Listening In (With Permission): Conversations About Today's Pressing Health Care Topics

Suzanne calls up Candace Shaffer, Senior Director, Benefits at Purdue University to discuss the benefits purchasing strategies that she and her team have implemented and some of the tremendous savings as a result of those strategies. They also discuss what goes into thorough strategic decision making; utilizing your data, understanding your business, and seeking regular input from plan members are all steps Candace and her team take to plan strategically, and based on the results, very effectively.

Andréa call Allison Sesso, President and CEO of RIP Medical Debt (RIP) to discuss the crisis of Medical Debt and RIP's unique mitigation strategy. They also discuss innovative policy on the state and federal level to help relieve consumers of medicals debt and make health care more affordable. "While we love our solution and we think it's really important to help resolve the issue for individuals right now...we very clearly understand and appreciate that we are not the answer, which is why we do need to focus on the systemic solutions and contribute to that proactively."

Andréa calls Dr. Vikas Saini, President of the LOWN Institute to discuss their Hospital Index which measures a hospital's social responsibility, examining how hospitals rank in terms of health outcomes, value and equity. The index is comprised of 53 different metrics, Dr. Saini explains how they collect and analyze their data. This podcast is sponsored by Embold Health.

Julianne calls up Doug Aldeen, ESQ an ERISA Healthcare Attorney and General Counsel to discuss the Reference Based Pricing (RBP) landscape, specifically how RBP has evolved over time. Doug recounts his experience defending RBP companies from lawsuits and saw the evolution from uniform level reimbursement to variation depending on the market. "Ultimately, the reason these facilities were coming after the RBP companies is it's a market threat...you're now a price maker, instead of a price taker."

Sarah Hostetter, Managing Director, Physician and Ambulatory Research at Advisory Board speaks with Suzanne about the landscape of physician practices. Whats happening with acquisition of physician practices? Are there any independent practices left? Why do some physicians choose to join larger practices? Sarah digs into the data and sheds light on how the changing landscape affects physicians themselves, but also the market at large.

Suzanne speaks to Marilyn Bartlett about the National Academy for State Health Policy's (NASHP) Hospital Cost Tool and her role in creating it. NASHP's interactive Hospital Cost Tool provides anyone from policymakers to researchers with insights into how much hospitals spend on patient care services. The tool also shows how those costs relate to both the hospital charges (list prices) and the actual prices paid by health plans.

Suzanne calls up Gloria Sachdev to discuss the Employer's Forum of Indiana's (EFI) latest tool, Sage Transparency. Sage Transparency is a tool that brings together public and proprietary data on hospital pricing and quality. It gives users access to price and quality data for thousands of hospitals across the United States—and it's free!

Suzanne calls up Karen Sepucha, PhD, director of the Health Decision Sciences Center in the General Medicine Division at Massachusetts General Hospital and an associate professor in Medicine at Harvard Medical School to discuss shared decision making. Shared decision making is "really focused on the physicians and the doctors and health care team bringing in what [they] know about the clinical evidence...having that doctors expertise [applied] to this patient sitting in front of them and also bringing out and really recognizing the expertise of the patient in terms of their lived experience."

Suzanne calls up Nick Reber, CEO and Founder of Garner Health to talk price transparency, analytics, and quality. So what do the data say? Well, they confirm a lot of what employer-purchasers are feeling at the moment. "We're seeing just about the fastest rate of health care inflation in our data ever." What's a solution? Price Transparency Data. We have all of this price transparency data, what are we going to do with it? Well, we need a new model if we're going to get consumers to use it. We have to get to them upstream, we have to make it really simple, and we have to change the incentives so that they save thousands of dollars by getting with the program.

Suzanne calls Jen Porto, Manager of Leader Education at Headspace Health to discuss strategies on developing a culture of mental wellness at work. Jen and her team launched a leadership education program to equip managers with science-backed practices to drive cultural change in organizations, support mental health and well-being in the workplace and improve employee engagement, productivity and retention.

Suzanne calls up Dr. Doug Salvador, Chief Quality Officer at Bay State Health and Board Member of the Society to Improve Diagnosis in Medicine (SIDM). Suzanne and Doug discuss the prevalence of diagnosis errors, steps to take to learn from them, and how to prevent them in the future. "You need to have some experts, in your organization in diagnosis and the diagnostic process. You need to set up learning systems, where failures of the diagnostic process or these opportunities are identified and reviewed by teams, including patients...you need to put in place standard processes for diagnosis...we need to get better at it overall in health care."

Suzanne calls up Thi Montalvo, VP, Analytics and Reporting at Transcarent, and Elodie Olsen, Senior Director North America Health Analytics Practice Leader at WTW to talk about wrestling data away from certain health plans, the reasons behind the proliferation of point solutions, and sometimes sneaky trend guarantees.

Suzanne calls Kelsey Brykman, Senior Program Officer at the Center for Health Care Strategies to talk about the intersection of primary care and health equity. Kelsey describes her work under the Promoting Health Equity through Primary Care Innovation in Medicaid Managed Care Project, working with a variety of state Medicaid agencies Kelsey and her team help them think through what levers they have for advancing health equity through primary care. "It's because primary care is so foundational both as an entry point into the health system and also as, ideally, as the way in which patients develop longitudinal relationships with their care team that it is a critical piece of advancing health equity."

Suzanne calls Rachael Jones, Senior Vice President, Performance Analytics & Quality at Cotiviti, to discuss health equity and what employers and other health care purchasers can do to advance it. "You really have to have a comprehensive strategy that looks at clinical data, financial data, member stratification, gaps in care..." ​ "Beyond having that strategy, payers should also think about this problem, or this issue of health equity, as not only theirs to solve. It's about a community and village of partnerships in the health care ecosystem..."

Suzanne calls up Bob Galvin, CMO of Blackstone and chairman of CPR's board of directors, to follow up on their previous discussion on the state of payment reform. So where are we at? Progress is slow, yet steady -- we've had rain delays, changing pitchers, changing managers, but the game isn't over. "It's hard getting through, inning by inning when you're creating something from a blank slate." All is not lost, "I could list 10 or 15 [hospital] systems where you really do have quality improvement, but I think where we've gotten hurt pretty much across the board is, we just haven't gotten at the affordability." So what's the answer? "Figuring out some ways to help regulate the market...government intervention in the market. I want to be quick to say that I'm not talking about a single-payer system, I'm not talking about price setting, but I'm talking about two things. I'm talking about one, making markets competitive...and doing something about price..."

Suzanne calls up Aneesh Chopra, Co-Founder and President of CareJourney, to talk about the current state of health care transparency policy and how the US is faring. So, what's the mood on current regulations and government oversight? “The general feeling in the field is one of skepticism,” says Chopra, but he's much more bullish on it. According to Chopra, based on research CareJourney conducted in partnership with Turquoise Health, “two thirds of hospitals as of the spring of 2022…actually have meaningful, high-quality transparency data.” The question now is are we going to see this information put to use?

Suzanne calls Alice Hm Chen, Chief Medical Officer at Covered California, and asks about her work in quality measurement and health equity. As the nation's largest state-based health insurance exchange, how is Covered California thinking about its responsibility to deliver equitable care to its member population? "I think a key thing for everyone to embrace is, equity is quality...you won't get to true high-quality care unless you are addressing equity."

Suzanne calls up Dr. Jeff Wells, CEO and co-founder of Marathon Health to talk about advanced primary care models and how it fits in with onsite and near-site clinic, and virtual care. Suzanne and Jeff dive into the term advanced primary care and how it differs from prior terminology used to describe high-value primary care strategies. In addition, they discuss why there is a lack of primary care providers compared to most other developed countries and what the future looks like for primary care.

Suzanne calls up Peter Lee, the former Executive Director of Covered California to talk about the last twenty years in health care reform. He explains how many of the payment reforms executed in the commercial space have really been on the margins, and many employees are spending more for worse care than ever before. So what's the problem? Lack of real alignment on measures, and not enough dollars at play at the right level. "We focused a lot on provider level payment...not at the health plans. Health care is a team sport, if we aren't making the quarterback of the team, the health plans, accountable for quality and value, nothing is going to happen."

Suzanne Delbanco speaks with Roslyn (Roz) Murray, a doctoral candidate at The University of Michigan School of Public Health and former Catalyst for Payment Reform Employee. Roz delves into her first peer-reviewed paper in Health Affairs, which concludes that the evidence on commercial value-based payment models is mixed. Suzanne and Roz dive into why there is such little research in the commercial sector on value-based payment and compare Roz's findings to research done in the public sector.

“80% of providers believe that the unpaid caregiver should have a seat at table, but only 20% believe they actually do.” Suzanne Delbanco speaks with Alexandra Drane, Co-Founder & CEO of ARCHANGELS, diving into the critical role of caregivers and why they must be part of the clinical care team. She also discusses how ARCHANGELS' Caregiver Intensity Index (CII) is designed to engage caregivers and help them see themselves in the role. It also calculates the level of “intensity” when measuring the impact of caregiver duties on caregiver health – the higher the intensity, the more likely caregivers are experiencing an adverse mental health impact. CII looks at the influence of multiple compounding impacts on caregiver health (cohorts include age, race, unpaid, essential worker, etc.). Lastly, Alexandra explains the role that ARCHANGELS plays in helping caregivers understand and assess their intensity, and connects people to existing resources (e.g., EAP programs and community, state, and local resources, etc.) to support them.

Suzanne Delbanco speaks with Dr. Irene Dankwa-Mullan, Chief Health Equity Officer at IBM Watson Health and Deputy Chief Health Officer within the Center for AI, Research & Evaluation. As an industry physician and scientist working at the intersection of AI, health equity, and health care, Dr. Dankwa-Mullan speaks to best practices for employers interested in measuring and addressing health inequities being experienced by those in their health benefits program, building on a Health Affairs article that she co-authored in December of 2020. Dr. Dankwa-Mullan cites definitions pioneered by Dr. Paula Bravemen for understanding what health equity and health disparities signify in the context of health care benefits. Health equity calls on stakeholders to focus on the unfair differences in health experienced by social groups based on the varying degrees of social advantages and disadvantages conferred to these groups, often across socially constructed racial and ethnic groupings. Diving deeper, Dr. Dankwa-Mullan highlights the lack of a uniform approach to collecting race and ethnicity data for use in addressing disparities. Amidst the lack of standardization and other challenges, the most important best practice is to have patients and/or plan members self-identify their race, ethnicity, primary language, and other cultural attributes that are important to their identity. Self-identification avoids inaccurate and incomplete categorizations. As employers and other stakeholders know all too well, health care benefits are a costly line item in any organization's budget. But inequitable health care adds even more costs. Dr. Dankwa-Mullan offers the following rationales for why employers should collect and measure health statistics by race and ethnicity. 1. To ensure that the employer's investment is reaching the full covered population in an equitable manner 2. To discover opportunities to improve population health 3. To demonstrate an organizational commitment to health equity Altogether, Dr. Irene Dankwa-Mullan highlights the need for employers and their business associates – including TPAs, consultants, and other partners - to acknowledge that health inequities exist and use their role as plan sponsors and benefits administrators to address them through comprehensive, data-driven, health equity strategies.

Suzanne Delbanco speaks with Jason Richmond, Head of Consultant Relations at Ginger, a digital mental health care provider. Jason Richmond explores the supply demand imbalance between mental health patients and providers in the United States right now, and why the traditional provider network model to access care doesn't carry over well into the mental health space. Jason describes the evolution that mental health care has gone through in recent years, transforming from a one-size-fits-all care program into a de-stigmatized spectrum of treatment plans, including behavioral health coaches. Finally, Jason offers advice for business leaders on how to de-stigmatize mental health care and use employee feedback to design a health benefits structure tailored to your covered population's needs.

Suzanne Delbanco speaks with Michelle Zettergren, President of Labor and Public Sector markets and Chief Sales and Marketing Officer for Brighton Health Plan Solutions, a health enablement company that serves as third-party administrator to self-funded employers and other health care purchasers. Michelle heads marketing, customer retention, and business intelligence units for the company, bringing over 30 years in the health insurance industry. Michelle Zettergren explores the barriers and benefits of employers contracting directly with a health system, and why this solution has earned a high Net Promoter Score among enrollees. Michelle also points to Centers of Excellence for high-cost procedures, like total joint replacement surgeries, as a proven way for employers to contain health care costs and secure high-quality care. Finally, Michelle shares what Brighton Health Plan Solutions is doing to help employer clients prepare for new ERISA regulations set to take effect in 2022 and 2023.

Suzanne Delbanco speaks with Scott Doolittle, CFO of Quantum Health, a health care navigation company providing care coordination and navigation support. Scott oversees Quantum Health's business intelligence units, where he leads a team that validates the company's actuarial results. Scott Doolittle provides insights into how Quantum Health engages both consumers and providers navigate the eligibility and coverage of each consumer's specific benefits plan. In this episode, you'll learn how health care navigation helps employers increase plan member uptake of benefits programs. Featured quote: “A provider is always going to want to get paid. They're always going to call to make sure the member's covered, and if we're that single point of entry and can provide that expertise and do it in a way that drives satisfaction for them, they're more likely to leverage us as we talk about care planning on a go-forward basis.”

Suzanne Delbanco consults Bob Berenson, MD, Institute Fellow at the Urban Institute, on what's going on with telehealth payment policy in both Medicare and the commercial sector and why employers should be paying attention. In May 2021, Bob Berenson testified at the Senate Finance Committee, where he laid out the reasons why fee-for-service is a not a viable way to continue paying for telehealth visits, especially in the primary care context. Listen in to learn about the intricacies of telehealth payment in Medicare, how the commercial sector has taken a different approach, and why a payment arrangement known as partial capitation holds the most promise for balancing the convenience of telehealth for patients with financial sustainability for health care purchasers.

Suzanne Delbanco speaks with Nate Freese, MBA, Senior Director of Data Strategy at Grand Rounds Health, a health care quality and navigation solution offering employers a data-driven clinical navigation platform paired with patient advocacy tools. Nate leads data strategy at Grand Rounds Health, where his team is responsible for building algorithms that match patients with the right providers based on billions of historical clinical interactions. Nate offers a helpful introduction to data science by describing the three types of analyses that data science tackles as well as use-cases that help physicians, pharmaceutical companies, and patients make informed value-oriented choices. He then explores the major challenges that health tech companies face in bringing their data use-cases to life, including the siloed and unstructured nature of health data and the talent shortage of data science professionals across the country. Finally, Nate shares the approach Grand Rounds Health uses to track and improve its ability to reduce health care disparities. Data science simplifies the unimaginably complex and predicts the future to help us make better decisions. In health care, the difference between the right and wrong decision can result in hundreds of thousands of dollars in spend, hospitalizations, or worse. In this episode, you'll learn how Grand Rounds Health is using data science to power its clinical navigation platform and patient advocacy tools, with an eye toward health equity and cost containment. Featured quotes: “Messy data is another challenge for applying data science in health care. The data often requires a lot further processing to make it useful, and is often inconsistent – you have systems with different definitions of the same concept or information. Ultimately, it takes very specific skills sets and domain expertise to make health care data sets useful. And that gets to the next big challenge, which is talent shortage.” “There's a big disconnect between the number of companies out there that have a compelling vision for how they could use data in a health care context, and the number of companies that are actually doing so. A big factor is finding the people they need to realize that vision.” “Data scientists are not one-size-fits-all. It's usually not that you need 1 or 5 data scientists at your company to realize your vision for using data. It's more likely that you need a couple of data engineers, you might need a couple of machine learning experts, a natural language processing expert, a statistician and a couple of epidemiologists. Each of these people are data scientists, but they bring a different skillset to the picture, and you need several of them to suite a particular use-case.”

Suzanne Delbanco talks with David Vivero, CEO and Co-Founder of Amino Health, a health care financial wellness solution that combines data, design, and consumer-first thinking to curate personalized recommendations for specific care needs. Prior to Amino, David was VP of Rentals at Zillow, a consumer internet company that has transformed the home and rental marketplace through increased transparency and a strong user experience. A self-described “product guy,” David Vivero shares his view on where price transparency can make the biggest impact for patients and plan sponsors in the commercial health care market. David and Suzanne discuss the federal government's recent price transparency legislations, including the Hospital Price Transparency Rule, the Transparency in Coverage Rule, and the No Surprises Act. Taken together, these three pieces of legislation have the potential to catalyze a “Cambrian Explosion” of new digital health tools, consumer experiences, and potentially even new types of health plans or business models that improve coverage and care delivery. As David wrote in a June 2021 commentary for Fast Company, these regulations bring “health care one step closer to obeying traditional market dynamics in which cost and value are correlated.” In this podcast, David Vivero explores why he's hopeful that the Transparency in Coverage Rule will create more of an impact than the Hospital Price Transparency rule has to date. A major difference lies in the penalties: the Transparency in Coverage Rule is a lot heftier at $100 per person per day for plans compared to $300 per day for hospitals in the Price Transparency rule. Finally, David shines a light on how new industries take time to reach their full potential, which is why he enthusiastic about the role of health technology products can play in helping make health care more affordable and user-centric moving forward. Featured quote: “In my view, price transparency is a platform. It's like Microsoft Windows, a basic platform or operating system. And, on top of that, all sorts of applications can be built that further the objectives of the U.S. health care system and the American economy.”

Suzanne calls Patrick Tigue, the Health Insurance Commissioner for the State of Rhode Island, to discuss the Office of the Health Insurance Commissioner (OHIC)'s initiatives to stem health care cost growth in RI. Rhode Island has established a cost growth benchmarking process to bring greater transparency to the market. They've also created a first-in-the-nation initiative that caps annual growth in prices paid by commercial health plans. Patrick and Suzanne chat about the impacts these programs have had on the market, and what may be ahead for Rhode Island and other states that follow its lead.

Suzanne Delbanco talks with Thi Montalvo, Health Analytics Practice Leader – Health and Benefits for Willis Towers Watson. In her role, Thi helps employers and other health care purchasers make data-driven decisions for their health benefits strategy. While she's seen many successful use-cases over her nine years specializing in health analytics, she's also seen firsthand the many problems that are hindering the acquisition and use of data for optimizing employer-sponsored health benefits. From onerous legal agreements limiting the use of the data, to incomplete data fields, to lack of visibility into necessary information like diagnosis codes or provider specialty information, employers and other health care purchasers are struggling to put their own benefits data to use, despite being the ones who are footing the bill. Learn how the proliferation of condition-specific benefit programs (often referred to as “point solutions”) has changed the data landscape in the employer-sponsored health care market, and what hoops benefit consulting firms like Willis Towers Watson have to jump through to perform the analyses that their clients need. Thi Montalvo and Suzanne also discuss what's necessary to improve data sharing moving forward, and how the secure and reliable flow of aggregated, de-identified health data is an important piece of the evolving journey to improve price and quality transparency in the commercial health care sector. “Are there opportunities to steer to a quality provider or facility down the street? If we can't do that with the data, then we're not serving the interest of our employers and their employees and getting them the health care that they need.” – Thi Montavlo, Willis Towers Watson

Suzanne Delbanco calls CJ Stimson, MD, the Senior Vice President of Value Transformation at Vanderbilt University Medical Center (VUMC), to discuss Vanderbilt’s direct contract bundled payment arrangement for maternity care with Metro Nashville Public Schools (MNPS). This call serves as follow-up to the webinar hosted by CPR in March 2021, where Dr. Stimson and David Hines of MNPS shared their insights one year after the program’s implementation. Dr. Stimson received both medical and law degrees from Vanderbilt, and is currently an Assistant Professor at VUMC, as well as a practicing urologic surgeon. Here, he and Suzanne discuss why VUMC and MNPS decided to launch a direct contract program on maternity care, the scope and contents of the bundle, and how payers and providers have reacted to this innovative strategy. CJ also takes a guess at what may be ahead for direct contract bundled payments, and what it will take to get more organizations on board with a similar arrangement.

Suzanne Delbanco chats with Nathan Counts, a seasoned health benefits professional who recently joined Amtrak as Head of Total Rewards. Previously, Nathan was Assistant Vice President – Global Benefits for a leading telecommunications company, where he actively participated in CPR membership activities, helping shape CPR’s Shared Purchaser Agenda between 2017 and 2020. Nathan, who holds a master’s in mathematics and got his start as an Actuarial Consultant, is at the forefront of the data revolution in health benefits. In 2018, he was recognized by Workforce for helping make his former employer’s benefit design decisions “truly data-driven.” In this interview, he raises the need for a unified data set for the commercially-insured population, citing the usefulness of the Medicare’s data set in answering valuable population health questions. Listen in as Nathan Counts reflects on his career in health benefits, why he sees alignment between Medicare and the commercial sector as critical, and what he thinks are the most promising opportunities to improve member experience.

Julianne McGarry catches up with Christopher Whaley, PhD, Policy Researcher at RAND Corporation and one of the lead authors of the RAND's Hospital Price Transparency Study. The study, spearheaded by the Employer's Forum of Indiana, has revealed price variation within and across health care markets by re-pricing hospital and outpatient services as a percentage of what Medicare would pay. By participating in the study, employers and other purchasers are able to pinpoint opportunities where benefit designs, like reference-based pricing and tiered networks, can help prioritize the use of high-quality, lower priced facilities. Some employers, like those in Indiana's Fort Wayne market, have already taken action with their re-priced hospital price data. The Hospital Price Transparency study has rocked the health policy world since its initial release in 2017, gaining additional momentum with subsequent releases in 2019 and 2020. During this discussion, Christopher Whaley shares what he has learned through the three iterations of the study and cites the best examples of how purchasers, including labor unions, can and have exerted influence on local health care prices. Julianne and Christopher also discuss how the study adds to the evidence around the weak correlation between prices and quality performance, and how data sharing agreements are instrumental in improving employer's ability to gain actionable insights from their health care spending data. RAND and the Employers Forum of Indiana are now in the process of the fourth iteration of the Hospital Price Transparency study. To learn more and participate, visit https://employerptp.org/.

CPR’s Program Director, Andréa Caballero, chats with Stephen Furia, Senior Vice President, Population Health at Mount Sinai Health System, one of the largest health systems in New York with 3,000 physicians, 400 locations, and a world renown medical school. The Population Health division is the business unit within Mount Sinai that works directly with employers and other health care purchasers, providing an array of services including primary care focused near-site health centers, Centers of Excellence arrangements for specialty care, executive health programs, and, more recently, assisting employers in responding to the COVID-19 pandemic. Reflecting on the Mount Sinai's five years of partnering with those who pay for health care, Stephen offers a set of principles that illustrate how the health system has successfully achieved maximum value in its direct to purchaser partnerships. Those principles are: • Investing more in primary care; • Referring to high-value providers for specialty care, when necessary; • Aligning incentives to promote value; • Encouraging healthy competition among providers in a given market. Listen in to hear Stephen’s explanation of what these principles look like in action for Mount Sinai as it delivers a transformed health care experience to its more than 40 purchaser clients. For starters, the health system’s primary care offering incorporates navigation and care management services to accompany patients from symptom onset to end of treatment and takes a holistic approach to disease prevention. Sound familiar to the models of others like Iora Health and OneMedical? That’s not a coincidence, according to Stephen- these best practices have been adopted throughout the country, marking a move away from away from the disaggregated model of multiple niche vendors filling in the gaps and moving to a broader definition of what high-value primary care entails. Stephen emphasizes how benefit managers play an important role in the success of care delivery transformation. A provider like Mount Sinai may be more willing to take on financial risk in an arrangement where the employer has specific tools in place, such as communications to make employees aware of the offerings and benefit design that makes primary care an easier and cheaper options for patients to access. Finally, Stephen reiterates a resounding truth about transforming care delivery: no one can do it alone. For Mount Sinai, that means collaborating with not only the purchaser itself, to understand the purchaser’s specific needs and pain points, but with the purchaser’s advisors and health plan administrators as well.

Andréa Caballero, MPA, speaks with Linda Schwimmer, JD, President and CEO of the New Jersey Health Care Quality Institute (Quality Institute) to learn about a pressing issue: the health of New Jersey’s Small Group Insurance Market. This market, which covers employers with 2-50 employees in the Garden State, is on the precipice of a downward spiral. At its height, it covered upward of 1 million consumers, but now its enrollment is hovering at about 300k consumers with the further threat of adverse selection creating an imbalanced risk pool. Without doing something to address this issue, the small group market, which offers small businesses a secure option for comprehensive health insurance, may effectively disappear in the Garden State. New Jersey is not alone; due to the COVID-19 pandemic as well as changes in health insurance regulations in the U.S., there is concern for the health of small group insurance markets all across the country. Linda Schwimmer explores how the health of the small group market impacts self-funded employers, the rise of alternative employer-sponsored health plans known as level-funded insurance, and, finally, what the short and long-term policy solutions are for strengthening the small group market. Interestingly, regulations that prohibit the use of high-value purchasing strategies, like site of service-based payments, reference pricing, and preferred drug lists, may be negatively impacting the small group market. While this episode strays a bit from CPR’s focus in self-funded health care coverage, it provides important insights on the interconnectedness of the health insurance ecosystem at large. As Linda points out, when one insurance market is suffering, there are implications for the health system as a whole. For more information on this topic, read the Quality Institute’s July 2020 White Paper, “Short and Long-Term Strategies to Support Health Care Affordability and Price Transparency for Small Employers and Consumers in New Jersey. https://www.njhcqi.org/wp-content/uploads/2020/07/Short-and-Long-Term-Strategies-to-Support-Health-Care-Affordability-and-Price-Transparency-for-Small-Employers-and-Consumers-in-New-Jersey.pdf

Suzanne Delbanco chats with Rick Abbott, VP of Product and Market Solutions at Premera Blue Cross. Premera Blue Cross is a health plan in the Pacific Northwest, serving about 2.2 million members with customers ranging from large tech companies to family-owned grocery stores. Suzanne and Rick discuss if narrow networks, also known as high-performance networks, represent a viable way to lower prices in the employer-sponsored health insurance market. Historically, employers have demanded broad access PPO networks that include the vast majority of providers and hospitals in their region. This trend has somewhat impeded health plans from using their volume to negotiate steeper discounts from providers. Rick describes how creating narrow networks based on provider quality provides a real opportunity to lower costs by both reducing wasteful spending on unnecessary or harmful care and by negotiating discounts from higher-quality providers in exchange for higher volumes of patients. Suzanne and Rick also discuss the opportunities and obstacles for employers interested in pursuing alternatives to the incumbent health plans, like alternative third party administrators or group purchasing initiatives. Rick points to Premera’s 85-year history as an important value-add for customers, allowing the health plan to implement strategic initiatives at scale. For instance, Premera Blue Cross recently launched a “virtual-first” health plan that allows members to designate a virtual network of providers as their primary care providers.

Suzanne Delbanco connects with Chris Cigarran, CEO of Imagine Health, an alternative health plan offering curated provider networks in select markets across the country. Prior to Imagine Health, Chris built the employer and government sales division of a wellness company and has also served as Chief HR Officer. To begin the interview, Suzanne lays out a pain point many self-insured employers are facing: the significant consolidation on the hospital, health system, and provider market. As the buyers of health care, employers do not have enough leverage to keep prices in check. Chris approaches this obstacle from the provider point of view, explaining that health system CEOs, like CEOs in other businesses, require customers to deselect their competitors in order to receive discounts. If a health plan or employer isn’t willing to steer their plan participants to certain providers and away from others, it limits their ability to negotiate more effectively in the provider marketplace. Suzanne and Chris examine the historical insistence among employers for broad access Preferred Provider Organization (PPO) health plans as a root cause of health care price inflation. This may be changing, as employers prepare to weather the current recession. Prior to the COVID-19 pandemic, employers were looking to add services in health benefits as opposed to making changes to save money. Now, employers are looking at reducing their health care spending as a way to avoid laying off employees. Chris Cigarran speaks to the power of the status-quo from a change management perspective. What’s clear is that the health care status quo is not meeting the needs of consumers, with the most blatant example being a patient with chronic conditions having to reach an exorbitant family deductible before their insurance kicks in. Chris Cigarran and Suzanne Delbanco also discuss the Medicare Plus contracting model pioneered by Montana’s state employee health plan. Chris shares his fascination with this novel way to approach health care. While the viability of this model is unclear, what is clear is the need for further experimentation. This interview is part of CPR’s current work to understand whether group purchasing efforts can secure better health care value for employer-purchasers. Funded by the Commonwealth Fund, CPR is assembling insights into the forces that can facilitate or hinder purchaser efforts to amass volume. Keep an eye out for more interviews on this topic.

Suzanne Delbanco interviews Ashok Subramanian, CEO and Founder of Centivo Health, an alternative Third-Party Administrator (TPA) that emphasizes value-based direct contracting and utilization of high-quality providers. Prior to Centivo, Ashok founded Liazon, a private benefits exchange acquired in 2013 by Willis Towers Watson. Suzanne and Ashok explore how employers can put downward pressure on health care prices, a critical topic given how much consolidation is happening among providers. Ashok emphasizes that unit price can’t be ignored in the pursuit of lower total cost of care. He suggests that health care purchasers aggregate volume in order to reduce costs, a key purchasing strategy in other sectors of the American economy. In addition to describing Centivo’s method of structuring customized provider networks, Ashok provides health plan examples of programs that attempt to shift care to certain providers. Ashok highlights the obstacles large health plans face when trying to execute a curated provider network, especially when they operate in multiple lines of business. Suzanne’s final question to Ashok explores the possibility of employers joining in groups to purchase health care together. Ashok comments that this type of purchasing is just another avenue to aggregate volume in pursuit of better deals from health care providers. He reinforces that employers are also looking to secure other capabilities from their contracted providers, like same-day access and care continuity within virtual care delivery. These additional sources of value may be as important to employers as the potential cost savings. Ashok Subramanian leaves listeners with an empowering outlook. While a lot of purchasers may lack the confidence to have a voice in conversations with local providers, they actually have a lot more strength in these conversations than they might expect. This interview is part of CPR’s current work to understand whether group purchasing efforts can secure better health care value for employer-purchasers. Funded by the Commonwealth Fund, CPR is assembling insights into the forces that can facilitate or hinder purchaser efforts to amass volume. Keep an eye out for more interviews on this topic.

Listen in as Suzanne Delbanco connects with Alan Muney, MD, MHA, former Chief Medical Officer of Cigna, former CEO of Equity Healthcare, and current health care advisor to multiple venture equity firms. Suzanne asks Alan a fundamental question: how can employers counterbalance the high and rising prices of health care providers? His answer: look at health care spending in a total cost of care format instead of focusing on unit prices. Drawing on his wealth of experience examining health care marketplace dynamics, Alan shares why the major incumbent health plans, especially those who have been acquired or have acquired pharmaceutical management companies, have a competitive advantage. Because drugs are such an important cost component, integrating pharmaceutical and medical utilization management gives these larger health plans end-to-end control over total cost of care. Suzanne points to the fact that, despite aggregating volume and negotiating unit cost discounts, incumbent health plans have failed to keep prices in check. Now new entrants to the Third-Party Administrator (TPA) market are trying to seize on these pricing failures. Dr. Muney asserts that while the new carve-out vendors may bring innovative capabilities - like using data to build high-quality provider networks- they lack the economies of scale and the total cost of care control that the larger incumbent health plans have acquired. During the interview, Suzanne and Alan Muney discuss why past efforts among employers to purchase health care as a group have failed and strategies employers can consider moving forward. Alan Muney recommends that employer coalitions move to total cost of care contracts including pharmacy. This interview is part of CPR’s current work to understand whether group purchasing efforts can secure better health care value for employer-purchasers. Funded by the Commonwealth Fund, CPR is assembling insights into the forces that can facilitate or hinder purchaser efforts to amass volume. Keep an eye out for more interviews on this topic.

Listen in as Suzanne Delbanco chats with Anna Sinaiko, PhD, Assistant Professor at the Harvard T. H. Chan School of Public Health. Anna Sinaiko studies patient or individual decision making in health care settings, often referred to as consumerism in health care. She and her colleagues are currently wrapping up a synthesis of evidence from the last 40 years of health care consumerism initiatives. By looking backward at past price and quality transparency efforts and employer-led benefit design programs, Sinaiko hopes to inform future policies aimed at helping patients make informed decisions in today’s complex health care market. The research will be a welcome asset for benefit managers, helping them understand patient attitudes and preferences around health care choices as well as what types of policies have successfully steered patients toward higher-value providers. In the podcast, Anna Sinaiko also speaks to the ineffectiveness of shifting costs to consumers through higher deductibles, a strategy that may be tempting to employers as a way to reduce costs during the current economic downturn but that research shows is ineffective in helping patients be better consumers.

Suzanne speaks with Peter Lee, Executive Director of Covered California Health Exchange, to discover how Covered California looks to accelerate positive change in the health care system. Peter Lee and his team at Covered California are preparing the contract language for the next phase of work with the 11 insurance carriers that participate in the Health Exchange. In preparation for the drafting of new contracts, Covered California organized three ways to receive meaningful input: a review of the evidence around value-enhancing strategies, a review of the first 5 years of Covered California, and a survey of what other private employers are asking from their health plan partners. All three of these inputs are defining the next phase of Covered California’s work, ensuring their 2.3M enrollees get high-value care while simultaneously transforming the delivery system for the better. What will the new contracts contain? Areas of focus include shifting resources to advanced primary care, holding ACO’s accountable as integrated delivery systems, and- to echo what other private employers are demanding- improved access and quality in mental health care.

Listen in as Suzanne dials up Bob Galvin, MD, Operating Partner of Equity Healthcare and former Executive Director of Health Services and Chief Medical Officer for General Electric. As one of CPR’s founders, Bob Galvin knows that employer-purchasers have the power to demand better value from the health system; the question is, how should employer-purchasers proceed now, in light of COVID-19? There is the possibility that this pandemic, and its aftermath, will provide the external force necessary to ramp up health care reform in the United States. It’s up for employers-purchasers to take advantage of the current window of opportunity, using the tools available to them like CPR’s new COVID-19 Reporting & Strategy Addendum, CPR’s Health Plan Renewal Questionnaire, and, finally, joining CPR’s Collaborative to work together with other benefit managers to evaluate both COVID-19 impacts and 2021 benefits strategies.

Suzanne Delbanco chats with Zach Brown, PhD, Assistant Professor of Economics at the University of Michigan. Zach Brown analyzed the impact of New Hampshire's price transparency website on health care spending. His research, which was featured in the Wall Street Journal (https://www.wsj.com/articles/one-states-effort-to-publicize-hospital-prices-brings-mixed-results-11561555562), examined spending on medical imagining services using a quasi-experimental approach. The research builds the case that price transparency - when delivered to patients in an easy to understand format - can help lower health care spending. Tune in to learn about the history of price transparency, the arguments for and against transparency, and where more research is needed.

Recorded on February 28, 2020. Listen in as Suzanne Delbanco speaks with Marilyn Bartlett, CPA, CMA, CFM, Senior Policy Fellow with the National Academy for State Health Policy (NASHP). Prior to joining NASHP, Marilyn served as administrator of the Health Care and Benefits Division for Montana’s state employee health plan. There, she led the successful effort to establish a Medicare Plus contracting strategy, bringing the average price paid to hospitals down to 230% of what Medicare pays, when previous payment levels ranged from 200-600% of Medicare prices. Marilyn examines the factors that helped her bold strategy succeed, including political pressure from the state legislature as well as the absence of large health systems who could more forcibly push back against the purchaser’s strategy. In addition to answering Suzanne’s questions about the effort that landed her a spot in Fortune’s World’s 50 Greatest Leaders list, Marilyn also shares anecdotes from her time as a CFO for a third-party administrator (TPA) and insights on how employers can implement more initiatives like Montana’s.

Suzanne calls Michael Chernew, PhD, director of the Healthcare Markets and Regulation (HMR) Lab in the Department of Health Care Policy at Harvard Medical School. They discuss his December 2019 publication in NEJM Catalyst, “How Different Payment Models Support (or Undermine) a Sustainable Health Care System: Rating the Underlying Incentives and Building a Better Model,” co-authored with Jermaine Heath, AB. The article examines the theory and evidence of fee-for-service, episode-based payments, and population-based payments, and makes recommendations around which payment models can create better incentives. Listen in to get into the weeds on how payment reform works while also staying grounded in a fundamental truth: we can’t expect any Alternative Payment Model (APM) to be successful if the model isn’t sustainable to those who deliver the care.

Can Electronic Health Records (EHRs) help reduce unnecessary health care spending? Suzanne speaks with Scott Weingarten, MD, MPH, consultant to the CEO at Cedars-Sinai and Professor of Medicine, and former Senior Vice President at Cedars-Sinai. Dr. Weingarten's experience implementing EHR reminders across a large health system shows how clinical decision supports embedded into point-of-care settings have the potential to improve clinical outcomes and contain health care spending. Learn how Cedars-Sinai has reduced the number of patients receiving low-value, or even harmful, tests and procedures through this initiative. Now that EHRs are ubiquitous across the country, the time is ripe to leverage their full potential for quality improvement. Technology advancements like machine learning and natural language processing in EHRs may mean that employers and other health care purchasers have a new ally in reducing wasteful health care spending and improving health care value for their plan members.

Suzanne Delbanco calls Christopher Koller, President of the Milbank Memorial Fund, to discuss top strategies for containing health care cost growth. They discuss the insurance rate review process that Rhode Island enacted during Christopher's tenure as as the state's health insurance commissioner, and how that regulatory process brought down hospital prices for all commercial purchasers. Christopher highlights how opening the black box of commercial prices continues to be necessary to change the health care industry. Suzanne and Christopher explore how today's nearly full employment marketplace is leading to more employers having the courage to stand up to health plans and hospitals to push for affordability.

CPR’s Program Director, Andréa Caballero, calls up MediQuire’s CEO, Emily Chen, to learn why purchasers are choosing to directly contract with providers in order to improve the value of their health care dollars. They discuss what makes a good match between purchasers and health systems seeking to work together, and what challenges self-funded employers and other purchasers may face when pursuing this type of arrangement, such as navigating an array of complex contracting terms. As the head of a data analytics company whose mission is to align payers and providers to focus on the patient, Emily Chen highlights the need for expanded data sharing between purchasers and providers in direct contracts in order to pinpoint the opportunities for improving health outcomes in the purchaser’s population. Emily shares why the direct contracting space is gaining so much momentum among purchasers. She explains that, when direct contracting works well, not only do purchasers and patients win in terms of better health and better value, providers are also poised to win, as direct contracts allow providers to secure a steady stream of patient volume through arrangements that empower their ability to provide population health management while maintaining their bottom line.

Listen in as CPR’s Director of Projects & Research, Julianne McGarry, checks in with Beth Waldman,JD, MPH, Senior Consultant with Bailit Health. Beth Waldman is one of the leading experts in Medicaid delivery system and payment reform design, having served as the Director of Medicaid for the Commonwealth of Massachusetts from 2003-2007 and consulting for a multitude of states and other stakeholders upon joining the Bailit Health team. Since the beginning of 2019, Beth has served as a subject matter expert to guide CPR’s work assembling key contract provisions from the 39 states with Medicaid Managed Care programs to help state Medicaid agencies leverage model contract language. During the call, Julianne asks Beth to provide a high-level look of the trends in how state Medicaid agencies use their contracts with MCOs to advance payment reform. She also asks Beth to gauge the enthusiasm level of state Medicaid agencies toward the payment reform movement. It's a special time when many providers are finally getting comfortable with certain payment reform methods put forward through programs like State Innovation Models, though it's still to early to know exactly which models are working. Want to hear more from Beth Waldman? Register for CPR’s Virtual Summit on Tuesday, December 10 where Beth will be speaking on a panel to explore how Medicaid MCO contracting is likely to evolve.

Price transparency is not one-size-fits-all. The optimal price information for a patient is different from the price transparency a physician would find useful and different, too, from what an employer-purchaser needs in order to play it's role in the health care ecosystem. Suzanne Delbanco calls Chapin White, PhD, Adjunct Senior Policy Researcher at the RAND Corporation to learn about the innovative Employer Hospital Price Transparency project. For this project - now embarking on it's third iteration, Chapin White and Christopher Whaley in conjunction with the Employers Forum of Indiana, analyzed claims data data from 4 million people who received hospital services from 1851 hospitals in more than 20 states. The project garnered attention from major stakeholders, including coverage in the New York Times and Wall Street Journal. Listen and learn why the Medicare fee schedule provides a standard benchmark that allows employers to see how good - or how bad - they have it as health care purchasers in the metro-areas studied.

How and why are social determinants of health making its way into the Medicaid managed care realm? To find out, Suzanne Delbanco calls Tricia McGinnis, MPP, MPH, Executive Vice President and Chief Program Officer of the Center for Health Care Strategies. The Center's December 2018 report, "Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations," analyzed 40 Medicaid managed care contracts and 25 approved § 1115 demonstrations across the country to analyze the trends in this emerging area of focus. Tricia McGinnis highlights states and health plans with programs and policies in place as well as new approaches to bringing social determinants of health investments to life. Through the Center's work in thinking through health equity, they have found that community-based organizations are well positioned to play an important role in bringing necessary and culturally-tailored support to patients.