponsors with guest Julie Selesnick, an attorney specializing in fiduciary responsibilities. The episode covers essential actions for plan sponsors, brokers, and employee benefit consultants to avoid conflicts of interest and ensure fiduciary compliance. Selesnick, a senior counsel at Berger Montague's Employee Benefits and ERISA Group, emphasizes the importance of obtaining and effectively using claims data, renegotiating administrative services agreements, and conducting independent claims reviews. The discussion also highlights practical strategies like carving out certain high-cost services and establishing a health and welfare fiduciary committee.

To read the full article and show notes with links mentioned as well as a full transcript, click here.

Love the show? Please consider signing up for our weekly newsletter. We'll send you an article covering the latest episode with show notes, mentioned links and a transcribed intro. Join the RHV Tribe.

05:48 What’s happening with the J&J lawsuit?

07:38 What’s going on with the DOL v BCBS case?

08:49 What do these cases mean for plan sponsors?

09:21 Why is engaging with claims data critical?

12:30 EP408 with Chris Deacon.

14:20 EP379 with AJ Loiacono.

16:58 What’s one solution to avoiding a conflict of interest?

18:02 Why there’s still not a total understanding about what to do with claims data once acquired.

20:58 NADAC (National Average Drug Acquisition Cost) to check pharmacy prices.

21:31 What advice do plan sponsors need to know that never gets recommended to them when dealing with conflicting interests?

27:02 EP337 with Olivia Webb.

28:41 EP285 with Dawn Cornelis.

30:24 “As a fiduciary, your money should only go to pay your plan’s benefits, not to other plan benefits.”

30:59 What’s Julie’s advice to advisors?

33:17 “Giving nonconflicted advice … is something you really can only do if you have no conflicts.”

35:57 What’s Julie’s advice for administering whole plans?

An experienced entrepreneur, Jacqueline has over 15 years of experience in software and health IT, in roles ranging from sales and marketing to system design and project management. Prior to founding Klio Health, Jacqueline was an early member of CRF Health, one of the leading providers of electronic patient diary systems for the clinical trials industry. In her career at CRF Health, she managed the implementation of patient data capture systems in over 50 Phase II and III clinical trials for global pharmaceutical companies across a variety of therapeutic areas. She was also previously on the management team of a venture-backed software startup in Helsinki, Finland. Jacqueline holds an MBA from INSEAD.

For more information on Klio Health, connect at:

http://www.kliohealth.com

https://twitter.com/kliohealth

https://vimeo.com/kliohealth

To contact Jacqueline Thong, reach out at:

https://twitter.com/jacthong

http://www.linkedin.com/in/jthong/en

Check out KlioHealth.com for more information.

In this healthcare podcast, we’re gonna zoom out and look at the entire healthcare industry. I am very confident that you know a lot about the healthcare industry and its basic stats. It’s huge. The healthcare industry is approaching the $4 trillion mark, and it employs more people than any other industry in 47 states. Think about that momentarily. More people work in healthcare than in any other industry in every state except for Wisconsin, Indiana, and Nevada.

We could get into (but we won’t) how many of the gigantic, consolidated incumbents in the healthcare industry are either for-profits sporting very happy shareholders or investors. Then, of course, we have our “nonprofits”—especially mega-nonprofit health systems—who enjoy some pretty healthy margins while, at the same time, these health systems in general offer up some fairly embarrassing levels of charity care considering the amount of taxes they deprive their communities of.

You also are probably eminently familiar with various ways that have been cited to transform the industry. So, the usual suspects here are, of course, changing incentives—offering true value-based care contracts, for example—and then the whole creative destruction angle, wherein upstarts come in with far superior products and services, à la the whole Kodak case study or what happened to Sears and Kmart. Maybe this will happen in healthcare. Other ideas to transform the healthcare industry include employers harnessing the latent power that they have in some markets and then, of course, getting rid of middle people, for sure. Or we could go single payer, of course. That’s another suggestion/solution.

Today’s conversation is a rather holistic look at all of this. I dig into this with David Muhlestein, who is chief research and innovation officer at Health Management Association (HMA). And when I say dig in, I mean dig in. David made some very intriguing points that I had not heard before, actually—and I’ve heard a lot in my time, so that’s saying something. I’m gonna tick off a couple of them, but I don’t do them justice. So, you’ll need to listen to David explain them and give context.

First off, what’s the problem with healthcare being a $4 trillion industry in this country—I mean, almost 20% of GDP—and employing more people than any other industry in 47 of our 50 states? There are other big sectors in our economy, after all, that get lots of love. Why is big healthcare “bad” and these other sectors “good” in economic terms when we talk about employment?

That’s one thing I wanted to know. And David made a point that may be self-evident for some but is worth reiterating in all cases. The government pays for roughly half of healthcare, and from a consumer or just American standpoint, it kind of sucks. I mean, I don’t see many Insta selfies of someone rocking their brand-new insurance premium. Dollars going to healthcare or health insurance are not going to consumer goods. And that matters economically as well as retail therapy. For all you econ geeks out there, this industry offers no marginal utility.

Here’s a second interesting point: Just changing incentives might not be enough. Organizations downstream and upstream need to be on board with the spirit and objective of the incentive change. If they are not, then it’s game on for every CFO and their revenue cycle managers to finagle how to find the loophole that enables revenue maximization. Revenue maximization. Period. Revenue. The end.

Which brings me to another interesting point: Boards of directors, CEOs, people with fiduciary responsibility … they need to know thyself and consider their actual customer.

Spoiler alert: 99% of the time, that actual customer is not patients, no matter what is printed in big letters on the front door.

No change can really happen unless those who serve in the upper echelons of these businesses get really real about where their bread is buttered. Organizations are built to serve their customer, after all. So, if a patient isn’t identified as a customer, the organization at its very core is gonna have a lot of difficulty serving the patient.

So, now what? If I want my organization to move forward in a way that is more patient-centric and less financially toxic, say, what to do? Here’s thoughts after chatting with David Muhlestein. Four main steps:

1. As I just said, you gotta get your current state unemotionally understood. For reals, who is the organization built to serve? So, first step is being introspective in the harsh light of day.
2. Consider the timeline of your existential demise. Ha ha, this show is so uplifting. But unless organizations really think out 5 years, 10 years, 25 years and really internalize the existential threat, it’s going to be hard to motivate change. I see this all the time. So do you. Inertia is real. Nobody does anything until they absolutely have to.
   • Sidebar: But if you need an eventual demise to bring up at your next strategy meeting, I just saw a paper come out saying that by 2030, cost-related nonadherence could become a leading cause of death in the United States, surpassing diabetes, influenza, pneumonia, and kidney disease. This is as per a study by the nonprofit West Health Policy Center and Xcenda. Nonadherence … what does that mean? It means the patient is not doing their treatment. They are not going to the doctor or getting medical care or not taking their drugs. Meaning no one is making money off of all of those patients, especially when they’re dead. This is where the rubber meets all of those excess profits everybody is reaping in the short term. I hope that was helpful for anybody trying to motivate change today.  
3. Consider what legacy we want to leave behind. Do we all want to wait until we’re forced to change to do so? Is this the healthcare system we want to leave behind to children and grandchildren? I mean, anybody who’s got a loved one in the hospital with anything complex, fighting for their own patient records, on the phone for hours a day with insurance carriers while care is delayed with possibly devastating consequences, the family having to coordinate care and cross their fingers and pray they don’t get a ridiculous bill for services that may or may not have been rendered and then use retirement savings to pay for them … if anyone is not looking to be a party to all of this, then let’s think about our strategy moving forward and how it will change to meet the future we want to see.
4. On to the evolve and change approaches: How exactly do you think about doing that? According to David Muhlestein, you can repair your current organization or remodel or rebuild.

It sounds daunting, but as Dr. Eric Bricker said on our recent interview together (EP351) and as others have said as well, this is already happening in some regions across the country. There are pockets with real transformation. These changes are on the edges right now, but they’re showing that this can and is possible.  

You can learn more at healthmanagement.com.  

David Muhlestein, PhD, JD, is chief research and innovation officer for Health Management Associates (HMA). He is responsible for the firm’s self-directed research and supports strategic planning and innovation.

David’s research and expertise center on healthcare payment and delivery transformation, understanding healthcare markets, and evaluating how the broader healthcare system is changing. He is a self-identified data nerd and regularly speaks and writes about healthcare system evolution.

David joined HMA via its acquisition of Leavitt Partners in 2021, where he was the chief strategy and chief research officer.

Additionally, David is a visiting policy fellow at the Margolis Center for Health Policy at Duke University, adjunct assistant professor at The Ohio State University College of Public Health, and a visiting fellow at the Accountable Care Learning Collaborative. He previously served as adjunct assistant professor of The Dartmouth Institute (TDI) at the Geisel School of Medicine at Dartmouth College.

David earned his PhD in health services management and policy, JD, MHA, and MS from The Ohio State University and a BA from Brigham Young University.

07:38 Is it an issue for the healthcare industry that it is one of the largest employers in the country?
08:42 “I think that we need to figure out what is an appropriate amount to spend on healthcare and get to that level.”
09:01 How do we not decrease the amount of healthcare we’re receiving while paying less for that healthcare?
10:11 What are the two ways we can look at decreasing healthcare spend?
15:39 “I think that a regional approach may happen.”
16:56 “When somebody takes less, others are going to follow them.”
17:33 Who is really paying in our current healthcare system?
19:47 “Any sort of a model that you start with influences everything else that you do.”
20:09 What’s the common challenge David Muhlestein sees in value-based care systems?
23:21 “There are countless things that you can do to improve the current system today.”
27:25 What are the three options for building up better healthcare?
28:19 David’s advice for healthcare executives.
33:22 “To really lower the total cost of … healthcare, it’s a 30-year process.”

You can learn more at healthmanagement.com.  

@DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Is it an issue for the healthcare industry that it is one of the largest employers in the country? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“I think that we need to figure out what is an appropriate amount to spend on healthcare and get to that level.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How do we not decrease the amount of healthcare we’re receiving while paying less for that healthcare? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What are the two ways we can look at decreasing healthcare spend? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“I think that a regional approach may happen.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“When somebody takes less, others are going to follow them.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Who is really paying in our current healthcare system? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Any sort of a model that you start with influences everything else that you do.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What’s the common challenge David Muhlestein sees in value-based care systems? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“There are countless things that you can do to improve the current system today.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“To really lower the total cost of … healthcare, it’s a 30-year process.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley

I was really vexed the other day when I read on Twitter—First rule of thumb: Stay away from Twitter—but I read on Twitter someone bashing telehealth because, for many older Americans, going to the doctor is the only thing on their social calendar. Ummm, OK. So, we celebrate the idea of paying a cardiologist or a nephrologist or an orthopedic surgeon or some other specialist how much in FFS (fee-for-service) payments to be a paid friend for 7 minutes?

So, we’re going to expect these expensive specialists to provide mental and behavioral health support when they have no particular mental health training, and, at the same time, we’re going to weirdly slam telehealth for not enabling this obviously failing and expensive model to continue. And I’ll tell you how I know it’s failing: We have an epidemic of loneliness in this country. So maybe, instead of this serpentine logic, we should instead actually directly address the epidemic of loneliness. Maybe we should directly address mental health and behavioral health.

Another oddity with this whole telehealth bash is how fast telepsychiatry services are taking off with COVID and how much, in general, people like it. Granted. Not sure about the elderly cohort who want to go see their doctor for the outing aspect of it, but if we’re talking in generalities here, telehealth/telepsychiatry has been a boon for patients able to access behavioral health and mental health services.

In this health care podcast, I speak with Don Fowls, MD. Dr. Fowls is president of Don Fowls and Associates, based in Scottsdale, Arizona. He’s also past president of the Arizona Psychiatric Society. Dr. Fowls talks to us today about the importance of considering behavioral health when committing to value-based payment models or the management of populations. But we bookend the topic by me taking the opportunity to quiz Dr. Fowls on the impact of telehealth on behavioral and mental health. Two big points of emphasis are integrated data and the vitalness of industry stakeholder collaborations.

Just to clarify some terms before we dive in here: Mental health is a subset of behavioral health. If we’re talking about managing populations of patients, managing both is essential. Mental health typically, people say, has to do with substance abuse and people’s thoughts and feelings. Behavioral health, meanwhile, has more to do with the specific actions people take and how they respond in various scenarios. Obviously, both are impacted by social determinants of health in a big way. And, as more and more evidence comes out, it becomes more important to integrate mental and behavioral health services within almost any site of care—or any site of care looking to improve patient outcomes and possibly succeed in a value-based world.

You can learn more on Dr. Fowls’s LinkedIn page.  

Don Fowls, MD, is a nationally known psychiatrist and health care consultant who works with organizations across the country to develop solutions for the many challenges they face today, including integration; value-based reimbursement; managing complex, special populations; and strategic partnerships. Dr. Fowls has helped several national and regional health plans and health systems integrate behavioral and physical health and develop value-based payment models to support this.

Dr. Fowls previously served as chief medical officer and executive vice president of business development for ValueOptions and its parent company FHC Health Systems for 11 years. He also worked at Schaller Anderson Inc. as executive vice president, business development, and president and CEO of its behavioral health subsidiary.

In Arizona, he recently served as chief medical officer for Mercy Maricopa Integrated Care as well as the behavioral health advisor to the Practice Innovation Institute in Phoenix, one of the CMS Transforming Clinical Practice Initiative grant awardees to transform the practices of health care providers. As part of this process, he co-led the Behavioral Health Affinity Group nationally. Dr. Fowls is chairman of the board of Copa Health, an Arizona-based community provider of services for behavioral health and intellectual and developmental disorders.

Dr. Fowls is also past president of the Arizona Psychiatric Society and a fellow in the American Psychiatric Association.

03:27 Is telehealth here to stay?
06:16 “Now there’s coverage in these medical clinics that there never was before.”
07:38 “It’s really trying to align the payment with the outcomes and services provided.”
08:51 What does good look like?
12:06 “It’s getting … plan and provider focused on achieving an outcome.”
16:43 Do you really see outcomes change after implementing value-based payments?
17:40 “What are we really trying to achieve with this population? It’s really four things. And these become … the pillars for outcomes.”
23:29 “Right now, there’s still way too much ‘more is better.’”
24:16 “Well, that’s great, but how did they do when they left? That’s what you really want to know.”
25:43 What are the three major data sets?
27:15 How is the pharmacy going to be impacted in mental and behavioral health moving forward?
28:05 “If you have data and facts behind you, it always helps.”

You can learn more on Dr. Fowls’s LinkedIn page.  

Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

Is telehealth here to stay? Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

“Now there’s coverage in these medical clinics that there never was before.” Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

“It’s really trying to align the payment with the outcomes and services provided.” Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

What does good look like? Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

“It’s getting … plan and provider focused on achieving an outcome.” Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

“Right now, there’s still way too much ‘more is better.’” Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

How is the pharmacy going to be impacted in mental and behavioral health moving forward? Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

“Well, that’s great, but how did they do when they left? That’s what you really want to know.” Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

“If you have data and facts behind you, it always helps.” Don Fowls, MD, discusses #valuebasedpayments in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #behavioralhealth

Rick is CEO of Wellville, a 10-year initiative founded by angel investor Esther Dyson to improve health and financial outcomes in five U.S. communities. In addition to overseeing the national project, Rick leads the Wellville effort in North Hartford, CT, working with Community Solutions and a multi-sector collaborative focused on achieving the Neighborhood Triple Aim: improved population health, wellbeing, and investment. Rick is also founder & CEO of Collective Health, which developed the Health Impact Bond, a pay-for-success financing model that leverages future health care cost savings to generate upfront investment in prevention. Before turning entrepreneur, Rick spent nearly a decade at the health insurer Cigna, where he was Chief Strategy & Marketing Officer for the national employer segment and launched the company’s Communities of Health venture. Prior to that, Rick was a corporate strategist at Ford Credit, Bank One and KPMG. Rick graduated from the University of Massachusetts, Amherst, and lives with his wife and two children in Simsbury, CT.

Websites: Wellville.net, Collectivehealth.net

Twitter: @WayToWellville, @collectivehlth

Facebook: facebook.com/waytowellville

To reach Rick: rick@hiccup.co; LinkedIn: linkedin.com/in/rrbrush

You can find out more at wellville.net or on twitter @waytowellville.

Healthcare costs keep rising, but what’s driving those increases? In this episode, Stacey Richter speaks with Dr. Vivian Ho, a health economist at Rice University and Baylor College of Medicine, to break down the real reasons behind skyrocketing commercial insurance premiums.

• Are insurance premiums rising faster than wages—and why does it matter?
• What’s the biggest driver of premium increases? (Spoiler: It’s hospital prices.)
• Are hospital price hikes justified by rising costs—or is something else at play?

Dr. Ho shares data-backed insights on hospital consolidation, executive incentives, and how health system pricing impacts self-insured employers and plan sponsors. If you’re a healthcare executive or a jumbo employer managing benefits, this episode is a must-listen.

=== LINKS ===

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05:12 Are insurance premiums going up?
05:59 What is the disparity between cost of insurance and wage increases?06:21 LinkedIn post by Byron Hugley.
06:25 Article by Michael Strain.
06:46 How much have insurance premiums gone up for employers versus employees?
09:06 Chart showing the cost to insure populations of employees and families.
10:17 What is causing hospital prices and insurance premiums to go up so exponentially?
12:53 Article by (and tribute to) Uwe Reinhardt.
13:49 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM.
15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices?
16:56 Collaboration with Marilyn Bartlett and the NASHP Hospital Cost Tool.
19:47 What is the explanation that hospitals give for justifying these profits?23:16 How do these hospital cost increases actually happen?
27:06 Study by Zack Cooper, PhD.
27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases?
30:12 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA.
33:17 Why is it vital that change start at the board level?

This episode with Chris Crawford, CEO of RxSaveCard, is not about the when, why, or how of GLP-1s for weight loss or best-practice prescribing. This episode very, very specifically is about the how and why of the pickle plan sponsors get themselves into often enough where if they impose formulary restrictions to limit the volume of meds that they are paying for, then unit prices go up, which is a thing for GLP-1s.

And this is critical just given how the costs associated with GLP-1s for weight loss contribute to some pretty significant increases in pharmacy trend for plan sponsors who choose to cover the GLP-1s for weight loss.

Chris Crawford and Stacey Richter discuss the challenges plan sponsors face with the rising costs of GLP-1 medications for weight loss. They explore how plan sponsors’ efforts to manage pharmacy trends often result in a tradeoff: lowering unit costs by increasing volume or vice versa. Chris also introduces a potential solution leveraging the growing cash marketplace, where employers can bypass traditional PBM contracts to achieve cost savings. Tune in for actionable insights into the perverse incentives in the pharmacy supply chain and innovative ways to navigate them. (Continued below the links)

=== LINKS ===
🔗  Show Notes with all mentioned links:  
hhttps://cc-lnk.com/EP461

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:
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Bottom line, there are some really impactful and not frequently delved into perverse incentives at play here. And we’re gonna talk about these today. And these are really key for anybody on or about the pharmacy supply chain in the U.S. to know about. This is very actionable insight.

So, again, there’s an unfortunate tradeoff, as it stands right now, for many plan sponsors. Lower your volume and raise the unit price or vice versa.

This episode is sponsored by RxSaveCard, and a big thanks for that. I really appreciate RxSaveCard for its financial support because this episode covers a really important topic that we probably would have covered anyway over here at Relentless Health Value.

And so, RxSaveCard standing up and offering their financial support to cover it was a really nice thing to do. And I thank them for their generosity.

07:57 What are the two pieces going on with GLP-1 PBM prices and rebates for employers?

10:00 Is the cash price for these name brand drugs currently less than the rebated PBM price?

11:49 Why does the rebate for GLP-1s disappear if employers try to put restrictions on who can receive access to these drugs?

15:07 Where does RxSaveCard come in to play here?

19:55 “We exist to save people money.”

20:45 EP456 with Brian Reid.

21:16 EP356 with Ge Bai, PhD, CPA.

21:37 EP439 with Luke Slindee, PharmD.

My guest in this health care podcast is Darrell Moon, who is the CEO over at Orriant.

I was super intrigued by some of the work that Darrell and his team are doing regarding high-cost claimants. Said a different and probably better way, certain people in need of care were identified because they were costing so much. Year after year after year, these individuals—I call them hyper-users during this episode, but it’s possible I made that term up myself—these hyper-users were getting all kinds of expensive health care, while at the same time, they were not getting any better.

So, Darrell and his team realized that something was afoot here, and it turned out to be a combination of maybe loneliness, maybe low self-esteem and low self-efficacy. And no matter how many times you go to the cardiologist or the rheumatologist or the pulmonologist, none of those things will be cured.

In fact, when someone’s identity becomes their myriad of health issues, they have a sort of perverse incentive, if you think about it, not to follow any of their doctor’s recommendations to take meds or make lifestyle changes. So, while their underlying condition—low self-esteem, low self-efficacy—remains untreated, their physical health tends to actually get worse, not better, despite all the medical attention. What’s necessary to help this type of patient is the best that behavioral science has to offer.

A nuance I found really interesting and important in the work that Darrell is doing is that it’s pretty easy to identify a hyper-user from someone with a horrid chronic condition simply requiring a lot of care. The hyper-users will respond and appreciate the extra attention that a behavioral health coach/program has to offer. In contrast, those with other ailments will just merely get annoyed—usually on the quick—so they exclude themselves from the program.

Sidebar: My guest Darrell Moon is organizing an Aspirational Healthcare Conference for July 14 and 15, 2021. In that virtual meeting, the intent will be to highlight Southcentral Foundation’s Nuka System of Care in Alaska and other similar health care models that achieve much better health care outcomes at half the cost. So, check that out if you are so inclined.

Thanks so much also to Lee Lewis from the HTA (Health Transformation Alliance) for the introduction to Darrell and Orriant.

You can learn more at orriant.com.

Darrell Moon founded Orriant in 1996 to change the dynamics of health care and give employers some control over the ever-increasing costs of the health care benefits they offer their employees. Darrell believed that engaging individuals in the management of their own health was a key that had to be inserted back into the economic equation of health care. Darrell received both his bachelor’s degree in finance and his master’s degree in healthcare administration from Brigham Young University. As the CEO, COO, or CFO, Darrell managed medical and psychiatric hospitals throughout the country for over 10 years prior to creating Orriant. He also has more than a decade of experience managing insurance and managed care products. Darrell is a Forbes leadership contributor.

03:11 What do CEOs want out of the health care system?
04:52 Is it a good strategy to focus on high-cost claimants?
07:04 Who are the people year over year that wind up in the high-cost claimant pool?
07:50 “Really, you have to get to the crux of the problem, which is … they’ve become a victim … to the health care system.”
08:16 Who are these “hyper-users” and how do we define them?
11:35 “Getting that person to have a regular relationship with someone isn’t the hard part; the hard part is then helping them to build their self-esteem.”
13:20 “That’s the key to building self-esteem—is helping people accomplish what’s most important to them.”
14:57 Why helping a patient not to view themselves as a victim helps them manage their care better.
17:45 “It’s often less the training and the right personality of the person.”
18:54 Do health outcomes correlate with the self-esteem of the patient?
19:28 “If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience.”
21:21 “They’re the customer/owner of their own health.”
24:23 “How do you help not just the 1% but everybody [in health care]?”
27:16 “The ideal environment is to have a massively powerful primary care team.”
27:47 “Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right.”
29:34 “It’s not about just when [people] reach out … but [getting] people to reach out early.”

You can learn more at orriant.com.

Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What do CEOs want out of the health care system? Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Is it a good strategy to focus on high-cost claimants? Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Really, you have to get to the crux of the problem, which is … they’ve become a victim … to the health care system.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Getting that person to have a regular relationship with someone isn’t the hard part; the hard part is then helping them to build their self-esteem.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“That’s the key to building self-esteem—is helping people accomplish what’s most important to them.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“It’s often less the training and the right personality of the person.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“They’re the customer/owner of their own health.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“The ideal environment is to have a massively powerful primary care team.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“It’s not about just when [people] reach out … but [getting] people to reach out early.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Darren is Chief Executive Officer at Aduro, Inc., a human performance company that delivers habit change programs that empower people and organizations to reach their full potential. He brings a unique outlook to the health care sector, combining his experience with the intricacies of the industry with potential he sees in groundbreaking technologies, human analytics and personalized well-being. With more than 15 years of expertise in demonstrated return on population health, Darren helps companies unlock the power of a happier, healthier, and higher-performing workforce.

Prior to founding Aduro, Darren has served as Associate Doctor, Clinic Director and Chief Executive Officer of Clear Chiropractic, a collection of practices in the Puget Sound Area specializing in the Blair Chiropractic Technique. Darren received his Doctor of Chiropractic from Georgia’s Life University and currently serves as Chairman of the Board at Clear Chiropractic.

Darren spends an increasing amount of time developing new opportunities to bring his purpose-driven approach to the larger community with support for behavior health and nutritional lifestyles. When he’s not igniting Aduro’s culture at a Friday Fire all-company huddle, he can be found curating crowd-pleasing playlists or traversing down the slopes at his favorite mountain hideaway.

Five Realities Hospital Execs Need to Face in 2024 with Peter Hayes

To read the full article and show notes with links mentioned as well as a full transcript, click here.

In episode 424 of Relentless Health Value, host Stacey Richter speaks with Peter Hayes about five critical topics hospital system executives must address in 2024. They discuss the implications of the Consolidated Appropriations Act, the necessity for hospitals to become more administratively and technologically efficient, the shift from fee-for-service to episode-based care, the need for transparency and accountability regarding tax-exempt statuses and 340B drug pricing, and the imperative of ensuring high-quality and safe patient care. The episode emphasizes the growing demand for hospital systems to adapt to regulatory changes and market pressures while maintaining fiduciary responsibility, quality care, and trust within their communities.

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For more on the wild problems with hospital pricing, check out this list of shows. But, spoiler alert, some of these are hair-raising.

08:04 Why do hospitals need to get real about the implications of the Consolidated Appropriations Act?

10:09 What is considered fair pricing for hospitals?

13:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD.

15:59 The medical transparency tool, Billy.

16:34 How does lowering prices become more challenging with consolidated hospital systems?

18:07 What is one of the solutions available to combatting this now?

19:31 Why do hospital systems need to get real about administrative and technology efficiencies?

22:27 EP373 with Cora Opsahl.

26:51 Why do hospitals need to get real about pivoting from fee-for-service reimbursement to episode-based care?

30:16 EP415 with Rob Andrews.

30:53 Why do hospitals need to get real about the 340B program and their tax-exempt status?

35:38 EP394 with Vikas Saini, MD, and Judith Garber, MPP.

38:19 What are the ethical and moral issues that are coming to a head with healthcare costs?

39:03 Why do hospitals need to reexamine their care quality and patient safety?

40:05 “We just need to make sure that the health industry is as accountable as some of our other industries.”

42:53 Why does Peter think it’s going to take regulation to move the dial?

Dr. Fahrni has been a licensed pharmacist in California since obtaining his Pharm.D. degree from the University of California, San Francisco School of Pharmacy in 1997. Jerry has a diverse background and has served in a variety of pharmacy roles during that time, including more than a decade of experience as a clinical pharmacist in various acute care settings, as well as spending time as a pharmacy technology industry insider. He currently works as an independent pharmacist consultant where he has a passion for helping pharmacies improve operational efficiency, increase patient safety, and drive cost-effective medication use through the use of automation, technology, and informatics. Jerry’s goal is to finds ways to improve pharmacy and create a more patient-centric practice model.

You can find out more at JerryFahrni.com, on Twitter @JFahrni, on LinkedIn, or by calling Jerry at 559-838-6014.

In this healthcare podcast, I’m talking with Brian Klepper. If you haven’t heard of him, Brian’s a longtime healthcare analyst and former CEO of the National Business Coalition on Health.

This interview takes off like a shot, as most of my conversations with Brian Klepper do. We’re talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the ’90s. This is a great comparator to really get a handle on what’s going on today. During the heyday of HMOs (back in the ’90s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn’t an accident that it was really hard to get an appointment with a PCP. 

On the other hand, it also wasn’t an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody’s happy then, right?

Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend … Oh right, everybody’s happy except the patient who can’t get care and the PCP who can’t do their job.

By the way, for more information on why the ’90s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the “why” really actually took me by surprise. 

But back to primary care … Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we’re not really counting urgent cares or what amounts to urgent cares in that mix—meaning, not counting a lot of the retail clinics because they don’t really manage patient care like you’d hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can’t manage a chronic condition in 15 minutes.

So, like I said, there’s three kinds of PCPs that are around today; and let’s call the first kind the OPCP, the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn’t really what their payer mix is. It’s that they’re not taking on much risk or any risk of real consequence.

Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered.

Third, we have what Brian calls industrialized primary care—or some people call it advanced primary care, or APC—but I’d probably call it something different. I’d call it “taking risk for the full continuum of care” primary care. Maybe I wouldn’t even call it primary care at all because this third category really is starting to color outside of the lines of primary care.

This third iteration requires many things to accomplish. It requires an unimpeachable relationship with the patient; you cannot be successful with this otherwise. It requires great virtual/digital capabilities. It also requires data—data to help ensure that care gaps are filled but also to make sure that patients are referred to high-quality, high-value specialists downstream who will actually create outcomes. It also includes optimizing specialty pharmaceutical usage, for example. Brian gets into this and how a state employee health plan is on track to save $1.3 billion in this fashion.

Brian believes that this third iteration of primary care—this APC industrialized primary care—is the third leg of a three-legged stool that is needed to transform healthcare. If you must know, the second leg is identification and the use of high-performing specialty services; and the third is value-based reimbursement environment.

Most of the second half of this conversation with Brian is about why there’s just a flurry of investment into various forms of these advanced or just maybe even regular primary care models and how they might evolve moving forward. I ask Brian about Carbon Health and their recent claim that they can do primary care with about 25% to 30% EBITA, even at Medicare FFS rates. So, there’s that.

One last thing: Next week, we’ll be posting an “Ask an Expert” with Brian Klepper, where he gives the backstory about how the RUC—that AMA committee—basically killed primary care. So, come back for that show after you’re done with this one. It’s a plot full of intrigue, that’s for sure.

You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com.

Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Advisors, a benefits consultancy focused on linking high-performance/high-impact healthcare organizations with purchasers. He founded and moderates a popular professional healthcare Listserv, Healthcare Hackers, which is a discussion forum on healthcare high performance and value and which has about 850 participating benefits managers, benefits advisors, and innovative vendors.

An active author and speaker, Dr. Klepper has provided healthcare commentary to CBS Evening News, the Wall Street Journal, the New York Times, and the Washington Post. He has published widely in healthcare trade and academic publications and in newspapers nationally.

Brian is a regular contributor to Employee Benefit News, the Health Affairs Blog, The Health Care Blog, The Doctor Weighs In, Kevin MD, and other expert healthcare blogs. He is a reviewer for Health Affairs and The Journal of Ambulatory Care Management.

He is an advisor to the Lundberg Institute and to several for-profit healthcare organizations.

In his spare time, Brian is an offshore sailor.

05:10 Is the HMO model of primary care a good model?
07:48 “Industrialized medicine is exciting.”
08:59 What does primary care have the opportunity to do?
09:21 “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.”
10:15 Where does direct primary care and advanced primary care fit into this model?
13:35 “At the end of the day, what primary care really needs to be about is … the management of life issues as well.”
14:05 EP295 with Rebecca Etz, PhD.
14:19 “Better relationships quantifiably translate to better care.”
21:48 “Almost nobody in healthcare wants any of this to happen.”
23:58 Why the huge amounts of money being invested into primary care is actually a big problem.
28:11 “We should be able to get wildly better health outcomes for about 40% to 45% of the money that we’re currently spending.”

You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com.

@bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

Is the HMO model of primary care a good model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

“Industrialized medicine is exciting.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

What does primary care have the opportunity to do? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

“The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

Where does direct primary care and advanced primary care fit into this model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

“At the end of the day, what primary care really needs to be about is … the management of life issues as well.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

“Better relationships quantifiably translate to better care.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

“Almost nobody in healthcare wants any of this to happen.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

Why the huge amounts of money being invested into primary care is actually a big problem. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

“We should be able to get wildly better health outcomes for about 40% to 45% of the money that we’re currently spending.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr. Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312), Ge Bai

Sonni obtained her medical degree at Louisiana State University in New Orleans and then completed an Internal Medicine residency at Mount Sinai Medical Center. She was eventually appointed Chief of Medical Services for the Palliative Care Service and Co-Director of Integrated Palliative Care/Geriatrics and Palliative Care/Oncology fellowships at Mount Sinai. During Sonni’s last clinical job as Medical Director of Visiting Nurse Service of New York’s inpatient hospice she became increasingly interested in using technology to facilitate communication with patients. After meeting Quality Reviews’ CEO and Co-Founder Dr. Edward Shin through a mutual colleague, Sonni joined the company in 2013 and is now Director of Account Management. Sonni occasionally works as a per diem hospitalist to maintain a connection to clinical medicine.

Listeners can reach out to Sonni via www.ratemyhospital.com