Podcast appearances and mentions of chris deacon

On this final encore episode of the Astonishing Healthcare podcast this year, we're replaying Episode 41, which featured three experts weighing in on rising litigation against employers and pharmacy benefit managers (PBMs) and was one of our most popular. We also want to take the opportunity to say, "Happy Holidays and New Year!" and thank our listeners and guests this year, including current and former colleagues; we couldn't have done it without you!In Episode 41, we discussed what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson & Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.This episode built on previous conversations, including AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan.Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"Related ContentAH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff HoganThe Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New ResponsibilitiesSelf-funded plans ignore the Consolidated Appropriations Act at their perilFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

I'm putting a meme in the show notes. It's my second meme ever, so I'm clearly on a roll. As you can see, it's a picture of two kids taking a test; and the one kid is cheating off the other kid. It's a How to Do Spread Pricing test, and the kid with carrier has his eyes all over the PBM kid's test. 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. Look, this is a thing now, medical spread. And similar to how PBM spreads adds up to millions, billions of dollars, medical spread is not change in the couch cushions. Did you see the lawsuit against Cigna? Cynthia Fisher mentions it in the conversation that follows. Spoiler alert, here's the numbers: Self-insured employer paid $4 million for a claim. In this case, there's a slide on this Cynthia Fisher gave me, by the way, if you want to see all this written out. So, the employer pays $4 million. The provider was paid—drumroll, please—$876,000. I'm pausing so that sinks in: $4 million paid by the employer; $876,000 of that makes it across the trench to the provider. What happened, you may be wondering, to the $3.2 million in the middle there that the self-insured employer wrote a check to their carrier for? If I'm the employer, I think I would sort of want to know where the $3.2 million went, because … yeah. I think anyone would be hard-pressed to explain how a prudent fiduciary is managing to pay millions of dollars of its plan members' money for services that actually cost a fraction of that. And this is just one claim. But you came here for a show about transparency. Why, you may be wondering, am I talking about medical spread pricing? It's not a super far leap, so many of you are probably there already; but let me quote Chris Deacon. She wrote, “As these conglomerates expand control over healthcare delivery and administration, radical transparency is our only bulwark. Patients and employers deserve to know exactly what they're paying for, without hidden fees disguised as care costs.” I don't think anyone would say that transparency alone is sufficient to transform healthcare, but it's definitely a start for sure. So, yeah … transparency. The reason why lawsuits about overpayments, big ones—and there's a bunch of them afoot right now, not just that Cigna one—but the reason that these are going down in the first place is because hospital prices and carrier prices are now somewhat available. And we have some plan sponsors—the ones who are worried about fiduciary duty, at least—these plan sponsors are able to cobble together the math to catch a glimpse of how much money is vanishing. Dollars they and their members are paying for medical claims that never make it to the care team providing the care. And who is shocked? Are you shocked? I'm not shocked. Let me read a sentence from a carrier contract that Justin Leader sent me the other day. Section 6.3: “Claim administrator's compensation for its services under the agreement shall include the difference between the net claim payments reimbursed to the claim administrator by the employer and the net amounts paid to providers by the claim administrator.” Translation: We are allowed to add spread pricing. We are able to arbitrage. We are able to mark up (or whatever you want to call it) by any amount we want, and you, plan sponsor, just signed up to pay for it. So, that happened. Listen to episode 433 with Justin Leader, by the way. The show is called “The Mystery of the Weekly Claims Wire,” otherwise known as the Not Transparent Weekly Claims Wire. So, look … transparency: We can talk about it in terms of medical prices. We can talk about transparency in terms of contracts. And actually also in terms of quality, but we don't get into that today. Bottom line, plan sponsors need enough access to billing data and hospital prices to calculate how much the middle folks are taking in spread, which is, as aforementioned, quite a thing. For more actual data on the magnitude of spread pricing goings-on, ask Dan Ross. That's my suggestion. He's got spreadsheets he can show you of how much plan sponsors are paying and how much providers are charging and how much is going missing in the middle. For even more on this, read the recent Owens & Minor lawsuit that just got filed, which is just a case study in how hard some of these middlemen/carrier entities are working to obscure and hide what they are doing. Because, yeah, sunshine is a great disinfectant, and that's what transparency is. Sunshine. Here's another interesting link from Chris Deacon. I say all this to say, this is the kind of transparency that Cynthia Fisher and I talk about in the show today: contract transparency, bill charges transparency, and hospital or medical price transparency for plan sponsors. We do not get into today consumers or patients using price information to shop, just FYI. We also do not get into, really, price convergence, which is what happens when hospital and carrier prices become available in a market and is often brought up on or about conversations about transparency. Okay, I will say just one thing about price convergence. There was some chatter in anti-transparency press releases from parties mostly that didn't want to be transparent at all, no way no how. But there was some talk a couple of years ago that if contracted prices became transparent, the healthcare industry would raise their prices to match the highest in the market and the result would be rising healthcare prices and greater total costs. That turns out, it seems, to be false. There's a study that shows that the bottom of the market (those with the cheapest prices) do, in fact, raise their prices but not as much as the top of the market lowers theirs. So, there is actually net savings. Read about the Turquoise Health study and an article that Forrest Xiao and team posted that shows this, and it's the first study of its kind, at least that I have seen. Okay, so contract transparency, data transparency, that's what's on deck to discuss today with Cynthia Fisher, as I have mentioned several times already, who has a long history as an entrepreneur in the healthcare space. So, Cynthia Fisher gets U.S. healthcare, and she gets being a plan sponsor and a fiduciary. She is founder and chairman of PatientRightsAdvocate.org, as well as Power to the Patients. Her focus is on ensuring that all healthcare shows prices up front so that we can have accountability and integrity in billing and at any point of care. Cynthia has said early and often that transparency protects the ultimate purchasers of healthcare—meaning plan sponsors, plan members, and patients—from overcharges, spread pricing, or otherwise. Where there's mystery, there is margin, as Anthony Ciaccia has said often. Cynthia's call to action is as follows, but listen to the show to hear her say it more eloquently. C-suites, CFOs, in-house counsel use purchasing discipline that your company probably uses elsewhere in the procurement of health benefits.  Cynthia Fisher also says as part of the call to action, refuse to sign blank checks to the healthcare industry and refuse anti-audit provisions. She also has a call to action for the accounting industry to stop ignoring auditing the health plans. And this matters just given the bald-faced fact right now that overcharges are party sized. Let me wrap up with this: There's a lot of brute force tactics out there being deployed by some plan sponsors that effectively keep plan members from getting the care they need because they are functionally uninsured. I've done multiple shows on this, and I link to some of them below. I just can't help to think, some of this brute force, you know, high-deductible health plans and some pretty savage cost containment strategies, might be unnecessary if middleman excess profits were eliminated. Well, I say this with some evidence, actually. Andreas Mang (EP419) was on the pod. He talked about saving 15% or more by being smart about contracts and plan assets at the financial and purchasing level. Brian Uhlig … was talking to him the other day. He was telling me he saved $80 million just doing contracts right. Also Claire Brockbank (EP453) talks about this; Cora Opsahl (EP452), too, from 32BJ. Those are two recent shows, again, about how much money can be saved by only signing contracts that ensure transparency. Also mentioned in this episode are Patient Rights Advocate, Chris Deacon, Justin Leader, Dan Ross, Forrest Xiao, Anthony Ciaccia, Andreas Mang, Brian Uhlig, Claire Brockbank, Cora Opsahl, Mark Cuban, and Mark Cuban Cost Plus Drug Company.   You can learn more at PatientRightsAdvocate.org.    Cynthia A. Fisher is founder and chairman of PatientRightsAdvocate.org, a nonprofit organization seeking healthcare price transparency, giving power to American consumers—patients, employers, and unions—to lower their costs of care and coverage through a functional marketplace and choice. Cynthia is best known for her pioneering work as founder and CEO of ViaCord, Inc., a leading price-transparent umbilical cord blood stem cell banking company which she started in 1993. In 2000, she co-founded and was president of the cellular medicines company ViaCell, Inc., of which ViaCord became a division. ViaCell went public in 2005, was acquired by PerkinElmer, and exists today under the ViaCord brand. Cynthia also serves on the public company boards of the Boston Beer Company, Inc. and Easterly Government Properties, Inc. She serves on the Florida Council of 100 and the board of the National Park Foundation, and she previously served on the board of directors of Water.org. Cynthia holds an MBA from Harvard Business School and a bachelor's and honorary Doctorate of Science degree from Ursinus College.   09:03 What is the goal of PatientRightsAdvocate.org? 10:28 Is American competitiveness being affected by healthcare spend? 13:47 Why is transparency a root cause to healthcare costs? 15:11 What's going on across the country to empower transparency in healthcare? 19:31 “I think people are fed up.” 21:22 The Cigna lawsuit in California. 26:36 How do employers navigate contracts against anti-steering? 28:54 EP419 with Andreas Mang. 29:33 EP452 with Cora Opsahl and EP453 with Claire Brockbank. 29:45 EP433 with Justin Leader.   You can learn more at PatientRightsAdvocate.org.   Cynthia A. Fisher of @PtRightsAdvoc discusses #medicalspreadpricing and #contracttransparency on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW40), Mark Cuban and Ferrin Williams (Encore! EP418), Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451)  

On this episode of the Astonishing Healthcare podcast, three experts weigh in on rising litigation against employers and pharmacy benefit managers (PBMs) and what employers sponsoring ERISA-covered health and welfare plans can do to show they are making an effort to establish processes and assess how "reasonable" the fees they pay are. Chris Deacon, Founder of VerSan Consulting; Jonathan Levitt, trial attorney and Co-Founding Partner at Frier Levitt; and Julie Selesnick, Senior Counsel in the employee benefits and ERISA Group at Berger Montague, joined host Justin Venneri for the discussion covering relevant provisions of the Consolidated Appropriations Act of 2021 (CAA), the recent lawsuits against Johnson & Johnson and Wells Fargo, and how plan sponsors can approach things like getting their data to make informed decisions.This episode builds nicely on previous conversations, including AH030 - Plan Sponsors Need a Source of Truth; Get Your Data Now & Find It, with Jeff Hogan.Chris, Jon, and Julie share their opinions about the similarities - or lack thereof - of the health plan lawsuits to the 401(k) and pension litigation of the early 2000s, why we will likely see more litigation, the reality and frustration of relying on traditional PBMs and carriers for data (and what to do about it), conflicts of interest in and around PBM procurement and broker/consultant relationships, and why Julie has a "fainting couch!"Stay tuned for more, and we'll add some new resources (scripts and checklists, for example) to the links as they become available!Related ContentAH004 - Data, Fiduciary Responsibility, and Reversing Trend with Jeff HoganThe Consolidated Appropriations Act & Prescription Drug Data Collection (RxDC): New Rules & Regulations Equal New ResponsibilitiesSelf-funded plans ignore the Consolidated Appropriations Act at their perilFor more information about Capital Rx and this episode, please visit Capital Rx Insights.

Last time Cora Opsahl was on the show, Michelle Bernabe, RN, KAT, wrote a comment on LinkedIn I thought encapsulated the gist of it all so well. She wrote, “[Cora] first became a mentor/ally through Relentless Health Value episode 372. … It opened a doorway to a whole group of very relentless people.” 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 want to start there because it's a nice comment, but it's also a call to action. Think about this and think about it not in the context of being a “stakeholder” and not in the context of being an organization but in the context of humans who work at these various organizations who, combined, comprise the bucket of companies that we lumped together using the old stakeholder word. All of these individuals are making choices every day, and all of these choices, they could be made with integrity and with the patient or member in mind … or not. In real life, right now, the overwhelming majority of members/patients in this country get their clinical care and the pleasure of paying for that care or drugs within the current ecosystem we have here in the USA. For any of us, or all of us who work within that traditional ecosystem, it is up to us to choose our own legacy here. It's probably why you listen to this show in the first place, actually. There are so many RHV (Relentless Health Value) listeners who are pushing for patients against the riptide that is the profit motives of the organization that they work for. It's hard. But yeah, it's all about finding our people and supporting each other. Okay, so let's get to the “between a rock and a hard place” portion of this discussion. Hospitals and ASOs (administrative services organizations)/carriers/TPAs (third-party administrators) often enter into or sometimes enter into what amounts to anticompetitive contracts with each other. Listen to episode 395 with Brennan Bilberry for the rundown on that one. But meanwhile, the CAA, the Consolidated Appropriations Act from 2021, holds employer plan sponsors accountable and responsible to ensure that plan assets are spent prudently, that costs paid are reasonable, and that there's no conflict of interest (COI). This is the definition of what a fiduciary is supposed to do, by the way—prudent, reasonable, and no COI. Anticompetitive contracts between a carrier and a hospital are the very definition of COI. And when that COI results in higher, maybe unreasonable, prices and non-prudent spend, well, plan sponsors are put between a rock and a hard place if they stick with their existing vendors. Rosa Novo from Miami-Dade County Public Schools put this really succinctly on a panel at a 32BJ event recently. She said what amounts to, I have no choice but to actually do the right thing here, for many reasons, but one of them is I do not look good in orange. She said, my personal butt is on the line here. And furthermore, who do class action lawsuits make look bad when their company or CEO or CFO are personally sued over conflicted benefits? See the Wells Fargo lawsuit, J&J lawsuit, etc. It sucks that employers or plan sponsors get put into this pickle by their own vendors. And that's what we're talking about today. This is a conversation that starts out talking about rates (ie, prices), edges into rights (ie, plan sponsor rights), and ends up all about power. And by the way, if you're a plan sponsor, especially in New York City, maybe doing the right thing here means hatching a plan to steer and tier in your benefit design, figuring out how to, for reals, help support the efforts of 32BJ to advantage pretty much every patient near and far. The pushback I often hear to doing something like this often involves the perception that plan members are too rich to care about reasonable prices, prudent plan spending, and COI. And yeah, to state the obvious, these same people are also sophisticated enough to smell a fine opportunity for a class action lawsuit; and also, they probably do care, as more and more studies suggest. Sorry if I just stumbled onto a sacred cow. Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members. And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today. And yeah, it's a freakin' tangled web we weave; and this tale is a perfect case study of it. It makes me even more invested in remembering my own manifesto (that was episode 400) to ensure that I can feel good about what I personally have accomplished and what I have been a part of and the net impact of my own personal actions, since I, too, very often work in the belly of the beast. Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available. More on that in the show that follows. Also mentioned in this episode are 32BJ Benefit Funds; Michelle Bernabe, RN, KAT; Brennan Bilberry; Rosa Novo; Marilyn Bartlett; Cynthia Fisher; Zack Cooper, PhD; Claire Brockbank; Andreas Mang; Chris Deacon; Elizabeth Mitchell; and Purchaser Business Group on Health.   You can learn more at health.32bjfunds.org and by following Cora on LinkedIn.   Cora Opsahl is the director of the 32BJ Health Fund, a self-insured Taft-Hartley benefit fund that sets comprehensive design parameters to ensure the 200,000 members and families of Service Employees International Union 32BJ have easy and sustained access to affordable, high-quality healthcare. Since becoming director of the Health Fund in 2021, Cora has prioritized a data-driven approach to healthcare, focusing on reducing trend; solving the affordability challenge on behalf of union members; and most important, keeping members at the center of every decision. Under her leadership, the 32BJ Health Fund has saved more than $35 million annually—which it has reinvested in new and better benefits, including the first fertility benefit for members—by removing NewYork-Presbyterian hospitals and physicians from its network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and establishing an expanded Centers of Excellence program. Most recently, Cora conducted an innovative medical request for proposal (RFP), stipulating that all finalists must have a signature-ready contract drafted by the Health Fund prior to award. By including the Health Fund–drafted contract in the RFP process, the Fund was able to negotiate an agreement that brought unprecedented visibility and increased accountability to the 32BJ Health Fund benefit. Cora is regarded as an expert in pharmacy benefit management and previously worked at Express Scripts, where she held a variety of roles, ranging from Medicare Part D to operations to strategy and acquisitions. She earned an MBA from Saint Louis University.   06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors? 09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design. 12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design? 14:12 How do these anticompetitive rights have quality implications as well as cost implications? 18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year? 19:46 What did the healthcare savings allow the unions and employers to do? 20:46 Study by Zack Cooper, PhD. 21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend. 24:15 Why 32BJ Health Fund wants to control the contracting process. 26:00 EP419 with Andreas Mang. 27:18 What are 32BJ Health Fund's four non-negotiables? 33:17 Wall Street Journal article on health insurance contract. 35:30 Upcoming episode with Claire Brockbank. 36:14 What is the challenge that exists in our current healthcare environment? 37:43 Cora's advice on how to get high-quality healthcare at an affordable price.   You can learn more at health.32bjfunds.org and by following Cora on LinkedIn.   @CoraOpsahl discusses #fiduciaryresponsibility in #healthcare on our #healthcarepodcast. #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary, Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9), Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402), Ashleigh Gunter, Dr Spencer Dorn (EP446)  

Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever. In this meme, I picture that Olympic silver medalist shooter from Turkey who showed up in a T-shirt and his hand in his pocket versus the others with all their fancy equipment that, turns out, may or may not be necessary, regardless of who might swear up and down that complexity requires even more complexity and plenty of expensive gear to shoot straight. Point being, it's amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just do their thing and follow the dollar. 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. And with that, Marilyn Bartlett has entered the chat. Marilyn Bartlett isn't called the “Queen of Healthcare” for no good reason, and nobody is joking when they say this. She was probably the first person (or one of the first, at a minimum) to truly identify the amount of money getting sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the healthcare and insurance and consulting industries. She is a through and through numbers person but also deeply cares. She is truly a senior stateswoman in our field. Let's start from the beginning here. But you'll have to listen to the interview that follows for the end and most of Marilyn's really sage advice and words of inspiration for any of you, for all of us, trying really hard to fix healthcare and, any day of the week, taking two steps forward and/or five steps back. It's what Mike Tyson was talking about when he said, “Everybody has a plan until [you] get punched in the face.” And yeah, I'd say pretty confidently that everyone in the Relentless Health Value tribe trying to fix healthcare has been there at some point or another. So, here's where I begin the conversation with Marilyn Bartlett today. One day in 2014 or 2015, Marilyn was minding her own business as a CFO at a regional TPA (third-party administrator) firm about ready to retire when the state of Montana reached out. They asked if she would consider being the plan administrator for the state employee health plan, which was, turned out, headed for bankruptcy. Marilyn took the job, and she took the state health plan from $9 million in the hole—they were in debt $9 million—to $112 million to the good. Well, meanwhile, plan members got better benefits. Think about that: $9 million in the hole to $112 million in the good. In fact, the plan had so much money in 2018 when Marilyn left that the state took some of it to pay for other things in the budget. This is truly mind blowing. I mean, get a CPA with their eye on the ball, and this is the difference that is possible to be made in a state health plan. It also just needs to be said that this same state plan, the one that was going bankrupt, clearly had seen over $100 million of taxpayer money exit stage left and wind up in the bank account of their vendors. Now might be a good time to mention something that Chris Deacon wrote about: the Federal Employees Health Benefits Program. This is a $55 billion program, once again funded by taxpayers. As per an OIG (Office of the Inspector General) audit, there are no written policies or procedures over approval and payment of funds to the carriers via ACH (Automated Clearing House). Wait, what? This is just one example, along with a whole lot of other things that kind of make you go, “Hmmm … can a CPA with a spreadsheet please get in there and do your thing?” In the conversation that follows, I ask Marilyn to tell me what she did in roughly three short years to do her thing and save the state of Montana over $100 million while improving benefits of the state workers. And she tells me, short version, she created a why—that's step one. Step two, she looked at her spreadsheets and financial analyses and quantified the situation. She was able to identify a few big hairy problems, which she then hit fast and hard with solutions. This is gonna accomplish a couple of things if you do this, find a solution for a big enough problem. First, it creates a quick win; and quick wins are needed to get some momentum to get started. Second, she knew that by solving big hairy problems, the solutions would have an outsized impact given the scope of these original problems. This is kind of Strategy 101. And then step three, she dug in on assembling the right team with the right skills to make it through what amounts to a change management process, I'm gonna say. What did Marilyn not do in those three years? She did not get captivated or sidetracked by any, I'm gonna call it, transformational theater—which is not easy because a lot of transformation theater has more glitter than a Las Vegas show and is really hard to look away from. It's as magical as most magical thinking. Also, Marilyn stayed the course in the face of what I am sure were many opportunities for personal gain that would have not been a win-win for the state of Montana or its employees. To emphasize how one should not take this for granted, I was talking to a benefits leader the other day and you know what she told me? She said she always goes with this one carrier every year because if you go with that one, when you get invited to their box at the NFL games, you can go out on the field afterwards. I mean, it's really fun to meet the players. Unfortunately, for so many in positions of power, when doing the right thing by taxpayers and/or plan members stands between them and box seats, the right thing gets escorted out of the building. Mentioned in this show, we have Cora Opsahl and Claire Brockbank, who both will be featured in upcoming shows about RFPs (request for proposals) and best practices and how they can go right and also occasionally take a left turn. Check the links to episodes about pharmacy benefits and PBMs (pharmacy benefit managers). I might think of some others, but you'll definitely want to listen to the show with Paul Holmes (EP397); the one with Mark Cuban and Ferrin Williams, PharmD, MBA (EP418); and also AJ Loiacono (EP379). Also mentioned in this episode are Chris Deacon; Cora Opsahl; Claire Brockbank; Mark Cuban; Ferrin Williams, PharmD, MBA; AJ Loiacono; and Shawn Gremminger. You can learn more by connecting with Marilyn on LinkedIn.   Marilyn Bartlett, CPA, CGMA, CMA, CFM, serves as a consultant focused on lowering healthcare costs and empowering employer health plans and state policymakers with data to support cost-saving initiatives. She recently developed the Hospital Cost Tool for the National Academy for State Health Policy (NASHP), an interactive online tool which utilizes hospital Medicare Cost Report data to calculate various hospital metrics used to support hospital and health system financial analysis and health policy. As administrator of the Montana State Employee Health Plan, she disrupted the status quo by implementing Medicare rate reference-based contracting with all Montana hospitals, enhancing primary care through near-sight health centers, moving to a transparent, pass-through PBM, eliminating duplication of vendor services, and improving data access and analytics. These efforts increased plan reserves from actuarial projections of -$9 million to $112 million in two years. For her efforts, Fortune magazine selected Marilyn as #13 of the World's 50 Greatest Leaders.   06:45 What gave Marilyn the confidence to fix Montana's state health plan? 08:11 Why Marilyn knew she would have enough power to make the changes needed in Montana's state health plan. 09:11 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan. 10:38 What were the “quick wins” Marilyn was able to achieve when she first took over as administrator? 17:33 Stay tuned for an upcoming episode that covers RFP in detail. 17:50 How Marilyn structured her plan for the Montana State Employee Health Plan. 21:21 What's the key to setting yourself up for success when doing what Marilyn was able to achieve? 25:02 Why putting together your own team is so important. 29:07 What happened when Marilyn left the Montana State Employee Health Plan? 31:08 Have the costs of the plan gone up since Marilyn's time working on it?   You can learn more by connecting with Marilyn on LinkedIn.   Marilyn Bartlett discusses #healthplan finances on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation #vbc   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Marty Makary, Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9), Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402), Ashleigh Gunter, Dr Spencer Dorn, Dr Tom Lee, Paul Holmes (Encore! EP397), Ann Kempski

For a full transcript of this episode, . The episode today is somewhat of a follow-on to the show with Lauren Vela, which was about employer inertia. If we're talking about inertia, though, we'd be remiss not to get a little circumspect about the whole affair and subject some other stakeholders to our microscope. One of these stakeholders is EBCs (employee benefit consultants), practice leads, and brokers, which AJ Loiacono talked about in to some extent; so we can check that box at least for now. That leaves TPAs (third-party administrators), ASOs (administrative services onlys), and health plans. And this hotbed of inertia is what I talk about today with Elizabeth Mitchell from PBGH, the Purchaser Business Group on Health. Similar to earlier shows, one disclaimer is that I am using the TPA and ASO terms sort of interchangeably here. Again, TPA is third-party administrator, and ASO is administrative services only, which is generally the term used when an insurance carrier offers services to a plan sponsor, like a self-insured employer. And these services don't include insurance, because … self-insured. So, the services are administrative only. One point to make clear before we dive in, this conversation is not about these carriers/payers/health plans in general and what they may or may not be doing. This conversation is very specifically focused on how well are those entities helping jumbo employers deploy their health benefits. And first we talk about the role of a TPA or ASO, both in terms of what a jumbo employer might want them to be doing versus what they are often actually doing. Spoiler alert: What they are often actually doing is acting like a full-on health plan and charging as such, even if the health plan part is not what the self-insured employer wants or needs, especially when somebody figures out exactly how much additional is getting charged for those ancillary health plan services. Listen to the show with Justin Leader () for a bead on just a piece of the how much additional that gets baked into the weekly claims wires many self-insured employers get. Bottom line, right now, there's a gap in the market. What is needed are indie TPAs who are effective and efficient and not owned by a health plan because, if history is any predictor of the future, the second the TPA gets owned by a health plan, the TPA sort of ceases to be a TPA and becomes a health plan—with all the attendant bells and whistles that, a lot of times, an employer can't opt out of. And also, the whole not sharing data becomes a thing, both cost data and also quality data. Now, just because there's a gap in the market, does that mean all jumbo employers are paralyzed into inertia? Well, it makes it harder, for sure. But it's also a reason to start figuring out how to solve for a problem when it has as many zeros at the end of it as this problem has. Have you seen these lawsuits popping up all over the place and just the numbers that are involved? Aramark's lawsuit against Aetna is just one example. Not to single out just this one, but in the interest of time, let's talk about this one. Aramark, a big employer, alleged that since 2018, Aetna has taken more than $200 million from it to pay for medical services that should not have been paid out and retains millions of dollars in undisclosed fees. Mark Flores about this one the other day. Also, there was that Cigna lawsuit where an electrician's union health plan was surprised to learn that the fees charged by Cigna had risen from around $550,000 in 2016 to $2.6 million in 2019. That was from a New York Times . For more on stuff like this, follow Doug Aldeen and/or Chris Deacon on LinkedIn. They're a great resource. I'd also listen to the “Who's Suing Who?” episode with Chris Deacon, which was . Because of all of this, the conversation today with Elizabeth Mitchell pretty quickly gets into the shift toward direct contracting between employers and providers to improve access quality and outcomes. If you can't beat them, get ruthlessly practical is my takeaway. I have to say, I truly admire some of these HR folks and their leadership willing to do what it takes on behalf of protecting the people that work for them. Now, important side note: There are certainly some health plans at least trying here, so I don't want to imply otherwise. There are some interesting initiatives that are afoot at, I'm gonna say, usually regional health plans. Elizabeth Mitchell has talked about some of these and made this clear also elsewhere. Lastly, if you aren't familiar with the CAA, which comes up in the episode today, there's a show () on the Consolidated Appropriations Act, which is what CAA stands for. Elizabeth Mitchell, my guest today, currently serves as the president and CEO of the Purchaser Business Group on Health. 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. Stay tuned on this topic, given just the absolute need for TPA services like we discuss in the show that follows, and given the smart, innovative, action-oriented people who are affected—1 plus 1 equals … yeah. Stay tuned. Very, very lastly, I just want to give a shout-out and thanks to Brad Brockbank for posing some great questions, which I pretty much turned around and asked Elizabeth Mitchell in this healthcare podcast. Also mentioned in this episode are ; ; ; ; ; ; ; ; ; ; ; ; ; ; and . You can learn more at and by connecting with Elizabeth on . You can also watch a on success with direct contracting.   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 “Vital Signs” Study Committee on core metrics, and a Guiding Committee member for the Health Care Payment Learning & Action Network. She now serves as a board member of California's Office of Healthcare Affordability. Elizabeth holds a degree in religion from Reed College and studied social policy at the London School of Economics.   06:48 What is the overarching context for health plans in healthcare purchasing? 09:00 with Olivia Webb. 11:44 Why is it important to reestablish a connection between the people paying for care and people providing care? 14:07 What are the needs of a self-insured employer when managing employee benefits? 19:41 Is it doable for employers to set their own contracts? 22:11 Is transparency presumed? 23:25 Will the new transparency upon us actually expose wasted expense? 27:45 “This is not about individual bad actors. … The systems … that is not aligned.” 29:32 Are there providers who want to work directly with employers? 32:46 Why is it important that incentives need to be aligned? 34:25 Why is the quality of care even more important than transparency? 36:29 with Rik Renard. 38:08 What's missing from the conversation on changing health plans?   You can learn more at and by connecting with Elizabeth on . You can also watch a on success with direct contracting.   @lizzymitch2 of @PBGHealth discusses #TPA and #healthplan inertia on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! , , , , , , , , ,

In this episode, Christopher Habig engages in a profound discussion with expert Chris Deacon from VerSan Consulting on the crucial topic of employer fiduciary responsibility in healthcare. As they unravel the complexities of this responsibility, they offer valuable insights into recent lawsuits, market dynamics, and the pivotal role of employers in shaping the future of healthcare.The conversation touches on the concept of fiduciary responsibility and its implications for employers in healthcare decision-making. Deacon provides clarity on the fiduciary role of employers and how it influences their choices in purchasing health benefits for their employees.The two also discuss the intricate web of market forces that drive healthcare, touching upon the involvement of insurance companies and the evolving roles of physicians. By dissecting these dynamics, they paint a comprehensive picture of the healthcare landscape and the challenges it presents.The episode underscore the significance of informed decision-making and proactive engagement in healthcare reform efforts. This is a must-listen for employers who make health benefit decisions on behalf of employees!More on Freedom Healthworks & FreedomDocSubscribe at https://healthcareamericana.com/episodes/More on Chris Deacon & VerSan ConsultingFollow Healthcare Americana: Instagram & LinkedIN

For a full transcript of this episode, click here. On the show today, I am going to use the term TPA (third-party administrator) and ASO (administrative services only) vendor kind of interchangeably here. But these are the entities that a plan sponsor—for example, a self-insured employer is a plan sponsor—but these plan sponsors will use to administer their plan. And one of the things that TPAs and ASOs administer is this so-called weekly claims wire. Every week, self-funded employers get a weekly claims run charge so they can pay expenses related to their plan in weekly increments. The claims run usually comes with a register or an invoice. This invoice might be just kind of a total (“Hey, plan. Pay this amount.”). Or there might be a breakdown like, “Here's your medical claims, and here's your pharmacy claims.” Maybe there's another level down from that of detail if the plan or their advisor is sophisticated enough and/or concerned enough about the fiduciary risk to dig in hard about what the charges are actually for. I was talking about this topic earlier with Dana Erdfarb, who happens to be executive director of HR at a large financial services organization. Dana I'm definitely gonna credit for inspiring this conversation that I'm having today with Justin Leader. Dana was the first one to really bring to my attention just the level of hidden fees that are buried (many times) in these claims wires … because when I say buried in the claims wire, I mean not charged for via an administrative invoice. These hidden fees are also not called out in the ASO finance exhibit in the contract, by the way. So, yeah … hidden. I don't know … if you have to hide your charges, in my mind that's a pretty big tell that your charges are worth hiding. Now the one thing I will point out is that just because the charges are worth hiding doesn't necessarily mean that the services those charges are for are unwarranted. Some of these services are actually pretty worthwhile to do. There's just a really big difference from a plan sponsor knowingly contracting at a known rate with a third party to do something versus paying for a service knowingly or unknowingly via fees hidden in a claims wire wherein the amount paid is not in the control of the one paying the bill. Anyway, I was talking about all of this earlier, as I mentioned, with Dana Erdfarb. That conversation was exactly the framework that I needed to snag Justin Leader, my guest today, to come on the pod and really dig into the detail level of what's going on with this claims wire. So, in this healthcare podcast, we're gonna talk about the five fees that tend to be tucked in to many claims wires. We also talk about one bonus—not sure if it's a fee—one bonus way that plan sponsors give money to vendors in ways the plan sponsor might be unaware of. Here are the five hidden fees that we talk about at length in the show today, and then I'll cover the bonus: 1. Shared Savings Fees. This is where a member of a plan goes out of network, and the TPA/ASO goes and negotiates a discount from the out-of-network provider and then shares the savings. Get it? Shared savings? This category also might include BlueCard Access fees, which we talk about in the show. But there also could be overpayment recoupment fees lumped in here. This is where the TPA messes up, overpays, and then charges the plan sponsor a percentage of the money they just got back when they corrected their own mistake. I'm just gonna pause here while everyone contemplates how we've all gone so wrong in life to not have figured out a way to charge others when we correct our own mistakes. Here's a link to a great LinkedIn post by Chris Deacon and a deep dive article on this topic. 2. Prior Auth Fees. Lots to unpack with this one, which Justin does in the pod. 3. Prepayment Integrity Fees. This is evaluation of the claim before it's being paid. Listen to the show for how this may (or may not) differ from what the TPA/ASO is supposed to be doing (ie, it's the TPA that's supposed to be [yeah, right] adjudicating and paying claims). 4. Pay and Chase Fees. This is where a bill was paid wrong, and it's not immediately the TPA/ASO's mistake. This is where something like a provider double billed or overcharged or something, and the TPA/ASO later figures this out and then chases the pay to get the money back. 5. TPA Claims Review Fees. Sort of self-explanatory but also not. Again, please listen to the show for more. When I'd been talking about all of this with Dana Erdfarb, as I mentioned earlier, just about this whole thing, she said something that Justin Leader echoes today: Many of these fees are structured as a percentage of savings. This is challenging for a plan sponsor because the savings is vendor reported and not validated. But it also means that if the savings increase annually with trend (as they, generally speaking, do), then the fees will increase with that trend as well—and that is something to keep in mind. Okay … so, here's the bonus thing that didn't get a number in the show today, but it is certainly a way that plan sponsors pay money to vendors. And this is medical claims spread pricing. This is buried in the claims wire and inside the dollar amounts the plan sponsor thinks they are paying a provider for a service. It turns out that it can turn out that the amount the plan sponsor is paying is more than the check that's being written to the provider for the service being delivered. Or the amount the plan sponsor is paying the provider for a service is more than for simply that service that has been rendered, right? The plan sponsor is paying the provider for other stuff as well, as is alleged in the DOL v BCBS of Minnesota lawsuit, which Justin brings up in the show today. It drives me nuts, honestly, when there are people who tout their transparency. But then it turns out if the equation is A plus B equals C, only like one of the numbers is transparent. Sorry, functionally, that doesn't count as transparency except in marketing copy. This is all to say—and here's Dana Erdfarb's actionable advice which sums up points Justin also made—when employers review their medical plan vendor contracts, they should make sure to identify, review, and document all fees being paid to their vendors and incorporate this knowledge into their renewal/RFP (request for proposal) discussions and negotiations. Jeff Hogan echoed this advice on LinkedIn the other day when he commented on this show: “Such a great opportunity for employers to have their administrative services agreements and other documents examined to discover these schemes. It's not hard to do. Also, a great advertisement for the value of having retrospective audits performed. It is eye opening to see not only the amount of arbitrage but often how payers don't even pay according to their contracts. Justin Leader is the perfect guest.” As mentioned a myriad of times already, my guest today is Justin Leader, who is president and CEO of BenefitsDNA. Justin works with plan sponsors, both commercial plans as well as Taft-Hartley plans, across the United States. Before we kick into the show today, I just want to thank By the 49ers for the really nice review on iTunes. By the 49ers calls Relentless Health Value a “leading voice in healthcare” and says he or she always leaves “with intrigue, a new idea or a new approach to problem solving.” Really appreciate that. That is certainly one of our goals around here. So, thank you so much. Oh, also, please subscribe to the weekly email that goes out. You can do that by going over to our Web site and signing up. There are a lot of advantages to doing so, which I've talked about before, so I'm not gonna do so again; but it is a great way to make sure that if you're a member of the Relentless Health Value Tribe, you are aware of the current goings-on. Also mentioned in this episode are Dana Erdfarb, Chris Deacon, Jeffrey Hogan, BenefitsDNA, Rik Renard, Cora Opsahl, Al Lewis, Julie Selesnick, Mark Davenport, Karen Handorf, Dawn Cornelis, AJ Loiacono, and Mike Miele. You can learn more at benefitsdna.com or wefixyourhealthcare.com. You can also follow Justin on LinkedIn.     Justin Leader began his career in the pharmaceutical and financial services industries. By 2011, Justin entered into the group benefits field consulting for many notable Fortune 500 clients. In 2014, he established BenefitsDNA, an objective, independent health and welfare benefit plan consulting firm providing compliance oversight, actuarial services, cost mitigation, and traditional broker services to Group Health Plan Sponsors. As a Certified Health Rosetta Chartered Advisor (eighth advisor to join), he's acknowledged for contributing to healthcare solutions in the United States both in policy as well as practice and is an avid supporter of Patient Rights Advocate. Throughout his career, Justin has been instrumental in introducing successful healthcare benefit solutions to the market, which have been pivotal in solving critical issues and saving millions for employers and their employees. As a mission-driven leader, he and his team are passionate about fixing healthcare one client, one member, and one partnership at a time. Having trademarked We Fix Your Healthcare™, their mission is one that his team takes seriously. Justin, a native of Bedford, Pennsylvania, holds a pre-medicine degree and a master's degree in exercise science from California University of Pennsylvania. His dedication extends to servant leadership, volunteering in the local community including serving on the PA State Council of SHRM (Society for Human Resource Management) since 2016. Justin is a public speaker and owner of Leaders Never Quit, where he dedicates his time to inspiring others with a message of hope, humor, and resilience.   07:55 How is the claims wire typically explained to a plan sponsor? 11:18 What is the whole point of self-funding? 11:27 Why is it so vital to understand what you're paying for? 12:38 What are the five “buried” items that wind up in these claims wires? 13:03 What is a shared savings fee? 17:10 “Rates are important, but so are your rights.” 21:01 What's going on with prior auth fees? 23:35 What is prepayment integrity? 28:16 What is pay and chase? 31:54 What is a TPA claim review? 35:47 Is there medical claim spread pricing?   You can learn more at benefitsdna.com or wefixyourhealthcare.com. You can also follow Justin on LinkedIn.   @JustinDLeader discusses #plansponsor #payments on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia  

Friends, There are over 160 million Americans who get their health benefits through their employers. Nearly 40% of all healthcare expenditures in the U.S. is paid for by self-insured employers. ...

There are over 160 million Americans who get their health benefits through their employers. Nearly 40% of all healthcare expenditures in the U.S. is paid for by self-insured employers. For ...

Friends, There are over 160 million Americans who get their health benefits through their employers. Nearly 40% of all healthcare expenditures in the U.S. is paid for by self-insured employers. ...

For a full transcript of this episode, click here. This show is different, so if you've already listened to or read all about the gory details of the J&J and/or the DOL v BCBS lawsuits, this is not gonna be a repeat of that information. Julie Selesnick, my guest today, does cover the very, very top line about these two cases. But after that, we move on fast—because what I wanted to get to today was not the potential landslide of legal action that may or may not be confronting plan sponsors or payers or even brokers today. I did not want to really even talk about the CAA (Consolidated Appropriations Act) and its inarguable adjacency here. I just feel like there's been a lot of talk about these topics already. What I wanted to get to, and fast, is … now what? If I'm a plan sponsor or actually, again, an EBC (employee benefit consultant) or broker, now what? What should I be doing and thinking about right now? To that end, I could not have been more thrilled to get a chance to talk to Julie Selesnick, who is an attorney deeply entrenched in helping plan sponsors and others understand and comply with fiduciary responsibilities. I want to get to this interview quickly (the conversation with Julie), so this intro is gonna be on the short side; but let me just summarize a few of the points that Julie makes during the interview that follows. First, we talk about the first step for pretty much everybody: Get your data, plan sponsors. But once you have that data, you also kinda have to use it. You can use it to ensure that you're paying claims right, which is what most do. As a result of these two lawsuits, it's also increasingly clear that you also have to use that data to ensure that the prices you're paying for things (like generic specialty meds, for example) are fair and reasonable. To get the data now, you may have to renegotiate administrative services agreements; and you might need to take a closer look at the disclosure agreements you're getting as a result of the CAA. And, by the way, it's not just brokers or EBCs who have to complete these disclosures. It's all covered entities that you, plan sponsors, paid more than $1000 to. Then we get into … okay, once you have the data and you've analyzed it, what are some in general things that could very well need to happen? And if the reason that they don't happen is because they weren't even considered, then plan sponsors have some risk exposure; and the brokers/EBCs who serve them might have some conflicts of interest. And it would be very interesting what would or could happen if a plan sponsor was able to back into those conflicts of interest, because if data clearly shows that something should be happening and it is not—and it is not even on the docket to be considered—if I'm a plan sponsor, I'm for sure gonna be wondering why. And maybe I'm gonna look into that and fast. Listen to the show with AJ Loiacono (EP379) from two weeks ago for more on some of the more egregious broker/EBC conflicts of interest, which could explain, potentially, the J&J lawsuit as well as definitely explains the earlier one in Osceola. And also, by the way, if you're sitting there wondering to yourself how exactly J&J managed to pay upwards of $10,000 for a drug that can be purchased for cash for something like $50, listen to the show next week with Luke Slindee, PharmD. We run through the exact pharmacy supply chain machinations that make all of this (and more) possible. But I got off track. What I was talking about is the things that could easily wind up being called for when the data is analyzed: 1. Carving out specialty generics, especially drugs or infusions, from the larger pharmacy benefit manager 2. Your payment integrity vendor should not be the same vendor who is processing claims. Talk about a conflict of interest. I do not need to be an attorney—and I need to know absolutely nothing about anybody's data—to tell anybody who's listening that if you have the same vendor or two vendors with the same parent company who are both processing your claims and then auditing their own work … yeah, fix that. 3. Shut down any cross-plan offsetting. And we get to this in the show if you don't know what cross-plan offsetting means. Lastly, we get into a bunch of stuff that plan sponsors might want to consider as they consider how to administer their plan, like, for example, setting up a health and welfare committee that has an independent fiduciary expert on said committee. I'm gonna say that's a good idea! As I have mentioned, my guest today is Julie Selesnick. Julie is senior counsel over at Berger Montague's Employee Benefits and ERISA group. Also mentioned in this episode are AJ Loiacono; Luke Slindee, PharmD; Justin Leader; Chris Deacon; Bridget Mulvenna; Mark Cuban; Olivia Webb; and Dawn Cornelis. You can learn more at Berger Montague. You can also follow Julie on LinkedIn.     Julie Selesnick has been practicing law since 2001 and has over 20 years of experience in complex dispute resolution forums representing plaintiffs and defendants. Julie has a wide variety of litigation, arbitration, and mediation practice, including first-chair jury and bench trial experience, representing some of the largest companies in the United States as well as small companies, labor unions, individuals, and classes of plaintiffs. Julie's current practice is a mix of class litigation on behalf of individuals, union funds, and employers, and a legal consulting practice advising self-funded health plans and service providers to self-funded health plans on minimizing litigation and regulatory risk, issues arising under ERISA, fiduciary obligations and best practices, and CAA compliance, including negotiating service provider contracts and business associate agreements, drafting plan documents and advising on plan design; helping health plans gain access to participant claims data, helping service providers draft and plan fiduciaries obtain § 408(b)(2)(B) compensation disclosures, assisting plans with ensuring their prescription drug data collection and reporting is properly conducted and copies are provided to plan fiduciaries, and ensuring proper review, MHPAEA Comparative Analysis reports on nonquantitative treatment limitations.   05:48 What's happening with the J&J lawsuit? 07:38 What's going on with the DOL v BCBS case? 08:49 What do these cases mean for plan sponsors? 09:21 Why is engaging with claims data critical? 12:30 EP408 with Chris Deacon. 14:20 EP379 with AJ Loiacono. 16:58 What's one solution to avoiding a conflict of interest? 18:02 Why there's still not a total understanding about what to do with claims data once acquired. 20:58 NADAC (National Average Drug Acquisition Cost) to check pharmacy prices. 21:31 What advice do plan sponsors need to know that never gets recommended to them when dealing with conflicting interests? 27:02 EP337 with Olivia Webb. 28:41 EP285 with Dawn Cornelis. 30:24 “As a fiduciary, your money should only go to pay your plan's benefits, not to other plan benefits.” 30:59 What's Julie's advice to advisors? 33:17 “Giving nonconflicted advice … is something you really can only do if you have no conflicts.” 35:57 What's Julie's advice for administering whole plans?   You can learn more at Berger Montague. You can also follow Julie on LinkedIn.   Julie Selesnick discusses advice based on the J&J and DOL v BCBS lawsuits on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372)  

For a full transcript of this episode, click here. Here on Relentless Health Value, we have done a bunch of shows lately on how some weird PBM (pharmacy benefit manager) and pharmacy goings-on impact plan members, patients, and also independent pharmacies. During the conversation with Benjamin Jolley, PharmD (EP422), for example, Benjamin mentioned that he thinks some of these contract terms that really hurt independent pharmacies are signed by employers at the urging of their brokers or employee benefit consultants (EBCs). Think about this. You have these huge vertically integrated PBMs who own their own retail pharmacies and/or mail order. You have EBCs that work with employers who, a lot of times, do not understand the contracts that they are signing. This is a recipe for what AJ Loiacono talks about on the podcast encore today: just how much those EBCs and brokers are, in some cases, being compensated to get employers to sign contracts that allow PBMs to corner the market and take all the profit. Even if you listened to this encore in 2022, you might want to revisit it and consider what AJ says in the context of these recent shows with Ge Bai, PhD, CPA (EP420); Joey Dizenhouse (EP423); Mark Cuban and Ferrin Williams, PharmD, MBA (EP418); and Benjamin Jolley, PharmD (EP422), as I just mentioned. Also keep in mind the shows with Scott Haas (EP365) and Paul Holmes (EP397) from earlier … Olivia Webb (EP337) as well. This show with AJ Loiacono is different than others you may have heard with him because in this healthcare podcast, we are not talking about PBMs. We're talking about brokers and EBCs. So, say I'm a self-insured employer. Here's the big question: Is my broker or EBC helping me make the right decisions, or is he or she helping me make decisions that will make them the most money? While there are some amazing and totally above-board EBCs and brokers out there, unfortunately, caveat emptor is a thing. Buyer beware, that is. Too many self-serving and I'm sure very charming sharks are out there circling plan sponsors. It is currently a fact that some EBCs and brokers and even TPAs (third-party administrators) or PBMs or others take hidden kickbacks or fees or percentages. They make a lot of money, maybe the most money, in these secret ways. All this money, money paid in secret backroom deals—let's not lose track, these dollars increase the total prices paid by plan sponsors and employees. Now, I say this to say that my guest today, AJ Loiacono, calls 2022, right now, a “magical moment” for plan sponsors—and for straight-shooting EBCs and PBMs and all the others who are actually doing the right thing by their clients also. It's because of the Consolidated Appropriations Act (CAA), which states quite clearly that plan sponsors can ask their healthcare and benefits service providers to disclose the money that they are making off of the plan—all of the money, not just the direct fees. The CAA went into effect December 2021, and contrary to what some people have said or may believe, it is in force right now. The field memo went out on 12/31/2021. So, the CAA is the rule right now. And in fact, the CAA makes it imperative under ERISA (Employee Retirement Income Security Act) to do what I just said: Plan sponsors must disclose the monies that they are paying out on behalf of employees and ensure that those fees are reasonable and free from conflict. If you're the fiduciary of the plan, you gotta disclose all these indirect and direct compensations of the people that you are paying or the people that you are paying who may be kicking back dollars to other people you are working with, unbeknownst to you. The Department of Labor is putting as much emphasis right now on healthcare as they put on 401(k) plans in the early 2000s, so this is a big deal—or it should be—for plan sponsors. So obviously, in order to comply with the CAA, self-insured employers should be requesting from their EBCs and brokers or others that they disclose, in writing, how much money they are making off the plan. You can see why this disclosure would be necessary if the plan sponsor is responsible to determine if those payments are reasonable and seem to be free from conflict, right? You can't evaluate something you do not know about, and if you don't know about it, the plan sponsor is the one at risk. Ignorance is not an excuse here. Here's one example: What if the EBC or TPA is collecting a $40 payment per prescription from the PBM? Wait … what? Some plan sponsor is paying $40 per script in, I guess you'd call it, a commission? Yes, that is a rumored example—$40/Rx. It is basically full-on arbitrage, and if anyone disagrees, let me know why and how it's not. Or let's say the EBC is making, say, $6 per script payable by the PBM, and this sum should be mailed quarterly to a PO box in another state. This was a condition, by the way, for a PBM to win an RFP (request for proposal) that the EBC wrote and picked the winner of. Yeah, you as the plan sponsor really probably want to know that this is going on because it's your butt on the line. So, in sum, the CAA is in effect right now. Penalties can be levied right now against plan sponsors. For a deep dive into the CAA, listen to the show with Christin Deacon (EP342) from 2021. So, what's the process if I'm an employer plan sponsor? Step 1: Request in writing the dollars that your EBC or broker is making off of you. Similar to the advice that you'll hear often on this show, ask for actual dollars, not a percentage of this or that. Ask for how much money did you (broker or EBC) make off each program that you recommended to us, and what did that total up to. Once you make that request, the EBC/broker/TPA (whoever you're asking) has 30 or 90 days to respond, depending on who you ask. But if they do not respond, then you, the employer, should report them to the Department of Labor. Keep this in mind: Once that EBC or broker is reported for failure to comply by anybody, meaning likely some other employer, it is only a matter of time before that information becomes public. And the second that info becomes public, I guarantee you that there's some attorney out there just waiting to file a class action lawsuit against every other self-insured employer who uses that EBC/broker because everybody else out there is now out of compliance. Right? I'm not a lawyer and I am certainly not a class action ambulance chaser, but even I can figure out that strategy. AJ Loiacono is the CEO of Capital Rx, which is a PBM 2.0, as they call it. To see how the CAA is playing out, you can read about one real-life example of a school district's lawsuit against an insurance consultant. Also mentioned in this episode are Benjamin Jolley, PharmD; Ge Bai; Joey Dizenhouse; Mark Cuban; Ferrin Williams, PharmD, MBA; Scott Haas; Paul Holmes; Olivia Webb; and Chris Deacon. You can learn more at cap-rx.com and find resources through law firms.   AJ Loiacono is a serial entrepreneur with over 20 years of experience in pharmacy benefits, finance, and software development. As the CEO of Capital Rx, his mission is to upgrade America's healthcare infrastructure to deliver the highest level of client service and patient engagement while reducing total cost of care. AJ has spent his career studying the pharmaceutical supply chain and developing solutions that have continually redefined the pharmacy benefit industry to achieve this goal. Before Capital Rx, AJ was a co-founder of Truveris, where he served for eight years as CEO, CIO, and a board member, leading the company to record growth (Deloitte FAST 500 and Crain's Fast 50). Prior to Truveris, AJ co-founded SMS Partners, a joint venture with Realogy (RLGY), and in 2010 exited the partnership with a buyout. In his first venture, AJ started Victrix, a pharmaceutical supply chain consultancy, which was successfully sold to Chrysalis Solutions in 2007.   07:09 Who can get in trouble for mismanaging employee funds? 07:48 “When you talk about conflicts of interest, they're everywhere.” 13:13 “You're paying for access.” 13:34 Why is it important to request that they disclose direct and indirect compensation? 14:04 What are the layers to these hidden fees and compensations? 18:13 What is a reasonable fee for a good plan admin? 19:27 “I think people need to take a step back and say, ‘How many different ways are they getting compensated?'” 24:50 “The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.” 25:06 “For every good broker consultant, there's a horrible individual lurking out there and it's easy to figure out: Ask for them to disclose their fees.” 28:08 “You can't win if you can't even pay the house fee to come in.” 31:35 Why do you need to ask for disclosure, and what do you need to ask specifically? 32:21 What are some of the characteristics of a good plan consultant?   You can learn more at cap-rx.com and find resources through law firms.   AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai  

GB2RS News Sunday the 21st of January 2024 The news headlines: British Science Week is approaching Updates on the RSGB's Strategic Priorities RSGB election deadline reminder   This year's British Science Week runs from the 8th to the 17th of March with the theme of Time. This event is a fantastic opportunity to raise awareness of amateur radio in your local area. The RSGB has some great activity ideas you could try at your local school, Scout or Guiding group or local youth club. Go to the web page at rsgb.org/bsw and click on the activity titles to find everything you need to know to be able to run that activity. Several radio clubs from across the UK have already planned outreach activities for British Science Week and the RSGB hopes its resources will inspire you to get involved too! RSGB volunteer John Hislop, G7OHO has provided these ideas but the Society would love to add other activities to enthuse young people about wireless communication. If you have an amateur radio activity on the theme of Time that you'd like to share, or if you'd like to get involved but aren't sure how to start, please direct enquiries to the RSGB British Science Week contact, Ian Neal, M0KEO. Ian's contact details will soon be available at rsgb.org/bsw At the Discussion with the Board session at the RSGB 2023 Convention, the RSGB President, John McCullagh, GI4BWM confirmed that the Board would keep members updated regularly on progress with the new strategic priorities. Two updates have now appeared in the January and February issues of RadCom and they are also available to read on the RSGB website. These updates highlight some important activities and achievements as well as new plans, so the Society encourages every member to take the time to read them. Go to rsgb.org/strategy and choose the ‘Strategy priorities updates' option from the righthand list. Further updates are being prepared so do check back regularly or look out for them in each RadCom. You can also watch the Discussion with the Board Convention session on the RSGB's YouTube channel at youtube.com/theRSGB The deadline for applications for the one elected RSGB Board Director position and eight Regional Representative roles is Wednesday the 31st of January. Amateur radio needs a strong and active national society so don't leave it to everyone else, step forward for one of these roles and play your part in the future of the RSGB. You'll find guidance and candidate forms on the RSGB elections web page at rsgb.org/election as well as contact details if you want an informal chat before standing for election. A reminder that the RSGB is looking for four licensed radio amateurs to help raise the profile of wireless communication amongst young people across the UK. We have had a good response, but we'd still like to hear from prospective volunteers in Northern Ireland and Wales. These volunteer Youth Country Representatives will represent the RSGB at externally organised events and will plan and deliver outreach activities. If you have plenty of ideas, a passion for getting young people involved in amateur radio and experience of running small-scale events, we would be very keen to hear from you. The deadline is Friday the 16th of February. For full details, see rsgb.org/volunteers and for an informal discussion, please email RSGB Board Director, Ben Lloyd, GW4BML at gw4bml@rsgb.org.uk GB2RS began broadcasting via the Es'hail-2 amateur satellite in May 2021. Every Sunday at 0800UTC you can hear the latest RSGB news on the dedicated narrow-band QO-100 transponder frequency of 10489.855MHz. This has proved so popular that, by the kind permission of AMSAT-DL, from the 4th of February 2024 we're introducing a second reading at 2100UTC. This will suit our international audience in the western lobe of the footprint. The existing team of three Newsreaders is looking for another volunteer to join them. If you are an RSGB member with a good QO-100 facility and would be interested in broadcasting the news, please contact the GB2RS Manager, Steve, G4HPE at gb2rs.manager@rsgb.org.uk for further details. During February, the RSGB's Photo Friday focus on social media is all about clubs. If you'd like your club to be included, let the RSGB comms team know what you've been up to and who's been involved and share all the brilliant things you've been doing. Email comms@rsgb.org.uk by the 31st of January with a brief summary of the activity and some photos, and please make sure that everyone in the photo is happy to have their face on social media! Chris Deacon, G4IFX has been awarded a PhD from the University of Bath after completing research on propagation. His thesis was entitled: “Radio propagation through ionospheric Sporadic-E”. This part-time work over many years involved looking at Sporadic-E on the 6m band, including making novel measurements of signal amplitude, phase, derived Doppler, polarisation and potential time delay to discover the nature of sporadic-E propagation at VHF frequencies. The RSGB Propagation Studies Committee congratulates Chris on this fantastic achievement. You can find out more by searching for Chris' name on the University of Bath research portal at researchportal.bath.ac.uk  Chris has done a number of presentations about propagation at RSGB Conventions over the years, which you can see on the RSGB YouTube channel at youtube.com/theRSGB And now for details of rallies and events The Lincoln Short Wave Club Winter Radio Rally will take place on Sunday the 28th of January at The Festival Hall, Caistor Road, Market Rasen, LN8 3HT. The doors will be open from 9 am and admission is £2. Ample free car parking and hot refreshments will be available. The tables cost £10 each. At 2 pm, after the Rally, there will be a used equipment auction. Items for the auction will be booked from 1 pm. Contact Steve, M5ZZZ for tables and details via m5zzz@outlook.com or 07777 699 069. The Canvey Rally will be held on Sunday the 4th of February at Cornelius Vermuyden School, Dinant Avenue, Canvey, Essex, SS8 9QS. The Rally is expected to be the usual hive of activity with plenty of traders on site. For more information contact Richard Stanley at 07725 551 263 or email g7oed@icloud.com  The MIDCARS Radioactive Rally will be held on Sunday the 11th of February at Nantwich Civic Hall, Market Street, Nantwich, CW5 5DG. The doors open at 10 am and admission is £5. There will be a wide variety of trader stalls covering every aspect of amateur radio. Raffles will be held throughout the Rally. Refreshments and snacks will be available in the hall and parking is immediately adjacent to the venue. Now the Special Event News A team of German amateurs is operating a special event call sign DM24EHF until the 28th of January. The EHF suffix stands for European Handball Federation. The 16th edition of the European Men's Handball Championship is being hosted in Germany from the 10th to the 28th of January. QSL via the bureau, or directly to DL2VFR. The Straight Key Century Club's Straight Key Month is currently underway. The annual on-air event commemorates the Club's founding in 2006 and celebrates the original instruments of early radiotelegraphy including straight keys, bugs and ‘cootie' keys. Listen out for the K3Y callsign which is being aired from the ten US call areas. Information on the event and QSL instructions can be found at skccgroup.com/k3y “Discovering Marconi” is an international amateur radio diploma organised by the ARI Radio Club of Fidenza in Italy. Commemorating the 150th anniversary of the birth of the great Italian scientist in 1874, this award aims to delve deeper into the thought, vision, capacity and character of Guglielmo Marconi. More details of special callsigns and award rules can be found at arifidenza.it Now the DX news Chris, WA7RAR will be active as 8P9CB from Barbados, NA-021, until the 25th of January. Most of his operations will be portable at various locations, especially Parks on the Air sites. He will be QRV on the 20 to 10m bands using CW and SSB. QSL via Logbook of the World, or directly to WA7RAR. Listen out for Bob, V4/N4RF who is active from Saint Kitts, NA-104, until the 25th of January. He will operate mainly CW, with some FT8 and SSB. QSL via Logbook of the World is preferred but is also available directly via his home call. Now the contest news On Tuesday the 23rd, the SHF UK Activity Contest runs from 1930 to 2230UTC. Using all modes on the 13cm band, the exchange is signal report, serial number and locator. The CQ 160m DX Contest starts at 2200UTC on Friday the 26th and ends at 2200UTC on Sunday the 28th. Using CW on the 160m band, the exchange is signal report and CQ zone. American stations send their state and Canadian stations send their province. The British Amateur Radio Teledata Group RTTY Sprint starts at 1200UTC on Saturday the 27th and ends at 1200UTC on Sunday the 28th. Using RTTY on the 80 to 10m bands, where contests are permitted, the exchange is a serial number. The UK Six Metre Group Winter Marathon began on Friday the 1st of December 2023. The contest will run until the 31st of January 2024. Using all modes on the 6m band, the exchange is signal report and locator. Now the radio propagation report, compiled by G0KYA, G3YLA, and G4BAO on Thursday the 18th of January 2024 We had yet another week with good solar conditions which, at this point in the cycle, is good news. The solar flux index remained in the 170s to 180s range and the Sun is currently peppered with spots. The Kp index never got above 3.33 and that was only for one three-hour period on January the 16th. We were also lucky with solar flares in that we only had minor C-class flares to contend with. An eruption was observed beyond the west limb on January 14th. The event generated a fast-moving coronal mass ejection or CME, but it was directed away from our planet. Daytime MUFs over 3,000km remain high at more than 28MHz. At night this reduces to around 6.9 to 9.5MHz, meaning only the 40m band is mainly open to DX, if at all. HF-wise, this is the best time for low-band DXing, such as 40m band contacts with New Zealand around sunrise, and overnight QSOs on the 80m band with the USA. Other DX being worked by members of CDXC includes XU7AKU in Cambodia on 40m CW in the early evening; V31XX in Belize, VP9KF in Bermuda, on 30m CW around 1000UTC; and E20AX in Thailand on 40m CW around 0930UTC. Next week, NOAA predicts that the solar flux index may remain in the 160 to 170 range with a maximum Kp index of 2. As always, take that Kp prediction with a pinch of salt as a single Earth-facing coronal mass ejection could send it sky-high with an accompanying lowering of the MUF and generally poor conditions. And now the VHF and up propagation news from G3YLA and G4BAO The main theme of the VHF and up propagation options is that we have three distinct phases coming up. The first phase is set to end today, the 21st. This will be the final blast of the cold northerly wind, which may produce some rain scatter near coasts from snow showers. It is probably not especially useful for Tropo, even inland, except perhaps for local overnight temporary short-distance enhancements due to surface cooling and night frosts. Phase two is the transition to very unsettled, wet and windy weather, which starts to arrive during this weekend, ending the 21st, and generally sets the pattern for much of the coming week. Maybe it will be a rain scatter option for the GHz bands, but the main radio consideration will be wind potentially damaging antennas, particularly in the south. Phase three will be the introduction of a weak ridge of high pressure over southern Britain in the second half of the coming week and the following weekend. This could bring some more productive Tropo to southern parts of the UK, especially into the last weekend of the month. Other propagation modes are available but don't seem to be elevated beyond chance occurrences for meteor scatter or aurora. There is a vanishingly small chance of Sporadic-E, as we are in the minimum period for this sort of propagation until after Easter. For EME operators, Moon declination is positive and rising, reaching a maximum on the 23rd. Path losses increase all week until apogee on Monday the 29th. 144MHz sky noise is low to moderate this coming week. And that's all from the propagation team this week.

For a full transcript of this episode, click here. Here's a quote from Ann M. Richardson, MBA. She wrote it on LinkedIn, and I love it: Quiet the noise that doesn't add value. Surround yourself with intelligent and respectful people who can deliver endless opportunities. Celebrate brilliance and new beginnings. Together, we've got this. Thanks for this beautifully stated call to action (I wish I would have written it myself) because it is also precisely the goal of Relentless Health Value and my hope for the Relentless Health Value Tribe—those of you who have connected with each other by way of this podcast vis-à-vis LinkedIn, or maybe you've met each other at an online or live event. For sure, subscribe to the weekly email to get notified of such goings-on. Now, this aspirational vision doesn't mean putting the onus on just any given individual to fix the systemic failings that get talked about on the podcast, but we can start somewhere. We can sit with ourselves; we can ask ourselves some big questions. We can decide the legacies we want to leave and what we want our life's work to add up to. That is what this show should, I hope, help you accomplish. And, yeah … together, we've got this. In this healthcare podcast, I am speaking with Peter Hayes; and we talk about five realities of 2024 for hospital chains, integrated delivery networks, health systems. Now, to make one thing very clear, as I have said many times on many Relentless Health Value shows: Not all hospital chains or hospitals are the same. There are large, consolidated, extremely rich, extremely politically and economically powerful organizations who are called health systems. And then there are rural or urban institutions that are barely scraping by and serving huge vulnerable patient populations. And despite the many aforementioned names for hospital chains and their associated outpatient facilities and owned physician groups and urgent care centers, all these names for these big care delivery entities are flabbergastingly meaningless because they do not separate the consolidated rich ones from the very desperately not rich ones. Today on the show, we're talking about the first kind of health systems: the big rich consolidated ones which are taking over every geography where there's money to be made. These are the ones where you read about their bad behavior in the New York Times or hear about them in YouTube videos like this one. Peter Hayes talks about the five things that these behemoth entities may really need to start thinking hard about, even in the face of their fierce and often-unrelenting market power and the political hold that they have over many local communities and all the regulatory capture that goes along with that. So, here's Peter's list in a nutshell—the five things to get real about: 1. Health systems need to get real about the CAA (Consolidated Appropriations Act) and its implications that plan sponsors only pay “fair and reasonable” prices for medical services. Now, before I dig in on this, jargon alert: When we say plan sponsors, that means entities such as self-insured employers—sponsors of health plans, if you will (the purchasers, the ones who are actually paying the bills). Peter explains the quick version of what the Consolidated Appropriations Act is in the show that follows, so do listen. But for more info on this really, really meaningful bit of legislation that is the law as of 2021, go back and listen to the episodes with Chris Deacon (EP342 and EP408) or check out the myriad of LinkedIn posts from Jeff Hogan. Also, others like Darren Fogarty, Justin Leader, Jamie Greenleaf, and others have some great words of wisdom that you will be able to find that really explain what the point is of the CAA, the Consolidated Appropriations Act, and its sprawling implications. 2. To survive on reduced commercial reimbursements, health systems need to get real about becoming ruthlessly aggressive in driving administrative and technology efficiencies. 3. They need to get real about pivoting from fee-for-service reimbursement to episode-based care based on taking real downside risks for good clinical outcomes. They need to pivot from a mindset of maximizing patient revenue to maximizing patient health. They need to move from a sick care reimbursement model to a healthcare reimbursement model based on health. 4. They need to get real about being completely transparent and accountable in reporting how they are using the value of their tax-exempt status. Similarly, they need to account for and report how they're using the estimated $55 billion in net margins that they're realizing off the 340B drug program. 5. They need to get real about quality and patient safety. We still have about 46% of our hospitals that have a C or lower Leapfrog rating. And, by the way, the chance of having a fatality on an avoidable error is 90% higher at a C or lower-rated Leapfrog entity versus a Leapfrog entity that has an A or a B. Now, some of you—and by some of you, I mean practically everybody listening—are thinking of reasons why any one of these “get real about” things is arguable or how one of the above is not holding up in some market. I think Peter would tell you the same thing that I would: You're not wrong. But trying to predict a zeitgeist or the next pet rock never works well because it's always a confluence of right time/right place where the whole is way more than the sum of its parts. Think about Malcolm Gladwell's The Tipping Point. It's about how small changes can have enormous effects if the context is right. So, now contemplate these five things that Peter brings up. All these forces are pushing in the same direction. Put it all into a stew where 48% of Americans have delayed or forgone care due to cost. Listen to the show with Wayne Jenkins, MD (EP358) for more on that. Or, you have the article John Tozzi just wrote in Bloomberg. Here's a quote: “In one California community, teachers have to pay an extra $10,000 a year to upgrade to insurance that covers the local hospitals. Teachers who can't afford it … give birth outside the county.” Meanwhile, insurers are making record profits, along with hospital CEOs and C-suites. At the same time, you know who I think is the third-biggest group with medical debt in this country? Yeah, it's people who work in hospitals—nurses, others. There's this frothing lack of trust for hospitals and what goes on there: 30% of physicians do not trust the leadership of their health system. And no wonder. There are examples of healthcare executives sitting up there in their palatial offices acting more like mobsters than the nuns they took over the hospital from. So, to orient your context, you are here. Peter Hayes is the newly retired former president and CEO at the Healthcare Purchaser Alliance of Maine. He is a national presence in healthcare strategy, innovation, and a keynote speaker. For more on the wild-ass problems with hospital pricing, check out this list of shows. But, spoiler alert, some of these are hair-raising. Encore! EP249: The War on Financial Toxicity in North Carolina as a Case Study Everybody Should Be Keeping Their Eye On, With Dale Folwell, North Carolina State Treasurer EP395: Consolidated Hospital Systems and Cunning Anticompetitive Contracts, With Brennan Bilberry EP390: What Legislators Need to Know About Hospital Prices, With Gloria Sachdev, PharmD, and Chris Skisak, PhD EP389: The Clapback When Hospitals Cannot Constrain Their Own Prices, With Mike Thompson EP346: How Did Health Systems Get Addicted to the Inflated Prices They Charge Employers and Some Patients? 2021 Update, With Peter Hayes, President and CEO of the Healthcare Purchaser Alliance of Maine EP394: Spoiler Alert: It Is Counterintuitive Which Hospitals Offer the Most Charity Care, With Vikas Saini, MD, and Judith Garber, MPP Also mentioned in this episode are Ann M. Richardson, MBA; Chris Deacon; Jeffrey Hogan; Darren Fogarty; Justin Leader; Jamie Greenleaf, AIF, CBFA, C(k)P; Wayne Jenkins, MD; John Tozzi; NASHP (National Academy for State Health Policy); Gloria Sachdev, PharmD; Chris Skisak, PhD; Leon Wisniewski; Cora Opsahl; Rik Renard; John Rodis, MD; Rob Andrews; Al Lewis; Eric Bricker, MD; Vikas Saini, MD; Judith Garber, MPP; Lown Institute; RAND Corporation; Dale Folwell; Brennan Bilberry; and Mike Thompson. You can learn more by following Peter on LinkedIn.   Peter Hayes recently retired as the president and CEO of the Healthcare Purchaser Alliance of Maine and formerly a principal of Healthcare Solutions and director of associate health and wellness at Hannaford Supermarkets. He has been recognized as a thought leader in innovative, strategic benefit design for the past 25+ years. He has received numerous national awards in recognition of his commitment to working collaboratively with healthcare providers and vendors in delivering health benefits that are focused on value (high-quality efficient care). He has been successful in this arena by focusing on innovative solutions for patient advocacy, chronic disease management, and health promotion programs. Peter has also been involved in healthcare reform leadership roles on both the national and regional levels with organizations like Center for Health Innovation, Care Focused Purchasing, and Leapfrog. He's also co-founder of the Maine Health Management Coalition and has been appointed by two different Maine Governors to serve on Health Care Reform Commissions to recommend public policies to improve the access and affordability of healthcare for Maine citizens.   08:04 Why do hospitals need to get real about the implications of the Consolidated Appropriations Act? 10:09 What is considered fair pricing for hospitals? 13:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD. 15:59 The medical transparency tool, Billy. 16:34 How does lowering prices become more challenging with consolidated hospital systems? 18:07 What is one of the solutions available to combatting this now? 19:31 Why do hospital systems need to get real about administrative and technology efficiencies? 22:27 EP373 with Cora Opsahl. 26:51 Why do hospitals need to get real about pivoting from fee-for-service reimbursement to episode-based care? 30:16 EP415 with Rob Andrews. 30:53 Why do hospitals need to get real about the 340B program and their tax-exempt status? 35:38 EP394 with Vikas Saini, MD, and Judith Garber, MPP. 38:19 What are the ethical and moral issues that are coming to a head with healthcare costs? 39:03 Why do hospitals need to reexamine their care quality and patient safety? 40:05 “We just need to make sure that the health industry is as accountable as some of our other industries.” 42:53 Why does Peter think it's going to take regulation to move the dial?   You can learn more by following Peter on LinkedIn.   @pefhayes discusses #hospitalsystems and what their executives need to do on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai, Andreas Mang, Karen Root (Encore! EP381), Mark Cuban and Ferrin Williams, Dan Mendelson (Encore! EP385)

Lauren Vela is back on the pod today with a summer short that originally was a section of episode 406 that, unfortunately, I had to cut. It was a little bit tangential to the “why with the employer inertia” theme that the original episode was about. But tangential does not mean unimportant. This clip has some really critical insights on a different topic that may or may not to a greater or lesser degree contribute to inertia. And I'm gonna call this other topic the benefit design that most employees might ultimately be the most satisfied with might not be the one that they are explicitly asking for. Let's start with three kinds of market research insights that Lauren Vela, my guest in this healthcare podcast, uncovered when interviewing friends and neighbors not in the healthcare industry about their benefits: 1. Nobody reads their benefit information. 2. They are unhappy with their benefits. 3. The most important thing for them is to have choice. They want to avoid the notion of “managed care.” In thinking about this, I was reminded of a Henry Ford quote: “If I asked my customers what they wanted, they would have told me a faster horse.” Or Steve Jobs famously said, “Some people say, ‘Give the customers what they want.' But that's not my approach. Our job is to figure out what they're going to want before they do.” Jobs's whole thing, after all, was that true innovation often comes from anticipating customer needs and desires before they can articulate them themselves. So, let me reconcile Lauren's findings when she interviewed people about what they want in their benefits and what Henry Ford and Steve Jobs have to say about the matter. First of all, patients/plan members—most people have never experienced a comprehensive primary care situation where they are assisted in finding the highest-quality specialists or sub-specialists and have their care coordinated. They have never had someone worrying about them in their “in-between spaces,” as Amy Scanlan, MD (EP402), put it, between appointments. This is all just a fantasy. It is a reputed Shangri-la that almost no one has ever seen with their own two eyes. But what many have seen—I have; you have—are narrow networks in which cost containment is wielded like a brute-force weapon, where, for example, the NCI-designated cancer centers are out of network as a way to make sure that people with cancer don't sign up for your plan … or don't last long on your plan if they do. (Did I say that out loud?) Do I sound like I suffer from a brutal lack of trust? Yes, I do—and I was just role-playing there an employee probably pretty accurately. Most of us remember the HMO a-go-go years when your PCP was an administrative gatekeeper and you had to see them to get a specialist appointment—except you never could see them. Wait times were weeks or months, obviously by design, right? But this way-too-expensive PPO model is the devil I know because, even if it totally sucks, it's better than the conspiracy theories and/or accurate or exaggerated recollections of other options. Here are my recommended next steps. Listen to the shows with Vivek Garg, MD, MBA (EP407), and Scott Conard, MD (EP391), and Douglas Eby, MD (EP312), as a start. All three make it really clear that advanced primary care—maybe even direct primary care—can not only save money, but it also can produce better health and patients are super happy and usually clinicians, too. It's like a quadruple aim home run. But none of this can happen if we say “integrated care or advanced primary care and you have to go there to get a referral” and then leave whatever that means up to employees' or plan members' imaginations. Communication is really required here, as it is when rolling out most new things—not just cars or cellular telephones.   You can learn more about Lauren's work by connecting with her on LinkedIn.   Lauren Vela is a passionate advocate for a more rational and sustainable healthcare system and recognizes the influence had by employers and other commercial purchasers through their oversight of employer-sponsored insurance plans. As an independent consultant, she partners with entities that are committed to changing the ineffective status quo. Previously, Lauren was the director of health care transformation with Walmart, where she partnered with the Walmart Benefits team to identify solutions concerning low-value care, site of care, and vendor evaluation. Prior to her tenure at Walmart, Lauren led market strategy and member initiatives for the Purchaser Business Group on Health, where she cumulatively spent two decades working within various healthcare sectors, including health information technology, provider organizations, and pharmacy benefit management. Lauren also served, for seven years, as the executive director of the Silicon Valley Employers Forum, a trade association of high-tech employers collaborating on innovative delivery of both domestic and international benefits. The cartoon. The decisions commercially insured employees across the country are truly facing … ©Dan Piraro 05:15 Do employees really understand what it means to have integrated care? 06:57 Why employees want choice and avoid the notion of managed care. 07:15 “I'm not sure that Americans really know what would be better.” 07:19 What would be a better way to do integrated primary care in America? 08:04 How do you fix it without disrupting what everyone thinks would be better?   You can learn more about Lauren's work by connecting with her on LinkedIn.   @laurenvela1 discusses #employeebenefitdesign on our #healthcarepodcast. #healthcare #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance Recent past interviews: Click a guest's name for their latest RHV episode! Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon  

This summer short is about the dynamic between payers and providers. An opening point that Jacob Asher, MD, my guest in this healthcare podcast, makes in the interview that follows is that, for a payer, it's super hard to competitively differentiate from both a cost and/or a quality perspective when you and all of your payer competition use the exact same PPO (preferred provider organization) networks. I mean, what? Are these same exact doctors gonna somehow do a better job with your members than with the rest of their patients? This is even more true if you think about this from a physician or a practice point of view. Will clinical teams in their clinical workflow figure out who your members are, first of all, which is a thing, and then switch up what they choose to do for your members that is special? Even theoretically, that sounds like an executional fandango, which is exacerbated in markets with lots of payers. I guess I am not shocked when I hear stories like Dr. Asher was talking about: Doctor sits down at desk after a long day and sees 27 “Dear Doctor” letters from all of the payers in his or her payer mix. “Hey, Doc. Let me tell you about our amazing new thing.” And Doc's like, “Pajama time awaits.” And—boom!—the letters, unopened, right in the recycle bin. From a payer's standpoint, back to square one, I guess. Now, I will chuck in the mix here—and this has nothing to do with the conversation with Dr. Asher that follows—but one thing I've spent my entire career doing is helping organizations set up programs to collaborate with other organizations. If I authentically solve an actual, authentic, prioritized problem, I usually can find many people who seem pretty pleased to work with me. Now, is this easy to do? No. It takes strategic thinking and executional competence and/or grit to see it through. You really have to understand and account for vested interests and all the weird perverse incentives. Personally, I gotta work with a whole team of others coming at this from all different directions to untie this Gordian knot. But anyone who really wants to or needs to reach across the aisle and engage with other stakeholders or customers, even in any sort of systemic way, it's just not possible to phone it in. Anyway, I just want everyone to succeed in working together. It is impossible to have a longitudinal patient journey if everybody is all up in their own silos fragmenting care.   You can learn more by connecting with Dr. Asher on LinkedIn.   Jacob Asher, MD, completed a residency in otolaryngology–head and neck surgery at the University of California, San Francisco, after receiving degrees from Brown University and the Boston University School of Medicine. Dr. Asher then practiced as an ENT (ear, nose, and throat) surgeon with Kaiser Permanente in Northern California and also served on the board of directors of The Permanente Medical Group, where he focused on physician compensation reform, member satisfaction initiatives, and retirement benefits. After transitioning to full-time health plan management, Dr. Asher served as a California commercial market medical director between 2008 and 2022 for Anthem Blue Cross, Cigna, and UnitedHealthcare. In those roles, he supported membership growth and retention in both fully insured and self-funded product lines and promoted value-based reimbursement, including capitation. He has led utilization management teams, collaborated with internal and external population healthcare advocates, and worked to develop clinical initiatives that sought to achieve the Triple Aim. In his role as the clinical face of the health plan to the local market, he worked with network colleagues on accountable care organization partnerships and hospital and physician contract renewals with integrated pay for performance, supported Obamacare exchange participation, engaged in quality improvement collaboratives, and supported regulatory compliance efforts. Currently, Dr. Asher is serving as a mentor for the Stanford Master in Medical Informatics program while exploring innovative solutions to healthcare delivery.   03:38 Why providers contracted with multiple health plans don't have a financial incentive to do something unique with one payer over another. 04:01 Why it doesn't make sense for providers to offer unique pathways for different payer organizations. 05:23 Why, broadly speaking, standards of care between payer policies aren't really differentiators in clinical practice. 06:47 Why financial incentives might not be aligned to make providers want to standardize their care. 09:16 What improvement has there been in plans making providers more aware of the benefits they offer? 11:47 Why won't providers off-load their pop health?   You can learn more by connecting with Dr. Asher on LinkedIn.   @JacobAsher18 discusses #payers and #providers on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg  

Here's a quote from Rolling Stone magazine: “A supergroup is a very fragile thing. Rock bands are always about balancing huge egos, but when those egos are oversized from the get-go it can lead to huge problems. That's why supergroups like Blind Faith often fail to go beyond a single album, and why long-lasting ones like CSNY had drama that never seemed to end.” Hmmm … that's apropos because, turns out, super ACOs (accountable care organizations) may have some similar issues. A super ACO means multiple ACOs or CINs (clinically integrated networks) which are each comprised of multiple practices or provider organizations, and it's all under different ownership. Said another way, there are multiple levels of competitors—frenemies, if you will—trying to work together or not work together as the case may be. There's a lot of infrastructure complexity and process complexity and, frankly, inefficiency. There's trust issues. There's the problem that rule #1 of change management is to create “quick wins” so that everyone can smell potential success and realize it's possible, so momentum happens. But if doing anything is hyper-complicated, then it's really tough to have a quick win. Today in this summer short, this is what I am chatting about with Eric Gallagher. We talk about how Ochsner evolved from a super ACO or super CIN into its current form. This summer short is a 13-minute clip that went a little far afield from the main topic of episode 405, which was the full episode with Eric Gallagher, and therefore, I cut it. But as I always do when I cut an actually pretty great section from a show for reasons of time, I have been on the edge of my seat to share it with you. This show is actually a very nice follow-on to the one with Dan Serrano (EP410) from last week. As Eric describes Ochsner's history and its path forward, it is a case study of some of the recommendations that Dan mentioned. This summer short also really echoes some of the themes in episode 409, which was the one with Larry Bauer, and also one upcoming with Jodilyn Owen. What will work in one local market, don't count on it working elsewhere—or not work as well at a minimum. Healthcare is local. This is a lesson many investors and entrepreneurs looking for rapid scaling prototypes have learned the hard way, and listening to Eric, it's really easy to catch the why for that. If this topic intrigues you, also listen to the show with Dr. Amy Scanlan (EP402). Also episode 349 with Lisa Trumble. And lastly, I would recommend the show with David Carmouche, MD (EP343). Dr. Carmouche was talking about Ochsner's work improving patient outcomes with a Medicare Advantage plan. One final note/point to ponder: scale. To really get value-based contracts, you need it. You need it to afford the infrastructure, and you need it to demand a seat at the table. But yeah with that … everything in moderation, I guess, because any scale that starts to approach monopoly proportions seems to invite bad behavior. You have to get big enough to matter in the market but not so big that your big footprint squashes market dynamics, because it seems like many succumb to the siren song at that point of putting profits over patients.   You can learn more at Ochsner Health Network. Eric Gallagher, chief executive officer for Ochsner Health Network (OHN), is responsible for directing network and population health strategy and operations, including oversight of performance management operations, population health and care management programs, value-based analytics, OHN network development and administration, strategic program management, and marketing and communications. Prior to joining Ochsner in 2016, Eric held leadership positions in healthcare strategy and execution—including roles at Accenture, Tulane University Health System, and Vanderbilt University and Medical Center. A New Orleans native, Eric earned a bachelor's degree in human and organizational development from Vanderbilt University and an MBA from Tulane University.   04:23 How Ochsner Health went from a super ACO to their current value-based care model. 06:09 What signs did Ochsner Health see that helped them recognize that the clinically integrated networks they were building wouldn't help them achieve the outcomes goals they were aiming for? 07:42 Why Ochsner Health's story is a classic example of change management. 08:41 What tough decision did Ochsner Health have to make that's ultimately led to much higher success rates? 10:46 “Really … it's about changing the economic model.” 11:03 Why was CMS a driver of change? 13:00 What's the more sustainable business model in Ochsner Health's market? 15:09 How has Ochsner Health been ahead of the game in the healthcare market?   You can learn more at Ochsner Health Network.   Eric Gallagher of @OchsnerHealth discusses #valuebasedcare and #superACOs on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela  

In this healthcare podcast, I am talking with Dan Serrano; and we're talking about payer/provider collaboration—blocking and tackling, I'm gonna say—from primarily a financial and revenue point of view. I'd classify this as, say, a 201-level discussion (ie, not entry level, but it's also not super deep in the weeds). We mainly cover the ins and outs of why a provider organization should probably be looking to get paid to better take care of patients with chronic disease and drive better patient outcomes at lower downstream costs and, to some degree, also why payers should be helping provider organizations in their local communities to do so by providing some help and shelter on the journey from here to a capitated payment. The focus today is really, I'd have to say, on the messy middle, where a provider organization does not have capitated contracts nor access to any premium dollars, which, by all accounts, is the holy grail here. The premium is where it's at, and provider organizations might want to be aiming to get a piece of that action. The why for this “get the premium dollar” prime directive is pretty self-evident when you look at the big bucks rolling around in the coffers of those who are collecting said premium dollars. So, this “get the premium” endgame is, for sure, a big piece of the why—why, if I am a provider organization, I might want to take the time and energy and spend the money to embark on a path that might lead me to be able to get compensated for the stuff that patients really want and need to do better, which includes all of the things that I spoke about with Eric Gallagher in episode 405. Also, Vivek Garg, MD, MBA, in episode 407 and Amy Scanlan, MD, in episode 402. Spoiler alert: It's not easy. Now, I asked Dan Serrano, as aforementioned my guest today, to offer up his advice here in the context of CKD (chronic kidney disease) patients. Why did I ask Dan to use the CKD case study, as a touchstone? Well, first of all, talking about this topic in totally theoretical terms is not ideal. We need an actual example for a lot of this to kind of make sense, combined with the first step for most outcomes improvement programs, which is to study your data and pick a patient population to focus on where the data suggests that you can have a big impact. And speaking of impact, did you know that an underlying reason why heart failure patients get hospitalized and rehospitalized is because of underlying CKD? So, impact in the short term and longer term, which I'll get to in a sec. Another reason is—and I'm quoting John Rodis, MD, MBA, here, who is the independent medical director of QC-Health®—Dr. Rodis said the other day, “I sure as heck hope I don't get CKD, because if I do, chances are I'm not going to be diagnosed. And even if I am diagnosed, I won't be treated properly.” So, there's that. And I can see why he's saying that. Two out of five patients with ESRD (end-stage renal disease) don't even know they have kidney disease at all. And the number of patients with progressing CKD on any kind of evidence-based treatment plan is stunningly low. But also, here's another reason I asked Dan Serrano to talk about CKD patient populations specifically as his example: I and Dr. Rodis and the team at QC-Health are not the only ones who have figured out that CKD patients are notoriously expensive and way underdiagnosed. You know who else has figured this out? Payers. Also, private equity. In fact, I was in a meeting with a payer recently, and they stated they had to get CKD patients into point solutions. This payer—and I've heard of others, too—none of these entities are waiting around. And I guess, fair enough, if you look at some of the population health data, that I'm sure these payers and others are looking at. But if you work for a payer and you're listening right now, what I would say, “Okay, with the point solutions, one that you have carefully vetted, of course, because we have patients suffering right now and dollars being frittered away right now.” But I also would submit that those point solutions will perform a whole lot better if we are all gunning for synergies. PCPs (primary care physicians) and traditional FFS (fee-for-service) models in this country need your help. The payment models and admin burden are decimating. Payers certainly are a group with some culpability here. (Sorry to be saying the quiet part out loud.) Instead of forgoing them, please help PCPs. Am I saying be altruistic? Actually, no. Listen to episode 409 with Larry Bauer or episode 391 with Scott Conard, MD, or an upcoming show with Jodilyn Owen and what you will hear is the amazing ability for clinicians rooted in the community to actually drive change in their local markets. In fact, I'd hypothesize that these community-rooted organizations probably have a better track record for actually moving the needle on patient outcomes than any snazzy tech that I have seen, although I am sure that there are one or two very effective snazzy techs out there—the exception proves the rule and all that. Bottom line: As I do so often, I am advocating for payers and provider organizations within communities to collaborate, regardless of whether there's a third party also in the mix. I am reporting all of this in the spirit of being helpful but also with some degree of urgency for any care delivery organization because, I mean, really, forget about the holy grail of trying to capture a percentage of the premium if the money is already going elsewhere to too many point solutions who are already capturing a portion of the premium. IRL, this is what's already going on out there. But where there's a challenge, there is also opportunity. As I have said pretty repeatedly for the past four minutes, because the bar is so low and because CKD patient outcomes are bad news, in general, from a lot of angles, CKD is actually a great place for providers to work hard to improve care and quality. From a financial standpoint, I think there's also a great business case for payers to help provider organizations do so. Doing better than the local standard of care is not hard, sadly. And what that means is that there's so much money that's possible to save due to the expense of this condition. And if you're a payer, even a payer with a third-party CKD solution, if you can help local PCPs and others level up their care, then either you don't have to pay for the third-party point solution for patients who can be managed successfully locally and/or there's a more frictionless path for those patients to be identified and get into the point solutions that are available to them. Let's all keep in mind that patients at rising risk are falling through a lot of cracks. You can have the best point solution in the world, but if patients aren't making it there, then, yeah, no outcomes will improve. No costs will be reduced. Everything I just went through are also all of the reasons why we picked CKD as our focus for a national Groundswell Movement™ that the benefit corp I am co-president of is kicking off to improve CKD patient outcomes. If you are also thinking about improving CKD patient outcomes, for sure, hit me up. On to a few thank yous. Thank you so much to Carl Hansen, MD, a direct primary care physician, for a really generous tip in our tip jar. Also, thanks so much to Keith Passwater, who is CEO of Havarti Risk Services and Pasco Advisers, for a really nice donation to the cause over here. It was such an honor and a pleasure to moderate a panel at the Society of Actuaries' latest meeting at Keith's invitation also. Additionally, may I extend thanks to Dffdgg, RKC2023, and Healthy economist for super nice iTunes reviews. The shout-outs are amazing, especially when public like this. Also much appreciated how you have shared Relentless Health Value with your colleagues. Back on track, let's hear from Dan Serrano, who is a consultant with COPE Health Solutions, where he works to help clients figure out the best way to make investments that drive better outcomes in a more cost-efficient way.   You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.   Dan Serrano joined COPE Health Solutions in September 2022 as principal and senior vice president. He supports Analytics for Risk Contracting (ARC) finance build and cost models in terms of drive and delivery with Great Lakes Integrated Network (GLIN). He is a seasoned healthcare/finance professional with 20+ years' experience and has held a number of roles across the industry and has primarily served as a senior finance leader with proven ability to drive strategy development and execution across multiple business lines for complex organizations in various stages of maturity. Prior to COPE Health Solutions, Dan served as senior vice president of finance at CareAbout, a private equity–backed start-up focused on driving performance for primary care physicians. He also was the vice president of value- and risk-based contracting at Mount Sinai Health System, where he worked to align contracting, operational performance, and network strategy for employed and voluntary physician groups. Prior to his role at Mount Sinai, Dan served as vice president of commercial products at Healthfirst, market chief financial officer at ChenMed, and Mid-Atlantic Region chief financial officer at Aetna, where he focused on driving strategic financial decisions by analyzing the value drivers for each of the stakeholders across the industry. Dan holds a bachelor's degree in finance from the Peter J. Tobin College of Business at St. John's University.   09:08 What is the importance of payer/provider partnerships in reducing costs with chronic condition care? 10:52 Josh Berlin, JD, of rule of three; look out for his episode in a few weeks. 11:19 What's the endgame here with this payer/provider collaboration? 11:43 What advice does Dan have for providers who want to do better by patients with chronic conditions? 15:11 Who's driving costs in the system? 15:50 Why is lowering the average cost of chronic condition care important? 17:03 Why is there a meaningful delta between well-controlled CKD patients and those who aren't well managed or identified? 21:57 What does a realistic time horizon look like for addressing chronic condition care? 22:38 Why is it important to start in a shared savings place? 25:25 William Shrank, MD, of Andreessen Horowitz; look out for his episode in the fall. 26:35 Financially, what is the goal and how are we achieving a sustainable goal? 29:06 What is the balance between progress and risk here?   You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.   Dan Serrano of @COPEHS discusses #chronicconditions and #payer #provider #collaboration on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249)  

In this healthcare podcast, we are talking about innovative primary care teams and, by way of Larry Bauer, my guest today, bringing you three inspiring case studies. Much can be inferred from these case studies, as much from how they are alike as how they are different. It is wildly important at the same time that it is wildly underappreciated how different local markets are. I love how Cody Coonradt put it on LinkedIn the other day. He wrote: “Healthcare is not a $4T market—it's 500 some-odd interconnected markets ranging in size from $1-50B. [It is] not a singular problem … each market [is driven] by unique third party payer incentives with unique patient cohorts. … “Before you figure out the next great idea—seek to understand the underlying health economic, revenue cycle, service provider contracting, and cash conversion processes that undergird it all. [That] is how to truly disrupt healthcare.” Or, said another way, if you're part of the community, if you are already caring for patients in that community because you're a doctor or another clinician, you probably have the best shot at truly—and in meaningful ways—helping patients in that community. This whole statement is a really uncomfortable truth for many in private equity and anybody else who wants to find the easy button to fix healthcare with some big-ass, scalable, rapid-fire bulldozer approach. It's also a very uncomfortable truth for any national payer looking for one model or one point solution to roll out in a broad stroke to every one of these 500 some-odd interconnected markets that Cody mentioned. One size does not fit all here, and leveling up patient outcomes and care is hard grueling work that requires local market knowledge, being rooted in the community with relationships to succeed. You gotta get a little closer to the ground. Policymakers, please take some notes here. And you, too, self-insured employers, payers. So many universal lessons are embedded in these three examples that Larry Bauer, my guest, shares today. But bottom line—and round of applause required—you go, all you doctors and nurses and other clinicians or mission-oriented teams who take it upon yourselves to find ways to address the problem of human suffering in your local area. Stay tuned for an upcoming show with Jodilyn Owen, where we dig into this whole dynamic hard. I'm talking about the dynamic where some barbarian at the gate (ie, some venture-funded start-up) has gotten money—in some cases, lots of money—while there are community-based organizations out there who are doing amazing work really helping patients in the community improving outcomes and cutting costs and struggling, scrambling for every penny they can manage to get their hands on. So, that's in the future. Talking about today, though, we're gonna cover the bright spots when you get a really creative and committed PCP (primary care) team who is part of their own community and who wants to do better by patients locally and got some money to attain that goal. Today, as I said earlier, I am talking with Larry Bauer, who has been working with innovative PCPs and other docs for decades. All three of these case studies that Larry describes on the show today concern frail elderly adults, and this is on purpose (this using of the same patient population) for a couple of reasons. One of them is just to highlight that the same population in different geographies is not the same population and, therefore, the solution set is going to be different if we're gonna reach out and care for them. The second reason for selecting three solutions that all pertain to frail elders is that this group is notoriously expensive and care is notoriously poor. Everybody has a story about how their frail elderly family member or friend died a bad death or did not “finish well,” as Larry Bauer puts it. It's a patient population at the mercy of this industry and unable, a lot of times, to advocate for themselves. So, solutions here solve, in a way, for the worst-case scenario and might be a great starting point for anybody contemplating how to help other patient populations, too. The three innovations we discuss today are: 1. Dan Hoefer, MD, and Suzie Johnson in their Transition Program in San Diego helping those at the end of their lives to “finish well.” This is a capitated program. 2. Ken Coburn, MD, who, along with his team, created Health Quality Partners in Pennsylvania. This is a nurse navigator program, and it is paid for by a CMS grant. 3. Alan “Chip” Teel, MD, at Full Circle America with a program to wire up patient homes so that the clinical team could monitor what was going on in the home, intervene in case of emergencies, as well as organize community services. This program is paid for by the patient or the patient's family, but, point of note, it is 10 times cheaper than a nursing home. I do ask Larry Bauer, by the way, how to best walk the line between right-sized care and not enough care (ie, the whole death panel counterargument to some of this stuff). I think Larry's answer was elegant. You're gonna need to listen to the show to hear it. My guest today is Larry Bauer, as I have mentioned four to six times already. He is a social worker by training who has been at this, as he says, for a very long time. He created a not-for-profit called Family Medicine Education Consortium (FMEC) over 30 years ago, and it became a platform for bringing together very talented and capable family physicians and some general internists. This gang has been really redefining and re-creating primary care … which is a great way to sum up the three programs that Larry Bauer will talk about today.   You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com. Larry wrote a “Bright Spot” report; check it out here.   Laurence Mahoney Bauer, MSW, MEd, served as chief executive officer of the Family Medicine Education Consortium, Inc., from 1994 to October 2021. The FMEC is a not-for-profit corporation designed to promote collaboration among the academic family medicine and primary care communities in the northeast region of the United States. He has also served as director of network development for the Center for Innovation in Family and Community Health in Dayton, Ohio, from January 2006. He is an associate clinical professor in the Wright State University School of Medicine, Department of Family Medicine, in Dayton. Previously, he served at The Ohio State University School of Medicine, Department of Family Medicine, for 4 years as director of organization and faculty development. He served as director of faculty development and behavioral science in the Department of Family and Community Medicine at the Pennsylvania State University School of Medicine in Hershey, Pennsylvania, for 13 years. Presently, he is an active consultant committed to the creation of a primary care–driven system in the United States. He lives in Hershey. He enjoys pickleball, basketball, and gardening.   06:53 In a brief overview, what does end-of-life care in America look like? 10:38 What are the three innovative systems and physicians Larry Bauer has worked with? 14:27 What does it mean to be in a capitated system? 19:14 What does the Health Quality Partners system look like? 22:13 Andreas Mang from Blackstone; look out for his episode in September. 22:50 What is a number one reason for hospital readmissions? 23:26 The third example of innovative primary care. 27:04 Why is comprehensive care at the community level so important and successful for end-of-life care? 28:03 “The number one goal is not cost containment; that's one of the outcomes.” 28:26 What is the core issue for these three types of innovative care? 31:02 What does good policy to encourage this type of innovation look like? 33:22 EP326 with Rishi Wadhera, MD, MPP. 34:14 Why is it important to trust physicians and be present and partnered with physicians?   You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com. Larry wrote a “Bright Spot” report; check it out here.     Larry Bauer of @FMEC_ discusses #innovation in #primarycare on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher

I cut this clip out of episode 407 with Vivek Garg, MD, MBA, from Humana; and it's actually a really nice follow-on from the show last week with Scott Conard, MD, where we talked about the blowback that happened with clinicians at a clinic. This clinic had put into effect a bunch of the comprehensive primary care kinds of things that Dr. Garg talks about in this summer short. But what happened in Dr. Conard's case is a new practice manager tried to go back to the olden days, and, spoiler alert, it was a kerfuffle. All the docs and the rest of the clinicians staged what sounded like a “mutiny on the bounty” moment from the way Dr. Conard described it. So, this summer short you're about to hear and the one from last week again share one key point: Doctors, advanced practice clinicians, medical assistants, pretty much everybody on the team really likes a well-executed, operationally excellent transformed primary care model. And it produces better patient care. I was reading Dr. Robert Pearl's book Uncaring the other day, and he summed up the reason why, I think, these transformed primary care practices do better. He was quoting Atul Gawande, and here's the quoted quote: “The public's experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it's pit crews people need.” I interviewed Dr. Pearl, by the way, so stay tuned for that show coming up. In this summer short, Dr. Garg digs into one common objection to more comprehensively comprehensive primary care, and that is that by improving care, we decrease throughput and, therefore, access to primary care, especially in areas where there are not enough primary care doctors.   You can learn more at humana.com, centerwellprimarycare.com, and the Humana report.     Vivek Garg, MD, MBA, is a physician and executive dedicated to building the models and cultures of care we need for loved ones and healthcare professionals to thrive. He leads national clinical strategy and excellence, care model development and innovation, and the clinical teams for Humana's Primary Care Organization, CenterWell and Conviva, as chief medical officer (CMO), where they serve approximately 250,000 seniors across the country as their community-based primary care home, with a physician-led team of practitioners, including advanced practice clinicians, nurses, social workers, pharmacists, and therapists. Dr. Garg is the former chief medical officer of CareMore and Aspire Health, innovative integrated healthcare delivery organizations with over 180,000 patients in over 30 states. He also previously led CareMore's growth and product functions as chief product officer, including expansion into Medicaid primary care and home-based complex care. Earlier in his career, Dr. Garg joined Oscar Health during its first year of operations as medical director and led care management, utilization management, pharmacy, and quality, leading to Oscar's initial NCQA accreditation. He was medical director at One Medical Group, focusing on primary care quality and virtual care, and worked at the Medicare Payment Advisory Commission, a Congressional advisory body on payment innovation in Medicare. Dr. Garg graduated summa cum laude from Yale University with a bachelor's degree in biology and earned his MD from Harvard Medical School and MBA from Harvard Business School. He trained in internal medicine at Brigham and Women's Hospital, received board certification, and resides in New Jersey.   02:31 Does advanced primary care reduce access to patients? 03:01 Are five-minute visits with patients really access? 04:17 Will advanced primary care provide outcomes that make certain PCP responsibilities unnecessary?   You can learn more at humana.com, centerwellprimarycare.com, and the Humana report.   @vgargMD discusses #advancedprimarycare on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Scott Conard, Brennan Bilberry, Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi

Back at the beginning of this year, I was so sad when I had to edit out the clip that follows from the original and extremely popular episode 391 with Scott Conard, MD. In the literally probably three minutes that follows in this clip with Dr. Conard after I finish my ramblings here, Dr. Conard introduces the impact that changing the practice model in a PCP practice in Queens, New York, had on the staff and patients alike. Spoiler alert: No way no how were they going back to the old way of doing things. The “Before” here was a clinic where the waiting room was filled to overflowing out into the hall with patients waiting to be seen, and this included a mix of really sick people who really needed to be seen and also … others. And thus they had, among a whole host of other bad things going on, the whole issue of suboptimal ER (emergency room) visits and urgent care usage. Anyone who couldn't wait just headed elsewhere. Also, as it is so many places, care was pretty transactional. A patient who wasn't in clinic had an “out of sight, out of mind” relationship with their PCPs. There was no systemic way for the clinical teams to really think about the “in between spaces,” as Amy Scanlan, MD, put it (EP402)—the spaces in between office visits. But then as a result, of course, we wind up dealing with uncontrolled chronic conditions and the failure to prevent preventable disease. We wind up with urgent needs for care and acute situations that had, frankly, no business getting to that stage in the first place. So, Dr. Scott Conard and his team worked on practice transformation, including focusing on operational excellence. I say all that to say, here's Dr. Scott Conard: DR. CONARD: We went and did one pilot clinic, which is, I think, the right way to do it. And then the practice manager was recruited by a competing group. They put another person in the clinic, another practice manager. And she immediately came in and thought that her job was to go back and put the old way of doing things in place, and within literally four or five days, they got together and sat down and said, “Look, we understand where you're coming from, but we will never go back. We are not going back to that old system. We are going to do things in this new way because it makes our lives—and we work together—so much better. And we enjoy being together, and we're seeing … we like not having 30 people waiting to get here at work. We like people getting … having a waiting room be close to empty as we just have one or two of the next people coming in. And we will never go back to that old system.” And, to her credit, she's like, “Okay … cool. Let me understand this.” And she's now one of the strongest leaders in that organization for this transformation. STACEY: So, the PCPs … it was like mutiny on the bounty. They were like, “No way no how are we going back.” DR. CONARD: Oh, it was the entire team: their receptionist, the telephone operator, the MAs. They have a patient navigator, which is another part of the equation we haven't talked about that's really important. And so, the whole team said no. Listen to the full episode 391 to learn more about Dr. Scott Conard and his team's approach to practice transformation. But in the meantime, Peter Watson, MD, captured a few learnings from the original episode really nicely on LinkedIn; so let me quote him here: Dr. Watson has some other really great posts on the topics of value-based care and primary care. I would highly recommend following him on LinkedIn. Should you continue to be interested in this topic of transformational primary care, additional shows on transforming primary care—including bright spots and challenges—are the shows with Eric Gallagher (EP405) and, as aforementioned, the show with Dr. Amy Scanlan (EP402). Also check out the upcoming show with Larry Bauer, which will be approximately episode 409, should I get my act together. And Vivek Garg, MD, MBA (EP407), who, by the way, is coming up in next week's summer short talking about the common rebuke of comprehensive primary care, which is that it diminishes patient access because PCP patient panel sizes tend to be smaller in comprehensive primary care models. Since the original show with Dr. Scott Conard aired, his new book Which Door? came out. I'm gonna say that this book is relevant. It's written for employers but still relevant here because employers have a terrible track record for helping (ie, paying for healthcare) in a way that enables PCPs who want to do comprehensive primary care to actually do comprehensive primary care. When an employer lets the status quo prevail, employees get fragmented care provided by PCPs struggling under the weight of brutal administrative burden and often nasty and counterproductive incentives.   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.   02:15 Why a transformed PCP practice didn't want to go back to the old way of doing things. 03:39 Dr. Peter Watson's takeaways from Dr. Conrad's EP391. 04:02 Can fee for service in the short term still benefit primary practice? 04:43 EP405 with Eric Gallagher; EP402 with Amy Scanlan, MD; upcoming episode with Larry Bauer; and EP407 with Vivek Garg, MD, MBA. 05:24 Scott Conard's new book, Which Door?   You can learn more by emailing Dr. Conard at scott@scottconard.com.   @ScottConardMD discusses #PCP transformation on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Brennan Bilberry, Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid

May I just take a moment and thank the Healthy economist for leaving a super nice review on iTunes? The title of the review is “Best podcast on the healthcare industry,” and the Healthy economist writes, “There's no one simple fix [for the healthcare industry], but [Relentless Health Value] contains valuable insights on what actions can be taken to make things better for consumers and patients.” Thank you, Healthy economist. In this summer short, I am talking with Brennan Bilberry; and we're talking about why everybody isn't suing health systems for behaving badly in sometimes pretty egregious ways. Why isn't anybody stepping in to prevent all of this consolidation that we all know, at this point, is pretty bad news? FTC, where are you? Brennan Bilberry cites three reasons for the way fewer antitrust lawsuits than you'd think would be going on: 1. A continuing lack of transparency. It's tough to sue someone when you aren't really sure what they're up to, and, even if you do, it's hard to prove because you can't get the data you need to prove it. 2. Political power of hospitals means legislatures have a hard time telling their major donors to kiss off and pass laws that actually enable legal recourse. 3. Turns out the FTC is a little toothless when it comes to those with tax-exempt (ie, nonprofit) status. Nobody expected nonprofits to act the way that some nonprofits are acting, and the laws haven't caught up with the reality of the situation. My guest in this healthcare podcast as aforementioned is Brennan Bilberry, who is a founding partner over at Fairmark Partners, which is a law firm litigating some of these antitrust lawsuits against some of these hospital chains. The original pod with Brennan (EP395) is entitled “Consolidated Hospital Systems and Cunning Anticompetitive Contracts.” Here's a link to an article I was thinking about while recording this show about Daran Gaus's hypothesis for how mergers will impact hospital prices. And here's a link to an article about how commercial prices for outpatient visits were 26% higher for patients receiving care at a health system than those visiting nonsystem physicians and hospitals. Covering some of the consequences of consolidation and what it tends to do in local markets is the show with Cora Opsahl (EP373) and also the encore with Dale Folwell, state treasurer in North Carolina. One last link is to the conversation I had with Scott Conard, MD (EP391), where the local hospital bought a local ACO (accountable care organization) physician organization and the community paid an additional $100 million to the hospital the following year.   You can learn more at fairmarklaw.com.   Brennan Bilberry is a founding partner of Fairmark Partners, LLP, a law firm focused on fair competition issues, especially in the healthcare industry. Fairmark has filed numerous antitrust cases against dominant hospital systems, seeking to tackle anticompetitive practices that lead to higher prices for businesses, consumers, and unions. Prior to founding Fairmark, Brennan worked as a policy consultant and political operative whose work included overseeing environmental public policy campaigns in numerous countries, providing international political intelligence for US investors, advising political campaigns around the world, and designing consumer and legal advertising. Brennan also worked on numerous US political campaigns, including serving as communications director for Terry McAuliffe's 2013 successful campaign for Virginia governor, serving as deputy executive director of the 2012 pro-Obama Super PAC Priorities USA, and developing research and policy communications for the House Democrats. Brennan is a native of Montana and South Dakota and has lived in Washington, DC, for the past 15 years.   00:23 Healthy economist's review of Relentless Health Value. 00:52 Why aren't more people suing hospitals? 01:16 How is the lack of transparency diminishing the number of lawsuits? 01:41 Why is the FTC a “little toothless” when it comes to nonprofits? 02:12 EP395 with Brennan Bilberry. 02:35 Why aren't there as many antitrust cases as there are instances of antitrust laws being broken? 03:10 Has consolidation of hospitals systems been good or bad? 03:45 What quirk in the law creates an impediment for FTC? 04:17 What are certificates of public advantage? 05:03 Why is private antitrust litigation important?   You can learn more at fairmarklaw.com.   @brbilberry discusses #hospital #antitrust cases on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan  

Thanks for joining me as we kick off the summer season. Here's what we're gonna talk about today in our 10-ish-minute conversation. Keeping it short and sweet. First up, we got three super interesting voice messages left by your fellow members of the Relentless Tribe that I wanted to share with you. Next up, I will cover plans for the summer, because this summer, we have plans. And then after that, just wanted to chat a little bit about what I am up to right now. Agenda item #1: Episodes 399 and 400 of Relentless Health Value were me sharing my manifesto as it were. At the end of the show, I said that if you have a manifesto of your own, to share it by going to relentlesshealthvalue.com and hitting the orange leave a voice mail button. Doug Pohl, CEO of HealthTech Content, did so; and here is what he had to say: “My name is Doug Pohl. I'm the founder and CEO of HealthTech Content, and I'm pretty frustrated by the lack of progress toward making the improvements we need for healthcare. So, I put this out there to sort of be a bat signal for anyone else who feels the same way I do but to also hold myself accountable to be congruent outwardly with how I feel inwardly. No longer will I accept healthcare's prioritization of the bottom line. No more will I ignore the flagrant victimization of our society. I won't sit silently while shortsighted greed ruins families. I don't accept a profit-first model that kills people daily. I can't let complacency keep me from taking action. I won't let my voice wither away in fear. I can't—and I won't—remain quiet. I believe in the potential of regular people. I know how powerful we can be working together. Every one of us is affected by healthcare eventually, and it will take all of us to create the healthcare we deserve. The first step is rejecting the status quo. I'm tossing it out the window. How about you?” And now let me share two more voice mail messages, and here's why they both are meaningful. We know that this journey to transform the healthcare industry in this country can be long and slow and, at times, lonely. But together we are stronger and more able to help patients receive the care that they need and deserve at a price that we all can afford. So, thank you for being part of our community, and here's two perspectives on why you being here matters. Here's a voice mail from Justina Lehman from the Infinite Health Collaborative (iHealth): “When you are in the work of creating change in healthcare and really working to align with value for the patient, value for the physician, the clinician so they have an environment that they can thrive in, the work can feel hard. And it can feel lonely, and you can feel on an island. And Relentless Health Value podcast is your people. We often say this in our team of … when you look to that podcast, you're reminded of all the amazing people across this country doing incredibly meaningful work. And linking up with one another can create that strength and help you with your resiliency, especially on those days where you're feeling down and that the work is hard and that you're doing it alone. And sometimes you may even question: Is this work of value? Will it be valued of others? The Relentless Health Value podcast, Stacey, all of her guests have really been those people for us. Not uncommon for us to share podcasts amongst each other during the work of reminding each other of the people out there doing great things. So, so incredibly grateful for what Stacey's built and for all the guests that have been on her show and the value it's adding and the support it's giving to those of us who are out in the trenches trying to make this happen. So, thank you, Stacey.” And here's a message from Amy Scanlan, MD, who was also a guest on episode 402: “Hi, Stacey. It's Amy Scanlan. Wanted to say thank you for your latest episode. It's so helpful to be reminded that, even though we're making little steps, we are making progress and we're part of a greater movement. Thanks so much for the inspiration and for always doing the good work. Bottom line, here's my point and call to action: Share this show, especially with colleagues, with anybody trying to find a path forward who may be helped by a little companionship along the way. I just got a note, in fact, from Rajiv Patel, MD, MBA, FACP, from Bluestone Physician Services, and he wrote, “I am only a six-month listener and pretty upset to have not found this podcast earlier.” So, help spread the word and there are some people out there—not everybody, but some people—who you would be doing, frankly, a great service to. It sucks to feel alone. Agenda item #2: Let's talk about our summer plans here at Relentless Health Value. These plans are made possible because I am a collector. I grew up in Pennsylvania Dutch country. What can I say? We don't throw things away. We get a recycled jar and start throwing, I don't know, old keys into it until—it's like a magic trick, really—suddenly we have a collection of old keys. You know you're a collector when you have to buy a Brother P-Touch label maker because you have so many collections you require fancy labels to keep track of them all. Here's why this is relevant to you: Over the past year or so, I started collecting the sound bites that we had to cut from our episodes. I'm not talking about bloopers. I'm talking about really good insights and information but on a topic that maybe was slightly off-topic from the main thrust of the episode or sometimes just a little too long. I try to keep our shows around the 32-ish-minute mark because … yeah, you people are busy. At a certain point, though, I realized I had maybe half a dozen of these 5- to 10-minute clips. So, that's what we're doing this summer. We're going to play a drawer of, I'll call them, “Summer Shorts.” Get it? Summer shorts? These shorts are all with previous guests, and each short shares one or two very concise insights. I have about seven shorts in this drawer, so this will take us through most of the summer. There will be an episode or two sprinkled in. We have one on deck from Larry Bauer, who goes through some really heartwarming bright spots in the delivery of healthcare, and another one from Dan Serrano talking about CKD (chronic kidney disease) from a financial modeling standpoint. We'll see how it goes. Feedback is welcome. Speaking of bloopers, though, after 400 or whatever shows, I have to say I'm very blasé about bloopers as you will discover if you ask me about them, which many people do. I've heard them all what feels like a thousand times each: the ambulances, the helicopters, the lawn guys, the kids screaming about not wanting to give their germs to the dog (come to think of it, I should have saved that one), squirrels in the mini blinds, dogs barking, obviously the cat on the keyboard, the ice machine, the doorbells, things beeping, an occasional rooster. I always just delete them because guests get embarrassed. But yeah, I probably have enough audio to put together a game show entitled Where Is the Guest Working From— Home, Hospital, Office? Answer correctly and win prizes. That was a detour. Back on track now. One of the other reasons for doing summer shorts is because … wow, I am really busy. QC-Health®, the benefit corp that I'm co-president of, is working really hard in the CKD space. Right now, we are collaborating with several provider organizations—amazing ones, if you ask me—trying to co-design with PCPs in a very helpful way (ie, a way that is intrinsically motivating) to diagnose CKD earlier, slow disease progression, and help their colleagues do so, too. Considering that 50% (five-oh percent!) of patients who go into dialysis crash into dialysis in the ER (ie, they go to the emergency room for something or other and, while there, they are told that the root cause of their problem is “Oh yeah, you have end-stage renal disease [ESRD] and need to be on dialysis,” which costs, what, a quarter million dollars a year [according to a study in JAMA Network Open]). Oh, and also, two out of five of those patients who crash into dialysis—this is sad—had no idea they even had CKD, meaning they had no chance to slow their disease progression even if they wanted to. So, lots of work to be done there. This said, if you are working on anything that has to do with CKD, hit me up. There may be some alignments that we could explore. The process that we are using here to address and try to level up CKD outcomes is the same process that we used in the chronic liver disease (CLD) space, in which we improved the use of clinical guidelines for end-stage liver disease by 23% in about six months nationwide. Yeah, I know. I actually have a day job and do real work. Now, I will say that if you have a drug in the CKD space or a device or you are an ESRD value-based provider … yeah, call me kinda quick. It's humbling and nice validation the number of folks who are interested in working with us, but we don't want to bite off more than we can chew. Moving on, here's some more news about me. Thanks so much to the Validation Institute for awarding me Healthcare Influencer of the Year. That was a really cool surprise, and I am looking forward to picking up the award in DC at thINc360. So, that happened. I'm also looking forward to giving the keynote at the Pittsburgh Business Group on Health Symposium in September. Please come and see me there. I would love to meet 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.   01:14 Doug Pohl's manifesto. 02:43 Justina Lehman's thoughts on why our podcast listeners are important. 04:05 Dr. Amy Scanlan's voice mail. 04:39 Note from Rajiv Patel, MD, MBA, FACP. 05:01 Relentless Health Value's plans for the summer. 09:18 Stacey's plans for the summer.   For more information, go to aventriahealth.com.   Our host, Stacey, discusses our #healthcarepodcast plans for the summer. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann  

I hope you enjoy this encore episode of one of the most popular shows in the last 12 months. One of my mentors often said price is irrelevant. He said he would sell anything for any price as long as he could define the terms of the deal. During this conversation today with Scott Haas about PBMs (pharmacy benefit managers), that quote was playing in my head like an earworm. I'm henceforth gonna struggle with the term rebate to define dollars that the PBM gets back from Pharma, because, according to my guest in this healthcare podcast Scott Haas, it turns out “rebates” comprise only about 40% of those back-end dollars that some PBMs manage to score from pharma manufacturers. I don't have any insight really into this, but Scott Haas certainly does—and this is the average that he has seen in his work and that we're going to dig into today. But in sum … wow! Let me just repeat that a mere 40 cents on the dollar of the gross amount that PBMs take in “rebates” from Pharma these days winds up going back to plan sponsors, even plan sponsors who are getting “100% of the rebates.” If you didn't understand what I just said, no worries. I'm gonna explain it right now. If you did and you know the why behind all of this also, you could probably skip ahead about five minutes. Here's the backstory on this whole rebate fandango. Let's start with part one of what is a two-part transaction. So, part one: the deal between pharma manufacturers and PBMs. In general, a pharma manufacturer signs a deal with a PBM to give back whatever percentage of their gross sales revenue to the PBM at the end of the year, say. It's along the same lines as a cash-back coupon for the PBM. Why would a pharma company be up for giving cash back like this? Well, to get on a PBM's formulary, giving cash back is like the price of admission. PBMs have a lot of leverage, after all—at least the big ones. They control access to millions and millions of patient lives. So, if Pharma wants their drug to be accessible to those millions and millions of lives, they have to play the cash-back game, otherwise known as the rebate game. They have to agree to give back to the PBM a certain amount of cash on the back end. So, PBM pays Pharma's list price up front—that's the gross amount paid, based on the list price of the drug—and then after all the cash back gets toted up at the end of the year, there'll be a net price. List price or gross price minus the cash back equals net price. It's this net price that's the true kind of final price which the pharma company gets paid per script by said PBM at the end of the day. These days, most everybody pretty much knows that PBMs are getting these so-called rebates—this cash back from pharma companies that I just explained. And it's pretty common knowledge the so-called gross-to-net bubble (the gross-to-net dollar amount) is pretty huge, meaning the rebate or cash-back amount is pretty huge. And many have also noticed that the gross-to-net dollar amounts seem to be growing bigger and bigger every year. I mean, for one insulin manufacturer, consider this: Their list price, their gross price, is $350 per script. And their net price after cash back/rebates was $52 this past year. Wait ... what? After all the cash back to the PBM, the insulin manufacturer got paid 86% less than their list price—$350 went down to $52 per prescription. The PBM vacuumed up 86% of the dough for every script written for this particular brand of insulin. Okay … so, say Pharma gives $100 back to the PBM based on the terms of their deal. Call that part one of this example transaction. Here's part two: the deal between PBMs and health plans or self-insured employers. Health plans and self-insured employers are customers of the PBM. They hire PBMs to manage the pharmacy benefits for their members or employees. So, because everybody knows this whole rebate thing is going on, as part of the contracts that the PBMs put in place with their customers (meaning the health plans or employers), the PBMs tell their customers that they're going to give 100% of the rebates back to the plan/employer. So, you'd think that if the pharma manufacturer paid $100 to the PBM, that the customers of the PBM (the plan sponsors) would get the $100 back then, right? The PBM would pass on 100% of the savings, as it were, if they're saying that they're gonna give 100% of the rebates. I mean, if this is actually true, that $100 in and $100 out, then the PBM is potentially performing a useful service, right? They're lowering drug costs for their customer, the plan sponsors for their members and employees. Except … turns out, not so much. Because what is a rebate, really? A rebate can be anything the PBM defines as a rebate. And it turns out that, on average, as I said before, according to those in the know, something like $60 of that $100 is not a rebate. It's an administration fee. Or a data fee. Or an education fee. A clinical program fee. Some other name that is not rebate. As my guest Scott Haas says, the term rebate is meaningless because it can mean whatever the PBM wants it to mean. It's like inconceivable from The Princess Bride. I do not think that word rebate means what you think it means. Now it is a tangled web we weave here, and for more on why I say that, listen to the episode with Chris Sloan (Encore! EP216) entitled “How Medicare Part D Plans Became Addicted to Drug Rebates.” There's also a show with Pramod John, PhD (EP353) where we dig into, specifically, specialty drugs and rebating and so-called rebate walls. But net net, all of this probably myopic focus on rebates means that you have to keep an eagle eye out for so-called exclusions in contracts if you are a plan sponsor. So, what are exclusions? This is that whole thing where some cheap generic is excluded from a PBM formulary while some expensive brand for the same condition is on formulary. Why would a cheap generic be excluded from a PBM formulary? Simple. Cheap generics don't have rebates. PBMs lose a lot of money when some high-priced specialty drug, for example, goes generic. They might have made thousands of dollars per script on that high-priced brand by collecting its rebate. Think about that insulin example. The rebate is 86% of the cost of the drug. And everybody wonders why some cheap generic insulin or biosimilar or whatever isn't on formulary. It is not a mystery when you're dealing with for-profit enterprises built around a model of revenue maximization. So, given all this, what's my guest Scott Haas's bottom-line advice in this whole thing? If you're a health plan or employer and you're trying to negotiate a PBM contract where your spend is predictable and your contracted price promises have any meaning whatsoever, Scott Haas's advice is, you have to ensure that the contract defines the actual prices for the drugs in the contract. With absolute numbers. Not percentages off or weird formulas or the empty promise of getting an AWP or a WAC (which means average wholesale price or wholesale acquisition cost) or any of the other various acronyms for some drug pricing schema. All of these are basically shorthand for “this price could change at any moment.” There's a reason in-the-know people say AWP stands for “Ain't what's paid,” meaning ain't what's ultimately going to be paid by plan sponsors. What is necessary in PBM contracts is the final price—that number. Some digits with a dollar sign in front of them and a “per unit” after them. No acronyms and no percentage signs. Whoever gets to define the terms ultimately controls the price. So, get the price up front. As mentioned several times already, I am talking to Scott Haas, who is a senior VP over at USI Insurance Services. He's speaking today from the perspective of a plan sponsor, meaning from the point of view of a health plan, including those health plans managed by and paid for by a self-insured employer and their employees. For more information on PBMs and how drugs get adjudicated, listen to the show with AJ Loiacono (Encore! EP231), which was one of the most popular episodes over here at Relentless Health Value. Somebody on a LinkedIn post the other day commented on how much she appreciated AJ Loiacono's frank assessment of things and how she would love to go to a meeting with more people similarly telling it like it is. That's pretty much what we aim to do at every episode over here at Relentless Health Value, and AJ nails it on that objective for sure in this episode. One last thing, also on the show: Scott Haas brings up GPOs that the Big Three PBMs have been spinning up to aggregate and maximize all of those rebates that we just talked about. I discuss this exact topic at some length in another incredibly popular episode with Mike Schneider (Encore! EP288).   You can learn more at usi.com or by emailing Scott at scott.haas@usi.com.   Scott Haas has over 38 years of employee benefits experience. His background includes the development and validation of care management programs; prescription benefit management solutions; provider network evaluation, valuation, and negotiation; and underwriting. Scott started and operationalized a third-party administrator (TPA) and a pharmacy benefit manager platform from scratch. He has worked in the arena of alternative funding for most of his career. Scott's primary focus is in the area of alternative delivery and financing of healthcare other than fee for service, along with prescription benefit and healthcare risk management consulting. Scott has held officer-level positions within Blues plans and TPAs as vice president of sales and marketing, vice president of underwriting, and president. Scott has also served as a trustee for both union and non-union health and welfare and pension plans. Scott frequently shares his consulting expertise speaking at national events hosted by organizations such as Health Rosetta, the International Foundation of Employee Benefits, the Health and Welfare Plan Management Conference, the Western Pension and Benefits Conference, and the Self-Insurance Institute of America (SIIA). Scott has authored and coauthored articles on various topics over his career. Scott earned his bachelor's degree in business administration and economics from the University of Nebraska at Kearney. Scott also holds Chartered Life Underwriter (CLU) and Registered Health Underwriter (RHU) designations.   10:34 What's the major flaw with the buyer-seller relationship between plan sponsors and PBMs? 12:08 What are the five things that need to be considered in order to get a fair price from a PBM? 13:21 Why does using average wholesale price cause problems for plan sponsors? 15:10 What does it mean to put the network risk on the PBM? 17:15 What's happening with drugs moving from specialty brand to specialty generic? 19:19 “A generic is a generic; in our world, it's binary.” 23:36 “The term 100% of rebates is really irrelevant.” 23:59 What does it mean to have a minimum guarantee in drug rebates? 26:43 “When you do a line-item assessment … is it producing an optimal result in comparison to competitively achieved … pricing for generics … and for specialty?” 27:57 “Plan sponsors need to grow a backbone.” 28:40 EP342 with Christin Deacon. 29:10 Why do you need to understand your consultant's process as a plan sponsor? 29:36 Why do you need to understand formulary exclusions as a plan sponsor? 29:46 Why is it important to create a more equal PBM contract? 30:57 “Rebates inure to the benefit of the plan sponsor; they don't necessarily benefit the consumer.” 31:50 What does Scott do at USI?   You can learn more at usi.com or by emailing Scott at scott.haas@usi.com.   Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400)  

I couldn't resist the “who's suing who” because, yeah, you can't go wrong with Aretha Franklin references. Back on the pod we have Chris Deacon, who is going to give us a rundown of the legal goings-on going on right now that impact self-insured employers, carriers, hospitals, and taxing authorities like cities. Chris breaks down the legal activity into three main categories, and then we discuss some examples of lawsuits in each category. So, here's the outline of our upcoming conversation: 1. Breach of Fiduciary Line of Cases Against Carriers a.    Bricklayers vs Anthem Class Action b.    Mass Laborers vs Blue Cross Blue Shield c.     Member vs Cigna 2. Carrier vs Hospital (upcoding) and Hospital vs Carrier (underpayment) a.    United vs TeamHealth b.    TeamHealth vs United 3. Taxing Authority vs Nonprofit Hospitals a.    Tower Health line of cases in Pennsylvania b.    Pittsburgh vs UPMC This episode itself is a little on the longer side—and I didn't want to edit too many of Chris's words of wisdom—so I'm gonna make this a little bit shorter, this intro. But just one point that I'll make, and this is about the first category of legal activity wherein self-insured employers mostly try to pass the “who is actually the fiduciary” hot potato to carriers, ASOs (administrative services only), and TPAs (third-party administrators). And the carriers, ASOs, and TPAs are like, “It ain't us.” Moving forward here, I'm just gonna say carriers as a catchall for carriers, ASOs, and TPAs to save myself a mouthful. But bottom line on this topic, I just want to underscore something that Chris makes clear later on in the show: Plan sponsors (ie, self-insured employers) are the fiduciary, the sole fiduciary, at least according to the carriers who are getting sued right now. This is the position that you can see them taking in every lawsuit that I have seen. What the carriers say also, as a follow-on, is that if there is any contractual language between the carrier and the employer that violates the CAA (Consolidated Appropriations Act) or any other regulations, it is or was the employer's responsibility to not sign the contract. It's not the carrier's responsibility to point out that there's stuff in their own contract that's in violation for the employer to sign. And this includes contracts that don't give self-insured employers the right to their own data, which is pretty much a rate critical for any and all CAA compliance. As Justin Leader wrote the other day in reference to the bricklayer case, “To get to the point of filing the suit, there was a solid 2 years of failed negotiations [for the bricklayers to get their own claims] data.” Two years trying to get claims data that is necessary for a fiduciary to have from a carrier who is saying essentially, “Good luck with that. You're the ones that signed our contract.” Here's one of Chris Deacon's latest LinkedIn posts about this topic. And here's another one from Jeff Hogan that was interesting. Also, here's the link to the earlier episode with Chris (EP342), where we dive into the deep end on the topic of the CAA, which was signed into law at the beginning of 2022 and states that self-insured employers have certain rights and responsibilities based on their role as the fiduciary of their health plan. For more on the Member vs Cigna case, check out the encore episode with Dawn Cornelis (Encore! EP285). The show with Vikas Saini, MD, and Judith Garber, MPP (EP394) comes up where we talked about hospitals and their charitable giving. And lastly, I mention the show with Suhas Gondi, MD, MBA (EP404) about who is on the board of directors of hospitals, big nonprofit hospitals in particular. My guest in this healthcare podcast, Chris Deacon, is a lawyer by training. She ran the state health plan for the state of New Jersey, which covered about 820,000 public-sector lives. She now has an independent consulting firm, VerSan Consulting.   You can learn more at versanconsulting.com and connect with Chris on LinkedIn. You can also email her at cdeacon@versanconsulting.com.   Chris Deacon has a deep understanding of the fiduciary role health plan administrators hold and should be leveraging in order to drive value for their plan sponsors and members. An attorney by training, Deacon formed VerSan Consulting, LLC, in order to educate and engage employers to be more prudent purchasers of healthcare. From creative procurement methodologies and demanding contracts to population health initiatives and primary care investment, Deacon believes that large employer-sponsored health plans have not only an opportunity but an obligation to drive healthcare transformation that delivers value for the market. Prior to founding VerSan Consulting, Deacon ran one of the largest health plans in the country for the New Jersey Department of Treasury, which covered over 820,000 public-sector lives, including state employees, teachers, and uniformed professionals. During her tenure, Deacon was credited with helping the state save over $3 billion through a number of initiatives, including enhanced oversight, payment integrity programs, procurement strategy, and strict accountability for the vendors with which the state engaged. Deacon has also served as a deputy attorney general and then special counsel to Governor Christie where she oversaw the Department of Banking and Insurance, Economic Development Authority, and Treasury. She holds a JD from Rutgers Law School and bachelor's degree in international affairs from The George Washington University.   04:47 What does the current legal landscape look like, and how does it bode for the future? 07:24 “We need to catch the legal framework up with the current reality.” 19:53 How is this first circuit decision affecting who might be found liable in future cases? 21:38 What happened in the Member vs Cigna case? 24:49 Are we heading in the direction of the employer having fiduciary responsibility? 25:47 What's happening in the Carrier vs Hospital cases? 28:49 Who's really paying the price for the current business practices being examined in court? 30:00 What's happened in the Tower cases?   You can learn more at versanconsulting.com and connect with Chris on LinkedIn. You can also email her at cdeacon@versanconsulting.com.   @VerSan_cdeacon discusses current legal affairs in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285)  

So, let's talk about North Carolina. What a weird outlier of the direction of other states getting active on their healthcare spend. I'm talking about Texas, Indiana, Wisconsin ... I'm naming so-called red states because the legislature in North Carolina is a Republican majority. Gotta say, normally I'm down for a little weird. I find it mostly charming. But with the information I have at present about what's going on in North Carolina, I don't love this for you. And when I say “you,” I pretty much mean any family who happens to live in North Carolina or any businesses in North Carolina trying to afford their employee health benefits right now. This whole shebang and the reason I'm covering this on Relentless Health Value is that it is also extremely relevant to anybody else in this country as a case study or a cautionary tale, depending on your point of view. So look, there's two pieces of legislation running through North Carolina's Senate and House right now, but both of these pieces of legislation—one that Blue Cross Blue Shield (BCBS) is angling for and the other one that UNC, a big hospital chain in North Carolina is all hachi machi to get passed—both of these have precedents. Both of these things were done elsewhere, and the results were not great, to put it mildly. BCBS wants to be able to open up a holding company that is able to take BCBS policyholder payments and invest them in for-profit ventures—BCBS being a nonprofit and all. Here's a quote Chris Deacon mentioned on LinkedIn from an article on this topic: “A 2019 examination of the aftermath of 11 conversions of BCBS affiliates showed that fully insured premiums increased roughly 13 percent … suggesting a post-conversion exercise of market power. Significantly, rivals of these large converting insurers also raised their prices following the conversions.” And here's a link to a Health Solutions podcast with Cristy Gupton, Chris Deacon, and North Carolina Commissioner Mike Causey. So, that's one of the pieces of legislation on the docket. Then, on the hospital side of the equation, we also have a proposed bill that could give UNC Health Care a green light to expand and buy more physician practices and hospitals without as much oversight. Proponents of the bill say that this will better enable UNC to take over struggling rural hospitals in danger of closing. Considering that UNC has already taken over rural hospitals in danger of closing, not exactly sure how or why basically removing federal and state antitrust scrutiny is helpful here. I went around looking for evidence that if you reduce antitrust scrutiny and enable more unfettered consolidation and expansion that population health outcomes improve. I could not find any. I did find lots of great talking points, but all of them seemed a little light on the evidence. There is, however, an insane amount of evidence at this point that shows unfettered hospital chain consolidation harms local communities from a financial standpoint without improving the quality or outcomes of patient populations, especially when hospital chains, in conjunction with third-party payers, are not willing to share their pricing, even with their largest customer. But I'm getting ahead of myself, because this is exactly what I'm talking about in this 2019 interview with Dale Folwell, the state treasurer of North Carolina. And it is a doozie of a frustrating story, just to cut to the chase. Look, you might be able to hear I definitely have an opinion formed on this topic, and I don't want to sway yours until you look into all of this yourself. But I loved what Jeff Leston wrote the other day. He wrote, “The North Carolina Legislature proves that they report to the healthcare industry in the State, not the people who actually elected them.” Okay … teeing up the interview today, this whole thing started when the North Carolina State Employees Health Plan (SEHP) crafted a proposal to pay network hospitals based on a transparent pricing schedule. Considering that SEHP purchases benefits for 720,000 people in North Carolina at a cost to taxpayers of billions of dollars, this seems reasonable. When you're the fiduciary of thousands of dollars, let alone add six more zeros, it would seem to be nonnegotiable to actually see the numbers and not write a check to a black box. Nonetheless, a few of North Carolina's largest hospital chains disagreed. They wanted to bill whatever they wanted to bill shrouded in a cloak of secrecy. In this healthcare podcast, as I mentioned earlier, I am speaking with North Carolina State Treasurer Dale Folwell. This is a rebroadcast from an interview in 2019 but still, somewhat sadly, completely relevant.   You can learn more at nctreasurer.com. You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell.     Dale R. Folwell, CPA, was sworn in as State Treasurer of North Carolina in January 2017. As the keeper of the public purse, Treasurer Folwell is responsible for a $100 billion state pension fund that provides retirement benefits for more than 900,000 teachers, law enforcement officers, and other public workers. Under Treasurer Folwell's leadership, the pension plan was rated among the top five highest funded in the country and won accolades for proactive management and funding discipline. In 2018, the state's coveted AAA bond rating was reaffirmed by every major rating agency, making North Carolina one of only 13 states in the country to hold that distinction. Treasurer Folwell also oversees the State Health Plan, which provides medical and pharmaceutical benefits to more than 720,000 current and retired public employees and is the largest purchaser of healthcare in North Carolina. Folwell was first elected to public office as a member of the Winston-Salem/Forsyth County Board of Education. He brought his problem-solving skills to the North Carolina General Assembly in 2004, where he served four terms in the House of Representatives, including one term as Speaker Pro Tempore. Treasurer Folwell began his career as a blue-collar worker and became a Certified Public Accountant and investment advisor after earning bachelor's and master's degrees in accounting from UNC-Greensboro.   05:59 The North Carolina state spend on healthcare. 07:21 “In medical terms, why has this become acute?” 08:00 One week of work for starting North Carolina troopers and teachers out of every four is going to family healthcare costs. 09:14 The problem of health insurance vs healthcare. 09:59 “If they can do this to the largest customers in this state … imagine what they can do to them.” 10:20 “This is about the industry whose whole business model is based on secrecy.” 11:47 “We've already focused on the why, and now we're [focusing] on the how.” 12:46 “We're trying to attack a problem.” 15:46 What the Clear Pricing Project aims to do. 18:08 “We're not trying to be disruptive; we're trying to fix a problem.” 19:55 Why the Clear Pricing Project went the self-insured route and how that's worked for them. 24:14 Who's behind the institutions fighting transparent pricing in North Carolina. 25:15 Instances where the Clear Pricing Project could actually stand to help rural hospitals make more money. 27:29 Dale's advice for other states trying to do this. 28:49 Dale's message to healthcare providers out there who want to see this change to price transparency.   You can learn more at nctreasurer.com. You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell.   @DaleFolwell discusses #financialtoxicity in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance   Recent past interviews: Click a guest's name for their latest RHV episode! Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes  

Should the law impact healthcare?Healthcare professional and lawyer, Chris Deacon, is known for her work as a public sector leader who oversaw the New Jersey State Health Plan. In this position, Deacon created positive change for the state of New Jersey and saved 2 billion dollars for the plan's members. North Carolina Commissioner of Insurance Mike Causey a politician that has served in his position since 2017. His goal is to fight for more competition in the healthcare industry and combat insurance fraud. He proudly serves the people of North Carolina.Healthcare professional and host, Cristy Gupton, interviews Chris Deacon and Mike Causey on the upcoming North Carolina bill, H346. They discuss the shady happenings behind the bill and their fears of how the bill will harm the people of North Carolina should it be passed.Learn more about the healthcare industry by following the Healthcare Solutions Podcast. Need healthcare consultation, retirement strategizing, wellness consultation, or benefits enrollment? Custom Benefits Solutions has your back.

Somebody wrote on Twitter the other day that he was gonna give a talk on the use of evidence in drug policy, and Barrett Montgomery replied, “That'll be a short talk then!” So, let's talk about the IRA (Inflation Reduction Act) for a moment, specifically the “CMS can negotiate for drugs for Medicare patients” part of the IRA. There's one topic I don't hear discussed what I would consider maybe often enough. Will these negotiations result in pricing that is evidence based? Will good drugs that companies developed using less taxpayer money for R&D, drugs that positively impact the patient lives or have spillover benefits for society or save downstream medical costs, drugs that have solid comparative evidence data, drugs that are a meaningful therapeutic advancement over competitors ... will these drugs be priced in line with that value? Everything I just mentioned, by the way, are things that CMS is supposed to take into account during its negotiations. So, that's what this show is all about. To have this conversation, I invited Dr. Peter Neumann on the podcast because Dr. Neumann (along with his two coauthors, Joshua Cohen and Daniel Ollendorf) just wrote a book about pharmaceutical pricing entitled The Right Price. I convinced Dr. Neumann to come on the show and talk about what the likely impact the IRA will have on these right drug prices. And short version, Dr. Neumann told me that “presumably drugs that offer more therapeutic advances will do better under these negotiations.” Here's a really, really top-line summary of the negotiation provisions that are in the IRA: CMS will negotiate prices on the highest gross spend top 10 Part D drugs in 2026, 15 Part D drugs in 2027, and 15 drugs from Medicare Part B and D for 2028. Small molecule drugs become negotiation contenders after 9 years, and biologics after 13 years. Once a generic or biosimilar comes out (ie, the patent is well and truly expired), then this negotiation provision is no longer in play. Now, CMS is given some discretion over how it's going to do things, and they will issue guidance and figure out how to implement the law over the next couple of years. As with so many things (and Chris Deacon talked about this recently on LinkedIn), it's how that law is operationalized that actually determines if it achieves this “right price” goal and/or—and Dr. Neumann, my guest in this healthcare podcast, makes this point really clearly, too—maybe the point of the law is as much about cost containment, frankly, as it is about achieving value-based “right” prices. And cost containment and value-based pricing are not the same thing. I'm gonna do a show on this coming up. So, what are the likely effects of the IRA pharma price negotiation provisions? And not talking about the whole IRA here and the cadre of other stuff like patient out-of-pocket caps and inflation caps. This show is complicated enough just talking about the negotiation portion and just talking about its potential to achieve pricing based on “value.” Here's a summary of likely impact of Medicare drugs being negotiated, some of which we talk about in this episode. There's “seven-ish” main implications: 1. “Some Medicare patients will benefit substantially from negotiations …, as a reduction in the drug's price will result in lower coinsurance and liability during the deductible phase.” Okay … this makes sense. 2. “Overall, negotiations are projected by the CBO [Congressional Budget Office] to reduce premiums, resulting in lower costs for all Medicare beneficiaries.” References: CBO estimates drug savings for reconciliation. Committee for a responsible federal budget. Accessed April 11, 2023. https://www.crfb.org/blogs/cbo-estimates-drug-savings-reconciliation  Congressional Budget Office. Estimated budgetary effects of Public Law 117-169, to provide for reconciliation pursuant to Title II of S. Con. Res. 14. Published 2022. Accessed April 11, 2023. https://www.cbo.gov/system/files/2022-09/PL117-169_9-7-22.pdf Okay … so, this #2 here is kind of thought provoking, especially when it's unclear at this time whether the negotiated price will refer to the list price, the AWP (average wholesale price), or the rebated price (ie, the price after rebates are applied). There are many, many implications if the negotiated price is before or after rebates, just given how “addicted” plans are to rebates and use the rebates, and cost shifting to patients, in a convoluted and super-inefficient way to try to keep premiums down. Listen to the show with Chris Sloan (EP216) for more on this. 3. There's more incentive to go after biologics than small molecule drugs—obvious, due to the 9-year versus 13-year thing. There's additionally some incentive for rare-disease and orphan drugs, most of which are biologics, in other parts of the IRA. 4. More interest in drugs for non-Medicare markets (ie, drugs for diseases of younger populations, perhaps) 5. Possibly less pharma innovation, fewer drug launches Oh, boy, with this one. Listen to the show with Mark Miller, PhD (EP380), for many, many nuances here. But let me give you a few things to think through, and I'd start with four words: We are chasing Goldilocks. There are two ends of the spectrum, and neither are good. On one end, Pharma charges way too much and the system gets bankrupted while pharma shareholders get rich. On the other side of the spectrum, there's not enough returns for any investors to invest in new drug development. It's all about moderation—finding the sweet spot in the middle—something the healthcare industry has a super hard time with. Bottom line, we want to incent meaningful innovation, drugs that actually work. If we pay a ton of money for drugs that don't work particularly well, then what's the incentive to find good drugs? As per my earlier point, if this legislation does as was intended, then good drugs should get rewarded and less comparatively effective drugs should be less rewarded. Let's cross our fingers, shall we? 6. Will Pharma raise its launch prices because the negotiations center on discounts? A higher price times the discount means a higher discounted price, after all. This one could be exacerbated by the part of the IRA that mandates inflation caps. There is some evidence that higher launch prices are already happening. 7. Manufacturers wait to launch until they have all their indications ready to go. If you didn't understand this, we explain in more detail during the interview. 8. There are incentives for Pharma to jack up commercial prices. Because they're making less money in Medicare, they try to make more money in the commercial market. But as Dr. Neumann says, you'd think that if Pharma could do that, they already would have done it. Or let me say that a different way: You'd think that if Pharma could have raised their commercial prices more than they already have been raising their commercial prices, they would have already done it. So, I think whether cost shifting actually increases here is a sizable question mark. 9. There's also less incentive for Pharma to innovate me-too kinds of drugs. If a drug in the same class for the same disease is being negotiated, then a new drug coming out in that same category might sort of have to charge a price similar to the negotiated price of the other drug. Dr. Peter Neumann, my guest in this episode, has a background in health economics and currently directs a research center that's focused on health economic issues. His group does a lot of work trying to understand the cost effectiveness of drugs and other health interventions. Other shows you should, for sure, listen to here are the ones with Mark Miller, PhD (EP380); Anna Kaltenboeck (EP303); Bruce Rector, MD (EP300); Scott Haas (EP365); and Chris Sloan (EP216). These shows offer context and adjacencies that are extremely relevant right now if you're gonna understand the potential impact of the IRA. Here's a quote from the book The Right Price (written by Dr. Peter Neumann and his coauthors, Joshua Cohen and Daniel Ollendorf) that I thought summed up some of the issues here very nicely: If there existed a Rorschach test for drug prices, it might conjure one of two images. Some people might perceive prices as a compass directing companies to invest in products that people value most. Aligning prices with value is akin to a “true north” orientation of the compass's arrow. Failure to link prices with value sends misleading signals to drug producers. Others might regard drug prices as a wall preventing patients from accessing the drugs they need. For them, the barrier should be as low as possible. But aligning prices with value might have little effect in lowering the wall. How then to accomplish that goal?   You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.   Peter J. Neumann, ScD, is director of the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center and professor of medicine at Tufts University School of Medicine. He is the founder and director of the Cost-Effectiveness Analysis Registry, a comprehensive database of cost-effectiveness analyses in healthcare. Dr. Neumann has written widely on the role of clinical and economic evidence in pharmaceutical decision-making and on regulatory and reimbursement issues in healthcare. He served as co-chair of the 2nd Panel on Cost-Effectiveness in Health and Medicine. He is the author or coauthor of over 300 papers in the medical literature and the author or coauthor of three books: Using Cost-Effectiveness Analysis to Improve Health Care (Oxford University Press, 2005); Cost-Effectiveness in Health and Medicine, 2nd edition (Oxford University Press, 2017); and The Right Price: A Value-Based Prescription for Drug Costs (Oxford University Press, 2021). Dr. Neumann has served as president of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). He is a member of the editorial advisory board of Health Affairs and the panel of health advisors at the Congressional Budget Office. He has also held several policy positions in Washington, DC, including special assistant to the administrator at the Health Care Financing Administration. He received his doctorate in health policy and management from Harvard University.   09:33 Is it imperative that drugs whose patents are expiring have their prices negotiated? 10:50 “We need innovation; we want to encourage innovation.” 11:01 Does this new law strike a balance between innovation and price regulation? 11:21 How are we assessing cost effectiveness and innovation in the drug space? 12:29 What's the problem with the current drug markets? 13:14 Why can't you rely on the drug market for the cost effectiveness of a drug? 14:13 Why very expensive drugs do not equate to poor value. 15:06 What are the likely outcomes of the IRA? 18:33 How does pharmacy budget factor into high-value drugs? 19:26 “Value-based pricing doesn't mean necessarily lower spending overall.” 22:59 What are the types of drugs that will be excluded from the IRA? 23:22 Who will the law create problems for? 24:44 What have pharmacy benefit managers (PBMs) been doing to move forward with the new law? 26:04 What are plan sponsors doing right now? 28:32 What are the most important value metrics according to Dr. Neumann?   You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.   @PeterNeumann11 discusses #drugprice #negotiations on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein  

If you go to the Sage Transparency dashboard Web site, you get a really graphical representation of the prices that any given hospital actually needs to charge so that they break even. You can see precisely which hospitals are operating on thin margins and which ones are not. You might be thinking, “Okay, so ... what's the big deal about this? Why is the Sage Transparency information so meaningful? Aren't hospitals (most of them) providing their financial statements already?” Well, let's discuss. First of all, we have the main hospital lobbying organization coming out with press releases such as this one saying (here's some quotes): “Hospitals have incurred serious losses …” “The vast majority of America's hospitals [are] in serious financial jeopardy …” Combine quotes like these (and there are many) with some of the funny stuff going on in some (not all) hospital financial reporting—like counting investment losses from their venture funds, not counting endowments or their big trusts in the math, paying C-suites way more than the average doctor or worker, or all of the varied things that get counted or overcounted as charity care or community benefit—yeah, these hospital balance sheets are too often as much of a PR campaign as the PR campaigns. When you dig into them, you find some very wealthy organizations dressing up in Tiny Tim Cratchit pants and leaning on a crutch … at least whenever the cameras are rolling. So, where are patients in all of this? Chris Deacon linked to a Qualtrics study recently. It seems that in 2020, 48% of people deferred care as a result of the pandemic. In 2022, 43% deferred care because of cost—48% from the pandemic, 43% deferred due to cost this past year … wow! There are patients saying, “Hey, I have this giant thing growing on my arm. Is it melanoma? I don't know, but I do know if I go to the doctor, I'll be $600 in the hole … so I'll wait.” It doesn't matter how many medical advancements are made when almost half of the patients are making decisions like this, including patients with so-called “good” insurance. Look, no one would or is arguing that hospitals aren't vital. They are essential. Hospitals can be amazing places where lives get saved. Amazing doctors and clinicians work in hospitals. But putting everything I just said together, let me summarize a textbook hospital chain one-two punch. The halo effect many hospitals enjoy is massive, and those administrators who choose to can take advantage of that halo for financial gain. When hospitals' administrators cannot manage to curtail their own spending and then demand that their communities foot the bills, then the good that a hospital can do starts to go bad. If you are a legislator, you might want to be paying attention to all of this. And when I say might be wanting to pay attention, I mean pretty much you want to be paying attention to all of this. With all of the data that is now available to especially more sophisticated employers, some companies are not building offices or plants in areas which are known to have healthcare prices that are multiples over what they should be. That might be in your legislative district or state. Healthcare prices can be the largest cost for employers after payroll. Starbucks famously spends more on healthcare than they do on coffee beans. Nearly 8 of 10 employers considered healthcare costs a significant threat to affordability. So, too high hospital prices are a community problem at the chamber of commerce as well as at the family and the patient level. After you listen to this show, go back and listen to the one last week with Mike Thompson (EP389) if you haven't already. It adds some context that you might want to have. Also stay tuned for a show coming up where we talk about just all of the anticompetitive stuff that some of these hospital system administrators have decided to subject their communities to. In this healthcare podcast, I have two titans of employer coalition building on the episode. Gloria Sachdev from the Employers' Forum of Indiana, who was instrumental in standing up the Sage Transparency dashboard that we talked about last week and we'll discuss a little bit more this week. Gloria is a pharmacist, which I did not know. She also sits on the board for the National Alliance of Healthcare Purchasers Coalition and Hoosiers for Affordable Healthcare. Also on the show is the one and only Chris Skisak, who leads the Houston Business Coalition on Health. He also speaks for the state of Texas through his role with Texas Employers for Affordable Healthcare. You can learn more at txeahc.org and houstonbch.org. You can also check out the Employers' Forum of Indiana Web site as well as sagetransparency.com. Gloria Sachdev, PharmD, serves as president, CEO, and board chair of the Employers' Forum of Indiana. She also serves as adjunct associate professor at Purdue College of Pharmacy. Forum initiatives focus on hospital price and quality transparency, value-based health benefit and payment strategies, and health policy. She serves as a member of the Board of Governors for the National Alliance of Healthcare Purchaser Coalitions and as board vice chair for Hoosiers for Affordable Healthcare. Dr. Sachdev received her bachelor of science and doctor of pharmacy degrees from the University of Oklahoma and completed a primary residency at the VA in Madison, Wisconsin. Thereafter, she practiced in primary care physician offices managing patients with chronic diseases for 12 years, followed by consulting in the space of incorporating clinical pharmacists into team-based care for 6 years. She retired from Purdue College of Pharmacy after 15 years but still teaches a few classes for fun. Chris Skisak, PhD, is the executive director of the Houston Business Coalition on Health, a multi-stakeholder but employer-centric 501(c)(3) focused on improving the cost, quality, and consumer experience in healthcare delivery. He is also the executive director of Texas Employers for Affordable Healthcare, a legislative advocacy organization focused on creating a competitive healthcare delivery ecosystem. Dr. Skisak also serves on the boards of directors of the National Alliance of Healthcare Purchasing Coalitions and Texas Business Group on Health. He serves on the leadership councils for Houston Cities Changing Diabetes, Houston Health Equity Collaborative, and Center for Houston's Future. He had previously worked 25 years with Houston Fortune 50 energy companies in a variety of population health management positions. He is originally from Chicago and attended the University of Illinois. He received his master of science degree and PhD from the University of Texas School of Public Health. 06:04 How could the healthcare market correct itself? 08:27 EP334 with Sunita Desai, PhD. 09:38 What strategies are needed to make changes in the healthcare market? 10:13 What can be done with respect to market forces? 12:33 What needs to happen in regard to healthcare legislation? 13:03 Gloria's ideas for legislation. 15:44 Why is it important to allow physicians to be independent again? 17:41 EP373 with Cora Opsahl. 18:21 Chris's thoughts on legislation. 22:51 Why is it important that employers become present in the legislative process? 26:48 What has been immensely helpful to better understand hospital financials? 31:08 EP385 with Dan Mendelson. 31:16 EP379 with AJ Loiacono. 32:11 Why is transparency foundational for healthcare market change? You can learn more at txeahc.org and houstonbch.org. You can also check out the Employers' Forum of Indiana Web site as well as sagetransparency.com.   @GloriaSachdev and @ChrisSkisak discuss #hospitalpricing and #legislation on our #healthcarepodcast. #healthcare #podcast #healthcarelegislation   Recent past interviews: Click a guest's name for their latest RHV episode! Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308)    

Healthcare prices continue to skyrocket, and payers from small employers to large public sector entities are struggling to keep up. In the midst of today's labor crisis, how do plan purchasers and fiduciaries keep costs in check while keeping both employees and the DOL happy? In this episode, we speak with Chris Deacon, Former Director of Health Benefit Operations for the State of New Jersey, about her success with the state's plan and what she learned along the way, why fiduciaries are in the hot seat, and what they can do to prepare themselves. Join us as we discuss: Best practices in healthcare procurement  The challenges public sectors are facing Why fiduciaries are in the hot seat (and what to do to mitigate risk) Improving the healthcare experience Best practices in the pharmacy space  Chris's research recommendations:  The Relentless Health Value Podcast  Revenue Cycle Management Blogs Amicus Briefs To hear more episodes like this one, subscribe to CHRO Champions on Apple Podcasts , Spotify , Google Podcast, or wherever you listen to podcasts

Post By: Adam Turteltaub Self-funded health plans are very common these days among larger employers and governmental entities. Private sector plans are typically subject to ERISA, which imposes a fiduciary duty, and even plans covering government employees have fiduciary obligations. What does that mean in practice? Chris Deacon, Senior Vice President of 4C Health Solutions and former director of the State of New Jersey Health Plan, explains in this podcast that the plan administrator, vendors and the plan, itself, have a fiduciary duty. That means all actions have to be performed for the best and sole interest of the beneficiaries and the plan. Vendors have to be selected and evaluated accordingly. Duties have to be carried out prudently. The plan's documents must be followed consistently. So, for example, the plan can't pay some out-of-plan claims and not others. It sounds fairly clear, but, she explains it isn't because of the opacity in health care pricing. It's difficult to know if the charges are reasonable or not. One step she strongly recommends is to demand ownership of the claims data and insist it be provided in a way that is usable. That will help ensure that the money is being spent properly, and the plan administrators are living up to their fiduciary obligations. Listen in to learn more about how to live up to the fiduciary duties of your self-funded plan.

Post By: Adam Turteltaub Self-funded health plans are very common these days among larger employers and governmental entities. Private sector plans are typically subject to ERISA, which imposes a fiduciary duty, and even plans covering government employees have fiduciary obligations. What does that mean in practice? Chris Deacon, Senior Vice President of 4C Health Solutions and former director of the State of New Jersey Health Plan, explains in this podcast that the plan administrator, vendors and the plan, itself, have a fiduciary duty. That means all actions have to be performed for the best and sole interest of the beneficiaries and the plan. Vendors have to be selected and evaluated accordingly. Duties have to be carried out prudently. The plan's documents must be followed consistently. So, for example, the plan can't pay some out-of-plan claims and not others. It sounds fairly clear, but, she explains it isn't because of the opacity in health care pricing. It's difficult to know if the charges are reasonable or not. One step she strongly recommends is to demand ownership of the claims data and insist it be provided in a way that is usable. That will help ensure that the money is being spent properly, and the plan administrators are living up to their fiduciary obligations. Listen in to learn more about how to live up to the fiduciary duties of your self-funded plan.

In this episode of The Real ResQ, we are joined by Chris Deacon, a highly experienced and personable paramedic from Auckland, New Zealand.  Throughout this fascinating conversation, Chris shares stories from his 29-year career working as an intensive care medic.  Chris has seen just about everything that a medic, on the ground and in the air, can see with his time on the job.  We discuss car accidents, boating accidents, exceptionally rare accidents, and even unparalleled accidents that include girl versus dolphin.  We hope that you like this conversation as much as we did! Enjoy! Thank you for sponsoring us, SR3 Rescue Concepts, https://sr3rescueconcepts.com/ Life Saving Systems Corp., https://lifesavingsystems.com/ Breeze-Eastern, https://www.breeze-eastern.com/ Flippin Coffee, https://www.flippincoffee.com/

GB2RS NEWS Sunday the 27th of September 2020 The news headlines: RSGB introducing Full exam remote invigilation Solar Cycle 25 is officially here Latest Online Convention news   Following on from the success of the remote invigilation exams for the Foundation and Intermediate licence, the RSGB is now expanding that to include Full licence exams. The automated booking system is now accepting exam bookings for all three licence levels. Please note that the earliest date available for exam bookings at any level is Wednesday the 21st of October. It is important to read the Candidate Instructions before booking an exam. You can find a link to these and the calendar to book your exam on the Society’s website at www.rsgb.org/exampay. The Solar Cycle 25 Prediction Panel, an international group of experts co-sponsored by NASA and NOAA, announced that the solar minimum occurred in December 2019, marking the start of a new solar cycle. Because our Sun is so variable, it can take months after the fact to declare this event. Scientists use sunspots to track solar cycle progress; the dark blotches on the Sun are associated with solar activity, often as the origins for giant explosions, such as solar flares or coronal mass ejections, which can spew light, energy, and solar material into space. This and more has been explained in a video on the NASA website. Go to https://tinyurl.com/gb2rs-nasa. During the online RSGB Convention for 2020, you will be able to enjoy some excellent lectures. On Saturday the 10th of October, the RSGB will be presenting two online streams for everyone to enjoy. In An introduction to… we will have Getting Started on Low Earth Orbit Satellites by Peter Goodhall, 2M0SQL. He will look at using low earth orbit satellites, what they are, how to use them and what equipment is required both from low-cost system using a handheld and a Yagi to automated tracked systems. In the Learn more about… stream, Bruce Pea, N9WKE will explain how to Take your CW to the next level. Happily, a lot of people are learning the code, getting on the air, and having fun with CW. This presentation explores methods and options for improving your CW, head copy skills, and increasing your speed. Bruce is the founder and host of Dit Dit FM, the podcast celebrating Morse code, the CW operating mode and amateur radio. You can find out more about the whole day of lectures at www.rsgb.org.uk/convention. Like the RSGB Convention, the AMSAT-UK Colloquium 2020 will also be online this year. Taking place on Sunday 11th of October, there will be a lecture stream from 11am to 4pm. Amongst the lectures on the day, Daniel Estévez, EA4GPZ will look at Decoding Mars spacecraft and explain the bit and pieces you can learn from spacecraft telemetry. Phil Ashby, M6IPX will talk about the FUNcube and creating an open platform in space. You can find out more at www.amsat-uk.org/colloquium. The registration URL is https://tinyurl.com/amsatukreg2020. The RSGB’s next Tonight@8 webinar on Monday the 28th of September is a bumper edition! RSGB Convention Chair David Bondy, G4NRT will give a short pre-recorded interview about this year's online Convention. After that, Tim Kirby, GW4VXE will give a usual Tonight@8 live presentation on My world of VHF. You can watch and ask questions on the Society’s YouTube or BATC channels. For more details see our website at www.rsgb.org/webinars. In the lead-up to this year’s online Convention, the RSGB has just published two more 2019 Convention presentations. In the first, Alwyn Seeds, G8DOH talks about Coax and connectors, the forgotten ingredient of high performance VHF/UHF stations. Whilst focused on VHF/UHF, this talk should be of interest to all radio amateurs. The second presentation features Chris Deacon, G4IFX talking about More on the polarisation of 50MHz signals via Sporadic-E. He looks at results from previous years and from newer experiments using more comprehensive measurement techniques, which are beginning to help answer key questions about the true nature of Sporadic-E propagation. Both can be found on the Society’s YouTube channel at www.youtube.com/theRSGB. The RSGB’s Examinations Standards Committee has published its 2020 report that looks back on activities during 2019 – you can read it and previous reports on the RSGB website via tinyurl.com/esc-reports. Now the special event news Since the change of regulations applying to special event stations in the UK, many activations are now able to go ahead. UK amateurs would like to thank Ofcom for their help in making this happen. PJ4TEN is a special event station that will be active during October 2020 to commemorate the 10th anniversary of the 10th of October 2010. On that date the former country of the Netherlands Antilles was dissolved and Bonaire became a special municipality of the Netherlands. As a result, Bonaire became a new DXCC entity on that date. Bonaire's radio amateurs are organising a month-long operating event. The rules for the award can be found on the PJ4TEN QRZ.com page. Hannes, OE1SGU will be active as OE1990SGU between the 1st and the 31st of October to celebrate his 30th anniversary in amateur radio. QSL via LoTW, eQSL, or via OE1SGU either direct or via the bureau. K1A will be operated as a special event station for the Amateur Radio Software Award until the 4th of October. Look for activity on 20 and 40 metres SSB. QSL direct to Claus H Niesen, PO Box 126, Ames IA 50010, USA. Now the DX news David, M0VDL will be active from Lundy Island, IOTA reference EU-120, between the 26th of September and the 1st of October. He plans to operate SSB and FT8 on 20, 40 and maybe 80 metres, primarily in the local morning and evening hours. Now the contest news Please remember to check before the contest for new rules due to lockdown and social distancing, which may differ around the world. The RSGB strongly advises obeying your own national and local government’s advice first and foremost, especially in the instance of local lockdowns. This weekend, the CQ World Wide DX RTTY contest ends its 48 hour run at 2359UTC today, the 27th. Using the 3.5 to 28MHz contest bands, the exchange is signal report and Zone, which is 14 for the UK. Today, the 27th, the UK Microwave group contest runs from 0600 to 1800UTC on the 5.7 and 10GHz bands. Using all modes, the exchange is signal report, serial number and locator. Also today, the 27th, the PW 70MHz contest runs from 1200 to 1600UTC. Using all modes, the exchange is signal report, serial number and locator. On Monday, the seventh FT4 Series contest runs from 1900 to 2030UTC. Using the 80m band, the exchange is your 4-character locator. On Tuesday the 50MHz Machine Generated Mode Activity Contest and the 144MHz MGM AC run from 1900 to 2130UTC. The exchange is the same for both contests, signal report, serial number and locator. On Wednesday the UK EI Contest Club 80m contest runs from 2000 to 2100UTC. It’s CW only and the exchange is your 4-character locator. Next weekend the IARU 432-245GHz contest runs for 24 hours from 1400UTC on the 3rd to 1400UTC on the 4th of October. Using all modes, the exchange is signal report, serial number and locator. On Saturday the 3rd of October, the 1.2GHz and 2.3GHz Trophy contests runs from 1400 to 2000UTC. Using all modes, the exchange is the same for both contests, signal report, serial number and locator. The Oceania DX SSB contest runs for 24 hours next weekend from 0800UTC on the 3rd to 0800UTC on the 4th of October. Using the 1.8 to 28MHz contest bands, the exchange is signal report and serial number. The Worked All Britain DX Contest takes place on the 4th of October from 0500 to 2300UTC. Using SSB only on the 3.5 to 28MHz contest bands, the exchange is signal report, serial number and WAB area. The DX Contest takes place next Sunday from 0500 to 2300UTC on the 4th of October. Using CW and SSB on the 3.5 to 28MHz contest bands, the exchange is signal report and serial number. The Portable Operations Challenge a new kind of HF contest, which takes place on the 3rd and 4th of October. The aim of the challenge is to create a level playing field for small portable stations against the large contest stations by using handicapping algorithms similar to the one used in golf. Open to all, participants choose their own 8 hour contiguous time window within the 48 hour weekend. Operating portable, contact distance, power level and mode affect the final score. Details can be found at foxmikehotel.com/challenge. Now the radio propagation report, compiled by G0KYA, G3YLA and G4BAO on Friday the 25th of September. We finally broke our long-running record of zero sunspots last week thanks to active region 2773. This new solar cycle 25 spot appeared over the Sun’s limb and pushed the solar flux index to 73. The end of the week also saw unsettled conditions due to a high-speed stream from a coronal hole. The hole in the Sun’s North-Eastern quadrant pushed the Kp index to four on Wednesday evening and five by Thursday morning. A pre-auroral enhancement on Wednesday saw MUFs rise to nearly 21MHz over a 3,000km path, but by Thursday morning they were struggling to reach 14MHz. As the month has moved on we have started to see an improvement in HF conditions generally. Laurie, G3UML reported working ZL4RMF in New Zealand on 40m SSB at 0645UTC on Tuesday and Andy, G3SVD worked FK8IK New Caledonia at 1006UTC on 20m CW. If you are looking for South Pacific contacts, Rob, F5VHN reports that Jim, E51JD on the South Cook Islands is often on around 14.225MHz SSB most mornings. Next week NOAA predicts the solar flux index will be around 70 again. The week may start unsettled thanks to a coronal hole, but the Kp index should improve as the week goes on. We expect HF DX conditions to improve as we move towards October and hopefully, we can expect to see some more sunspots from the new Solar Cycle 25 as well. And now the VHF and up propagation news. The weather patterns at this time of the year can be very fickle as the major driving jet streams can be seriously distorted by former-hurricanes from the USA side of the Atlantic. The predicted return of Tropo after midweek in the week just gone, was a bust for that reason. Other major distortions of the driving jet stream pattern are likely in the coming week, so the story is one of unsettled, changeable weather with periods of rain or heavy showers. That should mean another good week for rain scatter on the GHz bands, but tropo will not get much chance during this period. Moon declination is rising this week, going positive late on Thursday night, so we’ll see longer Moon visibility windows as the week progresses, reaching a minimum on Thursday. Path losses are still increasing until we reach apogee on Saturday. 144MHz sky temperatures are low all week, but low peak Moon elevations early in the week won’t help. The daytime Sextantids meteor shower peaked today but should still be active until the 9th of October. Continue to check around local dawn for the best random meteors, ie meteors that aren’t associated with any particular shower. And that’s all from the propagation team this week.

GB2RS NEWS Sunday the 30th of August 2020 The news headlines: Could you join the RSGB Board? Latest Online RSGB Convention news 200,000 downloads for GB2RS Podcast Following recent changes to the RSGB Board of Directors and the continuing effects of the ongoing pandemic, the RSGB is looking for Members to be considered for possible appointment to the Board. For more details about the Board, the essential personal attributes needed to be a Board Director and how to apply, see the RSGB website at www.rsgb.org/volunteers. During the online RSGB Convention for 2020, you will be able to enjoy some excellent lectures. On Saturday the 10th of October, the RSGB will be putting on two streams online for everyone to enjoy. In An introduction to… we will have the magic of six metres by Chris Deacon, G4IFX. Join him to learn what makes the 6m band so special, how to get started – and how to get the best out of it. In the Learn more about… stream, Olof Lundberg, G0CKV will speak about having fun with HF contesting. There are so many factors that influence contest results – contesting rarely takes place on an even playing field. The fairest competition might well be with yourself and Olaf will go through some ways to improve your scores and enjoy your contesting experience. You can find out more at www.rsgb.org.uk/convention. As the GB2RS Podcast approaches two hundred thousand downloads, two additional ways to receive the podcast have been added. Amazon Podcasts and Audible will carry the RSGB broadcast each week in addition to Apple, Blubrry, Stitcher and others who have been carrying the program for some time. A podcast is a short audio program that can be heard on a PC, smartphone or home audio device. It provides a way to publicise UK amateur radio even when listeners are out of range of the HF & VHF newsreaders. The GB2RS Podcast has been read by Jeremy, G4NJH for over 12 years. See https://rsgb.org/main/gb2rs/gb2rs-podcast for details. Fred, M3CTW will celebrate his 100th birthday on the 1st of September and we wish him many happy returns. He is still active on the air and a recent contact told us that Fred speaks with the fluency of a much younger person and operates his radio in an excellent manner. The media is still interested in the continuing growth of amateur radio and the RSGB is enjoying sharing stories with them, such as the interview with ten-year-old William, M7WHB that was featured in the i newspaper. The Society has also collected some great descriptions from new licensees who tell us why they are interested in amateur radio and what they’re keen to discover within the hobby. You can read all of these in the different parts of the Get on the air to care section of our website at www.rsgb.org/gota2c. The G5RP Trophy is an annual award to encourage any RSGB Member who has recently discovered and made significant progress in HF DXing. If you are an established HF DXer and want to recommend someone to be awarded the G5RP Trophy for 2020, send your nominations to Ian Greenshields, G4FSU by email to hf.manager@rsgb.org.uk to arrive no later than the 25th of September. The G-QRP club has released a detailed agenda for its Online Convention 2020, which takes place on Saturday 5th and Sunday 6th September. Details of the agenda and how to sign up can be found at www.gqrp.com/convention.htm. The RSGB 2020 Construction Competition is open for entries. There are four categories, including one specifically for people who are new to amateur radio. The deadline for entries is the 25th of September. For more details, including how to enter, see www.rsgb.org/construction-competition. International Air Ambulance Week will take place between the 5th and the 13th of September. It covers two weekends, giving amateurs a great chance to get involved and support the event. A free series of Awards will be available for those who support the event. Go to www.radio-amateur-events.org/IAW/Registration.htm. Now the special event news Since the change of regulations applying to special event stations in the UK, many activations are now able to go ahead. UK amateurs would like to thank Ofcom for their help in making this happen. Members of the Royal Air Force ARS will be operating GB80BOB from the 1st to the 28th of September to commemorate the 80th anniversary of the Battle of Britain. Due to Covid-19, Ofcom are allowing this call to be operated from homes. A list of operators and postcode locations will be displayed on the RAFARS website. A special QSL card is available. Details are at www.rafars.org/GB80BOB/ and QRZ.com. Now the contest news Please remember to check before the contest for new rules due to lockdown and social distancing, which may differ around the world. The RSGB strongly advises obeying your own national and local government’s advice first and foremost, especially in the instance of local lockdowns. Today, the 30th, The UK Microwave group’s High Band contest runs from 0600 to 1800UTC. Using all modes on the 5.7 to 10GHz bands, the exchange is signal report, serial number and locator. On Tuesday the 144MHZ FM Activity Contest runs from 1800 to 1855UTC. It is followed by the all-mode 144MHz UK Activity Contest at 1900 to 2130UTC. The exchange is the same for both: signal report, serial number and locator. On Wednesday the UK EI Contest Club contest runs from 2000 to 2100UTC. Using SSB only on the 80m band, the exchange is your 4-character locator square. Three RSGB contests take place over next weekend, the 5th and 6th September. SSB Field Day runs for 24 hours from 1300UTC on Saturday the 5th until 1300UTC on Sunday the 6th. Using the 3.5 to 28MHz contest bands, the exchange is signal report and serial number. The 144MHz Trophy is also 24 hours but ends at 1400UTC on the 6th. Its exchange is signal report, serial number and locator. The 5th 144MHz Backpacker runs from 1100 to 1500UTC on the 6th. Using all modes, the exchange is signal report, serial number and locator. Sadly, the HF and VHF Contest Committees have come to the conclusion that the Government guidance on Covid-19 does not yet allow the restart of multi-operator sections in RSGB contests. The rules for all RSGB Contests can be found at www.rsgbcc.org. The CW Open for 2020 takes place on the 5th of September. There are three sessions: from 0000 – 0359, 1200 – 1559 and 2000 – 2359UTC. The exchange is signal report and your name. The All Asian DX contest runs from 0000UTC on the 5th to 2359UTC on the 6th. Using SSB on the 1.8 to 28MHz contest bands, the exchange is signal report and age, with YLs sending 00. The IARU Region 1 Field Day runs from 1300UTC on the 5th to 1300UTC on the 6th. Using SSB on the 3.5 to 28MHz bands, the exchange is signal report and serial number. The Worked All Britain 144MHz QRO Contest is on Sunday the 6th from 1000 to 1400UTC. The exchange is the report, serial number and WAB square. The contest runs concurrently with part of the RSGB contest and RSGB serial numbers will be accepted. Due to Covid-19, no multi-operator entries are allowed. See http://wab.intermip.net/default.php for details. Now the radio propagation report, compiled by G0KYA, G3YLA and G4BAO on Friday the 28th of August. It was a quiet week, with zero sunspots and relatively quiet geomagnetic conditions and a maximum Kp index of three. After the new sunspots appeared over the past few weeks it did look like Solar Cycle 25 was getting underway. But it now looks like we may have to wait a little longer, languishing at solar minimum for the next couple of months. It was not all bad news though. Laurie, G3UML reports good conditions on 20m SSB. He worked A25 Botswana and ZS3 South Africa, plus Ross, ZL1WN in New Zealand via the long path. Laurie said signals from the Middle East were also strong. A series of narrow coronal holes are now beginning to partially face Earth. An elevated coronal hole stream should begin to move past Earth by Saturday 29th August, which could lead to an elevated Kp index and visible aurora at higher latitudes. Other than that there is little to see on the STEREO Ahead spacecraft imagery. Barring surprises, this suggests the Sun will remain quiet from Monday. NOAA has the solar flux index at 70-71 for the next seven days. The elevated Kp index over the weekend may cause MUFs to decline, but next week should see the ionosphere settle back down to a Kp maximum of two and normal HF conditions. Maximum usable frequencies over a 3,000km path should remain similar to previous weeks. Expect 20 metres to be the DX band of choice, with some openings on 17m at times. There is always the chance of DX appearing on 15, 12 and even 10 metres, but these openings are likely to be short-lived and infrequent. The good news is that next week we move into September, which should see a return to higher MUFs and better DX as the month progresses. This will also be a good time to work North-South paths, such as the UK to South Africa and South America. And now the VHF and up propagation news. This period of more changeable weather is going to be hard to break and it looks like any weak ridges between the lows will be transient affairs. They are therefore unlikely to feature highly as Tropo events, although the odd temporary lift is possible. The nature of unsettled weather, like the spell we’re in now, is such that the late summer sunshine can easily produce showers or even thunderstorms. These are very good for rain scatter and for most of the period from this weekend to next, a weather front or heavy showers may not be far away. So we’re entering another potentially productive period for the GHz rain scatter enthusiasts. We are running out of time to mention Sporadic-E, so this may be the penultimate week. Clutching at straws perhaps, but there are some good jet streams in periods of unsettled weather and the next week will continue to look promising from a weather perspective, even though events are likely to be thin on the ground. Moon declination is at a minimum today, but goes positive again on Friday, meaning Moon windows are getting longer. EME path losses are still rising, with apogee a week today. 144MHz sky temperatures are low all week, but the low Moon elevations mean that the noisy horizon will be in antenna beamwidths for the first part of the week. Just one small meteor shower this week, the Aurigids, peaking on Monday with a Zenith Hourly Rate of six. And that’s all from the propagation team this week.

September 30, 2018 sermon by Rev. Chris Deacon. Text: Exodus 14:5-7, 10–18; Exodus 14:21-29

September 23, 2018 sermon by Rev. Chris Deacon. Text: Genesis 39:1–10; Genesis 39:11–23

September 16, 2018 sermon by Rev. Chris Deacon. Text: Romans 4:13-25; Genesis 12:1-9

September 9, 2018 sermon by Rev. Chris Deacon. Text: Genesis 6:5-22; Genesis 8:5-12, 9:8-17

September 2, 2018 sermon by Rev. Chris Deacon. Text: 1 Corinthians 11:22-34; John 6:35-51

Aug 26, 2018, sermon by Rev. Chris Deacon. Text: 2 Samuel 11:1-15; Romans 8:31-39

Aug 19, 2018, sermon by Rev. Chris Deacon. Text: 1 Kings 19:19–21; Acts 13:1-14

Aug 12, 2018, sermon by Rev. Chris Deacon. Text: Acts 8:26-46; Esther 4:1-14

July 22, 2018, sermon by Rev. Chris Deacon. Text: Judges 6:11–18; Ruth 1:8-22

July 15, 2018, sermon by Rev. Chris Deacon. Text: Psalms 121:1-8; 1 John 3:16-24

July 1, 2018, sermon by Rev. Chris Deacon. Text: Romans 15:1-6; Exodus 1:8–19

June 10, 2018, sermon by Rev. Chris Deacon. Text: 2 Samuel 12:1–14; 1 Corinthians 13:1–13

June 3, 2018, sermon by Rev. Chris Deacon. Text: Acts 9:1–9; Acts 9:10–18

May 20, 2018, sermon by Rev. Chris Deacon. Text: Psalm 150:1-6; Acts 2:1–21