Descant

Gayle is joined by Daniel Cruz, health actuary and consultant, to discuss the state of the actuarial profession in light of recent communications about rating of Affordable Care Act plans.  The actuarial profession plays an important role in safeguarding the institution of insurance for the benefit of society.  We are a self-regulated profession.  We rely on a combination of standards of practice, professionalism, examinations, continuing education, and a disciplinary review process to ensure that we fulfill our obligations to the public ourselves, without oversight or control from outside the actuarial profession.  Gayle mentioned two recent communications related to ACA rating, which cause her to wonder what is happening behind the scenes. Why are committees of the American Academy of Actuaries apparently implying that actuaries don't have to follow laws and regulations when it comes to ACA rating, while patient advocacy groups are warning Health and Human Services that actuaries are not following rating rules?  Beyond the questions about the actions of actuaries rating ACA plans, these communications create concern about the AAA's procedures for writing such letters.  What is the procedure for AAA committees to make pronouncements about how actuaries should do their jobs?  Are views of all ACA pricing actuaries solicited and considered before sending the letter to the government agency charged with regulating ACA plans?  If not, does that call into question the ability of the actuarial profession to self-regulate?With the stage set with these questions, Gayle was joined by Daniel Cruz.  Daniel took us back through the history of the ACA marketplace and explained that the single risk pool requirement was not enforced in the chaos that unfolded in the first couple years of the ACA marketplace.  You'll recall that numerous carriers left the market and others raised rates dramatically to ensure they could get to profitability and continue to offer ACA plans going forward.  At first it was not clear what precisely had happened, but everyone breathed a sigh of relief when the ACA marketplace stabilized, and carriers began to return.  Continuing the story, Daniel explained how the problem became clearer after cost-sharing reduction payments were ceased and changes were made to the ACA subsidy system starting in the 2018 plan year.  Daniel shared his views of why the failure to follow the single risk pool requirement has not been remedied, and why it is coming to light now.  He explained how the interests of consumers are not being protected when the ACA single risk pool requirement is not enforced.  While it would be preferable for challenges facing actuarial practice to be discussed in an open, transparent and timely manner so that we can collectively ensure we fulfill our obligations to the public, it's not too late. Daniel left us with a possible silver lining.  He suggested that perhaps we are turning the corner on this issue; perhaps the letters signify that the actuarial profession is ready to have the conversation we should have had four years ago and show that we can self-regulate.This actuary hopes he is right.+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++Gayle has launched the Primary Care Mindset newsletter and is soon launching the podcast Nurturing the Heart of Family Practice.  Subscribe here https://subscribepage.io/primarycaremindset 

In this episode, Gayle and Joyce are joined by Dr. Lee Kurisko, a Canadian radiologist who left practice in Thunder Bay Ontario to pursue a career stateside after becoming disillusioned with Canada's centralized approach to healthcare delivery. His firsthand knowledge of waiting lines, physician and staff shortages, and outdated imaging equipment forced a change of heart from the great confidence he initially felt in Canada's healthcare system. He soon discovered greater efficiency and less rationed care in the U.S. and while our current system is not without challenges, he feels it is far superior to Canada's system. Canadians, Dr. Kurisko explained, are indoctrinated into the notion that government should provide healthcare and that U.S. citizens are being left in the cold because the government does not directly arrange and pay for all medical treatment. He shares how the Canadian cultural ethos takes considerable pride in the government's role in healthcare. Indeed, surveys suggest that Canadians remain very proud of their system even though approximately 17 percent lack access to a primary care physician. This ethos is even more puzzling when you consider that in Canada, a primary care referral is needed in order to receive specialty care; those who do not have a primary care physician also do not have access to specialty care in Canada. Dr. Kurisko's move to the United States was in part driven by exhaustion where he and his two colleagues daily confronted 10 to 14 hours of workload meant for 13 radiologists. He states that because governments are constrained by budgets (vs. profits seen with private enterprise) – it leads to a severe and perverse form of rationing which is not only impractical but immoral as well. The view that healthcare is a right necessarily implies that medical providers' freedoms can be curtailed; after all, someone must provide the discounted or free service that another person claims a right to receive.The inherent complexity seen in healthcare pleads the case for bottom-up solutions that lead to less rationed, better quality care. He suggests that because healthcare is so important it behooves us to seriously consider limiting the role of government. Dr. Kurisko advocates for an uninterrupted doctor-patient relationship without arbitrary price controls. He suggests that a better value proposition is possible if we embrace transparent pricing that facilitates the delivery of a desired service – just as we do with other goods and services provided in the United States. In that sense, healthcare is not special. Our conversation touched on “proper” insurance which only covers large, unexpected losses and preferably is purchased individually and not through an employer. Over-insurance (that is, using insurance for routine, inexpensive care) causes excess testing and other excessive utilization, which of course contributes to out of control spending.  Lastly, he emphasizes the need for supply side solutions associated with charity care to address our nations indigent patient population.How to induce or layer such change within our current system vexed with bureaucracies and vested interests, remains to be seen. But it is a challenge we should not shrink from in light of Medicare insolvency concerns and ever-growing healthcare demand that continues to eat up a larger percentage of our GDP.  At least we have greater clarity on what to avoid as we promote a more bottom-up approach to healthcare reform, thanks to Dr. Kurisko's insights about the problems in the Canadian healthcare system.

Gayle recently talked with Leo Wisneiwski, founder of Health Cost Labs (www.healthcostlabs.com) about hospital price transparency and how this newly disclosed data will be a game changer for health care expenditures.  Leo described how his experiences with fee schedules and billing data at an insurer lead him to found a company that cleans hospital price data and makes it usable for brokers, employers and patients.  When insurers change fee schedules, providers respond by billing the same procedure with different codes to maximize revenue.  Insurers claim they are controlling costs, but the data does not support this claim.  Leo says this lack of empathy for patients who cannot afford care drives him to make the data available so people can shop for value and hold insurance companies and providers accountable.Health Cost Labs data is available for purchase by state and more hospitals are releasing their pricing data every week.  So far, many of the Health Cost Labs customers are brokers who want to help employer groups save on hospital expenditures.  Leo talked about the new fiduciary requirements that go into effect in 2022 that require employers to act on this sort of price data.  And uninsured patients will have new protections in 2022 as bills too far in excess of the good faith estimate will be arbitrated.  Since Leo has an actuarial background, Gayle wanted to know his view of whether actuaries are doing as much as they should to address dysfunctions in the healthcare system.  Leo believes most actuaries are entrenched in their bubble; they trend and risk adjust but they don't embrace broad price transparency efforts.  He says there's apathy about the system from middlemen, whether it's actuaries or other leaders in managed care; if there's always a buyer for my services, I don't actually need to do anything about spending.  Gayle and Leo touched on the importance of bottom-up empowerment and mindset in improving the results we see in healthcare.  And Leo warned that he sees a day of reckoning coming for the high cost players.  It will be exciting to see what happens as more people use newly disclosed hospital price data in 2022. 

Greg recently completed a research report for the Society of Actuaries entitled “Uninsured Rate” Measurements and Health Policy Considerations, available at www.soa.org/resources/research-reports/2021/uninsured-rate-measurements/.  He became interested in the measurement of the uninsured rate because we don't really know the impact of reforms on the uninsured rate, and there's no agreed-upon definition of being uninsured despite the importance of lowering the rate of uninsurance; every significant reform from Medicare and Medicaid to the Affordable Care Act has had as a primary goal to increase the portion of Americans who are covered.  Unlike with many other data elements important for healthcare, there is no file of uninsured Americans.  This information must be obtained by survey.  Greg's report explains the various sources of uninsured rates.  In this podcast episode we discuss the many layers of complexity to uninsured data.  There are definitional issues of what counts as coverage and what length of time without coverage constitutes being uninsured.  Additionally, surveys experienced considerable challenges gathering data after the pandemic started.  Many important questions that are highly relevant for health policy are beyond  the scope of the uninsured rates and the surveys that generate them.  Questions such as why the half of uninsured Americans who are eligible for free coverage have not signed up remain unanswered.  The conversation touched on how changes implemented in the Trump and Biden administrations affected certain subsets of the uninsured and why higher income young people still find ACA Exchange plans unattractive.  Greg shared his view that at this point, it's not about affordability, but rather, whether inflated premiums and more generous subsidies result in a good value for consumers.  Gayle also wonders whether the burden to taxpayers of more and more subsidies is too high.  Finally, we discussed the role of actuaries; are we thinking broadly enough and doing enough to watch out for the interests of the public?  We agree that actuaries should be objective truth tellers and actuaries do have an obligation to the public; we agree that actuaries certainly should speak up about the things we know and only we know given our experience and training.  Greg shared that many actuaries have told him privately that they feel restrained and can't speak out as freely as they'd like.  In today's time of hyper-partisan hyper-polarization, actuaries are in good company in that regard; physicians, scientists, public health officials and many others also feel restrained from speaking their minds because others have been censored or canceled.  Perhaps openly discussing our concerns about healthcare reform in a format like this will play a small role in encouraging others to speak openly as well.

Dr. Wendy Molaska offers many points of view about Direct Primary Care.  In just over 35 minutes, we touch on all of the important aspects of DPC, examined through a variety of lenses including·         Physician and patient perspectives in DPC and traditional primary care·         Physicians employed by a big system vs practicing independently·         Physician incentives in DPC vs in the “sick care” system·         Copays and deductibles are barriers to primary care access; flat DPC fees remove the barrier ·         Why “it feels so different” to spend time and energy figuring something out that directly benefits the patient vs spending the same time and energy to save the insurance company a few bucks·         What DPC advocacy looks like in a Medical Society and in Academic Medicine·         Scope of practice, transparency and frustration·         Physician burnout and workforce shortages·         Educating the public and the patient about DPC·         Primary care in rural vs urban areas; doctors are returning to rural hometowns as small practices are sustainable in a DPC model ·         Medicaid debit cards for DPC fees improve the health of high risk patients and avoid expensive emergency department and hospital care

Fritz Busch describes being smitten with DPC the first time he heard a DPC physician talking about the model. He found the model very appealing because it seemed like it would work, it would provide better care.  Fritz had always been bothered that so many physicians are burned out.  He was very pleased to learn how much physicians loved practicing in a DPC model, as there was finally something that's going directly at our physician burnout problem.  Fritz wanted to study DPC, to see if he could prove that results are better in DPC.  He ultimately was involved in the Society of Actuaries' study of Direct Primary Care (available here: https://www.soa.org/resources/research-reports/2020/direct-primary-care-eval-model/) and other DPC papers and consulting projects. Next we discussed the changes he's seen in the last several years, in terms of the DPC model and the consulting work associated with it.  We discussed that self-insured employers have the flexibility to adopt DPC and that much of the growth of DPC is taking place in this market.  Fritz also noted that lines are blurring between corporate DPC and onsite clinics.While DPC isn't particularly actuarial (primary care is not insurable in a technical sense as costs are almost entirely knowable), DPC clinics seek consulting for a variety of reasons.  Some are looking to add services that, similar to primary care, have high frequency, knowable costs (such as physical therapy).  Others are looking at increasing the value they provide to their patients in terms of revenue per square foot of clinic space.  Modeling risk and risk sharing are other areas where DPCs may seek consulting services.  Fritz described a current project that involves both qualitative and quantitative analysis of the value of DPC.  The inclusion of qualitative methods recognizes that the better experience for employees is not fully captured in a financial analysis involving DPC fees, savings due to lower spending on primary and downstream care, and savings in patient cost sharing.Finally we got into the biggest problem in the healthcare system.  Fritz gave a detailed and insightful answer involving distortions caused by 3rd party payment and too much money being thrown into the healthcare system by Medicare and Medicaid paying automatically (without competition). Given how our system is set up, we really can't expect anything other than the very expensive system that we have.  Thanks for a great conversation, Fritz!

You don't want to miss this wide ranging conversation with perhaps one of today's foremost experts on healthcare systems.  Health actuary and retired Milliman Principal, Mark Litow spoke with Joyce and Gayle about how healthcare systems work, the main disconnects in the US system, and how reform efforts have led to the numerous problems we face today, including  poor doctor-patient relationships, unaffordability, generational inequity, workforce challenges, and long term unsustainability.  Mark leads the Concerned Actuaries Group or CAG (www.concernedactuaries.org) and he went into detail about how CAG has modeled the US healthcare system.  The model focuses on six signals that together form a comprehensive view of the system: cost, coverage, access, health status, economic impacts, and long term sustainability.  The six signals are modeled across all markets, such as Medicare, large employer group, uninsured, and individual. The idea is to model each mutually exclusive population group based on the type of medical coverage they have, as incentives and behaviors will vary by these groups.  The model projects the results of a reform into the future and compares it to a continuation of today's healthcare system.  As a powerful testament of the model's predictive ability, Mark explained that it predicted that individual insurance premiums would increase 60% after the implementation of the Affordable Care Act.  Individual market premiums actually increased between 55 and 60%.  The CBO's model, in contrast, predicted an increase of 10-13%.  Our conversation touched on the proper role for insurance and the effects when subsidies are too low or too high; Mark mentioned work he did in South Africa, modeling the health care system and developing a new insurance plan that was successful until the political winds changed.  Finally Mark talked about the actuarial profession and how it has changed over his career.  He takes very seriously the obligation of actuaries to speak out if a social insurance program is poorly designed or will have significant negative unintended consequences.  He noted that regulatory filings were a small part of what Milliman actuaries did when he first worked there, but by the end of his career, filings comprised about 2/3 of the work. The political pressure on actuaries to soften or remove assumptions that lead to unfavorable projections about pending legislation and regulations has increased as well.  It is important for actuaries to hold true to our actuarial principles and our responsibility to the public.We extend a big thanks to Mark for sharing a bit of his knowledge with us today.

Today's guest was Troy Robert, who has multiple entrepreneurial ventures in the healthcare system related to physical therapy and staffing of allied health professionals.  Troy explained different models of delivering and paying for physical therapy.  He compares the incentives of fee-for-service and direct pay models, plus a new model that aims to change the way PT is accessed for large employer groups.  This new model uses a per member per month approach and has patients access PT quickly after an injury or problem so that assessment and treatment can begin right away.  This approach is in contrast to the typical approach that involves primary care sending the patient for images and referring to an orthopedist.  Troy explains how his approach minimizes the delay to the start of treatment and can lower the use of opioids and imaging to provide an outcome that is often superior for less spending as compared to the typical approach.  We are looking forward to seeing what happens as this new model takes off.Troy talked about how PT fits into the healthcare system, including whether physical therapy is a catastrophic expense and how PTs and other allied health professionals were dramatically affected when the Medicare reimbursement approach was reworked in 1998.  This particular change led to the creation of his company, Quantum Health Professionals, Inc. Troy and Gayle wrapped up the conversation with a lively discussion of what's wrong in the healthcare system, how we got here, and how we need to change our thinking if we hope to improve it so that it better serves everyone in a much simpler and less expensive way.  

Richard Young MD, family medicine physician, faculty, researcher and innovator, has spent most of his career at a safety net hospital. He details how quality metrics and payment based on CPT codes devalue the practice of family medicine.  Primary care is disadvantaged compared to other specialties, with family physicians earning perhaps one half to one third what other specialists earn.  Yet primary care physicians are responsible for the care of the whole patient, which often involves effects of mental health, socioeconomic and other challenges.  By contrast, specialists and emergency department physicians are usually able to restrict their care of the patient to the specialty or emergency at hand.  The complexity of dealing with the whole patient means quality metrics based on individual disease measures are very inadequate to reflect the totality of care primary care physicians provide.  Dr. Young describes the Sentire system he developed for primary care delivery, in which patients pay directly for services and insurance is not involved; he compares his system to Direct Primary Care, characterizing them as close cousins.Dr. Young explains how primary care is a complex adaptive system.  While some healthcare services (e.g. surgeries) can be viewed as a linear or mechanical system, attempts to view primary care or the health care system in simple mechanical terms leads to failure.  In a mechanical system, one-size-fits-all rules can be implemented in a top-down fashion and the results are predictable.  In most of healthcare, such approaches lead to failure and unintended consequences.  Dr. Young points out that HMOs, PPOs, HEDIS, PCMHs, MIPS, MACRA, etc, have all failed to control costs and have damaged patient care and family medicine practice.  What can be done to improve our healthcare system?  Dr. Young shares what he has learned by observing general physicians in Britain and studying how healthcare is delivered in other countries.  He points out that America is the only country where we don't put limits on healthcare.  In Britain and Canada, patients know they can discuss one concern in a visit to their GP.  Brits accept that they cannot have all the healthcare they want.  In the US, patients expect to discuss all of their concerns and they expect to receive all of the services they want.  Dr. Young says we need a paradigm shift, a new mindset if we are ever going to get a handle on our healthcare spending.  Gayle suggests that the NHS in Britain and the systems in other countries use top-down one-size-fits-all approaches such as global budgets to have some control over spending. Perhaps instead we should consider that in the US, we think about and deliver healthcare completely differently than other goods and services.  Perhaps the paradigm shift that we need is to stop thinking about all healthcare under the same umbrella and realize that primary care is a routine expense, akin to oil changes and furnace filters; we don't use car and home insurance to pay for routine expenses so perhaps we should pay for primary care directly.  Dr. Young agrees that his Sentire system and DPC get rid of lots of the overhead that results from EMRs, quality reporting, and many other top-down mandates.One thing is for sure.  To improve healthcare delivery, restore the doctor-patient relationship and liberate the practice of family medicine, we must engage with physicians such as Dr. Young, who know what is going on in the trenches.

Dr. Michel Accad has a direct cardiology practice and a direct primary care practice; he has authored a book (Moving Mountains: a Socratic Challenge to the Theory and Practice of Population Medicine) and he blogs (www.alertandoriented.com) and podcasts (www.accadandkoka.com).Dr. Accad explains why he left traditional insurance-based practice and started his direct cardiology practice where patients pay directly for services and insurance is not involved.  He later added a direct primary care (DPC) practice that primarily serves older people and operates on a membership basis like many other DPC practices. We discussed the increasing interest in direct specialty care. We imagined a “healthy branch” of healthcare delivery where DPC is the foundation, patients have coverage for catastrophic expenses but insurance is not used for routine expenses, leading to dramatic savings on insurance premiums, and patients are empowered to save for their own healthcare expenses in an HSA or similar account.  Dr. Accad does not see navigating this healthier patient-centered delivery system as a significant barrier to care, as it is the responsibility of DPC doctors to help patients through the process of finding and receiving downstream care.  The bigger challenges would be patient understanding and engagement leading to their interest in this approach, and the difficulty of contractually defining what specific care is catastrophic and thus covered by insurance.  We also need more primary care and specialty care physicians using direct approaches for the “healthy branch” to grow.We discussed population health and Dr. Accad's book Moving Mountains.  He characterizes population health as an idea promoted by academics focused on health policy.  They think about populations in terms of averages.  While increasing population metrics like the number of people screened for cancer or the number of diabetics with hemoglobin A1c in the desired range may be a worthy goal, such metrics don't always translate well to care of individual patients. It's not difficult to imagine a diabetic patient whose A1c is not the top concern, particularly if the patient has other chronic conditions.  Population metrics should not dictate the care of individual patients.Finally, we touched on Dr. Accad's view of the biggest problems in healthcare.  His response touched on personal responsibility, moral hazard, and how our focus on technical solutions to natural health problems increases the public's anxiety about their health.

Join Gayle and Joyce as we talk with Deb Gordon, author of The Health Care Consumer's Manifesto: how to get the most for your money.  Deb's research starts with the observation that Americans consume health care differently than we consume other goods and services and seeks to understand why.  Deb explained the genesis of her research, which involved a trip to Australia, New Zealand and Singapore to learn how healthcare consumers in those systems behave.  Manifesto is full of fascinating insights including that shopping is a complex process and that many Americans don't connect a notion of shopping with their healthcare expendituresthat the American healthcare system is not built around consumers the way other industries are, and this implies that the root of the problems in our healthcare system are deep structural problemsthat empowerment in other economic transactions is bottom-up and a great example of this in healthcare is Direct Primary Care  some areas of healthcare will continue to be a challenge even if we are able to make American healthcare more consumer-focused; one such area is cancer care – cancer patients will continue to need others to advocate for themit's not easy to define quality in healthcare; each patient has their own view and their own values Medicare is one of the most consumer-centric areas of American healthcare; seniors have many coverage options and they have better financial protection than other healthcare consumersprices for mental health services are more transparent than other healthcare prices because insurance is less prevalent and many patients pay out of pocket; therapists are motivated to provide value to patients and naming one's fee involves declaring one's worth Deb's fresh perspective about American healthcare from the consumers' vantage point provides valuable insights about why we behave differently when purchasing healthcare vs anything else, and these insights offer important clues to what is wrong in our system and how to fix it.  You don't want to miss this fascinating conversation! You can find out more about Deb and purchase her book at debgordon.com.

Dr. John Goodman of the Goodman Institute for Public Policy Research joins us for an insightful conversation on healthcare economics, which he states virtually no one understands because of its complexity and disconnect from normal market forces. He submits that one cannot approach healthcare delivery with supply and demand curves so instead, he focuses on incentives. Indeed in his acclaimed 2012  book entitled "Priceless - Curing The Healthcare Crisis," he suggests that our current system begs the wrong question, e.g., "How can I [the provider, hospital administrator, etc] squeeze more money out of the payment formula today?" Clinicians should be asking "How can I make my service better, less costly, and more accessible to patients today?" And so his focus is on creating good incentives as a solution to many of the issues we face.  Dr. Goodman further explains how the suppression of normal market processes has not helped any of us be it, physician or patient. He suggests that we are really no different from the Canadians or Europeans because we have been enamored by the idea that no one should have to choose between healthcare and other uses of money. Underscoring all of this is the notion that we primarily pay for healthcare with time and not money.  We are in essence paying only a fraction of an inflated price since employers or the government are typically picking up a majority of the tab either via direct payment for premiums or via subsidies or Medicare etc. We ultimately have a bureaucratic system in play that not only suppresses pricing information but also creates these non-market barriers to care such as waiting times and an endless myriad of rules and regulations that impede the delivery of care. We discuss the success of telehealth initiatives ushered in under the Trump administration and other efforts to deregulate the industry which highlight how market forces can fulfill a market need – although it took tremendous political will to make these changes. Despite these wins, we still must contend with entrenched beliefs and existing stakeholders for whom vested interests oftentimes stifle innovation. Indeed, the politics of medicine has constructed a system that mirrors the British National Health Service in many ways. The focus is to spend money on healthy people. In Britain, it's quite easy to see a physician but if you need diagnostics and specialty services you will likely encounter long waiting lines and denied care. Here, stateside, we are facing the same pressures. Case in point - ACA plans are not accepted at some of our nation's leading centers such as the Mayo Clinic, MD Anderson, Cleveland Clinic, or UTSW to name a few. It's ultimately a race to the bottom. What we in large part have for insurance is high deductible Medicaid for the worried well.Dr. Goodman is concerned that we lack the political will to reform the system which is unfortunate given some of his ideas on how to best address and finance care for the chronically ill and more. He discusses some of the lessons we can learn from Medicare Advantage plans which allow for risk adjustment – so physicians actually get paid more per visit with higher acuity patients. He would like to see the role of HSA accounts expand and highlights Medicaid's Cash and Counsel program for the homebound disabled. They are actually given accounts and can choose who will provide their care. It puts control into the hands of the disabled who are incentivized to use their dollars wisely. The program has a satisfaction rating of 90%. As we continue to discuss and think about ways to improve healthcare delivery in the U.S., Dr. Goodman advocates for market solutions, such as Direct Primary Care.You can order his newest book entitled “New Way to Care: Social Protections that Put Families First” by visiting the goodmaninstitute.org. 

Greg Fann returns for more ACA discussion.  He explains why he favors further improvements to ACA rather than destroying it by offering a public option designed to pull enrollees from the individual market.  Greg explains how a “Platinum Public Option” could provide a new option to certain enrollees while giving politicians a win in a way that does not threaten the health and stability of the individual market.  Further information can be found in Greg's latest article, “Actuarial Clarity for Building on the ACA: Let's 86 the 8.5% Myth and Other False Narratives” available at www.descant.info/blog.     Greg continues on his quest to challenge misinformation with actuarial acumen and a deep understanding of the mechanics of the ACA.  He points out how both sides mischaracterize the impacts of ACA changes made in the Trump administration and proposed in the Biden administration.  He says we must be willing to do a little math if we are to understand ACA mechanics and how changes affect people differently by age and income.  Greg does not see the level of miscommunication declining in the near future, so let's follow his example by being willing to do a little math so that we are not susceptible to ACA misinformation. 

Dr. Kashyup Patel is CEO of Carolina Blood and Cancer Associates. As a Medical Oncologist, Dr. Patel has worked hard to institute care initiatives that foster ease of access for patients suffering from cancer while improving metrics that save time and money. He is a leader within his specialty and has fearlessly tested and implement alternate payment models. As a patient advocate, he has worked tirelessly to define and create "patient-centered care." His strategic thinking is notable, and this year he takes the helm as President of the Community Oncology Alliance. We discuss the challenges unique to patients diagnosed with cancer in the community setting in addition to the difficulties facing so many clinicians today. Dr. Patel is placing an emphasis on addressing ethnic and racial disparities in cancer care - from diagnostics and precision medicine to enrollment in clinical trials.  His interests run deep and range from healthcare policy, value-based initiatives, to advocating for the adoption of biosimilars and more. He is a person that is deeply fond of his patients and his warm, kind personality is felt throughout our conversation - all the more reason to champion his cause. In this intimate dialogue, we also discuss his recent book “Between Life and Death: From Despair to Hope,” which chronicles real patients facing end-of-life concerns with compassion, acceptance, and understanding. He shares stories that bring peace and consolation for all of us who have suffered loss from cancer. We end on a note of optimism as Dr. Patel highlights his driving ambition in life which is that the glass is always full - even if it contains but a drop of water. To order "Between Life and Death: From Despair to Hope," click here.

Dr Keith Smith, anesthesiologist, managing partner and co-founder of the Surgery Center of Oklahoma (surgerycenterok.com), and co-founder of the Free Market Medical Association (fmma.org) believes that providing medical care should be a mutually beneficial exchange between the physician and the patient. That's how transactions work in other sectors of the economy. But being employed by a hospital pits the physician against the patient; they become financial adversaries.  The Surgery Center of Oklahoma (SCO) offers high quality care for a fraction of the cost of surgery at a hospital.  Prices are bundled and completely transparent.  Their simple successful business model highlights the contrast between thinking of health care as a good or service not unlike any other, and the convoluted and dysfunctional healthcare system dominated by government and large entrenched players such as “non-profit” hospitals and insurance companies.  Dr Smith sheds light on what is wrong in the healthcare system and explains how it is designed to benefit hospitals and insurance companies at the expense of patients and physicians.  We discuss the function of insurance and how our over-reliance on insurance to finance health care adds considerably to health care spending.  Dr Smith leaves us on an optimistic note; he sees that people (both patients and physicians) are increasingly seceding from the government run health care system and seeking out mutually beneficial exchange between physicians and patients.

Prominent health actuary Greg Fann joined Descant for our first conversation with an actuary.   After the Affordable Care Act passed, Greg kept hearing economists say that the ACA exchanges would attract young people.  He understood the math of the subsidies and knew this was wrong.  When he saw that no one was talking about this, Greg decided that he had to speak up.  Actuaries should be objective truth tellers, and if we want ACA markets to work, we have to be truthful about them.We discussed the role of actuaries in the health care system and why actuaries tend not to opine about prices and affordability.  Greg explained how the changes implemented in the Trump era have improved the functioning of the ACA markets, and what he's expecting in 2021. 

Today I, Joyce L, interview Carla Balch - founder of Spesana (Spesana.com) a data and services platform designed to unlock greater efficiencies in physician workflows. Driven by machine vision technology Carla and her team hope to equip physicians with easy access to the world's latest science, knowledgebases, and real-world evidence to make the optimal choices for each patient. Spesana includes a virtual collaboration space for providers, pharma, payors, and scientists. Instantly referring a patient from one provider to another accelerates the timeline for patients getting diagnosed and treated.  In particular, we discuss how her application can and will revolutionize cancer care.  I am enthused about her virtual tumor board and the ability to quickly identify relevant clinical trials for patients.By consolidating disparate data - think medical records, lab information, diagnostic testing, payor, and coverage information - Spesana enables multi-domain decision support.  Revolutionizing cancer care assumes better technology in addition to new treatment algorithms. Spesana is nicely positioned as a game-changer and I'm pleased to spread the word!

In this episode, Joyce and Gayle are joined by Dr. Tony Dale, founder and chairman of the medical cost sharing company Sedera.  We discuss Sedera's model of health cost sharing and their approach to personal responsibility, high value care, and the doctor-patient relationship.  Find out more at Sedera.com.Dr. Dale shares how his views were shaped by his experiences as a family physician in the U.K. and as a patient and entrepreneur in the U.S. We delve into the transfer of value between the buyer and seller in an economic transaction and the dramatic differences between a health care transaction and transactions for other goods and services in the U.S.; we consider free market principles to guide health system transformation and our views about what is possible.  

In this episode, Dr. Kevin Knopf discusses the challenges of delivering value-based care despite recent advancements in cancer treatment. Complexity in our healthcare model can drive disparate outcomes and price inflation due to competing interests amongst a plethora of players.  We discuss the role of insurance and alternate means of financing healthcare to drive efficiency and proper incentives - all of which are so essential when thinking about cancer as a catastrophic risk.

John Chamberlain, former executive in hospital management and physician practice management discusses why he left hospital employment and started Citizen Health to reconnect physicians and patients and simplify health care transactions.  Citizen Health is one of thirty organizations that comprise Free2Care.  John says that with Free2Care's 8.5 million patient and physician members, “We now have a voice.” He says that the most important thing for the average Joe to understand about health care is that you do have a choice.  You can seek out low cash prices for labs and imaging; you're unlikely to hit your high deductible anyway.  Why pay $2500 when you could get the same high quality service for $400?  John urges those working on fixing the health care system, “Never give up.  People are depending on us.”  I could not agree more!

How have Direct Primary Care patients and doctors been affected by the pandemic and economic shut down?  DPC doctors do not accept insurance, but rather, they provide unlimited access to a defined set of primary care services on a monthly membership basis. Listen to Dr. Elizabeth Eaman and Dr. Jeffrey Gold describe the challenges and benefits of this model of primary care delivery during the Covid-19 pandemic and economic shut down.  Learn how operating outside the 3rd party payer system allows them to be flexible in caring for their patients and in finding innovative ways to support their communities and their patients through tough economic times.  Many traditional insurance-based primary care practices have experienced significant financial difficulty since the majority of visits were cancelled or delayed starting in February. One study estimated that primary care practice revenue will decline by nearly $68,000 per full time physician. Does Direct Primary Care provide a more financially sustainable practice model during times of uncertainty?