Podcast appearances and mentions of brian klepper

I was talking to one health plan sponsor, and she told me if she sees any charges for value-based care anything on any one of the contracts that get handed to her, she crosses them off so fast it's like her superpower. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. What, you may wonder? Shouldn't employers and plan sponsors be all over value-based care–type things to do things preventatively because we all know that fee-for-service rewards, downstream consequences–type medical care, no money in upstream. Let's prevent those things from happening. Listen to the show with Tom Lee, MD (EP445); Scott Conard, MD (EP391); Brian Klepper, PhD (EP437). My goodness, we have done a raft of shows on this topic because it is such a thing. So, why wouldn't a plan sponsor be all over this value-based care opportunity? Now, I'm using the value-based care words and big old air quotes. Let's just keep that very much in mind for a couple of minutes here. I'm stressing right now that value-based care isn't a one-to-one overlap with care that is of value. So, let me ask you again, why wouldn't a plan sponsor be all over this air-quoted value-based care opportunity? Let me count the ways, and we'll start with this one. Katy Talento told me about this years ago. She said, it's not uncommon for dollars that a plan sponsor may pay to never make it to the entity that is actually providing the care to that plan sponsor's plan members. So, I'm a carrier and I say, I'm gonna charge you, plan sponsor, whatever as part of the PEPM (per employee per month) for value-based care or for a medical home, or pick something that sounds very appealing and value-like. Some of that money—not all of it, because the carrier's gonna keep some, you know, for administrative purposes—but whatever's left over could actually go to some clinical organization. Maybe it's the clinical organization that most of the plan's members are attributed to. Or maybe it's some clinical organization that the carrier is trying to make nicey nice with, which may or may not be the clinical organization that that plan sponsor's patients/members are actually going to. Like, the dollars go to some big, consolidated hospital when most of the plan's members are going to, say, indie PCPs in the community, as just one example. So, yeah, if I'm the plan sponsor in this mix, what am I paying for exactly and for how many of my members? I've seen the sharp type of plan sponsors whip up spreadsheets and do the math and report back that there ain't much value in that value-based care. It's a euphemism for, hey, here's an extra fee for something that sounds good, but … The end. Then I was talking to Marilyn Bartlett the other day and drilled down into some more angles about how this whole “hey, let's use the value-based care word to extract dollars from plan sponsors” goes down. Turns out, another modus operandi beyond the PEPM surcharge is for carriers to add “value-based fees” as a percentage increase or factor to the regular claims payments—something like, I don't know, 3.5% increase to claims. These fees are, in other words, hidden within billing codes. So, right, it's basically impossible to identify how much of this “value-based” piece of the action is actually costing. These fees are allowable, of course, because they're in the contract. The employer has agreed, whether they know it or not, to pay for value-based programs or alternative pay, even though the details are not at all, again, transparent. And that not at all transparent also includes stuff like, what if the health systems or clinical teams did not actually achieve the value-based program goals? What if they failed to deliver any value-based care at all for the value-based fees they have collected? How does anybody know if the prepaid fees were credited back to the plan sponsor, or if anything was actually accomplished there with those fees? Bottom line, fees are not being explicitly broken out or disclosed to the employers. Instead, they are getting buried within overall claims payments or coded in a way that obscures the value-based portion. So, yeah, charges for value-based care have become a solid plan to hide reimbursement dollars and make carrier administrative prices potentially look lower when selling to plan sponsors like self-insured employers. Justin Leader touches on this in episode 433 about the claims wire, by the way. Now, caveat, for sure, it's possible that patients can get services of value delivered because someone uses that extra money. And it's also possible that administrative costs go up and little if any value is accrued to patients, right? Like one or the other, some combination of both. It goes back to what Dr. Tom Lee talked about in episode 445. If there's an enlightened leader who gives a “shed,” then indeed, patients may win. But if not, if there's no enlightened leader in this mix, it's value based alright for carrier shareholders who take bad value all the way to the bank. Al Lewis quotes Paul Hinchey, MD, MBA, who is COO of Cleveland-based University Hospitals. And Dr. Hinchey wrote, “Value-based care has increasingly become a financial construct. What was once a philosophy centered on enhancing patient care has been reduced to a polarizing buzzword that exemplifies the lack of alignment between the financial and delivery elements of the healthcare system.” And then on the same topic, I saw William Bestermann, MD, he wrote, “The National Academy of Medicine mapped out a plan to value-based care 20 years ago in detail. We have never come close to value-based care because we have refused to follow the path. We could follow it, but we don't, and we never will as long as priorities are decided by businessmen representing stockholders. It is just that simple.” Okay, now. Let's reset. I'm gonna take a left turn, so fasten your seatbelts. Just because a bunch of for profit and not-for-profit, nothing for nothing, entities are jazz-handing their ways to wealth by co-opting terminology doesn't mean the intent of value-based care isn't still a worthy goal. And it also doesn't mean that some people aren't getting paid for and providing care that is of value and doing it well. There are, for sure, plenty of examples where an enlightened leader was able to operationalize and/or incentivize care that is of value. Occasionally, I also hear a story about a carrier doing interesting things to pay for care that is of value. Jodilyn Owen talked about one of these in episode 421. Justina Lehman also (EP414). We had Larry Bauer on the show (EP409) talking about three bright spots where frail elderly patients are getting really good care as opposed to the really bad care that you frequently hear about when you even say the words frail elderly patient. And all of these examples that he talked about were built on a capitated model or on a model that facilitated patients getting coordinated care and there being clinicians who were not worried about what code they were gonna put in the computer when they helped a patient's behavioral health or helped a patient figure out how they were gonna get transportation or help them access community services or whatnot. There are also employers direct contracting with health systems or PCPs and COEs (Centers of Excellence) and others, contracting directly with these entities to get the quality and safety and preventative attention that they are looking for. And there are health systems and PCPs and practices working really hard to figure out a business model that aligns with their own values. So, value-based care—the actual words, not the euphemism—value-based care can still be a worthy goal. And that, my friends, is what I'm talking about today with Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH). PBGH members are really focused on innovating and implementing change. We talk about some of this innovation and implementation on the show today, and it is very inspiring. Elizabeth argues for for-real alternative payment models that are transparent to the employer plan sponsors. She wants prospective payments or bundled payments, and she wants them with warranties that are measurable. She wants members to get integrated whole-person care in a measurable way, which most health plans (ie, middlemen) either cannot or will not administer. Elizabeth says to achieve actual care that is of value, cooperation between employers, employees, and primary care providers is crucial (ie, direct contracts). She also says that this whole effort is really, really urgently needed given the affordability crisis affecting many Americans. There's been just one article after another lately about how many billions and billions of dollars are getting siphoned off the top into the pockets of the middlemen and their shareholders. These are dollars partially paid for by employees and plan members. We have 48% of Americans with commercial insurance delaying or forgoing care due to cost. If you're a self-insured employer and you're hearing this, don't be thinking it doesn't impact you because your employees are highly compensated. As Deborah Williams wrote the other day, she wrote, “Co-pays have gotten high enough that even higher-income patients can't afford them.” And she was referencing a study to that end. So, yeah … with that, here is your Summer Short with Elizabeth Mitchell. Also mentioned in this episode are Purchaser Business Group on Health; Tom X. Lee, MD; Scott Conard, MD; Brian Klepper, PhD; Katy Talento; Marilyn Bartlett; Justin Leader; Laurence Bauer, MSW, MEd; Al Lewis; Paul Hinchey, MD, MBA; William Bestermann, MD; Jodilyn Owen; Justina Lehman; and Deborah Williams.   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH), supports the implementation of PBGH's mission of high-quality, affordable, and equitable healthcare. She leads PBGH in mobilizing healthcare purchasers, elevating the role and impact of primary care, and creating functional healthcare markets to support high-quality affordable care, achieving measurable impacts. Elizabeth leverages her extensive experience in working with healthcare purchasers, providers, policymakers, and payers to improve healthcare quality and cost. She previously served as senior vice president for healthcare and community health transformation at Blue Shield of California, during which time she designed Blue Shield's strategy for transforming practice, payment, and community health. Elizabeth also served as the president and CEO of the Network for Regional Healthcare Improvement (NRHI), a network of regional quality improvement and measurement organizations. She also served as CEO of Maine's business coalition on health, worked within an integrated delivery system, and was elected to the Maine State Legislature, serving as a state representative and chair of the Health and Human Services Committee. Elizabeth served as vice chairperson of the US Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee, board and executive committee member of the National Quality Forum (NQF), member of the National Academy of Medicine's (NAM) “Vital Signs” Study Committee on core metrics and now on NAM's Commission on Investment Imperatives for a Healthy Nation, a Guiding Committee member for the Health Care Payment Learning & Action Network. She now serves as an appointed board member of California's Office of Healthcare Affordability. Elizabeth also serves as an advisor and board member for healthcare companies. Elizabeth holds a degree in religion from Reed College, studied social policy at the London School of Economics, and completed the International Health Leadership Program at Cambridge University. Elizabeth was an Atlantic Fellow through the Commonwealth Fund's Harkness Fellowship program.   10:36 What are members and providers actually asking for in terms of value-based care? 10:56 Why won't most health plans administer alternative payment models? 12:17 “We do not have value in the US healthcare system.” 12:57 Why you can't do effective primary care on a fee-for-service model. 13:30 Why have we fragmented care out? 14:39 “No one makes money in a fee-for-service system if people are healthy.” 17:27 “If we think it is not at a crisis point, we are kidding ourselves.”   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   @lizzymitch2 of @PBGHealth discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation #vbc   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402), Ashleigh Gunter, Dr Spencer Dorn, Dr Tom Lee, Paul Holmes (Encore! EP397), Ann Kempski, Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter

This show is about getting or not getting patient outcomes and getting them in an efficient or not efficient way that is in alignment or not in alignment with the values of clinicians trying to care for their patients in the best way that they can. And I'm beginning this conversation with this preface, lest anyone lose track of the ends which we seek, which are Quadruple Aim–type goals. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. I'm starting here so that we don't get confused between what is a goal and what is a means to achieve a goal because today we're sort of gonna talk about technology, but we're really not gonna talk about technology. And if we're not gonna talk about technology, then, of course—because go big or go home on this show—we're not gonna talk about the mother of all healthcare technology: EHR systems (electronic health records). Ah, so cryptic, but let's proceed. I want to dig in here because this is really important, actually, to everybody, including (and especially) anyone buying healthcare services such as employers. It's also a level set for anyone involved in or about the purveyance of said healthcare services. Here's my first point. Conversations about technology may be unduly focused on technology, and this includes EHRs. I saw a Tweet recently by Joshua Liu that struck me because it really mirrors my own experience working with clinical teams. Joshua wrote, “Let me show you … why studies evaluating the same tech can have very different outcomes. Why the very same tech implemented with different workflows and people can lead to wildly different results.” See the great (and pretty funny, actually) visual that Joshua Liu made about this, but the point is this: Technology is not a thing unto itself. It is not a magic pill like those gelatin caps that you can buy at toy stores and when you toss them in the bathtub, they expand into surprisingly large foam dinosaurs. I mean, you can buy any given healthcare, digital technology, anything … and what doesn't pop out of the box along with purchase are any sort of “why” for an end user to actually use the thing, or implementation plans, processes, change management, empowered people who are bought in, adequate training, adequate staffing levels, and ongoing communication. So, look … here's the point. Unlike the bass, it's not all about the tech. There are people; there are processes. I say all this to say, it's weird to me; and Spencer Dorn, MD, MPH, MHA, my guest today, said pretty much the same thing. It's weird to me how we evaluate technology, and this includes EHRs and patient portals, which we talk about today, and even AI, which we will talk about in a shorter episode that will air in September. But it is so very, very common to talk about tech like it exists in a vacuum and is an end unto itself. For example, you hear often enough people talking about optimizing the EHR. Maybe instead, the title of the conversation should be “Optimizing the Patient-Doctor Encounter” or “Optimizing Patient Health” or “Optimizing the Ability of Clinicians to Work Together as a Team.” Tech is certainly a vehicle to achieve these goals. But whether said tech is a force of good or bad or something in the middle, or succeeds or fails, isn't inherent in the tech itself. As Dr. Dorn says, there is no intrinsic property of the technology that determines the outcome. It's how we use it, how we implement it, how we put it into daily practice, is really, ultimately, the arbiter of what happens and how it impacts lives. I'd also add, just to be a bull in the china shop, even if the tech itself has some glitches, someone decided to make everyone use it in its current form. So … yeah. Therefore, first takeaway from this show is going to be don't ascribe any given technology a label of good or bad or even neutral. This, by the way, is Kranzberg's First Law of Technology, which, of course, comes up because you know me … I cannot miss any opportunity to nerd out over something like Kranzberg's First Law of Technology. And that wraps up takeaway one: Technology by itself is not good or bad or even neutral. Reference Kranzberg's First Law of Technology. Thank you, Melvin Kranzberg. Second major takeaway is that if you're thinking about the ultimate impact of people and processes that have some technology in their midst, technology such as an EHR system, the ultimate impact will not be a black or white binary. Let's just acknowledge that we as humans love binaries, especially polarized binaries, because it's very tidy. Putting things in clear boxes removes ambiguousness that our lizard brains just do not like. But I'm keeping in mind what Tom X. Lee, MD, said on episode 445 last week. Most things in life, IRL, are somewhere in the gray murky middle. And if we understand that, we can make that middle space productive. Dr. Lee called it the productive middle. Here's how I'd put it: Don't be an edgelord. It's generally not a fact-based place to be, but also, it's not productive. Dr. Spencer Dorn and I discuss all of the above, and he makes some great points and he's very articulate. Here's the three dimensions (lots of nuances). Listen to the show for a ton of nuances, but just top-line: 1. EHR-embedded operations have the capacity to empower clinicians with information and/or overwhelm clinicians with information. Most likely what's going on will be somewhere in the middle of these two poles. 2. Impact, which is so often stated as a binary that is actually not a binary but, again, a continuum. An EHR deployment may extend or diminish human connections between docs and patients and between clinicians working together. 3. Not a binary but a continuum is whether operations with EHRs (or any tech really) make clinicians more effective and efficient or less effective and efficient from a clinician standpoint. Dr. Spencer Dorn, my guest today, is a gastroenterologist practicing in North Carolina. He spends his time doing a few different things. That includes taking care of patients. He also helps lead a large academic practice. And lastly, Dr. Dorn works in healthcare IT and clinical informatics. So, therefore, the perfect guest to talk about this whole topic with today. This is a really interesting conversation, so I hope you listen to it. Also mentioned in this episode are UNC Department of Medicine; Joshua Liu, MD; Tom X. Lee, MD; Robert Wachter, MD; and Shawn Gremminger. You can learn more at the UNC Department of Medicine Web site and by following Dr. Dorn on LinkedIn.   Spencer Dorn, MD, MPH, MHA, is vice chair and professor of medicine at the University of North Carolina (UNC), where he works to develop care models that best support clinicians and meet patients' needs, serves as a UNC lead informatics physician, conducts clinical trials, and examines the broad forces shaping healthcare. Clinically, he works with adults experiencing disorders of gut-brain interaction and GI motility.   06:15 Breaking down Kranzberg's Laws of Technology. 08:16 How do EHRs go right? 12:49 “EHRs empower us with information, yet they also overwhelm us with information.” 16:00 How do EHRs bring healthcare workers closer together? 19:35 The Digital Doctor by Robert Wachter. 21:33 “The whole point of healthcare is to help people live healthier, happier lives.” 22:41 How the same EHR deployed in different places can be more or less efficient. 25:51 Why the problem is not necessarily the EHR but actually operational. 28:51 How technology has also changed our expectations on timing and value.   You can learn more at the UNC Department of Medicine Web site and by following Dr. Dorn on LinkedIn.   Spencer Dorn, MD, of @UNC_SOM discusses #patientoutcomes using #healthtech on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Tom Lee, Paul Holmes (Encore! EP397), Ann Kempski, Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter, David Muhlestein, Luke Slindee, Dr John Lee, Brian Klepper

Today is an encore because I am going on vacation next week. It always feels a little bit like a time warp because by the time this show will air, I will be back from vacation. This show with Paul Holmes was one of the most popular episodes of 2023 and definitely is just as relevant now. A lot of the things that Paul talks about are worth repeating or listening to again. For a full transcript of this episode, click here. Before we kick in, though, I'm gonna repeat something that Ge Bai, PhD, CPA, says a lot: There's no angels and there's no devils in the healthcare industry. But we are talking about for-profit entities. And if there's one thing that's generally true about a for-profit entity, especially one that is publicly traded, it's gonna do whatever it can get away with. It becomes up to the customer to set expectations and using the purchasing discipline that they probably use everywhere else in the business because it basically is good business to have purchasing discipline. Before we kick into the episode, just a couple of things. Thing one, if you haven't, do subscribe to the weekly email that goes out describing the show. Here's just one reason to do so. It's really efficient because what is transcribed in that email is the whole beginning half (usually) of the introduction. So, if later on you are trying to remember which episode you heard something in, you can just search your email and find the show. How you subscribe is go to relentlesshealthvalue.com, hang out for probably 15 seconds, and there will be a pop-up. And while you're on the Web site, here's something else you could do. Go to the lower right-hand corner of the Web site. You will notice a little button. It's an orange button. There's a microphone. Click on that; say something like your name, your company name, maybe a word or two about Relentless Health Value; and then encourage others to subscribe to the weekly email that goes out, similarly to what I just did. Then what our team will do is take that recording and potentially use it at the end of some of the shows so we can hear somebody else talk besides myself. So, please do go over to the Web site, click on that little microphone, and record something that you might want to share with the other members of the Relentless Tribe. And with that, here's your encore. If this were a video show, I would stare into the camera with steely eyeballs right now and say that I have a special message for employer CFOs. If you aren't a CFO, pretend that you are so that you get the full effect here. So, now that we're all CFOs, let's pull up the company P&L (Profit and Loss) statement. This is what keeps us all up at night, right? Making sure that the net profit line at the bottom looks good. We could decide to lay off a few people. Reorg something or other. Beat up a vendor. We also could go over and have a strident conversation with sales leadership about what they can do to jack up their sales revenue. Top line begets bottom line and all that. Or, here's another idea: In this healthcare podcast, I am speaking with Paul Holmes, who is an ERISA (Employee Retirement Income Security Act) attorney with a specialty in PBM (pharmacy benefit manager) contracts, especially the PBM contracts from the big PBMs that get jammed in employer plan sponsor faces by whomever and which they are told look fine and that the employer plan sponsor should just go ahead and sign. Now, if we, meaning all of us CFOs, sign that paper, or someone on our benefits team signs the paper … fun fact, our company just spent 30% to 40% over market for our pharmacy benefits. That contract we just signed contains all kinds of expensive little buried treasures—treasures accruing to the PBM and other parties, to be clear, and coming at our expense. There's 17-ish very common treasures in your typical PBM contract, and none of us will ever spot them unless we know what we are looking for. But let's dig into this for a sec, especially for all of us newly minted CFOs because the real ones already did this math. Say our company spends whatever—we're a bigger company, and we spend $100 million a year on our drugs. That's a minimum of $30 million that we got taken for … $30 million a year. Because of the huge dollars at stake (30% to 40% of drug spend), it's certainly the advice of almost anybody that you talk to who's an expert in PBM contracts to have a third party—not your EBC (employee benefit consultant), which we'll get into in a sec, but somebody else (a third party)—review every PBM contract. I mean, what's the worst that can happen for anybody considering having an independent third party review their PBM contract? It costs a couple grand in lawyer fees, and they give it a stamp of approval. Knowledge is power, and now we know. But let's just say this third-party review doesn't happen. We all go with a “devil may care” about this whole PBM overcharging us by 30% to 40% possibility. And let's say the PBM contract is, in fact, a ride on the Hot Mess Express but we don't know it. Here's two pretty bad downsides, especially now, this year, since the passage of the CAA (the Consolidated Appropriations Act). Number one bad thing: Plan sponsors may get sued as per the CAA for ERISA violations. It's not just the company paying that extra $30 million, or 30% to 40%, right? It's also employees. This is risk exposure, bigly. Just like it was on the 401(k) side of the house, which Paul Holmes, my guest today, mentions later on in the interview. He talks about just how much those lawsuits cost and, yeah, exposure. As I mentioned three times already, today I am speaking with Paul Holmes about PBM contracts in all their stealthy glory. The one thing I came to appreciate is that these things are works of art … if you're into those paintings of pretty flowers where, if you look hard enough, you spot a skull tucked in the greenery (memento mori). Paul is a longtime ERISA attorney. He has dedicated his career to helping plan sponsors in their negotiations with PBMs and trying to help them reduce drug spend, especially drug spend that isn't actually paying for drugs. Here's a link to an article we discuss about how a school district in Florida is suing their longtime EBC for taking $2 million a year in alleged secret payments. We also mention an episode with AJ Loiacono (EP379). And along similar lines, Jeff Hogan mentioned on LinkedIn the other day, “It's pretty amazing that just in the course of the [past few] weeks, I'm reading, seeing, and hearing about big new CAA breach of fiduciary duty cases.” So, Paul Holmes says this more eloquently, but if you're a plan sponsor, definitely get your PBM contract reviewed and maybe consider working with an EBC who's happy to sign the disclosure statement that your lawyer has provided without disclaimers. Also mentioned in this episode are Ge Bai, PhD, CPA; AJ Loiacono; and Jeffrey Hogan.   You can learn more by emailing Paul at pbh@williamsbarbermorel.com.   Paul B. Holmes, JD, is a seasoned ERISA lawyer with nearly 40 years of specialization in that field. Paul joined Williams Barber & Morel Ltd. recently, after 31 years with Nixon Peabody LLP and Ungaretti & Harris LLP. Paul is one of the few ERISA lawyers in the United States, concentrating his practice on PBM contracting and oversight. Paul represents large employers, Taft-Hartley welfare funds, and governmental units in their selection, contracting, auditing, and disputes with large pharmacy benefit managers (PBMs). This work includes active oversight of the request for proposal (RFP) process for selecting a PBM, the negotiation and customization of PBM contracts, and legal audits of PBM compliance with their contracts. Paul provides insightful guidance on the prudent selection of independent pharmacy benefit consulting firms (who do not receive indirect compensation from PBMs), which independence is expressly required under Section 202 of the Consolidated Appropriations Act of 2021 (CAA). Recent efforts have focused on reducing wasteful drug spend promulgated by large PBMs in dozens of categories. These include the preference of Humira® biosimilars, reducing off-label utilization of GLP-1s, reducing huge markups on certain specialty generics, and customizing PBM formularies and clinical protocols to better control spend. He was selected, through a peer-review survey, for inclusion in The Best Lawyers in America® (2020 and 2021) in the field of Employee Benefits (ERISA) Law. Paul received his bachelor's degree from Bradley University and his Juris Doctor degree from the University of Illinois College of Law.   07:41 What are Paul's usual observations when a PBM contract crosses his desk? 08:34 “If you just sign … one of their model contracts …, you're probably gonna pay 30% to 40% above market on your drug spend.” 12:11 What is a PBM lawyer? And why is it important to find an ERISA PBM lawyer? 17:12 EP379 with AJ Loiacono. 17:40 Who is on the hook for the cost of the PBM contracts? 21:05 What's the problem with most ERISA lawyers today? 22:56 Lawsuit about PBM contract. 27:43 What's Paul's advice for benefits consultants? 31:40 How much might a plan sponsor be paying their consultant versus what a consultant might be making from a PBM?   You can learn more by emailing Paul at pbh@williamsbarbermorel.com.   Paul Holmes discusses #PBMContracts on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Ann Kempski, Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter, David Muhlestein, Luke Slindee, Dr John Lee, Brian Klepper, Elizabeth Mitchell, David Scheinker (Encore! EP363)  

For a full transcript of this episode, click here. Unintended consequences is a thing. ERCowboy wrote on Twitter a while back, “In any complex system, the likelihood of unintended consequences vastly outweighs the predictability of intended ones.” In this healthcare podcast, we're talking about two state laws where this is apropos: CON (Certificates of Need) laws and then COPA (Certificates of Public Advantage). Turns out, states actually have pretty much power to impact the competitive landscape in their state. They have a lot of levers they can pull. States really can make a difference in terms of improving real competition on value and on cost and quality. So, these two laws are, in a way, their attempt to do so. Before we kick into what's going on here, I think it is important to point out that these laws on their face aren't an obviously and overtly terrible mistake. This isn't like equivalent to accidentally putting ChapStick in the dryer. There were good people who spied a problem and had an idea for how to fix it. I'm reminded of something I read by Nicholas Kristof on a totally different topic, but he wrote, “The central problem is not so much that the effort was unserious as it's more focused on intentions than on oversight and outcomes.” And that pretty much sums up, I think, the gist of what's going on here. And I can say that because here we are in a position to Monday morning quarterback. So, I've invited Ann Kempski on the pod to point out what hindsight may reveal about these well-intentioned efforts, the CON and COPA laws. First up, let's talk about Certificate of Need laws, or the CONs. Currently, we have 35 states and Washington, DC, that operate CON programs with wide variations by state. The National Conference of State Legislatures has a good overview of each state's laws. Why did these laws originally get put into effect? They got put into effect to cut down on supply-driven demand that was considered to potentially raise total cost of care—because in healthcare, unlike Econ 101, more supply doesn't mean lower prices. In the real world, if you have more supply, volume goes up and total cost of care goes up, too. So, it could be considered good thinking to limit the amount of supply. Except there's four problems that wind up happening often enough, which is why some states are busy repealing these CON laws. We cover these four problems in the show that follows. Spoiler alert: What happens a lot of times is that the big get bigger. Consolidated entities have an upper hand, and we all know consolidated entities are generally not known for their competitive prices or their desire to rationalize volume. So, yeah … we dig into this and parse it out into, as I said, four main problems; but this is most commonly where it all winds up (ie, total cost of care does not go down). I have included links that Ann Kempski shared with me, including a statement from the Federal Trade Commission (FTC) and Department of Justice detailing the anticompetitive effects of state CON laws. There's also a document written by a former FTC commissioner that highlights how state CON laws can inhibit competition. And then lastly, a systemic review of 90 studies that find the costs of CON laws exceed their benefits. Okay, so let's move on to our number two state law that often does not go as planned; and this is the Certificate of Public Advantage, or the COPA, laws. Approximately 19 states have them, and these laws attempt to immunize hospital mergers from antitrust laws by replacing competition with state oversight. The idea here is that a state tells the FTC to stand down and gives their seal of approval to a merger to stop it from getting scrutinized for antitrust violations. So, like, a big dominant health system gets an okay to buy a rural hospital. Meanwhile, everybody realizes this will lead to a situation where there is a dominant health system and that dominant health system will reduce competition. But the state may choose to do this because … public advantage, as in the “PA” in COPA, Certificate of Public Advantage. But they'll do this because the state has decided that the public advantage of allowing the possibly problematic anticompetitive merger to move forward, the public advantage is a bigger advantage than having competition. Hmmm … what could go wrong here? Well, several things that Ann Kempski discusses in the show that follows. The Federal Trade Commission strongly advised the states against enacting these laws. Here is a link to this article that was on the FTC Web site. I was so thrilled to get the chance to chat with Ann Kempski, who knows so much about these topics. Ann Kempski is an independent healthcare consultant with a background in the labor movement, advocating for healthcare workers and purchasers for many years. Ann Kempski collaborates with clients to strengthen primary care, enhance union health funds, and reduce commercial prices. She often partners with academics from Johns Hopkins to analyze hospital transparency data for insights into market trends. Before we jump into the episode, we've had a loss in our community. We've had actually several, one of them being Marshall Allen, another one being Suzanne Delbanco. I know our guest today worked alongside of and really admired Suzanne. Ann Kempski says: “Suzanne was a kindred spirit and a real inspiration for me and many others. She founded two very influential nonprofit organizations: first, The Leapfrog Group and then, second, Catalyst for Payment Reform, which is dedicated to empowering purchasers to be more effective purchasers in the healthcare marketplace.” Additional Resources on State Laws and Policies That Promote Hospital Consolidation, Inhibit Competition Certificate of Public Advantage (COPA) Laws A recent story from Tennessee highlights the weak oversight and observed in COPA-related hospital mergers. Competition and Antitrust in Healthcare “Is There Too Little Antitrust Enforcement in the US Hospital Sector?” by Zarek Brot-Goldberg, Zack Cooper, Stuart Craig, and Lev Klarnet, April 2024 Catalyst for Payment Reform publications and white papers The Great Reversal: How America Gave Up on Free Markets, by Thomas Philippon, 2019   Also mentioned in this episode are Nicholas Kristof; Marshall Allen; Suzanne Delbanco; Brian Klepper, PhD; and Gloria Sachdev, PharmD.   You can learn more by following Ann on LinkedIn.   Ann Kempski is an independent health policy consultant with 30 years of experience as an analyst, advocate, and strategist advancing health reforms related to coverage, quality, and payment in public programs and commercial insurance. She has served in leadership roles in several organizations, including Kaiser Permanente, SEIU (Service Employees International Union), and the State of Delaware. Ann currently supports organizations and efforts to strengthen primary care payment and transition away from fee for service, promote competition in commercial healthcare prices and coverage, and expand access to evidence-based behavioral health services. Ann is especially grateful to collaborate with and learn from talented graduate students and faculty at Johns Hopkins Bloomberg School of Public Health on research and policy analysis to understand commercial market and price dynamics and provider behavior. She has an undergraduate degree in economics from the College of William & Mary and a master's degree in industrial and labor relations from Cornell University.   06:20 Ann remembers Suzanne Delbanco. 06:55 EP224 with Suzanne Delbanco. 07:40 What are state Certificate of Need laws? 08:44 Why are states getting rid of these CON laws? 13:26 Why CON laws are created. 15:43 EP437 with Brian Klepper, PhD. 16:09 What are the conflicts of interest and problems that arise when CON laws are created? 20:55 What happens when states get rid of these CON laws? 24:10 How are Certificate of Public Advantage laws different from CON laws? 27:58 Why does the research show that COPAs don't usually accomplish their goals? 31:34 What encouraging current events are happening in the realm of COPA laws? 32:08 Gloria Sachdev, PharmD, of Employers' Forum of Indiana.   You can learn more by following Ann on LinkedIn.   @kempann discusses #COPA and #CON state #healthcarelaws on our #healthcarepodcast. #healthcare #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Marshall Allen (tribute), Andreas Mang, Abby Burns and Stacey Richter, David Muhlestein, Luke Slindee, Dr John Lee, Brian Klepper, Elizabeth Mitchell, David Scheinker (Encore! EP363), Dan Mendelson    

In Episode 440 of 'Relentless Health Value,' host Stacey Richter engages with David Muhlestein to explore the optimal size for a medical practice, concluding that 10 to 20 physicians supported by a capable team provide the best balance of economies of scale and community integration. The conversation transitions into the challenges large healthcare systems face, particularly the Diversification Discount. This diversification often impedes patient care and operational efficiency by misaligning values with business practices. The episode delves into the paradox of optimizing primary care while still supporting specialty care, reflecting on how organizational values impact healthcare outcomes. Muhlestein suggests implementing business units or decentralized models to realign with patient care values and efficiencies. To read the full article and show notes with links mentioned as well as a full transcript, click here. 08:12 From a business and patient/better outcomes standpoint, what does an optimal provider practice look like? 11:48 EP412 with Robert Pearl, MD. 13:06 Why isn't the current landscape what David considers optimal? 14:53 What leads to the “crisis of autonomy”? 15:13 How do medical practices get to the phase of delegation? 17:39 EP438 with John Lee, MD. 18:55 EP437 with Brian Klepper, PhD. 20:53 EP432 with Kate Wolin, ScD. 20:55 EP421 with Jodilyn Owen. 23:48 Medicare Meet-Up podcast with Mai Pham, MD. 24:45 What metrics should boards of directors also be held accountable for? 28:48 Why is an efficiency-focused business not necessarily the best at managing population care? 31:13 What is the “diversification discount”? 32:49 Pivot podcast with Kara Swisher and Scott Galloway, MBA. 35:53 What can primary care doctors do to optimize their practices? 36:48 Why do we need to shift the mindset from “bigger” and “more”?  

For a full transcript of this episode, click here. Cognitive dissonance is kind of rampant in the healthcare industry. Cognitive dissonance is when what someone winds up doing, their actions, are in conflict with what they believe in. Cognitive dissonance also can mean when someone holds two contradictory beliefs at the same time. Let's say a person believes they want to do well by patients but their performance review depends on, as just one example, making care less affordable for patients. But somehow, this individual is able to conclude that what they're doing is a net neutral or a net positive despite (in this hypothetical, let's just say) obvious indications that it is not. In this hypothetical, there are, say, clear facts that show that what this person is up to is indisputably a problem for patients. But yet at every opportunity, this person talks about their commitment to patients. This rationalization, or earmuffs don't look, don't see, is cognitive dissonance. Now, it's harder to engage in cognitive dissonance the closer you are to patients because you see the impact up close. This is probably why moral injury and burnout is most associated with clinicians who are seeing patients. Unless these at-the-bedside clinicians enjoy a robust lack of self-awareness, those who are seeing patients don't, a lot of times, have the luxury of pretending that what is going on is good for patients when they can see with their own two eyes that it is not good for patients. The further from the exam room or the community, however, the easier it is to not acknowledge the downstream impact—if you can even figure out what that downstream impact is, which is also worthy of being mentioned. When the machine is really big, sometimes it's legitimately difficult to connect the dots all the way down the line to the customers, members, or patients. Kate Wolin, ScD, talked about this in an episode (EP432) a couple of weeks ago. But this whole dissonance exploration was a big reason why actually I created my manifesto, which is episode 400, because almost everything that we do in healthcare wherein we are making money or helping someone else make money is dissonant to some degree. And it literally keeps me up at night contemplating how much dissonance is too much dissonance or how much self-interest is too much self-interest. This is tough, subjective stuff. So, again … episode 400 for more on at least how I think about this. But in this healthcare podcast, I am talking with John Lee, MD, about what to do in the face of all this when working in the, as I call it, belly of the beast—working for a large healthcare organization such as a hospital. Because hospitals sometimes (and we certainly do not want to put all hospitals in the same category—they are a wildly diverse bunch), but sometimes some people at some hospitals do some things which are not things I think they should be doing anyway. They're fairly egregious breaches of trust, actually. But yet within that same organization, you have doctors and other clinicians or others who are working really hard to serve patients as best they can. This is the real world that we're talking about. And the question of the day is … so, now what? While it would be amazing if someday we build a whole new health system that didn't include some people doing things that I don't think they should be doing, that day is not today. And it's not tomorrow. I'm gonna hope that there's other people in our village who are full-on doing the disruption thing. But if we're not able to do that personally, for whatever reason, but we still want to inch forward within the existing environment and do the things that make us feel like we're achieving our mission, what's the best way to think about this? That is what I asked Dr. John Lee, and that's what our conversation is about today. Summing up his advice, which is really good advice, Dr. Lee talks at length about how it's so important to celebrate the small wins and feel good about care that is a little bit better than it was six months ago. He talks about acknowledging that you can't do everything. He talks about incremental improvement that helps both patients but also colleagues, and that's not insignificant to really consciously consider how to work together and help to support each other. Look, I just finished reading a post on LinkedIn about toxic medical culture and just how brutal and cruel some physicians and physician leaders and others can be to their colleagues. Ann Richardson writes about topics like this a lot. Follow her on LinkedIn if you're interested. So does J. Michael Connors, MD. But just saying, it's pretty cognitively dissonant to talk about the potential of team-based care and then condone or engage in toxic behavior with those same team members. There's like 90 studies on this whole topic linked to this book. But bottom line, fixing cognitively dissonant paradigms in any sort of durable or scalable way is, for sure, going to require a culture that inspires constructive criticism, innovation, and collaboration. It also requires—and this is Dr. Lee's last piece of advice—it's really important to seek out like-minded individuals as sounding boards and as a support network to commit to supporting each other. And I hope, all of you, that you feel like you've found your tribe here at Relentless Health Value. You guys are an amazing bunch, so know that and don't hesitate to reach out to each other when you need help. And I know, I know, I need to create a directory so you can all hook up more easily, so do subscribe to the weekly email because I am inching closer to finally managing to get this done and you won't know about it unless you're subscribed. Go to the Web site relentlesshealthvalue.com. You will be hit with a pop-up window fast enough, but back to easing cognitive dissonance and the why here. I thought Michelle Bernabe put how much of a difference the right culture can make for patients and those who work together really eloquently recently. This is a great why, since we spend so much of our life at work. She wrote, “Each day, we come together [ready to] roll up our sleeves, committed to our own growth, our boundaries, … and our teamwork. This collective dedication resonates throughout our organization and is, I trust, felt by our clients and [our] partners!” In the conversation that follows, Dr. John Lee offers a really nice array of examples of incremental, in the belly of the beast, stuff that might be possible in the real world (at least in the bellies of some beasts), plus some other points of contemplation. Dr. Lee is an ER (emergency room) doc by training, who is also an informaticist and chief medical information officer. I can tell you from personal experience that Dr. Lee is one of the most creative and pragmatic problem solvers that I have encountered. He says he's dedicated to trying to help move the ball forward and changing our healthcare system using information technology and using our ability to be far more transparent with the things that we try to do in a positive way in healthcare. Below are some additional episodes concerning heart failure readmissions: EP326: The Unfortunate News About HRRP, With Insight Into How to Fix It, With Rishi Wadhera, MD, MPP INBW34: The Absence of Collaboration Between Healthcare Stakeholders: What It Means EP361: The Gap in Closing Care Gaps, With Carly Eckert, MD, PhD(c), MPH Also mentioned in this episode are Kate Wolin, ScD; Ann M. Richardson, MBA; J. Michael Connors, MD; Michelle Bernabe, RN, KAT; Scott Conard, MD; Jodilyn Owen; Rob Andrews; Rishi Wadhera, MD, MPP; Peter Attia, MD; Barbara Wachsman; Kenny Cole, MD; and Mark Cuban.   You can learn more by following Dr. Lee on LinkedIn.   John Lee, MD, is both a practicing emergency physician and a highly regarded clinical informaticist. He has served as chief medical information officer at multiple organizations and has an industry reputation for maximizing the utility and usability of the electronic medical record (EMR) as a digital tool. He was the recipient of the HIMSS/AMDIS Physician Executive of the Year Award in 2019. He has deep expertise in EMRs, informatics, and particularly in Epic. He has multiple analyst certifications, which gives him a unique advantage in delivering solutions to Epic organizations. His vision is a healthcare system that is driven completely by transparent data, information, and knowledge, delivered efficiently.   07:37 What is cognitive dissonance relative to the healthcare industry? 08:57 What are the systems that start to bear down on individuals within the healthcare system? 10:14 EP391 with Scott Conard, MD. 10:48 EP421 with Jodilyn Owen. 10:59 EP415 with Rob Andrews. 12:30 EP326 with Rishi Wadhera, MD, MPP. 13:10 “The system has almost gamed them.” 17:49 EP430 with Barbara Wachsman. 19:07 How can alignment still be achieved in the face of cognitive dissonance? 20:34 EP431 with Kenny Cole, MD. 24:06 Why does it take more than one person to solve the dysfunction in the healthcare system? 26:26 What are some little changes that can help change the cognitive dissonance in healthcare? 28:22 Why is a hierarchal healthcare structure not necessarily beneficial? 30:38 The RaDonda Vaught story. 37:58 “Be happy in the small things.”   You can learn more by following Dr. Lee on LinkedIn.   John Lee, MD, discusses overcoming #cognitivedissonance on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Brian Klepper, Elizabeth Mitchell, David Scheinker (Encore! EP363), Dan Mendelson, Dr Benjamin Schwartz, Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole  

For a full transcript of this episode, click here. “Anyone who isn't confused really doesn't understand the situation.” That's a quote by Edward R. Murrow and very apropos. I started thinking about this conversation that I had had with Brian Klepper, PhD, because so much going on right now—so many discussions and dissections taking place about primary care financial struggles, about what is value in healthcare. And the RUC (Relative Value Scale Update Committee) is, at a minimum, an underlying factor; but yet it doesn't come up. Almost ever. Merrill Goozner called the RUC the AMA's (American Medical Association's) “dark secret,” and I can see why. Just one procedural note before I roll tape with Brian Klepper. We're gonna go a little rogue today because you kind of got to understand what the RUC is before I can get into the two points I really want to make about it. So, here's my outrageous plan, which will shake up our standard Relentless Health Value format. Today, I'm gonna make the points I want to make after the interview, not before, like usual. I will, however, just mention the two points so you can keep them in mind as I talk with Brian. Here's the first point, and it's about the doomed financials of primary care. Why is it that primary care has a lot of times no business model unless part of the business model includes driving profitable downstream utilization? And when I say utilization, do I mean services with bigger RVUs (relative value units)? Why, yes, I think I do. We'll dig into this later. Here's my second point, and it's my view on the nature of any postulations that the “value of healthcare services” is equivalent to the prices that we pay for said services. Again, more on that later, but here is my original conversation with Brian Klepper. Brian Klepper is a longtime healthcare analyst and former CEO of the National Business Coalition on Health. Also mentioned in this episode are Merrill Goozner and Elizabeth Mitchell. People who have written about primary care: Scott Conard, MD; Paul Buehrens, MD, FAAFP; Larry McNeely; Primary Care Collaborative; Nisha Mehta, MD; Dan Mendelson; Tony Lin, MD; Juliet Breeze, MD; Raymond Tsai, MD; Linda Brady; Guy Culpepper, MD; David Muhlestein, PhD, JD   You can learn more in this article and on the AMA Web site.   Brian Klepper, PhD, is principal of Worksite Health Advisors and a nationally prominent healthcare analyst and commentator. He speaks, writes, and advises extensively on the management of clinical and financial risk, on high-performance healthcare, and on realizing the potential of primary care. His current focus is on high-performing healthcare organizations that consistently deliver better health outcomes at lower cost than usual approaches in high-value niches and how, integrated with advanced primary care, they can be configured into turnkey comprehensive high-value health plans that can disrupt the status quo.   02:29 What is the RUC? 06:26 Why is primary care not the “easy” specialty? 09:42 What are three low-value things per RUC? 10:33 EP436 with Elizabeth Mitchell. 10:38 What is a root cause of why primary care doesn't get paid more? 12:50 Why doesn't value equal money?   You can learn more in this article and on the AMA Web site.   @bklepper1 discusses #TPA and #primaryhealthcare and #mentalhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Elizabeth Mitchell, David Scheinker (Encore! EP363), Dan Mendelson, Dr Benjamin Schwartz, Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman  

For a full transcript of this episode, click here. Here's a great musing that I read on LinkedIn: How will alternative primary care models fare when growth mode gets balanced with profitability and VC-supported burn rate is transformed to Big Retail bottom-line expectations? Mission v. margin. I'm gonna add to this: How will alternative primary care models, or even just doing good primary care, fare when it encounters the current system rife with perverse incentives of all kinds, including, yeah, for sure, Big Retail bottom-line expectations but also Big Health System and Big Payer bottom-line expectations and current business models? This show from last year was wildly popular—maybe one of our most popular shows—and relisten to it in the current context of what's going on right now in the primary care and MSO (Managed Services Only) space. Coming up, I'm gonna probably do a whole show on this if I can get my act together; but this encore is really relevant right now. One piece of podcast business before we get into the episode: Please sign up for our weekly email if you haven't already, especially if you consider yourself part of the Relentless Health Tribe. I am mentioning this not only because it's a great way to keep track of our shows because you can do an email search to remember where you heard something, since a good deal of the show intros are in the emails, but also, there's a plan afoot to hold some Zoom meetings to talk about different topics etc—and you won't be notified of such goings-on unless you're subscribed. You can unsubscribe whenever you want, by the way; and I am way too busy to send more than one email a week or spam if that was a concern. On Relentless Health Value, I don't often get into our guests' personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here. Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point-blank that Dr. Conard's experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today. Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of the show. He says: So, this isn't about punishing or blaming aspects of care that are being overrewarded today. It's really about what's the path forward for corporations, for middle-class Americans, and for primary care doctors who don't choose to be part of a big system. We have to figure out how to solve this problem. I hope people don't hear this and think that there are horrible people at some not-for-profit hospital systems, for example. There are some great people at not-for-profit health systems, but they have some really screwed-up incentives. A few notable notes from Dr. Scott Conard's journey and words of wisdom that I will just highlight up front here: He says that as a PCP, you actually can produce high-value care in a fee-for-service model … if you think differently and you change practice patterns. I have heard this from others as well, including most recently David Muhlestein, PhD, JD, who says this in an episode (EP393). As Dr. Scott Conard says later in this episode, healthcare organizations must embrace the art of medical leadership. So, I guess that's a spoiler alert there. Another point that Dr. Conard makes very crisply toward the end of the show is that doctors can kinda get pushed and pulled around in this mix. You have docs just trying to provide good care, and they work for one entity that gets bought and now it's some other entity … and what's happening upstairs and the prices being charged or somebody somewhere deciding not to make prices transparent, or deciding to sue low-income patients for unpaid medical bills or what charity care to offer or not to offer. These are not doctors in clinics making these calls, and we need to be careful here not to homogenize what some of these health systems are choosing to do like some kind of democratic vote was taken by everybody who works there. Health systems, hospitals, are many-celled complex entities. And a third takeaway—there are a bunch of takeaways in this show, but a third one I'll highlight here from Dr. Conard's story—is the old fiduciary responsibility code word being used by health system administrators as a euphemism for strategies that might need a euphemistic code word because the strategy has questionable community benefit. In the case study that we talk about today, the local health system managed to raise healthcare spend in North Texas by $100 million year over year. Employers and employees in North Texas communities wound up paying $100 million more year over year in healthcare one particular year. This was prices going up. It also was removing a big systemic initiative to keep heads out of hospital beds. Reiterating here, we are not talking about doctors here particularly because, of course, the vast majority of doctors are trying to prevent avoidable hospitalizations. But suddenly in North Texas, physicians did not have the population health efforts and the team really standing behind them helping to prevent avoidable hospitalizations. That sucks for everybody trying to do the right thing, and, as has been said, burnout is moral injury in a cheap Halloween costume. Moral injury happens when you have good people, clinicians, doctors, and others who realize that what is going on, at best, is not helping the patient. Also mentioned in this episode are Benjamin Schwartz, MD, MBA; David Muhlestein, PhD, JD; Brian Klepper, PhD; Al Lewis; Robert Pearl, MD; Karen Root, MBA, CCXP; and Wendell Potter.   You can learn more by emailing Dr. Conard at scott.conard@converginghealth.com.   Scott Conard, MD, DABFP, FAAFM, is board certified in family and integrative medicine and has been seeing patients for more than 35 years. He was an associate clinical professor at the University of Texas Health Science Center at Dallas for 21 years. He has been the principal investigator in more than 60 clinical trials, written many articles, and published five books on health, well-being, leadership, and empowerment. Starting as a solo practitioner, he grew his medical practice to more than 510 clinicians over the next 20 years. In its final form, the practice was a value-based integrated delivery network that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the chief medical officer for a brokerage/consulting firm and an innovation lab for effective health risk–reducing interventions. Today, he is co-founder of Converging Health, LLC, a technology-empowered consulting and services company working with at-risk entities like self-insured corporations, medical groups and accountable care organizations taking financial risk, and insurance captives to improve well-being, reduce costs, and improve the members' experience. Through Dr. Conard's work with a variety of organizations and companies, he understands that every organization has a unique culture and needs. It is his ability to find opportunities and customize solutions that delivers success through improved health and lower costs for his clients.   06:54 What triggered Scott's career journey? 07:31 What caused Scott to rethink what is good primary care? 08:11 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms? 09:25 EP335 with Brian Klepper, PhD. 09:53 How did Scott's practice change after this realization? 10:04 What is a “Whole-Person Risk Score”? 11:08 Scott's book, The Seven Numbers (That Will Save Your Life). 13:05 “You start to move from a transactional model to a relationship model.” 15:31 Did Scott have any risk-based contracts? 16:08 Why is it so important to look at total cost of care and not just primary care cost? 21:08 Scott's book, The Art of Medical Leadership. 22:13 EP381 with Karen Root. 30:43 Why did Scott move over to help corporations? 33:10 EP364 with David Muhlestein, PhD, JD. 33:51 “Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned.” 34:31 EP384 with Wendell Potter. 34:43 “It's the system that's broken; it's not bad people.”   You can learn more by emailing Dr. Conard at scott.conard@converginghealth.com.   @ScottConardMD discusses #primarycare #marginvsmission on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Jerry Durham, Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen

This is a conversation about physician compensation, which is often oddly misaligned from the way that the whole physician or provider organization is getting paid. Now, first thing to point out: There are lots of different kinds of physicians doing all kinds of different things. As with most everything in healthcare, lumping everybody together and making general proclamations about what is best is a really cruddy idea. With that disclaimer, if you think about the main models of physician compensation, there are two; and this is oversimplified, but let's call one fee for service (FFS), which is really getting paid for generating RVUs (relative value units)—in short, getting paid for volume. The more you do (especially the more expensive things you do), the more you get paid. And then we have getting some kind of capitation payment. A capitated payment is some kind of per member per month-ish flat payment to ideally keep patients healthy, and you will make the most money if you can figure out how to have the least volume of expensive stuff. As an individual doc getting a salary to care for a patient panel of a certain size, let's just consider commensurate with that. These incentive models obviously have a big impact on any given doctor's ability to get paid to do things that they think they should be doing. For example, the current fee-for-service RVU fee schedule frequently rewards those doing the stuff a lot of specialists do much more than those doing primarily cognitive work, including those doing work for patients who aren't sitting in the exam room at the time—like a PCP arranging for a patient to go to hospice or answering patient portal questions. In my opinion, the goal here should be to pay docs and others fairly for providing high-value care. These payments also should actually be proven to actually incent that high-value care. Here's the obvious problem: Neither of these two things, either the quantifiable definition of high-value care and/or the best way to pay for it, has any kind of canon. There are no rules which are considered to be particularly authoritative and definitive here, really. So, what is the downside of not aligning physician compensation models to what good looks like, meaning to the kind of care that patients really need in that particular community? A couple of downsides for you: One is moral injury. Not the only reason, but a reason for moral injury is getting paid in misalignment with what is best for patients. That sucks. You want to help your patients as best you can, and then you can't earn a living and/or you get in trouble with the boss if you do what you think is right. This can cause real mental anguish for especially PCPs but also others who see the need to do anything that doesn't have a billing code. Here's another downside to not worrying about physician compensation, and it's for plan sponsors (employers, maybe) who are trying to get integrated care or a medical home for their employees. I was talking to Katy Talento about this. She was telling me that in ASO (administrative services only) contracts, there are often line items for value-based care and for capitated payments. So, good news? Well, let's follow the dollar here, because we wind up with a disconnect that doesn't help patients but certainly can earn a nice little kitty for those who can get away with it. Here's where that dollar goes: This VBC (value-based care) or capitated payment kitty may go to a health system that the ASO says is to be a medical home for employees or plan members. But the PCPs mainly who are treating members in those medical homes are getting paid, it often turns out, fee for service with maybe some quality kickers. So, the plan is paying a value-based care payment, but the PCPs are getting paid FFS. Is anyone shocked when the members report that they don't actually feel like they are getting integrated care, that they are getting rushed in and out because maximizing throughput becomes a thing when you're getting paid for volume? Dan O'Neill also talks about this at length in episode 359, because IPAs (independent physician associations) are doing kinda the same thing. Getting so-called value-based care contracts with MA (Medicare Advantage) plans or CMS or employer groups, I'd imagine, and then paying all the individual practices or the solo practitioners fee for service and scooping up the excess payments themselves, most docs manage to provide high-enough-quality care that the contract holder can scoop up the profit off the capitation without actually having to share the capitation to achieve this high-enough-quality care. In this healthcare podcast, I am digging into all of this physician compensation ballyhoo with Rachel Reid, MD, MS. She was an author on a study at the Center of Excellence on Health System Performance at RAND. This study specifically set out to look at how health systems and provider organizations (POs) affiliated with those health systems incentivize and compensate the physicians who work there. Short version: Yeah, it's confirmed. Most docs are paid using the classic RVU productivity measures representing a big chunk of their compensation, even PCPs. There's frequently some kickers or extra payments to achieve some kind of quality metric, but this is the icing, not the cake. The cake is still very fee for service-y. This is true regardless of how the physician organizations, the provider organizations themselves are getting paid by payers. I asked Dr. Rachel Reid a bunch of questions about this, but one of them was (this seems weird, a weird misalignment), Why is this happening? And Dr. Reid listed out five reasons beyond the macro existential question of what is value and do we even know how to change human behavior to get it. 1. The payment is not big enough from the payer for the physician organization to go through all the time and trouble and risk frankly of changing the whole comp model. 2. The value-based payment arrangements that do exist at the organizational level often have a fee-for-service chassis with an icing of quality payments or some kind of value payment on top of it. So, maybe there's actually more alignment than we might think. 3. It's hard to try to change comp models—it's a thing. And there is risk in messing it up. 4. Inertia. The ever-present inertia. 5. We know what we want to move from, but what exactly are we moving to? And this “What do we want to move to?” is going to change for PCPs and for every single different specialty and could even vary by patient population. I then also asked Dr. Reid what could be done by plan sponsors, for example, to pay docs in alignment with the goals of the contract; and she said, write physician comp expectations into the contract. Something to think about. We dig into all of this today. Shows that you should, for sure, listen to for additional insights include the one with Dan O'Neill (EP359) as aforementioned. Also the show with Brian Klepper, PhD (AEE16), where we dig into how the RUC is behind some of these FFS rates. Also episode 391 with Scott Conard, MD. My guest today is Rachel Reid, MD, MS. She is a physician policy researcher at RAND Corporation and a primary care physician at Brigham and Women's Hospital.   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.     Rachel Reid, MD, MS, is a physician policy researcher at the RAND Corporation. Also a practicing primary care physician, her research focuses on measuring cost, quality, and value in healthcare. She has particular interest in the primary care delivery system, physician payment and compensation, and delivery and payment system reform. Dr. Reid has been engaged in the RAND Center of Excellence on Health System Performance, assessing health systems' compensation and incentives for physicians, leading work related to assessing low-value healthcare delivery, and measuring primary care spending. She is the principal investigator on an NIH-funded grant assessing novel Medicare billing codes for transitional care provided after hospital discharge. Prior to joining RAND, Dr. Reid worked in the Research and Rapid Cycle Evaluation Group at the Centers for Medicare & Medicaid Services' Innovation Center. Her clinical work has included ambulatory primary care and hospital-based internal medicine. She is an associate physician at Brigham and Women's Hospital and an instructor in medicine at Harvard Medical School. Dr. Reid received her AB in biochemical sciences from Harvard University and her MD and MS in clinical research from the University of Pittsburgh School of Medicine.   07:13 What did Dr. Reid's recent study show about how doctors are currently being paid and incentivized? 08:11 Why Dr. Reid decided to do the study in the first place. 09:49 What are the main foundations of what doctors are paid on? 10:31 Why is value-based compensation still just the “icing” on the cake? 13:08 What is the biggest value add for doctors, and does it vary between specialties? 14:32 Why wouldn't a physician organization change their comp models? 19:55 Are we at a moment of evolution? 20:20 “Tying dollars to measured quality gaps doesn't necessarily produce results.” 20:42 EP295 with Rebecca Etz, PhD. 22:04 “I don't think there's a current gold standard for how to pay doctors.” 25:37 Job one: What are we trying to incent? 31:28 From the payer or insurer perspective, what's the leverage they have to change doctor compensation?   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.   Rachel Reid, MD, MS, of @RANDCorporation discusses on our #healthcarepodcast how doctors get paid. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry

On Relentless Health Value, I don't often get into our guests' personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here. Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point blank that Dr. Conard's experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today. Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of the show. He says: So, this isn't about punishing or blaming aspects of care that are being overrewarded today. It's really about what's the path forward for corporations, for middle-class Americans, and for primary care doctors who don't choose to be part of a big system. We have to figure out how to solve this problem. I hope people don't hear this and think that there are horrible people at some not-for-profit hospital systems, for example. There are some great people at not-for-profit health systems, but they have some really screwed-up incentives. A few notable notes from Dr. Scott Conard's journey and words of wisdom that I will just highlight up front here: He says that as a PCP, you actually can produce high-value care in a fee-for-service model … if you think differently and you change practice patterns. I have heard this from others as well, including most recently David Muhlestein, PhD, JD, who says this in an upcoming episode. Now here's a surefire way to fail at that, though: Be a physician who is getting asked to basically do everything a patient needs done alone and by themselves with little or no help and being told to do all of this within a seven-minute visit. This surefire way to not do well also could mean working on a team that's a team in name only because it's more of a marketing thing than an actual thing. As Dr. Scott Conard says later in this episode, healthcare organizations must embrace the art of medical leadership. So, I guess that's a spoiler alert there. Another point that Dr. Conard makes very crisply toward the end of the show is that doctors can kinda get pushed and pulled around in this mix. You have docs just trying to provide good care, and they work for one entity that gets bought and now it's some other entity … and what's happening upstairs and the prices being charged or somebody somewhere deciding not to make prices transparent, or deciding to sue low-income patients for unpaid medical bills or what charity care to offer or not to offer. These are not doctors in clinics making these calls, and we need to be careful here not to homogenize what some of these health systems are choosing to do like some kind of democratic vote was taken by everybody who works there. Health systems, hospitals, are many-celled complex entities. And a third takeaway—there are a bunch of takeaways in this show, but a third one I'll highlight here from Dr. Conard's story—is the old fiduciary responsibility code word being used by health system administrators as a euphemism for strategies that might need a euphemistic code word because the strategy has questionable community benefit. In the case study that we talk about today, the local health system managed to raise healthcare spend in North Texas by $100 million year over year. Employers and employees in North Texas, communities, wound up paying $100 million more year over year in healthcare one particular year. This was prices going up. It also was removing a big systemic initiative to keep heads out of hospital beds. Reiterating here, we are not talking about doctors here particularly because, of course, the vast majority of doctors are trying to prevent avoidable hospitalizations. But suddenly in North Texas, physicians did not have the population health efforts and the team really standing behind them helping to prevent avoidable hospitalizations. That sucks for everybody trying to do the right thing, and, as has been said, burnout is moral injury in a cheap Halloween costume. Moral injury happens when you have good people, clinicians, doctors, and others who realize that what is going on, at best, is not helping the patient. You can learn more by emailing Dr. Conard at scott@scottconard.com. Scott Conard, MD, DABFP, FAAFM, is board certified in family and integrative medicine and has been seeing patients for more than 35 years. He was an associate clinical professor at the University of Texas Health Science Center at Dallas for 21 years. He has been the principal investigator in more than 60 clinical trials, written many articles, and published five books on health, well-being, leadership, and empowerment. Starting as a solo practitioner, he grew his medical practice to more than 510 clinicians over the next 20 years. In its final form, the practice was a value-based integrated delivery network that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the chief medical officer for a brokerage/consulting firm and an innovation lab for effective health risk–reducing interventions. Today, he is co-founder of Converging Health, LLC, a technology-empowered consulting and services company working with at-risk entities like self-insured corporations, medical groups and accountable care organizations taking financial risk, and insurance captives to improve well-being, reduce costs, and improve the members' experience. Through Dr. Conard's work with a variety of organizations and companies, he understands that every organization has a unique culture and needs. It is his ability to find opportunities and customize solutions that delivers success through improved health and lower costs for his clients. 05:26 What triggered Scott's career journey? 06:02 What caused Scott to rethink what is good primary care? 06:42 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms? 07:56 Encore! EP335 with Brian Klepper, PhD. 08:24 How did Scott's practice change after this realization? 08:35 What is a “Whole-Person Risk Score”? 09:39 Scott's book, The Seven Numbers (That Will Save Your Life). 11:37 “You start to move from a transactional model to a relationship model.” 14:02 Did Scott have any risk-based contracts? 14:39 Why is it so important to look at total cost of care and not just primary care cost? 19:39 Scott's book, The Art of Medical Leadership. 20:44 EP381 with Karen Root. 29:14 Why did Scott move over to help corporations? 31:42 EP364 with David Muhlestein, PhD, JD. 32:22 “Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned.” 33:02 EP384 with Wendell Potter. 33:15 “It's the system that's broken; it's not bad people.” You can learn more by emailing Dr. Conard at scott@scottconard.com. @ScottConardMD discusses #privateequity on our #healthcarepodcast. #healthcare #podcast #PCP #patients Recent past interviews: Click a guest's name for their latest RHV episode! Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372)    

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday December 8 will be futurist Jeff Goldsmith; privacy expert Deven McGraw (@healthprivacy), and employer and care consultant Brian Klepper (@bklepper1). Deven has a bunch of insights from her new study on health data access!

We got two new reviews this week on the podcast, which I was thrilled to see. The first was from, it turns out, Dave Chase from Health Rosetta, who wrote that “with so many people in healthcare practicing ‘innovation theater' and bloviating versus driving real change, it's a breath of fresh air to listen to Relentless Health Value.” Thank you so much for saying that, Dave. We try really hard to get guests who are actually doing great things such as yourself. And then there's another review from mattiw2002, who says, “For anyone trying to stay abreast of developments in the healthcare space, there's none better than … Relentless Health Value.” Thank you so much to the two of you who took the time to write a review—could not appreciate it more. There have been two inbetweenisodes this year where I get deep into the why behind the “why collaborate.” And when I say collaborate, what I mean is anybody in the healthcare industry working together with and for the patients that we're supposed to be serving here. It's creating alignment amongst stakeholders around what's best for the patient. Here is the nutshell version of the two previous shows. First point: Patients fall into one care gap after another. You hear this from any PCP you talk to who's working in a care setting when there's little, if any, collaboration effort on the front end to ensure a non-fragmented patient journey. So then, all these care gaps wind up getting surfaced, which, by the way—let's not forget this—these care gaps were there all along negatively affecting patient outcomes. It's just, in the past, we didn't know about them. But now that we know about them, it becomes the fee-for-service PCPs' job to mop up all the care gaps while the faucet is still running. So, that's the situation analysis, and if we're going to put an end to this, it means that payers have to align with providers and give enough incentive for those providers to create a non-fragmented patient journey (ie, making sure that the care gaps don't happen to begin with). This also means providers need to talk amongst themselves and collaborate. Keep in mind that a multi-morbid Medicare patient sees something like 5 to 13 doctors, on average, depending on what study you look at … 13! If anybody thinks that a patient can see 13 doctors not collaborating with each other and coordinating care and not wind up with some polypharmacy adverse event or materially conflicting advice … I don't know. Call me. I just do not understand how consistent excellence in patient outcomes or patient care even could be achieved. That whole cliché the left hand doesn't know what the right hand is doing? That's a cliché for a reason, and I seriously suspect the entire field of medicine isn't weirdly excluded from it. So, first point: Collaboration/alignment is required amongst healthcare stakeholders for patients to get decent outcomes, especially patients with multiple chronic conditions. Payers gotta pay for the right stuff, and providers have to coordinate care. Otherwise, you wind up with all of the care gaps that PCPs currently working in systems with fragmented patient journeys are seeing. Here's the second point from earlier episodes: Financial toxicity is clinical toxicity. Patients are forgoing care they need and not taking drugs they need because they cannot afford them. This is not speculation. Trilliant Health just released a report that showed this. Healthcare utilization, if you subtract COVID care and behavioral health, might be permanently down. Other reports speculated that by 2030, a leading cause of death might be nonadherence due to cost concerns. Wayne Jenkins, MD, in episode 358, talks about a whole constellation of negative effects when patients can't afford care; and yeah … here we are. Patients cannot afford their care. They cannot afford premiums, deductibles, out-of-pockets. These are insured patients a lot of times we're talking about here. Also, this is not a “Medicaid” problem, as Dan Mendelson put in episode 385. So, go back and listen to the earlier shows for the who and the what and the why of the above and much more context; but nothing I've just said is stuff that I personally would regard as my personal opinion. There is one study after another that bears all this out. There is just one anecdote after another. Fragmented patient care and care that is way more expensive than a patient can afford is going to result in outcomes that are not, let's just say, super. Alright, all of this being said, does then aligning payers and providers, and providers collaborating with each other and coordinating care … if these things are done, do patient outcomes improve? Do care gaps reduce? Are patients more satisfied with their care? Said another way, when physician practices get paid to deliver health and not paid for sick care, does patient health actually improve? Why, yes. Yes, it does. Why do I say this? First of all, this very much seems to be the conclusion of CMS. Here's from the Center for Medicare & Medicaid Innovation (CMMI). They released a report updating their strategic vision for implementing value-based care. One of the key new strategies focuses on creating greater care coordination between primary care doctors and specialists. What might be some of the success stories that precipitated the CMMI focusing their strategy on exactly what I've been running around squawking about for one to three years now? The ChenMed Case Study: ChenMed focuses on the most vulnerable patients and dramatically improves access for those patients, which has led to a 30% to 50% reduction in hospitalizations. They published there's been a 20% to 30% reduction of stroke. They've doubled six-month cancer survival rates and, in some cases, reduced heart failure readmissions by 50%, 70%, up to 90%. They see evidence that they are extending lives five or more years. How? By the providers being aligned with the payers and then also making sure that there is very coordinated care going on there. Johns Hopkins has a paper in JAMA that concluded that a care coordination model can be associated with improved outcomes, including substantial cost reduction. I was talking to Larry Bauer from FMEC, the Family Medicine Education Consortium; and he sent me probably a 40-page PDF of really great patient results when care is coordinated and payers are aligned to pay for health. As just one example, Dr. Daniel Hoefer from Sharp HealthCare, they have created what they call their Transitions program. And the idea is by moving aggressive care upstream via community-based palliative medicine, they have proven that the vast majority of people never need to see the inside of a hospital during the last year-ish of their life. The revolving door of hospitalization should be considered an archaic residual of a bygone era, as they put it. Again, this is very well-coordinated care with payer alignment. Do patients actually want this stuff? Before I get into our evidence here, just let me remind you that Kaiser is a payvider with a narrow network and also that Centivo is an innovative TPA (third-party administrator) pulling together narrow networks. On the podcast the other week, Dan Mendelson (EP385) from Morgan Health said that 40% of new employees are choosing lower-premium plans with either Kaiser or Centivo benefit designs. They are choosing lower-cost plans just as much for the lower premiums as for the care coordination and the “I don't want anybody between me and my doctor” messages. This is what happens when payers and providers are aligned. Nobody gets in the middle there. Heard a similar story from Nick Stefanizzi (EP383) from Northwell Direct. They're doing direct contracting with customers like Whole Foods. Everybody I talk to here is surprised how many employees are electing these kinds of plans. So, yeah … The Nuka System of Care in Alaska (EP312), where I get into this with Doug Eby, MD, MPH, CPE, in great detail. But wow, just wow there. With the Nuka ecosystem, they went from basically a failing mess into the health system that many consider to be the best or one of the best in the country at something like half the price per patient than in mainland US. They have this whole thing where they integrate specialty care into primary care. They have established an agreed-upon referral patterns and also an agreed-upon way to work with specialists that very much involves PCPs talking to specialists so that the whole person, the whole patient can be considered. They structure their whole program around paying for health and getting paid for health. Also, Nuka has a 96% patient satisfaction rate. So again, patients are certainly on board with this. If I was gonna sum up these five examples, I would certainly say that any physician practices looking to take better care of patients, rediscover clinical excellence and focus … get aligned with payers (CMS or otherwise). That's step one and certainly easier said than done. After that, work to collaborate with fellow providers. All of these entities that we just talked about who can brag about their patient outcomes and care quality are doing both of the stuff that we just talked about: aligning and collaborating with payers and other providers. They are also, at the same time, folding three other things into their strategy. And this other stuff is required because you kinda can't align with payers and you can't collaborate unless you're doing these three things at the same time: standardizing best-practice care, getting and using data, and using good technology in conjunction with that data. All of this in the service of this last thing, which is turning transactions into relationships. Human relationships. Relationships with patients. As Rebecca Etz, PhD, and her team at The Larry A. Green Center have shown quite crisply (discussed in episode 295), no relationship with a patient means worse outcomes for patients. End of sentence. But then there's also having relationships with colleagues and relationships with other docs who have patients in common. It is really tough to coordinate care without relationships, and it's also not very fulfilling. Alright, moving on to another question: Are doctors happy in these models where payers are paying for health and where it's a must-have to coordinate across the continuum of care? Well, I can tell you a couple of things. ChenMed has been named to Newsweek's “Most Loved Workplaces” list. Nuka System has a 93% employee satisfaction rating. Considering that elsewhere one out of two family practice docs are burned out, this is pretty striking in contrast. Also, here's another quote from a physician leader about good accountable care where health is being paid for. He said, “This has changed our physicians' lives … the idea that we can get paid to actually take care of people. To actually have data to send people to the best for follow-up care, who we know will continue and contribute to the patients' well-being in the same way. Burnout reduces here because burnout is moral injury in a cheap Halloween costume.” I'm really sorry I can't remember who said that because it's a great quote and so true. Larry Bauer from FMEC also told me the other day that DPC (Direct Primary Care) conferences have never had a session on burnout. Larry says he tells people if they want to see what 350 happy primary care docs look like, they need to come to a DPC summit. They're happy as clams. Now, while DPC isn't the “be entirely responsible for downstream costs” kind of accountable care, what is going on in DPC is, these docs are accountable to their patients and for the care that they are providing. Here's another anecdote which I think, in sum, adds up to a “yes” if the question is “Do docs really like this stuff?” I had a long conversation with Scott Conard, MD, the other day about his work with clinics in Queens. What I learned was, these clinics, they used to have waiting rooms overflowing with patients who had been waiting the entire day to be seen and just ... it wasn't good for anybody. Fast-forward a few years—high-risk patients get seen fast, and there's time for care coordination. Patients are happy; outcomes are better. But here is why I inferred that the docs are happy in this model: There was a new office manager. New office manager starts trying to go back to the old way, the “normal” way that practices are run. And it was mutiny on the bounty. No way no how were those docs going back. I took that as a pretty solid testimonial if I ever heard one. So, I don't know if anybody has done any sort of global physician satisfaction studies to determine if physicians who are in pay-for-health models where they're collaborating with one another are happier and less burned out than doctors in the current fee-for-service (FFS) environment. But I can tell you that if somebody did do this, there's gonna be one really big confounding factor … and this is what it is: There's a world of difference between a well-functioning accountable care model and a very terrible one. I have had a series of (as I said earlier) pretty heartbreaking, honestly, conversations with PCPs around the country who think value-based care pretty much sucks. For the big why on this, listen to the show with Dan O'Neill (EP359). But in short, in “not quite there yet” value-based care models, one's still in the two canoes messy middle (ie, they've got one foot in the value-based care world and one foot firmly in the FFS world). Life can get really hard for PCPs especially because they get the worst of both. They get to be care gap cowboys and cowgirls while, at the same time, having to do all of the FFS coding; and they still have seven-minute visits and RVU targets. There's not really great population health. Nobody's figured out how to defragment the care journey. And then there's the whole measurement industrial complex that gets piled on top of their day. I cannot stress this enough. Alright, so let's just check off our last big question here for the money motivated. This especially comes up when talking with especially specialists, who are doing very well, thank you very much—financially, I mean—in the current FFS status quo. So, let's not avoid the elephant in the room. Is taking on risk, getting paid for value, being accountable to deliver great results, deliver health … is it worth it from a financial standpoint? Alright, let's take a look at this. Here's from show 343 with David Carmouche, MD, when he was at Ochsner. He said, “Anything that we can do to convert the effective reimbursement in the Medicare space to something greater than Medicare fee-for-service rates, we think that this is in our best interest. So, we have gone very heavy into moving as much of our Medicare business into risk as we can. And we will take full capitation under a couple of Medicare advantage contracts.” So, that includes primary care as well as specialist care. Let's talk about One Medical for a moment. Five percent of One Medical members account for 51% of the company's revenue. You know which 5% account for that 51% of revenue? Right, the at-risk ones that are part of the Iora value-based medical group with a capitated model. That is a pretty strong financial endorsement there. There's a whole show with Brian Klepper, PhD (EP335), about why private equity is willing to pay $55,000 per patient in a capitated model. So, some actuaries somewhere think this is a very financially sound way to go. I am not sure if I would die on this hill, but I'd also say there's likely a downside to making zero effort on the accountable care front and banking on FFS being a forever cash cow. Everything I've just said, not a secret. Not at all. You see CMS moving in the “making providers accountable” direction. I already mentioned this and what CMMI is up to. But this is very much an overall strategy. Currently, 44% of traditional Medicare beneficiaries with parts A and B are in a care relationship with some accountability for quality and total cost of care. CMS aims to boost that number to 60% by 2024 and 100% by 2030. In sum across the industry, it looks like 19.6% of healthcare payments were risk-based in APMs (Alternative Payment Models) that include upside and downside. This is a couple points higher than in 2020, but it's not like it's skyrocketing. So, that might be a curb to our enthusiasm. However, in 2022 here, looking forward to 2023, you know who besides CMS is going heavy on trying to pay for health and not sick care? I have never seen my entire career more CEOs of Fortune 500 companies—CEOs!—who are actively taking a role in their employee health benefits. I think it's because they can't afford not to at this point. Again, financial toxicity is very, very real for employed individuals. Here's something that Jeff Hogan called out from a McKinsey report: “VBC [value-based care] models that show promise in the employer context include high-performance provider networks with cost- and quality-based metrics, episode-based payments for standardized patient-care journeys … , and risk-based contracts for end-to-end management of high-cost conditions.” You know what all those things have in common that I just rattled off? Only high-performing docs are in network—and this includes specialists. I say all this to say, I don't know, if I were a practitioner of healthcare and I knew that all this data was floating around about my practice patterns and given that doctors that don't perform well as per that data are being excluded from networks … I don't know, just given all of the signs that are pointing in a risk-based direction, learning to take on risk just seems like—I was never a Boy Scout, but the whole “Be prepared” seems pretty sound advice right now, especially given how long it takes to get good at this.   For more information, go to aventriahealth.com. To listen to the playlist of the mentioned episodes, click here. Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.   05:03 When physician practices get paid to deliver health and not paid for sick care, does patient health actually improve? 05:46 What is the ChenMed Case Study? 06:26 Can a care coordination model be associated with improved outcomes, including substantial cost reduction? 06:38 Are there examples of really great patient results when care is coordinated and payers are aligned to pay for health? 07:29 Do patients actually want this stuff? 07:46 Are employees choosing lower-cost plans just as much for the lower premiums as for the care coordination and the “I don't want anybody between me and my doctor” messages? 08:29 What is the Nuka System of Care in Alaska? 09:25 “I would certainly say that any physician practices looking to take better care of patients, rediscover clinical excellence and focus … get aligned with payers (CMS or otherwise). That's step one and certainly easier said than done.” 10:45 Are doctors happy in these models where payers are paying for health and where it's a must-have to coordinate across the continuum of care? 11:16 “This has changed our physicians' lives … the idea that we can get paid to actually take care of people. To actually have data to send people to the best for follow-up care, who we know will continue and contribute to the patients' well-being in the same way. Burnout reduces here because burnout is moral injury in a cheap Halloween costume.” —Physician leader 13:25 “There's a world of difference between a well-functioning accountable care model and a very terrible one.” 13:59 “Life can get really hard for PCPs especially because they get the worst of both. They get to be care gap cowboys and cowgirls while, at the same time, having to do all of the FFS coding; and they still have seven-minute visits and RVU targets.” 14:43 Is taking on risk worth it from a financial standpoint? 16:05 “There's likely a downside to making zero effort on the accountable care front and banking on FFS being a forever cash cow.” 17:11 “I have never seen my entire career more CEOs of Fortune 500 companies—CEOs!—who are actively taking a role in their employee health benefits. I think it's because they can't afford not to at this point. Again, financial toxicity is very, very real for employed individuals.” 17:54 “Only high-performing docs are in network—and this includes specialists.”   For more information, go to aventriahealth.com. To listen to the playlist of the mentioned episodes, click here.   Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast When physician practices get paid to deliver health and not paid for sick care, does patient health actually improve? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast What is the ChenMed Case Study? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Can a care coordination model be associated with improved outcomes, including substantial cost reduction? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Are there examples of really great patient results when care is coordinated and payers are aligned to pay for health? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Do patients actually want this stuff? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Are employees choosing lower-cost plans just as much for the lower premiums as for the care coordination and the “I don't want anybody between me and my doctor” messages? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast What is the Nuka System of Care in Alaska? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “Are doctors happy in these models where payers are paying for health and where it's a must-have to coordinate across the continuum of care?” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “There's a world of difference between a well-functioning accountable care model and a very terrible one.” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Is taking on risk worth it from a financial standpoint? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “There's likely a downside to making zero effort on the accountable care front and banking on FFS being a forever cash cow.” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “Only high-performing docs are in network—and this includes specialists.” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington  

This show was one of the most popular episodes in the past 12 months, so enjoy this encore while I am in Chicago moderating a panel on pharmacy benefit management at the WTW Conference Board. But while I have you, I just wanted to thank everyone for listening. You really are a part of our Relentless Tribe, and I could not thank you enough for your commitment to doing the right thing for patients and for this country—and that dedication is evidenced by you listening as often as you do to Relentless Health Value. Our show has the largest following of individuals who are truly pushing hard for patients over profits, and since, according to LinkedIn anyway, 40% of our listeners are at the “highest level of seniority in their organization,” I'm guessing that we have the muscle to do this thing. Thanks for being part of the Relentless Tribe and for all that you do. In this healthcare podcast, I'm talking with Brian Klepper. If you haven't heard of him, Brian's a longtime healthcare analyst and former CEO of the National Business Coalition on Health. This interview takes off like a shot, as most of my conversations with Brian Klepper do. We're talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the '90s. This is a great comparator to really get a handle on what's going on today. During the heyday of HMOs (back in the '90s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn't an accident that it was really hard to get an appointment with a PCP. On the other hand, it also wasn't an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody's happy then, right? Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend … Oh right, everybody's happy except the patient who can't get care and the PCP who can't do their job. By the way, for more information on why the '90s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the “why” really actually took me by surprise. But back to primary care … Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we're not really counting urgent cares or what amounts to urgent cares in that mix—meaning, not counting a lot of the retail clinics because they don't really manage patient care like you'd hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can't manage a chronic condition in 15 minutes. So, like I said, there's three kinds of PCPs that are around today; and let's call the first kind the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn't really what their payer mix is. It's that they're not taking on much risk or any risk of real consequence. Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered. Third, we have what Brian calls industrialized primary care—or some people call it advanced primary care, or APC—but I'd probably call it something different. I'd call it “taking risk for the full continuum of care” primary care. Maybe I wouldn't even call it primary care at all because this third category really is starting to color outside of the lines of primary care. This third iteration requires many things to accomplish. It requires an unimpeachable relationship with the patient; you cannot be successful with this otherwise. It requires great virtual/digital capabilities. It also requires data—data to help ensure that care gaps are filled but also to make sure that patients are referred to high-quality, high-value specialists downstream who will actually create outcomes. It also includes optimizing specialty pharmaceutical usage, for example. Brian gets into this and how a state employee health plan is on track to save $1.3 billion in this fashion. Brian believes that this third iteration of primary care—this APC industrialized primary care—is the third leg of a three-legged stool that is needed to transform healthcare. If you must know, the second leg is identification and the use of high-performing specialty services; and the third is value-based reimbursement environment. Most of the second half of this conversation with Brian is about why there's just a flurry of investment into various forms of these advanced or just maybe even regular primary care models and how they might evolve moving forward. I ask Brian about Carbon Health and their recent claim that they can do primary care with about 25% to 30% EBITA, even at Medicare FFS rates. So, there's that. One last thing: We'll be posting an “Ask an Expert” with Brian Klepper, where he gives the backstory about how the RUC—that AMA committee—basically killed primary care. So, come back for that show after you're done with this one. It's a plot full of intrigue, that's for sure. You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com.   Brian Klepper, PhD, is principal of Worksite Health Advisors and a nationally prominent healthcare analyst and commentator. He speaks, writes, and advises extensively on the management of clinical and financial risk, on high-performance healthcare, and on realizing the potential of primary care. His current focus is on high-performing healthcare organizations that consistently deliver better health outcomes at lower cost than usual approaches in high-value niches and how, integrated with advanced primary care, they can be configured into turnkey comprehensive high-value health plans that can disrupt the status quo.   05:59 Is the HMO model of primary care a good model? 08:36 “Industrialized medicine is exciting.” 09:44 What does primary care have the opportunity to do? 10:06 “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.” 11:00 Where does direct primary care and advanced primary care fit into this model? 14:19 “At the end of the day, what primary care really needs to be about is … the management of life issues as well.” 14:48 EP295 with Rebecca Etz, PhD. 15:03 “Better relationships quantifiably translate to better care.” 22:21 “Almost nobody in healthcare wants any of this to happen.” 24:30 Why the huge amounts of money being invested into primary care is actually a big problem. 28:43 “We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending.” You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com.   @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Is the HMO model of primary care a good model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Industrialized medicine is exciting.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What does primary care have the opportunity to do? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Where does direct primary care and advanced primary care fit into this model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “At the end of the day, what primary care really needs to be about is … the management of life issues as well.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Better relationships quantifiably translate to better care.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Almost nobody in healthcare wants any of this to happen.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Why the huge amounts of money being invested into primary care is actually a big problem. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Recent past interviews: Click a guest's name for their latest RHV episode! Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert  

As one of our guests, Dr. Tony DiGioia (EP332), has said, healthcare has been pushed to its limits this past year; but that doesn't mean that nothing good has come of it. Celebrating our bright spots and using our experiences to inform future innovations is really the key to more accessible, equitable, and higher quality of care. While the timing of the celebration could, in general, be better given the latest pandemic news, as they say, there's no time like the present. So, let's do this thing. Also, it's just definitely good from a mental health perspective to find bright spots and to be grateful for them. So, let me kick this off with all of the gratitude I can hold in my two hands for anybody listening who is on the so-called front line of healthcare. My appreciation cannot be expressed more fiercely. I wish, in fact, that there was more that I/we could do to address the systemic issues that plague our healthcare industry and really impact you directly. Speaking of doctors as one of these frontline healthcare groups, in the Doximity Physician Compensation Report that was released for this past year, here's four stats to know:   Twenty-two percent of physicians are considering early retirement because of overwork. Sixteen percent of physicians are looking for another employer because of overwork. Twelve percent of physicians are looking for another career because of overwork. Twenty-seven percent of physicians said they're not overworked, so I guess there's that—that's a bright spot. So, all you docs, nurses, PAs, social workers, therapists of all kinds, any other healthcare workers: Thank you for all that you do even in the face of these adversities and a bunch of seemingly shortsighted policy and/or administrative decisions. Take care of yourself first and foremost. We need you; we appreciate you. Thank you. I'd also like to thank everybody who listened to Relentless Health Value this past year. Thank you for being part of an inspired and inspirational community of individuals who are trying hard to do the right thing and learn and connect with others on a similar journey—even in the face of all the perverse incentives and calcified status quo processes, the whole host of factors that add up to formidable barriers to positive change. All of us—and I'm thinking that includes you—we continue to press forward. This is important because the more of us there are, the more of us who link hands and do some combination of educate, cajole, scold, guilt into, demand, lead, vote, wear down … the more of us who consider ourselves part of the change, the more effective we can be. So, recruit your fellow thinkers and let's continue to make inroads. I want to give a special thank you to the many of you who have reached out to me over this past year. You have encouraged, coached, and debated with me. You have added details and case studies. You've provided context. You have offered up topics to explore and introduced me and our team over here to some great guests. You have changed my mind. You have made me realize that there's some maybe underlying reason for something that is, in fact, valid or a consequence that maybe hasn't been thought through well enough by me and/or others. I couldn't be more thankful or appreciative to every single one of you. For more information, go to aventriahealth.com.   Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. 03:36 Thank you to our listeners and the feedback you've given the show over the years. 05:10 “Good and bad is a matter of extremes.” 06:20 Thank you to Dr. Steve Schutzer, Dr. George Mathews, Dr. Ge Bai, Troy Larsgard, Dr. Hugh Sims, Vinay Eaton, Dr. Brian Decker, Jeff Hogan, Peter Hayes, Dr. Aaron Mitchell, Parker Edman, Andre Wenker, Doug Aldeen, Cristy Gupton, LynAnn Henderson, Chad Jackson, and Darrell Moon. 07:27 Thank you to our iTunes reviewers. 07:47 If you haven't given us a review yet, please do here. 08:01 Thank you to Malfoxley, Jopo1234, and Teresa O'Keefe for your 2021 reviews. 08:19 Thank you to Dr. Nadia Chaudhri, who sadly died this past year of ovarian cancer but who did so much to advance the awareness of ovarian cancer and pursue better outcomes and better patient care. Look through her Twitter feed. 08:39 Thank you to Brian Klepper, who is a great writer but also runs what might be the largest Listserv for those on the innovative self-insured employer side of healthcare. What I most admire about Brian is his ability and dedication to fact-based and productive debate. Brian is featured on several RHV episodes this past year. You can check them out here: EP335 and AEE16. 09:09 I'd also like to thank Dr. Eric Bricker for his series called AHealthcareZ. Dr. Bricker is a guest on an episode coming up that I'm so looking forward to publishing. 09:45 Thanks to these writers for taking the time and effort to put out such worthwhile content: Brendan Keeler, Kevin O'Leary, Nikhil Krishnan, Olivia Webb, Joe Connolly, Christian Milaster (Telehealth Tuesday), Gist Healthcare daily/weekly newsletter and podcast, John Marchica's newsletter and podcast, and Merrill Goozner.10:10 If you don't already, I'd also recommend following these individuals on LinkedIn: Darren Fogarty, Leon Wisniewski, and Christin Deacon (listen to Christin's episode about the CAA this past fall). 10:26 David Contorno and Emma Fox, thanks so much for all of your work motivating collaboration and inspiring self-insured employers to wield the power they possess in meaningful ways. There's a symposium coming up that anyone interested should check out. 10:42 I appreciate and periodically check out Julie Yoo from Andreessen Horowitz's collection of resources on a Google doc. 10:55 Thanks to Rohan Siddhanti and Ezequiel Halac for organizing events in NYC. 11:03 People often ask me for podcast recommendations, so here's a few I listen to regularly: John Lynn's podcasts, Creating a New Healthcare with Dr. Zeev Neuwirth, Race to Value with Eric Weaver, Radio Advisory, Gist Healthcare Daily, The #HCBiz Show! with Don Lee, and Primary Care Cures with Ron Barshop (I was on the show released Thanksgiving week). There's also the Pharmacy Podcast Network.11:42 Also thanks to the following publications who have given us press credentials and passes to conferences: STAT News, NODE.Health, HealthIMPACT, and JAMA. 12:03 Lastly, we have a tip jar on our Web site which we don't really publicize. I say this to emphasize that those who choose to donate are just simply kind and gracious individuals: Alex Dou, Linda Garcia, James Farley, Arthur Berens, Lois Drapin, James Cheairs, Robert Matthews, Lois Niland, Teresa O'Keefe, Richard Klasco, Hugh Sims, Matt Warhaftig, Meredith Fried, Chad Jackson, Vidar Jorgensen, and Brandon Weber. 12:38 Thank you ALL for your continued leadership in improving healthcare. 12:42 Christin Deacon has said, “What we need more of in the healthcare industry are leaders who are willing to take on legacy institutions and their lobbyists, in both public and private discourse. We need leaders that are willing to take on an industry that makes up about 20% of our GDP and is willing to go on record stating that the goal is not just to curb growth but, rather, stop it and rebuild this whole thing better for patients.” For more information, go to aventriahealth.com. From all of us at Relentless Health Value, THANK YOU for your listenership and support. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #podcast #digitalhealth Did you know you can review our #podcast? https://relentlesshealthvalue.com/4-steps-rate-review-podcast-itunes/ Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth In memory of @DrNadiaChaudhri, check out her Twitter feed for info on better #patientoutcomes and care. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth Check out @DrEricB's AHealthcareZ for in-depth industry information. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth Thanks to @healthbjk, @olearykm, @nikillinit, @OliviaWebbC, @JConnol, @GistHealthcare, @DarwinHealth, @_GoozNews, and @HealthChrism for putting out great content. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth We appreciate and recommend following @julesyoo for more #healthcareinsights. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth Thanks to @RSiddhanti and @halac_ezequiel for their event organizing in NYC. Our host, Stacey, shares highlights and resources from this past year on our latest #healthcarepodcast. #healthcare #digitalhealth We love #podcasts! Check out some of Stacey's recs in our show notes, including @techguy, @ZeevNeuwirth, @Eric_S_Weaver, @raemwoods, @Alexolgin, @The_HCBiz, @RonBarshop, and @PharmacyPodcast. #healthcare #healthcarepodcast Thanks to the following #healthcarepublications as well: @statnews, @HITHealthIMPACT, @JAMA_current, and @nodehealthorg. Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen  

S1E2: Disrupting the Status Quo of Healthcare host Dr. Nick talks to Brian Klepper, PhD, CEO of Worksite Health Advisors. Our healthcare system is broken – it is working as it was originally designed but costs have ballooned to levels that are economically unsustainable and the outcomes have slipped. The most recent Commonwealth report, Mirror Mirror 2021: Reflecting Poorly, compares 11 high-income countries healthcare systems and their outcomes with no two systems alike in the way they deliver care. The analysis looked at multiple performance measures across five domains. Despite the US spending far more of its gross domestic product on health care than any of the other countries is ranks last in all categories except one. We, the people, the citizens of this country are not getting the value we want or could get from the healthcare system. Your better pill to swallow is to stop accepting status quo and the expectation that healthcare insurance costs must continue to rise. A thriving healthcare market system is like every other business marketplace where we expect and see costs continue to decline and efficiencies rise. Help is available to assess your individualize company needs, understanding your employees and finding the solutions to fit. Step outside the traditional insurance marketplace. Insist on a reduction in spend that is not linked to a reduction in benefits or cost shifting to your employee's portion of the healthcare insurance spend. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play HealthcareNOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

I was listening to a panel discussion and heard Brandon Weber use the phrase the “barbarians at the gate” of the healthcare industry. I think I reached out to invite him to come on the podcast before the end of the segment. But at risk of spoiler alerts, let me sum up what I think is so interesting about Brandon's insights, which he talks about on the show. First of all, it isn't an “oh, heavens, some companies out there are trying to disrupt the status quo,” like this is some sort of news flash that hasn't been tossed out with police lights and sirens however many times already over however many years. Brandon gets into the sheer magnitude of what's going on, right now, from a capital investment standpoint but also from a human capital standpoint. How many crazy smart proven disrupter-type people have come along with that capital? Brandon also touches on something I've been thinking about lately: coalition building, for lack of a better word for it. If we have status quo behemoths with market caps of a third of a trillion dollars out there, some start-up who is super happy to have scored a however-many-million-dollar seed round is not a threat in and of themselves. But if many of these littles are aligned and working together in win-win ways that ultimately take market share from the big dogs, now things get interesting. So, while much attention is focused on point solutions that disrupt some aspect of care delivery, we might want to take another look at the less visible entities that are putting platforms underneath: the companies that are building out services that offer economies of scale, that create “pipes” helping patients connect with appropriate solutions that make this emerging market just work better. It's these platform companies, combined with a general willingness to collaborate, that make ganging up a sort of natural strategy to build a really flourishing ecosystem. And it's that whole ecosystem that I would consider the most likely disrupter within an industry very much designed for the big to get bigger. Anecdotally, I see both of these ecosystem-building factors happening (ie, the platforms and then also a really unprecedented level of collaborative, all-boats-rise kind of thinking). There are communities like the one that Brian Klepper runs for benefits professionals or Health Tech Nerds or outofpocket.health. But based on what I see in these groups and elsewhere, the sharing and helpfulness is really encouraging and heartwarming if you're not an incumbent, I guess.  My guest in this podcast, as mentioned, is Brandon Weber, who is the CEO and founder of Nava. This is one of those foundational-type upstarts. Brandon's company Nava is a benefits brokerage but one that's built on a platform that crochets together everything it takes to support a best-practice employer health plan. For example, point solutions have to be easy to buy and fold in, while on the back end, all of those point solutions and others need access to the right data so that appropriate employees can be engaged and make the most of the benefits offered. If you think about it, it's easy to see how having a really strong foundation here amplifies the value that can be delivered and accelerates change management. Coming up also, stay tuned because I'm interviewing Kristin Begley about optimal digital front doors, which is sort of an extension of the conversation that you'll hear in this episode. You can learn more at nava.io or by visiting their LinkedIn page. Brandon Weber is the cofounder and CEO at Nava, a modern benefits brokerage on a mission to provide high-quality, affordable access to healthcare to all Americans. By melding cutting-edge tech solutions with deep industry expertise, Nava aims to fix healthcare, one benefits plan at a time. Prior to Nava, Brandon cofounded VTS, a tech-driven leasing and asset management platform that transformed the commercial real estate marketplace. Trusted by over 45,000 brokers and asset managers around the globe, it's now used in over 50% of all office buildings in the United States and is consistently ranked one of New York's best places to work. Outside of work, he enjoys retreating into nature and is passionate about backcountry skiing, mountaineering, and trail running. 04:13 What does it mean to have “barbarians at the gate” of healthcare? 05:32 What is the overly complex gate to healthcare? 07:28 “No one can make the argument that we've seen this before.” 08:37 Are the “barbarians” in healthcare going to expand the system that already exists? 09:25 What is the number one pain point in healthcare? 13:25 “Typically, the innovation doesn't come from the incumbents.” 17:16 “We were actually just blown away by the amount of innovation that is already happening … [in] care delivery.” 17:58 “The future is actually here; it's just not evenly distributed.” 18:08 Why is there a need for a distribution layer in healthcare? 20:57 “Everyone is vying to be that one app in the pocket that acts as the aggregator, the hub, the steering point.” 26:32 “If you build it, they will come … that is absolutely not true in [healthcare].” 29:46 “The benefits broker is likely the most underappreciated stakeholder in the healthcare industry.” You can learn more at nava.io or by visiting their LinkedIn page. @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation What does it mean to have “barbarians at the gate” of healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation What is the overly complex gate to healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation “No one can make the argument that we've seen this before.” @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation Are the “barbarians” in healthcare going to expand the system that already exists? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation “Typically, the innovation doesn't come from the incumbents.” @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation What is the number one pain point in healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation “We were actually just blown away by the amount of innovation that is already happening … [in] care delivery.” @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation “The future is actually here; it's just not evenly distributed.” @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation Why is there a need for a distribution layer in healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation “Everyone is vying to be that one app in the pocket that acts as the aggregator, the hub, the steering point.” @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation “If you build it, they will come … that is absolutely not true in [healthcare].” @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation “The benefits broker is likely the most underappreciated stakeholder in the healthcare industry.” @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss  

This conversation starts out talking about the RUC, which is a committee run by the AMA, who has the sole source contract with CMS to figure out how many RVUs any given procedure or service is worth. There are roughly four times as many specialists on this RUC committee as PCPs. You might be able to see where this is going, but let me let our guest in this healthcare podcast, Brian Klepper, explain how primary care got trampled by the goings-on. Brian Klepper is a longtime healthcare analyst and former CEO of the National Business Coalition on Health. You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Advisors, a benefits consultancy focused on linking high-performance/high-impact healthcare organizations with purchasers. He founded and moderates a popular professional healthcare Listserv, Healthcare Hackers, which is a discussion forum on healthcare high performance and value and which has about 850 participating benefits managers, benefits advisors, and innovative vendors. An active author and speaker, Dr. Klepper has provided healthcare commentary to CBS Evening News, the Wall Street Journal, the New York Times, and the Washington Post. He has published widely in healthcare trade and academic publications and in newspapers nationally. Brian is a regular contributor to Employee Benefit News, the Health Affairs Blog, The Health Care Blog, The Doctor Weighs In, Kevin MD, and other expert healthcare blogs. He is a reviewer for Health Affairs and The Journal of Ambulatory Care Management. He is an advisor to the Lundberg Institute and to several for-profit healthcare organizations. In his spare time, Brian is an offshore sailor. 01:00 What is the RUC? 03:18 What is the goal of the specialists in the RUC? 04:32 Why health plans and not health systems? 06:55 “All this time, the hospital community was waging war against the HMO community.” 07:59 “The incentives that have been at play have been very formidable.” 08:23 “Primary care has developed a reputation for being the easy specialty … and it's just not so.” You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What is the RUC? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What is the goal of the specialists in the RUC? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Why health plans and not health systems? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “All this time, the hospital community was waging war against the HMO community.” @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “The incentives that have been at play have been very formidable.” @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Primary care has developed a reputation for being the easy specialty … and it's just not so.” @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Recent past interviews: Click a guest's name for their latest RHV episode! Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312)

In this healthcare podcast, I'm talking with Brian Klepper. If you haven't heard of him, Brian's a longtime healthcare analyst and former CEO of the National Business Coalition on Health. This interview takes off like a shot, as most of my conversations with Brian Klepper do. We're talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the '90s. This is a great comparator to really get a handle on what's going on today. During the heyday of HMOs (back in the '90s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn't an accident that it was really hard to get an appointment with a PCP.  On the other hand, it also wasn't an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody's happy then, right? Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend … Oh right, everybody's happy except the patient who can't get care and the PCP who can't do their job. By the way, for more information on why the '90s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the “why” really actually took me by surprise.  But back to primary care … Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we're not really counting urgent cares or what amounts to urgent cares in that mix—meaning, not counting a lot of the retail clinics because they don't really manage patient care like you'd hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can't manage a chronic condition in 15 minutes. So, like I said, there's three kinds of PCPs that are around today; and let's call the first kind the OPCP, the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn't really what their payer mix is. It's that they're not taking on much risk or any risk of real consequence. Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered. Third, we have what Brian calls industrialized primary care—or some people call it advanced primary care, or APC—but I'd probably call it something different. I'd call it “taking risk for the full continuum of care” primary care. Maybe I wouldn't even call it primary care at all because this third category really is starting to color outside of the lines of primary care. This third iteration requires many things to accomplish. It requires an unimpeachable relationship with the patient; you cannot be successful with this otherwise. It requires great virtual/digital capabilities. It also requires data—data to help ensure that care gaps are filled but also to make sure that patients are referred to high-quality, high-value specialists downstream who will actually create outcomes. It also includes optimizing specialty pharmaceutical usage, for example. Brian gets into this and how a state employee health plan is on track to save $1.3 billion in this fashion. Brian believes that this third iteration of primary care—this APC industrialized primary care—is the third leg of a three-legged stool that is needed to transform healthcare. If you must know, the second leg is identification and the use of high-performing specialty services; and the third is value-based reimbursement environment. Most of the second half of this conversation with Brian is about why there's just a flurry of investment into various forms of these advanced or just maybe even regular primary care models and how they might evolve moving forward. I ask Brian about Carbon Health and their recent claim that they can do primary care with about 25% to 30% EBITA, even at Medicare FFS rates. So, there's that. One last thing: Next week, we'll be posting an “Ask an Expert” with Brian Klepper, where he gives the backstory about how the RUC—that AMA committee—basically killed primary care. So, come back for that show after you're done with this one. It's a plot full of intrigue, that's for sure. You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Advisors, a benefits consultancy focused on linking high-performance/high-impact healthcare organizations with purchasers. He founded and moderates a popular professional healthcare Listserv, Healthcare Hackers, which is a discussion forum on healthcare high performance and value and which has about 850 participating benefits managers, benefits advisors, and innovative vendors. An active author and speaker, Dr. Klepper has provided healthcare commentary to CBS Evening News, the Wall Street Journal, the New York Times, and the Washington Post. He has published widely in healthcare trade and academic publications and in newspapers nationally. Brian is a regular contributor to Employee Benefit News, the Health Affairs Blog, The Health Care Blog, The Doctor Weighs In, Kevin MD, and other expert healthcare blogs. He is a reviewer for Health Affairs and The Journal of Ambulatory Care Management. He is an advisor to the Lundberg Institute and to several for-profit healthcare organizations. In his spare time, Brian is an offshore sailor. 05:10 Is the HMO model of primary care a good model? 07:48 “Industrialized medicine is exciting.” 08:59 What does primary care have the opportunity to do? 09:21 “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.” 10:15 Where does direct primary care and advanced primary care fit into this model? 13:35 “At the end of the day, what primary care really needs to be about is … the management of life issues as well.” 14:05 EP295 with Rebecca Etz, PhD.14:19 “Better relationships quantifiably translate to better care.” 21:48 “Almost nobody in healthcare wants any of this to happen.” 23:58 Why the huge amounts of money being invested into primary care is actually a big problem. 28:11 “We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending.” You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Is the HMO model of primary care a good model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Industrialized medicine is exciting.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What does primary care have the opportunity to do? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Where does direct primary care and advanced primary care fit into this model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “At the end of the day, what primary care really needs to be about is … the management of life issues as well.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Better relationships quantifiably translate to better care.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “Almost nobody in healthcare wants any of this to happen.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Why the huge amounts of money being invested into primary care is actually a big problem. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp “We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending.” @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Recent past interviews: Click a guest's name for their latest RHV episode! Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr. Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312), Ge Bai  

One way to spot a flash point is to notice when people are using different words to describe the same concept. Throughput is one example of this. On one side of the table, you have those who grasp that if a provider organization is concerned about patient outcomes, with few exceptions, building relationships with said patients is essential. It’s not entirely clear to anyone anywhere how you manage to build relationships and trust without spending a certain amount of time with patients. These “we need time with patients” people will bring up the Quadruple Aim issues that arise from rigid 7-minute appointments or even 50-minute appointments really. On the other side of the table, you have those who have built practice fiscal models on the backbone of however-many-minute appointments. They use different terminology for this whole concept, however. They call it throughput. How many patients can a physician manage to squeeze into a day? Some of these folks will tell you that throughput success is “more is more.” In other words, throughput is one of those things that you can never have too much of. Let me back up for a sec and mention the mission of this show. It is to connect health care leaders together by helping everyone understand each other well enough to communicate effectively, which is rate critical numero uno for any collaboration. You can’t collaborate if parties don’t really grasp what anyone else is actually saying when they communicate their WIIFMs (their “what’s in it for me?”) or their organizational imperatives. If we consider that the health care industry can only transform when multiple stakeholders collaborate, these little “language discrepancies” actually can have macro implications. In this respect, this throughput example—not in all cases but at a minimum—it’s an exemplar illustration and certainly something to contemplate. Consider people arguing against 7-minute appointments without mentioning the word throughput. They’re probably not going to even reach the headspace of those who just spent the past two decades in meetings to increase throughput. It’s like two ships passing in the night. You could be sitting there right now pooh-poohing what I’m saying, but I’ve sat in enough meetings where people talk around each other using different terminology, think they’ve agreed on some collaboration or compromise or solution, except nothing happens because everyone got to walk out without addressing the elephant in the room. It sounds something like this: DOCTOR OR NURSE: We need you to enable patients to have quality time with their doctors and the rest of the care team. SOMEBODY ELSE: We need to get rid of inefficiencies, which means driving maximum throughput. ANOTHER PERSON: OK, let’s compromise. Doctors should have quality time while maximizing throughput. Don’t laugh. I’ve heard “action items” like this often enough, and so have you if you think about it. That’s why I originally started this podcast—because I can also guarantee you if this is the action item, no action will actually take place. The only way this conversation is going to net any change is if people around that table head-on confront that quality time with patients means less throughput. And how much less are we going to agree on and/or how are we going to creatively change the practice model so throughput is an archaic term (ie, asynchronous stuff, etc)? I say all this to say that this throughput business also leaks into the technology space in ways that we should probably think about. Increasing throughput, after all, is one of the key ways to increase FFS (fee-for-service) revenue. FFS is all about the need for speed. The faster you can smack a billing code on a patient visit, the more patient visits you can pack into a day, the more billing revenue you can rack up. To some extent, throughput is code word for an addiction to FFS. You can always tell a tech vendor who is used to selling in an FFS environment because the second slide of their pitch deck is always one of two things: either how much faster the tool will get patients in and out of a doctor’s line of sight or what the billing code is for the tool (but that’s a whole different topic). I just described the second slide in an FFS-centric technology vendor deck. The first slide in those “use our AI thingamajig to revolutionize your throughput” decks is always some mission statement about improving patient care. And this is where not everybody using the same language creates immense wiggle room for profit over patients under cover of mismatched terminology. To add one point of context, when I say throughput here or increasing throughput, nobody is talking about making the front desk more efficient, minimizing faxing things around, or streamlining prior auths or duplications in the workflow (ie, fixing things that are in desperate need of a fix). What we’re talking about in this health care podcast are tools like the one I saw the other day. This biz dev person of this company was up and about early promoting some AI diagnostic tool. With this tool, so their slide deck promised, a physician could see 50 patients a day. Even for this particular vendor, I guess a full-throated “Hey, let’s burn out all your doctors and make patients wonder if they imagined their doctor visit would happen so fast”—a blunt message like that—presumed a little too much avariciousness on the part of the practice. So, they tempered their message by stating the inarguable fact that there is a physician shortage in rural America and that this tool will help resolve that. OK … that’s a worthy thing to fix. But, seriously, is the goal to get rural patients an automagical visit with a doctor that, in hindsight, they wonder if they hallucinated it was so fleeting? Or is it to actually help patients get better health? Also inarguably, health care that leads to better health requires less than pedal-to-the-metal throughput. If you think differently and want to change my mind, feel free but show me the study. I say all this to say that I called up Arshad Rahim, MD, MBA, FACP, a little bit ago to see what he thought of my aforementioned burning premises (aka rants) about throughput; and he kindly agreed to come on the show again. Dr. Rahim is senior medical director of population health at Mount Sinai. He was last on Relentless Health Value on EP219 talking about population health for reals in the real world. Go back and listen to that show after this one if you want to hear more of Dr. Rahim’s sage advice.  One more recommendation: For more insights into the impact of maximum throughput, read the awesome op-ed in MedPage Today by Brian Klepper, PhD, and Jeff Hogan.  You can connect with Dr. Rahim on LinkedIn.  Arshad Rahim, MD, MBA, FACP, is a practicing physician and a health economist at his core. He enjoys a track record of building innovative health care businesses, including Mount Sinai Population Health, Healthgrades, and Sg2. As the vice president, clinical integration and population health, at Mount Sinai Health System, Dr. Rahim is responsible for the 4500-provider Mount Sinai Clinically Integrated Network (CIN) and has built a team-driven practice focusing on key value-based care metrics of utilization, cost, access, and quality. He is also leading a team driving ambulatory care standardization for six key chronic conditions across Mount Sinai Health System. Dr. Rahim has a bachelor’s degree in economics from Duke University, an MD from the University of North Carolina, and an MBA from Emory University. He completed his internal medicine residency at Yale University and Northwestern University and is an actively practicing hospitalist at the Mount Sinai Hospital. 07:37 When does throughput negatively affect patient care? 08:55 Why does diagnostic inaccuracy become a problem with throughput? 09:27 Do population health outcomes decline with less throughput? 10:20 “The way you can also be most financially successful is by taking care of sicker patients.” 10:53 What do patients actually want and need? 11:55 “The emotionality in a health care interaction is always there … [when] you’re focused on throughput, you can definitely lose the healing and calming presence.” 14:18 What do doctors need from their organizations to sustain a high level of care? 15:59 “The actions vary across the spectrum from very supportive to not very supportive at all.” 17:02 “There definitely is a challenge of competitive pay.” You can connect with Dr. Rahim on LinkedIn.  Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools and #throughput on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools When does throughput negatively affect patient care? Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools Why does diagnostic inaccuracy become a problem with throughput? Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools Do population health outcomes decline with less throughput? Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools “The way you can also be most financially successful is by taking care of sicker patients.” Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools What do patients actually want and need? Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools “The emotionality in a health care interaction is always there … [when] you’re focused on throughput, you can definitely lose the healing and calming presence.” Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools What do doctors need from their organizations to sustain a high level of care? Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools “The actions vary across the spectrum from very supportive to not very supportive at all.” Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools “There definitely is a challenge of competitive pay.” Arshad Rahim, MD, MBA, FACP, of @MountSinaiNYC discusses #digitaltools on our #healthcarepodcast. #healthcare #podcast #digitalhealth #digitalhealthtools

I don’t know what I thought we were going to talk about during my interview with David Carmouche, MD; but I’m glad it turned out exactly as it did. Lately, we’ve had a number of guests on Relentless Health Value talking from the point of view of the employer: what a self-insured employer wants and needs from the large, and small, providers in their network. In this episode, we’re flipping the script and talking about what a large provider organization wants and needs from the commercial side of its payer mix. If value-based care or risk shares are to be a thing, we can’t have, as Troy Larsgard has put it, all risk and no share. In this health care podcast, I had the honor and pleasure of speaking with Dr. David Carmouche. Dr. Carmouche started out as a physician in a multi-specialty group. He practiced there for about 15 years before leaving to become chief medical officer at BCBS (Blue Cross Blue Shield) of Louisiana. Five years ago, Dr. Carmouche transitioned to Ochsner Health, where he is currently executive vice president of value-based care and network operations. At Ochsner, Dr. Carmouche helps lead the value-based care agenda—that’s everything from managing strategic partnerships with payers, as well as managing risk in value-based contracts for Ochsner and affiliated network partners across their ACO (accountable care organization) and CIN (clinically integrated network). Highlighting one point that Dr. Carmouche makes early in our chat, there’s four things that have to come together for meaningful value creation for providers: (1) willingness of providers and provider leadership to think and do things different than they have historically; (2) they have to be able to affect payment for those things; (3) they have to have data and be able to access it; and then (4) some control over steering patients. This kind of sets the stage, actually, for our fast dive, in this conversation, right into employer and commercial collaborations. Three of the four things on that list—affecting payment, data, steering patients—are right in the wheelhouse of forward-thinking employers, or commercial payers/TPAs (third-party administrators) trying hard to compete for or serve employers. Just a quick heads-up here: Coming soon, we’re going to release a second episode with Dr. Carmouche giving some great advice for the leadership of provider organizations who are trying to figure out their transition away from FFS (fee for service) to a more risk-based, value-based model. One quick point that I thought was also relevant to the show here: It was super interesting to me how quickly Dr. Carmouche got from “transition to value” to “knows how to collaborate with other organizations.” Here’s the pretty obvious inference: You can’t transition to value if you don’t know how to play well with others to co-create value and share the rewards of such an endeavor. There might be a broader lesson in here for whoever you are in the health care ecosystem. And I’m looking at you, pharmacy, Pharma, tech, societies, BUCAs, etc. Thanks so much to Brian Klepper for the introduction to Dr. Carmouche. You can learn more by visiting Dr. Carmouche’s LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  David Carmouche, MD, views health care from three distinct perspectives: as a physician provider, an executive for an insurance company and as a leader in a health system. Specifically, he built a large, multidisciplinary internal medicine and preventive cardiology practice in Louisiana; served as the chief medical officer for Blue Cross Blue Shield of Louisiana; and currently has a triad of responsibilities with Ochsner Health, the largest nonprofit academic health care system in the Gulf South. He was recently promoted to serve as executive vice president of value-based care and network operations in addition to his duties as president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network. He is known as an expert in value-based care. He led one of the top 25 performing accountable care organizations in the United States, managing billions in care spend and generating millions in year-over-year shared savings. Dr. Carmouche earned a bachelor’s degree from Tulane University and a medical degree from Louisiana State University School of Medicine in New Orleans. He completed his residency in internal medicine at the University of Alabama at Birmingham. 04:15 Who needs to be working together to create value-based success? 04:31 “I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers.” 04:45 What four things have to come together for meaningful value? 06:02 “We’re focusing specifically on payer employers today. We think that’s where there’s the biggest opportunity.” 07:23 What’s the overarching reason for health systems to want to grow their commercial market share? 14:00 Is the competition moving upstream? 16:20 “In all honesty, we’re competing for pieces of the business.” 16:23 What’s the ultimate competition? 18:36 “There is a consumer experience that is available inside these … collaborative efforts.” 20:53 “We really haven’t changed the paradigm of benefit design as it comes to drugs.” You can learn more by visiting Dr. Carmouche’s LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare Who needs to be working together to create value-based success? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare What four things have to come together for meaningful value? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “We’re focusing specifically on payer employers today. We think that’s where there’s the biggest opportunity.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare What’s the overarching reason for health systems to want to grow their commercial market share? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare Is the competition moving upstream? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “In all honesty, we’re competing for pieces of the business.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “There is a consumer experience that is available inside these … collaborative efforts.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare  

Hosts Gregg Masters and Fred Goldstein meet Dr. Brian Klepper, Principal of Healthcare Performance, Inc. and Worksite Health Advisors, both specialized health benefits consulting firms connecting high performance, high impact health care organizations with organizational health care purchasers and health industry players. They discuss the role of high value healthcare and particularly the importance of primary care as ‘quarterback’ vs. ‘HMO gatekeeper’, DPCs and the role of health benefits in the innovation cycle. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play HealthcareNOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

On PopHealth Week our guest today making an encore appearance is Brian Klepper, PhD, a healthcare analyst, commentator and entrepreneur who relentlessly focuses his attention on health care market dynamics and the drivers of the cost crisis. He is Principal of Healthcare Performance, Inc. and Worksite Health Advisors, both specialized health benefits consulting firms connecting high performance, high impact health care organizations with organizational health care purchasers and health industry players. He is a former owner and Principal of a worksite clinic/medical risk management firm, and a former CEO of the National Business Coalition on Health (NBCH), representing 52 regional business health coalition and some 5,000 organizational health benefits purchasers. Much of Brian’s work has focused on the mechanisms that underlie America’s healthcare cost crisis and how institutionalized clinical and business practices have distorted care and cost patterns, driving unnecessary cost. His perspective favors patients, whose medical care often exposes them to needless physical risk, and purchasers, whose health care costs are double those in other developed nations, creating a cascade of negative economic impacts. Join us! ==##==  

If you are a forward-thinking specialist right now, alarm bells may be going off, given COVID and/or the prospect of another COVID-style pandemic. Also, all of the capitated and advanced PCP (primary care provider) practices popping up. Also, virtual care models. FFS is a cushy status quo revenue model until it isn’t. One underappreciated point might be that FFS is not only a revenue/payment model. It’s also a business model. And as a business model, FFS very much drives how practices structure themselves to realize that FFS revenue. Consider that to earn a fee for a service, someone (a human person) has to physically do the service. So, all FFS-style businesses have an inherent incentive to add labor and not use technology in any way that actually reduces the amount of billable human hours involved in providing care to patients. But if that top-line revenue line goes down—wow!—you’ll find yourself as many did with way too many employees. An FFS business model has zero flexibility when it comes to revenue that isn’t consistently going up or, at a minimum, a flat line. If revenue plummets and payroll is big—big so as to power a way higher revenue number than is possible for whatever reason—you have a major financial problem on the quick. That is what I talk about in this health care podcast with Alan Kaplan, MD, MBA. Dr. Kaplan is assistant professor of urology at Georgetown University, and he is a practicing urologist. He recently cowrote a paper with Dan O’Neill in the publication NEJM Catalyst Innovations in Care Delivery. The article discusses COVID-19 and health care’s “productivity shock,” as they call it. Dan O’Neill, by the way, was on the show. Also, he was on EP287 and part of EP292. But in the article that Dr. Kaplan and Dan O’Neill wrote, they give some advice to specialists and hospitals who are looking to evolve with the changing marketplace. Spoiler alert: Conceptually, it’s a shock to move from a place where, every year, you can count on your billings going up and up and move to a model instead that assumes that this is not the case. So, yeah, there’s a little talk for sure about the joys and challenges of transitioning to value or a value-based payment model. But that’s only the very first consideration. It’s also about reconsidering the operating model and the strategic use of digital technologies. We talk about all of the above in this health care podcast. Quick sidebar: My interview with Dr. Steve Schutzer (EP294) might be a good follow-on for a very actionable work plan for specialists to implement some of the advice that Dr. Kaplan gives in this podcast.   You can learn more by contacting Dr. Kaplan via LinkedIn. Alan L. Kaplan, MD, MBA, is a practicing surgeon, innovator, and health services researcher. After finishing his urology residency, a health care administration fellowship, and an MBA, all at UCLA, Alan helped build a multispecialty medical group in a highly underserved area of South Los Angeles. Alan is currently an assistant professor of urology at Georgetown University; an attending physician at the Washington, DC, VA Medical Center; and a physician advisor at IDEO, a human-centered design firm. Alan’s work over the past 10 years has centered on value-based care redesign, aiming to transition to a more just, equitable, and sustainable health care system for all Americans. 03:51 Who are we actually discussing when we use the term specialist? 05:58 How does the PCP taking on more risk affect the specialists’ path to value-based care (VBC)? 09:42 “Technology leads to … a reduction in labor burden … but in health care, that really hasn’t been the case.” 11:36 “Technology … in health care … has never really been about making the bottom line more efficient. It’s been about expanding the top line.” 13:39 What do specialists need to be considering if they want to stay relevant in the next 5 years? 14:27 EP292 with Brian Klepper, PhD. 16:53 Is there a future where specialists can transition from FFS to VBC while skipping the messy middle of a transition? 18:37 “The way we always did things is not the way that we have to always do things in the future.” 25:20 “When all is said and done, the relationship between [PCPs] and the specialists that they refer … those relationships are really, really important.” 26:14 EP219 with Arshad Rahim, MD, MBA, FACP. 28:13 What’s going to be a big driver for providers to become more independent in the next 5 to 10 years? You can learn more by contacting Dr. Kaplan via LinkedIn. @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #ffs Who are we actually discussing when we use the term “specialist”? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs How does the PCP taking on more risk affect the specialists’ path to value-based care? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs “Technology leads to … a reduction in labor burden … but in health care, that really hasn’t been the case.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs “Technology … in health care … has never really been about making the bottom line more efficient. It’s been about expanding the top line.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs What do specialists need to be considering if they want to stay relevant in the next 5 years? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs Is there a future where specialists can transition from FFS to VBC while skipping the messy middle of a transition? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs “The way we always did things is not the way that we have to always do things in the future.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs “When all is said and done, the relationship between [PCPs] and the specialists that they refer … those relationships are really, really important.” @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs

Welcome to Episode 292, Part 2. This is the second part of a two-part episode, but, in a way, you can listen to whichever part you want first. So, if you wound up here first, no worries. Just go back when you have a sec and listen to Part 1. There’s some good stuff there you don’t want to miss, including some background information that might be good to have.  This episode, as well as the last one, is about Teladoc buying Livongo. I am going to call the combined organization T&L because I heart acronyms as much as you do. Here’s the thing with T&L: They are not alone in their quest to disrupt the traditional health care delivery market. You also have Aetna making a plan design that advantages CVS clinics. You got Humana doing the home health thing. You got Walmart and Oak Street hooking up in Texas and risk contracting with managed Medicaid and Medicare Advantage. You have employers across the country direct contracting with Centers of Excellence and buy in perspective bundles. Also, speaking of employers, on the on-site clinic space, Premise Health just recently acquired CareHere. These two organizations will reach 11 million eligible lives at 2200 customers in 300 markets. All this being said, let me make a fairly obvious point: Increasingly, the competition is going to be about outcomes—or perceived outcomes. Competition is going to be around the value delivered (ie, quality divided by cost). This I like. To me, it’s a tragedy that the health care industry can get away with charging prices no one would consider fair and delivering subpar health care let alone health. I want some of these organizations that do a really nice job coordinating care and which patients really appreciate to do well by doing good. And I love that some of the payers out there—some of the employers and even some of the Medicare Advantage and other health plans—recognize the value that these organizations can deliver. But let’s consider the implications of this—notably, here’s one: Few, probably even the very best, for example, endocrinology practices or maybe even cardiology practices, have a bead on how well they ultimately attenuate downstream medical costs. They might not even know, outside of what they are required to report for quality incentives, how well they are consistently creating better patient outcomes. Livongo does—or at least claims they do—and lots of employers and plans buy the results they’re selling to the tune of something like $300 million in sales this year. Here’s what I don’t like: What is shaking out is a turf war, and the weapon of choice may or may not be authentically better patient outcomes. Some of the weaponry here is built on a marketing “chassis.” The one who has the best marketing shall triumph. People judge books by their covers, and that’s a cliché for a reason. You can read Al Lewis’s blog post on Livongo, where he dug into their purported results. Then listen with your left ear to some of the chatter on the street about how Livongo is more of an employee retention tool than, you know, a clinical tool. I don’t kn0w where these rumors started, but I keep hearing that because the Livongo NPS (Net Promoter Score) is high and employees, including executives, think it’s pretty cool as a service, that maybe, given this, that it’s okay if many of the Livongo charts and graphs don’t have labels on their Y axes. And it kind of, you know, makes sense if you actually sit there and stare at them as I have done.  All this I just said? Background noise. The games have begun, and the winners will be those who consumers/patients love. It’ll be the ones who know how to market to employers or Medicare Advantage plans. It’ll be the ones who can succeed in risk-based models. There you go. There are your three success factors. In this health care podcast, I speak with Matt Anderson, MD, MBA. Matt sees the ecosystem through the eyes of an innovation leader at a health system. And my finale interview of our two-part series here is Brian Klepper, PhD, principal over at Worksite Health Advisors. Brian will speak from the POV (point of view) of employers. You can learn more at bannerhealth.com and drmatthewanderson.com and connect with Dr. Anderson on Twitter at @DrAnderson19 and on LinkedIn. You can also learn more at careandcost.com, by emailing bklepper@gmail.com, and by visiting validationinstitute.com.  Matthew Anderson, MD, MBA, has a passion for finding unique solutions to difficult problems in health care. He focuses on creating environments that allow patients and physicians to have frictionless experiences. Through insights gained in private practice, leading physician groups, and embedding himself in the health care innovation landscape, he can empower those looking to improve the health of communities and the well-being of those that dedicated their lives to providing care. He has been a business owner, medical director, and chief medical officer and now leads clinical innovation projects for Banner Health and advises several health care start-ups and venture teams. Brian Klepper, PhD, is executive vice president of the Validation Institute, principal of Worksite Health Advisors, and a nationally prominent health care analyst and commentator. He speaks, writes, and advises extensively on high-performance health care, primary care clinics, and the management of clinical and financial risk. His current consulting focus is on health care organizations that consistently deliver better health outcomes at lower cost than conventional approaches in high-value niches. In his role at the Validation Institute, he spearheads programs that identify, validate, celebrate, and promote true high-performance health care programming. 05:06 What is the viewpoint about this merger from an MD, MBA in a health system? 06:30 “They’re really starting to become someone who can provide that continuity of care in a way that I don’t think anyone’s really done before.”—Matt 07:38 “When you are competing for patients, by definition you’re competing for revenue.”—Matt 10:09 “At baseline, their goal is to provide care but at the lowest cost possible.”—Matt 12:17 What is a forward-thinking provider organization doing right now? 12:31 “This is going to be a space race for health care innovation right now.”—Matt 15:43 “Sometimes it just comes down to the basics, and if you get the basics right, you can apply it in any situation.”—Matt 16:29 What’s forced the inertia in the industry to become action? 17:23 “Things are moving slowly but surely in the right direction, and that’s something I’ve never seen during the course of my career.”—Brian 19:56 “Everybody and his wooden-legged brother claims that they have a high-value service, but very few actually do.”—Brian 21:13 “I think that the stakes have just gotten much higher for health systems … and physicians … of all types.”—Brian 23:46 EP252 with Chad Gray.25:12 “High-performance organizations represent a new paradigm in their niche.”—Brian 25:35 “It speaks to the core problem of American health care, which is that we’ve developed a culture of excess.”—Brian 27:42 Where’s the top of the bell curve right now? 28:10 “A lot of this is driven by policy … and that has sort of rigged the game.”—Brian 29:46 “There’s a tipping point, and then everything really, really will change quickly.”—Brian You can learn more at bannerhealth.com and drmatthewanderson.com and connect with Dr. Anderson on Twitter at @DrAnderson19 and on LinkedIn. You can also learn more at careandcost.com, by emailing bklepper@gmail.com, and by visiting validationinstitute.com.  Check out our newest #healthcarepodcast with @DrAnderson19 and @bklepper1 as they discuss the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth “They’re really starting to become someone who can provide that continuity of care in a way that I don’t think anyone’s really done before.” @DrAnderson19 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “When you are competing for patients, by definition you’re competing for revenue.” @DrAnderson19 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “This is going to be a space race for health care innovation right now.” @DrAnderson19 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “Things are moving slowly but surely in the right direction, and that’s something I’ve never seen during the course of my career.” @bklepper1 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “Everybody and his wooden-legged brother claims that they have a high-value service, but very few actually do.” @bklepper1 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “It speaks to the core problem of American health care, which is that we’ve developed a culture of excess.” @bklepper1 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast

Joining me today were regulars: writer Kim Bellard, tech policy expert Vince Kuraitis, patient advocate Grace Cordovano, radiologist Saurabh Jha, employer consultant Brian Klepper, consumer health privacy expert Deven McGraw, and a new guest, former ONC consumer head Lygeia Riccardi, now at startup Carium! We had a great discussion about patient experience, whether telehealth is really the permanent new normal, hospitals losing money & whether the US can do testing and contact tracing. The video is below.

Joining me today will be Saurabh Jha, Ian Morrison, Kim Bellard, Grace Cordovano,Vince Kuraitis, Brian Klepper, and a special guest – Alexandra Drane (@adrane, founder of Eliza, Queen of the Unmentionables, CEO of ArchAngels and sometimes Walmart cashier) are all going to discuss some new updates surrounding the pandemic as well as new movements in the patient care giver space as weill as opening up the economy amidst COVID19 — Matthew Holt

This week, joining me today are Deven McGraw, Kim Bellard, Vince Kuraitis, Michael Millenson, Brian Klepper, Grace Cordovano, & Daniel O'Neill. It was a fun and argumentative discussion about the developments around COVID19 and what we should pay attention to— Matthew Holt

On this episode of Valid Points, our guest is Kristin Begley, PharmD, the Chief Commercial Officer of Wildflower Health, a health IT company committed to “Growing healthy families” that has developed an enterprise platform for user personalization allowing healthcare to feed the same way Netflix delivers spot on recommendations or how Pinterest helps you find your next great purchase.   Wildflower Health was born from the experiences of the founder and CEO Leah Sparks, who struggled with two high-risk pregnancies and has expanded the mission from pregnancy alone to now supporting women in all life stages of family life with personalized education, tracking and calls to action for kids, dads and aging parents.   Wildflower does this by combining information from demographics, EMR data, and a host of tools/trackers, to customize individual experiences while amplifying the impact of health plans, providers and employer procured vendors. Allowing us to bring employer, payer and provider resources together in one digital user experience, connecting consumers to the right support at the right time via their smart phone or tablet for the evolving needs of families across all life stages.   Follow Kristin and Wildflower Health's work on the web via www.wildflowerhealth.com and on twitter @wildflowerhlth ==##==

Hosts Fred Goldstein and Gregg Masters are joined by seasoned healthcare analyst and Executive Vice President of Validation Institute, and host of ValidPoints podcast series Brian Klepper PhD on PopHealth Week’s last show of 2019, for an update on progress towards fulfillment of the triple aim. Want to stream our station live? Visit www.HealthcareNOWRadio.com. Find all of our show podcasts on your favorite podcast channel and of course on Apple Podcasts in your iTunes store or here: podcasts.apple.com/us/podcast/heal…1301407966?mt=2

On PopHealth Week's last show of 2019, seasoned healthcare analyst and Executive Vice President of Validation Institute, and host of ValidPoints podcast series Brian Klepper PhD join PopHealth Week hosts Fred Goldstein and Gregg Masters for an update on progress towards fulfillment of the triple aim. We explore the question of 'are we there yet' with a deeper dive into the continuation of lack of affordability, high variability in quality and outcomes including the well known 'book of business' driven access problems in healthcare equity. 2019 has been a landmark year for PopHealth Week. Of note is our continued scheduling of national thought leaders, system executives and many in the lesser know world of innovation and advancing the triple aim. We are very happy to witness the continued growth and expansion of our work and reach via collaboration with HealthcareNOW Radio. 2020 will be a make or brake year for the burden placed upon healthcare leadership writ large. We'll engage many on the front lines of this transformational imperative. Happy Holidays and Happy New Year!   ==##==  

On this episode of Valid Points, our guest is Nelson L. Griswold President of BottomLine Solutions a Nashville based NexTGen Benefits Consulting and Advisory firm. You can follow Nelson's work on the web via www.insurancebottomline.com and on twitter @nelsongriswold Do mark your calendars for the ASCEND's'Agency Growth & Leadership Summit'January 9-12th, 2020 - Dallas, TX where top benefit firm leaders discover innovative strategies and industry solutions to grow their business. Details on Ascend can be found at www.attendascend.com Finally, for more cutting edge insights into the emerging value based health benefits advisory space be sure to subscribe to the ‘Valid Points’ newsletter; and this Valid Points podcast for an informative series featuring top industry talent. Go to www.validationinstitue.com/validpointspodcast and follow Validation Institute’s work on twitter via @valid_institute.   ==##==                  

Everyone says that they are a high-performing organization, but which ones really are? Which health care organizations have proven to deliver better outcomes at lower costs? This week, John sits down with the dynamic Brian Klepper, Ph.D., executive vice president of The Valuation Institute. Brian offers examples of unusually high-performing health care organizations and the secrets to their success.

On this episode of Valid Points, our guest is Brian Klepper PhD, Principal at Worksite Health Advisors. Brian also serves as Executive Vice President at Validation Institute. The mission of Validation Institute is: "to deliver better health value and stronger outcomes than conventional health care." Brian is interviewed by Fred Goldstein, President of Accountable Health, LLC. Validation Institute is a network of trusted healthcare vendors, health benefits advisors and purchaser benefit managers focusing on delivering better health value and stronger outcomes than conventional healthcare.   For more information or to learn how you can move the needle towards a sustainable, value oriented healthcare economy go to Validation Institute. Be sure to subscribe to the ‘Valid Points’ newsletter; and this Valid Points podcast for an informative series featuring top industry talent.   Follow Validation Institute’s work on twitter via @valid_institute. ==##==        

We have gotten ourselves into this pickle: Americans—all of us as taxpayers, as patients, as employees, as employers—spend exorbitantly for highly variable results. Great work, great health care in some areas by some great physicians and their teams, and then voluminous other areas rife with overtreatment, errors, abysmal chronic care management, predatory pricing by entities owned by private equity or with billing departments gone wild. Who will be our knight in shining armor when it comes to fixing health care in the United States today? Will it be legislators? Will it be our current crop of large health care stakeholders? Will it be a self-proclaimed disrupter like Amazon or Haven Healthcare, that Amazon, Chase, and Berkshire Hathaway collaboration? In this health care podcast I speak with Brian Klepper, PhD. Brian has opinions on these questions. Spoiler alert: Some of the entities that Brian points to as intrinsic to the mission of fixing American health care are brokers who are not compensated in secret by insurance carriers. He also calls out primary care physicians and new primary care models as crucial. If you’re looking for brokers of this kind, go to healthrosetta.org for a list of them. You could also listen to my podcast with David Contorno (EP186). On the primary care side of the equation, listen to my chat with Jed Constantz (EP209) and also the one with Alex Lickerman (EP184). In case you haven’t heard of him, Brian is a health care analyst, commentator, and also an entrepreneur. He’s executive vice president at the Validation Institute, executive analyst and editor at the Health Value Institute, and principal of Healthcare Performance, Inc, a health care strategy and business development practice. He’s also principal of Worksite Health Advisors, a benefits consultancy. Formerly, Brian served as the CEO of the National Business Coalition on Health. You can learn more at careandcost.com, by emailing bklepper@gmail.com, and by visiting validationinstitute.com. Brian Klepper, PhD, is executive vice president of the Validation Institute, principal of Worksite Health Advisors, and a nationally prominent health care analyst and commentator. He speaks, writes, and advises extensively on high-performance health care, primary care clinics, and the management of clinical and financial risk. His current consulting focus is on health care organizations that consistently deliver better health outcomes at lower cost than conventional approaches in high-value niches. In his role at the Validation Institute, he spearheads programs that identify, validate, celebrate, and promote true high-performance health care programming. 02:54 How solving the health care crisis can be done within the marketplace. 04:13 “Half or more of everything that we do in health care is unnecessary or inappropriate.” 04:29 “We have come to depend upon doing the wrong thing.” 04:39 How we fix health care when the vested interests have no incentive to do so. 08:50 Money on the table vs doing the right thing. 10:24 What we should be doing right now to fix this before we price ourselves out of health care. 12:34 Why the health industry does have a marketplace. 18:29 Laser focusing initiatives to fix health care by fixing the biggest costs of health care and following the money. 19:37 “We’re not just talking about managing care; we’re talking about managing health care, clinical, and financial risks.” 22:34 EP186 with David Contorno. 22:50 Lee Lewis of Gallagher. 24:25 How the Validation Institute identifies high-performance vendors. 25:54 Why working with a broker is essential for employers in order to find health providers they can trust. 28:05 Health Rosetta, founded by Dave Chase. 28:17 An outcomes-accountable health care place. 28:30 Brian’s advice on what one of the “BUCAs” should be doing right now. 29:18 “Are they willing to make less money?” 30:53 “Big change is coming.” 31:15 Brian’s advice to organizations to prepare for and fix health care’s coming inflection point. 34:11 Places to watch that are ahead of the rest of the nation in making these changes: the South. You can learn more at careandcost.com, by emailing bklepper@gmail.com, and by visiting validationinstitute.com. How can the #healthcare crisis be solved by the #marketplace? @bklepper1 of @careandcost discusses on our #healthcarepodcast. #podcast #digitalhealth #healthcost #healthincentives “Half or more of everything that we do in #healthcare is unnecessary or inappropriate.” @bklepper1 of @careandcost discusses on our #healthcarepodcast. #podcast #digitalhealth #healthcost #healthincentives “We have come to depend upon doing the wrong thing.” @bklepper1 of @careandcost discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcost #healthincentives How do we fix #healthcare when vested interests have no incentive to do so? @bklepper1 of @careandcost discusses on our #healthcarepodcast. #podcast #digitalhealth #healthcost #healthincentives Money on the table vs doing the right thing. @bklepper1 of @careandcost discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcost #healthincentives Does the #healthindustry have a marketplace? @bklepper1 of @careandcost discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcost #healthincentives Following the money to fix health care. @bklepper1 of @careandcost discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcost #healthincentives “We’re not just talking about managing care; we’re talking about managing health care, #clinical, and #financialrisks.” @bklepper1 of @careandcost discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcost #healthincentives How does the #validationinstitute identify high-performance vendors and #providers? @bklepper1 of @careandcost discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcost #healthincentives

On this episode of Valid Points, our guest is Brian Klepper PhD,Principal at Worksite Health Advisors. Brian also serves as Executive Vice President at Validation Institute. The mission of Validation Institute is: "to deliver better health value and stronger outcomes than conventional health care." Brian is interviewed by Fred Goldstein,President of Accountable Health, LLC. Validation Institute is a network of trusted healthcare vendors, health benefits advisors and purchaser benefit managers focusing on delivering better health value and stronger outcomes than conventional healthcare.   For more information or to learn how you can move the needle towards a sustainable, value oriented healthcare economy go to Validation Institute. Be sure to subscribe to the ‘Valid Points’ newsletter; and this Valid Points podcast for an informative series featuring top industry talent.   Follow Validation Institute’s work on twitter via @valid_institute. ==##==            

In episode 242 I’m joined by Dr. Brian Klepper who brings us an update of issues in the US healthcare system and other similar systems. We also get deeper into high performance healthcare, as he defines it, and some helpful resources of which the well informed healthcare innovators would be aware. This week on MCF!

In episode 241 I’m re-airing my interview with Dr. Brian Klepper. A healthcare analyst, consultant and speaker. He talks healthcare challenges and outlines what he refers to as high performance healthcare. This week on MCF!

Brian Klepper, Principal at HC Performance Inc. and Worksite Health Advisors, believes that the value being delivered in today's health care system is a “train wreck” and that many are complicit – and know that they are complicit. He explains why he believes that Fee For Service is the crack cocaine of healthcare. The good news is that Brian sees a new model emerging that focuses on delivering value across the entire health care delivery chain. You can find show notes and more information by clicking here: http://bit.ly/2xmUmzA 

Brian Klepper, Principal at HC Performance Inc. and Worksite Health Advisors believes that the value being delivered in today's health care system is a “train wreck” and that many are complicit – and know that they are complicit. He explains why he believes that Fee For Service is the crack cocaine of healthcare. The good news is that Brian sees a new model emerging that focuses on delivering value across the entire health care delivery chain. You can find show notes and more information by clicking here: https://bit.ly/2pS0P0D

Wednesday, September 13th, 2017 our special guests are: Brian R. Klepper, PhD is a  principal at Healthcare Performance, Inc. and Principal at Worksite Health Advisors . Klepper is a health care analyst, commentator and entrepreneur who has specialized on health care market dynamics and the drivers of the cost crisis. He is a former CEO of the National Business Coalition on Health (NBCH), representing 52 regional business health coalitions, about 5,000 employer and union health benefits purchasers and some 35 million people. Linda K. Riddell, M.S., Principal, Health Economy, LLC. Ms. Riddell has worked in health policy and health care since 1985. Her recent public sector work has included projects for Maine’s Medicaid program. Linda is an independent population health scientist, consulting with private and public sector organizations on measuring outcomes.  She is also the Strategic Initiatives Manager for the Validation Institute, Inc.  She will be in charge of reviewing the Health Value Award applicants' measurable results.   We'll discuss current market conditions and the HealthValue Awards Program a co-venture of World Congress, in partnership with The Health Rosetta Institute and The Care Innovations Validation Institute. Join us!  

On the Wednesday, Februart 3rd, 2016 broadcast at 12 Noon Pacific/3PM Eastern our special guest is Brian Klepper, Ph.D. (follow on twitter via @bklepper1). Dr. Klepper: 'is a health care analyst, commentator and entrepreneur who has specialized on health care market dynamics and the drivers of the cost crisis. He is President of Health Value Direct, a benefits brokerage connecting high performance, high impact health care organizations with organizational health care purchasers. He is a former CEO of the National Business Coalition on Health (NBCH), representing 52 regional business health coalitions, about 5,000 employer and union health benefits purchasers and some 35 million people.' Join co-hosts Fred Goldstein (@fsgoldstein) and Gregg Masters (@2healthguru) as we glean insights from this disruptive innovator. Enjoy!

On a special broadcast Thursday, October 9th, 2014 at 12 Noon Eastern and 9AM Pacific we continue the 2nd installment in the series 'Countdown to the Population Health Alliance PHA Forum 2014'.   The PHA Forum is an annual 'go to' industry standard for the entire ecosystem of population health management stakeholders including innovators in accountable care, care management and the general pursuit of the triple aim - better care, improved outcomes and lower per capita cost. This dynamic community gathers in Scottsdale, Arizona from December 10th - 12th.   On this broadcast we hear from health care analyst and the CEO of The National Business Coalition on Health (NBCH) who will supply an overview of the large employer persepctive and by proxy the essesnce of the purchaser communities message to the domestic provider comminuty writ large. More about NBCH: The National Business Coalition on Health (NBCH) is a national, non-profit 501(c)6, membership organization of purchaser-led health care coalitions. NBCH and its members are dedicated to value-based purchasing of health care services through the collective action of public and private purchasers. NBCH seeks to accelerate the nation's progress towards safe, efficient, high-quality health care and the improved health status of the American population. NBCH has a membership of 53 coalitions across the United States representing over 4,000 employers and approximately 35 million employees and their dependents. A detailed agenda for the PHA Forum 2014 is available here. For more information, or to register click here.

On the Wednesday, January 19th 2011 program at 11AM Pacific and 2PM Eastern, my guest commentator is thought leader, nationally known blogger, health care analyst, business development consultant, writer and speaker on health care cost and quality issues Brian Klepper, Ph.D. For more information, see: http://careandcost.com/ Over many years, Brian Klepper has developed a national reputation for thoughtful, reasonable perspectives on complex health care issues. Dr. Klepper consults with health care organizations and business groups to create market visibility that leverages performance, and to take advantage of emerging trends that promise to positively transform both health care quality and cost. Dr. Klepper serves as Editor for MedPedia, as Editor-at-Large for Community Oncology, and as one of only three non-physicians on the International Editorial Board of Medscape General Medicine, and is also a regular columnist on several of the best-respected and most widely-read expert health care blogs - The Health Care Blog, Health Care Policy and Marketplace Review, Health Commentary and Health Wonk Review. Klepper is a Principal in three firms. Healthcare Performance provides market analyses and strategic services to the industry. Health 2.0 Advisors counsels health care firms on ways to use the Web to facilitate knowledge exchange, patient engagement, pricing and performance transparency, transactional streamlining and decision support. WeCare TLC develops and manages onsite clinics for employers and other organizations. Please join us for an informative exchange!