Podcast appearances and mentions of dave chase

This episode has three chapters. Each one answers a key question, and, bottom line, it all adds up to action steps directly and indirectly for many, including plan sponsors probably, community leaders, and also hospital boards of directors. Here's the three chapters in sum. 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. Chapter 1: Are commercial insurance premiums rising faster than the inflation rate? And if so, is the employee portion of those premiums also rising, meaning a double whammy for employees' paychecks (ie, premium costs are getting bigger and bigger in an absolute sense, and also employees' relative share of those bigger costs is also bigger)? Spoiler alert: yes and yes. Chapter 2: What is the biggest reason for these premium increases? Like, if you look at the drivers of cost that underpin those rising premiums, what costs a lot that is making these premiums cost a lot? Spoiler alert: It's hospitals and the price increases at hospitals. And just in case anyone is wondering, this isn't, “Oh, chargemasters went up” or some kind of other tangential factor. We're talking about the revenue that hospitals are taking on services delivered has gone up and gone up way higher than the inflation rate. In fact, hospital costs have gone up over double the amount that premiums have gone up. Wait, what? That's a fact that Dr. Vivian Ho said today that threw my brain for a loop: Hospital costs have gone up over double the amount that premiums have gone up. Chapter 3: Is the reason that hospital prices have rocketed up as they have because the underlying costs these hospitals face are also going up way higher than the inflation rate? Like, for example, are nurses' salaries skyrocketing and doctors are getting paid a lot more than the inflation rate? Stuff like this. Too many eggs in the cafeteria. Way more charity care. Bottom line, is an increase in underlying costs the reason for rising hospital prices? Spoiler alert: no. No to all of the above. And I get into this deeply with Dr. Vivian Ho today. But before I do, I do just want to state with three underlines not all hospitals are the same. But yeah, you have many major consolidated hospitals crying about their, you know, “razor-thin margins” who are, it turns out, incentivizing their C-suites to do things that ultimately wind up raising prices. I saw a PowerPoint flying around—you may have seen it, too—that was apparently presented by a nonprofit hospital at JP Morgan, and it showed this nonprofit hospital with a 15.1% EBITDA (earnings before interest, taxes, depreciation, and amortization) in 2024. Not razor thin in my book. It's a, the boards of directors are structuring C-suite incentives in ways that ultimately will raise prices. If you want to dig in a little deeper on hospital boards and what they may be up to, listen to the show with Suhas Gondi, MD, MBA (EP404). Vivian Ho, PhD, my guest today, is a professor and faculty member at Rice University and Baylor College of Medicine. Her most major role these days is working on health policy at Baker Institute at Rice University. Her work there is at the national, state, and local levels conducting objective research that informs policymakers on how to improve healthcare. Today on the show, Professor Vivian Ho mentions research with Salpy Kanimian and Derek Jenkins, PhD. Alright, so just one quick sidebar before we get into the show. There is a lot going on with hospitals right now. So, before we kick in, let me just make one really important point. A hospital's contribution to medical research, like doing cancer clinical trials, is not the same as how a hospital serves or overcharges their community or makes decisions that increase or reduce their ability to improve the health and well-being of patients and members who wind up in or about the hospital. Huge, consolidated hospital networks can be doing great things that have great value and also, at the exact same time, kind of harmful things clinically and financially that negatively impact lots of Americans and doing all of that simultaneously. This is inarguable. Also mentioned in this episode are Rice University's Baker Institute for Public Policy; Baker Institute Center for Health Policy; Suhas Gondi, MD, MBA; Salpy Kanimian; Derek Jenkins, PhD; Byron Hugley; Michael Strain; Dave Chase; Zack Cooper, PhD; Houston Business Coalition on Health (HBCH); Marilyn Bartlett, CPA, CGMA, CMA, CFM; Cora Opsahl; Claire Brockbank; Shawn Gremminger; Autumn Yongchu; Erik Davis; Ge Bai, PhD, CPA; Community Health Choice; Mark Cuban; and Ferrin Williams, PharmD, MBA. For further reading, check out this LinkedIn post.   You can learn more at Rice University's Center for Health Policy (LinkedIn) and Department of Economics and by following Vivian on LinkedIn.   Vivian Ho, PhD, is the James A. Baker III Institute Chair in Health Economics, a professor in the Department of Economics at Rice University, a professor in the Department of Medicine at Baylor College of Medicine, and a nonresident senior scholar in the USC Schaeffer Center for Health Policy and Economics. Ho's research examines the effects of economic incentives and regulations on the quality and costs of health care. Her research is widely published in economics, medical, and health services research journals. Ho's research has been funded by the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality, the American Cancer Society, and Arnold Ventures. Ho has served on the Board of Scientific Counselors for the National Center for Health Statistics, as well as on the NIH Health Services, Outcomes, and Delivery study section. She was elected as a member of the National Academy of Medicine in 2020. Ho is also a founding board member of the American Society for Health Economists and a member of the Community Advisory Board at Blue Cross Blue Shield of Texas. Ho received her AB in economics from Harvard University, a graduate diploma in economics from The Australian National University, and a PhD in economics from Stanford University.   05:12 Are insurance premiums going up? 05:59 What is the disparity between cost of insurance and wage increases? 06:21 LinkedIn post by Byron Hugley. 06:25 Article by Michael Strain. 06:46 How much have insurance premiums gone up for employers versus employees? 09:06 Chart showing the cost to insure populations of employees and families. 10:17 What is causing hospital prices and insurance premiums to go up so exponentially? 12:53 Article by (and tribute to) Uwe Reinhardt. 13:49 EP450 with Marilyn Bartlett, CPA, CGMA, CMA, CFM. 14:01 EP452 with Cora Opsahl. 14:03 EP453 with Claire Brockbank. 14:37 EP371 with Erik Davis and Autumn Yongchu. 15:28 Are razor-thin operating margins for hospitals causing these rising hospital prices? 16:56 Collaboration with Marilyn Bartlett and the NASHP Hospital Cost Tool. 19:47 What is the explanation that hospitals give for justifying these profits? 23:16 How do these hospital cost increases actually happen? 27:06 Study by Zack Cooper, PhD. 27:35 EP404 with Suhas Gondi, MD, MBA. 27:50 Who typically makes up a hospital board, and why do these motivations incentivize hospital price increases? 30:12 EP418 with Mark Cuban and Ferrin Williams, PharmD, MBA. 33:17 Why is it vital that change start at the board level?   You can learn more at Rice University's Center for Health Policy (LinkedIn) and Department of Economics and by following Vivian on LinkedIn.   Vivian Ho discusses #healthinsurance #premiums and #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #changemanagement #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford (EP461), Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41)  

I'd LOVE to hear from you! Now you can send a TEXT MESSAGE! Be sure to leave your contact EMAIL so I can return your message!In this episode of the "My DPC Story Podcast," host Dr. Maryal Concepcion interviews Dave Chase, co-founder of Health Rosetta, about community-driven health initiatives and the Direct Primary Care (DPC) model.  They discuss healthcare reform, celebrating DPC's transformative impact, and the role of the Rosetta Fest in fostering a new healthcare economy. Dave emphasizes the importance of local action in addressing critical community needs such as food deserts, education, and senior loneliness. The discussion also covers the financial burdens of the current healthcare system and the positive impacts of healthcare redesign through DPC. Dave highlights the significance of events like Rosetta Fest in Washington, DC, from September 11th to 13th, and the opportunity for virtual participation. Rosetta Fest will gather clinicians, employers, and policymakers to share success stories and best practices in DPC implementation. Take $100 off your in-person or virtual registration with code MYDPCSTORY100. Visit rosettafest.org to register today!Join the myDPC story Patreon for more exclusive content. For more information, visit the podcast and learn about the Direct Primary Care revolution.The Growth GearExplore business growth and success strategies with Tim Jordan on 'The Growth Gear.Listen on: Apple Podcasts SpotifySupport the Show.Be A My DPC Story PATREON MEMBER! SPONSOR THE PODMy DPC Story VOICEMAIL! DPC SWAG!FACEBOOK * INSTAGRAM * LinkedIn * TWITTER * TIKTOK * YouTube

In this episode, Halle speaks with Dave Chase, co-founder and CEO of Health Rosetta, who is on a mission to end the 30-year heist of stolen income from the working middle class. He's working to popularize a new parallel economy: community-owned health plans (COHPs). Dave explains how these plans aim to transform healthcare from a driver of debt and bankruptcy to a driver of well-being and wealth.We cover:- The structure and benefits of community-owned health plans (COHPs)- How these plans can reduce healthcare costs while improving care quality- The role of primary care, including direct primary care models, in reshaping healthcare delivery- Challenges with the current employer-based health insurance system- Recent legal developments pushing for change in employer-sponsored health plansDave shares insights on how community-owned health plans can address issues like misaligned incentives, inefficient spending, and poor health outcomes. He also discusses the potential for these models to redirect healthcare savings into community investments, ultimately improving social determinants of health.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

To read the full show notes with links mentioned, be sure to visit our episode page and consider signing up for our free weekly newsletter. Episode 443 of Relentless Health Value pays tribute to the late Marshall Allen, an investigative journalist dedicated to exposing injustices within the American healthcare system. Hosted by Stacey Richter, the episode features Dave Chase, founder of Health Rosetta, who shares memories and insights into Marshall's tireless work in investigative reporting. The episode highlights Marshall's impact on healthcare legislation, his significant contributions to ProPublica, and his book 'Never Pay the First Bill,' which empowers patients and employers to fight back against corrupt billing practices. The episode also includes an earlier interview with Marshall, focusing on his perspective as an investigative reporter, the exploitation within the healthcare system, and the importance of patients and employers demanding transparency and fairness. The episode encourages listeners to continue Marshall's legacy by subscribing to the Marshall Health Academy and purchasing access for employees. 09:28 What's the point of view that Marshall is coming from with his investigative reporting? 09:57 “How does this affect the people who are paying for it and the people who are undergoing the care?” 10:49 “There's a lot of good people working within this very messed up system.” 11:03 Why are patients considered outsiders in the healthcare system? 11:45 “What's happened in healthcare is that the stakeholders treat each other more as the customer.” 13:45 What is upcoding? 17:18 “These are schemes that have been created within the industry to increase revenue.” 17:46 “This system is not set up for the benefit of the patient.” 18:13 “On the financial side, the industry is actually oppressing the American people.” 19:14 “We have been expected to pay whatever aggregate sum is thrown at us.” 20:21 Why have patients been so passive toward this crooked healthcare system so far? 22:05 What's the difference between making a profit and profiteering? 29:45 What are the first-order and second-order consequences of what's happening in health care right now, and which of these consequences will actually drive change? 30:45 “When you tell the truth about what's going on … they become so ashamed … that they change their behavior.” 32:00 “The patient … is not their most important customer.” 32:50 “The sleeping giant is the employers.”

In this episode of Healthcare Americana, host Christopher Habig, CEO of Freedom Healthworks, sits down with Dave Chase, the visionary founder of Health Rosetta. Together, they explore the groundbreaking work Health Rosetta is doing to transform the healthcare landscape into a system that is transparent, accountable, and value-driven.Dave Chase shares insights from his journey, starting from the release of his influential book, “CEO's Guide to Restoring the American Dream,” to the establishment of Health Rosetta, a network of benefit advisors committed to delivering world-class healthcare at half the cost. They delve into the critical role of direct primary care (DPC) and how Health Rosetta's approach is making high-quality primary care the centerpiece of healthcare plans.Listeners will gain valuable perspectives on the importance of data in health plans, the challenges of educating workforces about new healthcare models, and the practical steps HR professionals can take to reduce costs while improving care quality. Tune in to learn about the innovative solutions Health Rosetta offers and how employers, advisors, and physicians can collaborate to create a more efficient and effective healthcare system. Whether you're a healthcare professional, an employer, or simply interested in healthcare reform, this episode is packed with actionable insights and inspiring stories.More on Freedom Healthworks & FreedomDocSubscribe at https://healthcareamericana.com/episodes/More on Dave Chase & Health RosettaFollow Healthcare Americana: Instagram & LinkedIN

In this podcast episode, we delve into the transformative journey of Health Rosetta and its co-founder, Dave Chase. Join us as we explore the personal reasons behind the creation of Health Rosetta, driven by a profound mission to change the healthcare narrative. In this episode, Dave shares the powerful motivation behind co-founding Health Rosetta, fueled by a series of impactful personal experiences. We uncover the innovative approach of Health Rosetta in redirecting the currently wasted $1.5 trillion in healthcare towards social determinants of health, such as income and better food. We delve into Health Rosetta's groundbreaking transformation of health plans, turning them from contributors to debt, poverty, and bankruptcy into catalysts for well-being and wealth.

For a full transcript of this episode, click here. I want to kick off this show with a clip from episode 415 with Rob Andrews, wherein he so very eloquently sets the stage here: We think that one of the core problems here is that too many intermediaries and providers in the system, their compensation is not in any way dependent on the outcome. So, let's think about this NICU baby problem again. Looking at the hospital system—and I'm not at all implying or suggesting any hospital system tries to do this—but I think it is clear that they actually benefit commercially from more babies spending more days in the NICU. NICU's usually a pretty good margin business. It's expensive. Lots of money is paid, and margins run pretty well there. So, I don't think there's a hospital system in the country that intentionally says, “Oh, good … let's go out and try to fill up the NICU every day.” But when it gets filled up, they benefit. On the other hand, if the hospital invests significantly in early effective intervention prenatal or even pre-pregnancy, there's no upside to that financially. They don't get rewarded for that. They might win an award from some magazine for best practices, but their margin suffers. Then if you look at the intermediaries, the carriers, and PBMs [pharmacy benefit managers], their outcomes are irrelevant to their performance. If an employee of a self-insured employer has a significant risk prenatal or pre-pregnancy and the carrier does a great job identifying that problem and solving it, they make the same amount of money off that patient or that consumer that they would if they did nothing. So, it's a bit harsh to say this, but the carriers make the same amount of money if every child is born healthy and there's not a day spent in the NICU as if they do if every child's born with severe crises and winds up in the NICU. It's not a big mystery in the US economy that people do what you pay them to do. And if you have a system, which we do now, where the case of maternal health, diabetes management, musculoskeletal management, cholesterol and cardiac management … when you have a system where many, many players in the system, at best, make the same amount of money for bad outcomes as they do for good ones and, at worst, they prosper from the bad outcomes, that explains the problem. So, is this show about improving maternal health outcomes in the US, where it is relatively deadly to have a baby compared to other industrialized nations? Yes. But improving maternal health is also a great case study for what needs to be done to just improve health. You could apply it to primary care. You could apply it to chronic care management. It is a fairly broad-spectrum solution, as it were. I'm thinking right now about how Dave Chase, co-founder of Health Rosetta—how does he put it?—he says every big problem in healthcare already has been solved. The existing challenge is how to massively replicate proven solutions. So, yeah … keep that in mind when we talk about what Jodilyn Owen has accomplished with her team in Washington State with their birth and health center. Also, as you consider how you might replicate, keep in mind the struggles she has faced getting contracts from self-insured employers or payers to pay her clinic and a very interesting encounter she had with a VC/PE (venture capital/private equity) funded maternal health start-up. It's just interesting where the money is flowing and where it's not flowing. But let's talk about Jodilyn's clinic's outcomes. Their zip code is one of the most diverse in the nation. There are 79 languages spoken. There is lots of social determinants of health going on. It is a medically underserved area. It is a federally designated provider shortage area. So, this community has every right to have horrible outcomes. Meanwhile, nearby, there is a wealthy community. In that zip code, they live 17 years longer than in Jodilyn's clinic's zip code. But if you compare the outcomes that Jodilyn's clinic has compared to the outcomes in the hospital in that fancy neighborhood, Jodilyn's group has far less cesarean rates, far less NICU admissions, far less incidence of gestational diabetes, far quicker access to treatment for hypertension. You might be wondering how much their birth bundle costs that they are having trouble getting most payers except one to pay for and getting no VC dollars or funding at all. They're charging $5000 to $7000. So, let's just say $5000 to $7000 compared to … what does one NICU admission cost? So, yeah … this is an exact example of what Rob Andrews was talking about. An EXACT example. So yeah, enjoy this episode; it's as heartwarming and actionable as it is frustrating. And if you are a payer or self-insured employer in South Seattle, please give this clinic a contract. Not to drop a major spoiler alert here, but you know what Jodilyn's “secret sauce” is? Nuances for sure, but bottom line, it's about trust. It's about relationships. It's about listening to the patient. It's being part of the local community. If you're shocked right now, raise your hand. There's gonna be no one with their hand raised. How many times do we have to figure this out? Jodilyn Owen is the clinical director of the Rainier Valley Birth & Health Center. She is a licensed midwife along with a bunch of other credentials. Also mentioned in this episode are Rob Andrews; Dave Chase; Vivek Garg, MD, MBA; and Larry Bauer.   You can learn more by emailing Jodilyn at jodilyno@myrvcc.org. You can also connect with her on LinkedIn.   Jodilyn Owen, LM, CPM, Ma MCHS, is a licensed, certified professional midwife and co-founder of Rainier Valley Birth & Health Center. She was born and raised in Seattle and raised her own family in South Seattle, working as a doula and parenting educator for 13 years before becoming a midwife. This is where she saw healthcare through the lens of observation of hundreds of families and provider experiences of maternal and child healthcare. An avid learner and critical thinker, Jodilyn began to reimagine healthcare and to develop a vision for what access in its truest form might be, not just to healthcare for the deeply underserved and mis-served families of South Seattle but also to quality healthcare delivery for the providers who want to give more than what the system allows. Jodilyn built her practice around the idea that parents know themselves and their babies best, and her direct patient work is designed to promote this first relationship. She provides individualized, gentle, and holistic pregnancy, birth, and postpartum care for families planning a home, birth center, or hospital birth. Jodilyn is currently director of clinical partnerships and staff midwife at the nonprofit–for purpose Rainier Valley Birth & Health Center. She provides infrastructure development, guides clinical programs and partnerships, and supports students from multiple university health professions and public health programs at all levels from high school through doctoral studies.   07:12 How much cost savings is there when you avoid a NICU admission? 09:43 How is “slow care” feasible among an ob-gyn shortage in many communities? 10:42 “Start people at the risk that they are appropriate for.” 11:37 EP407 and Summer Shorts 3 with Vivek Garg, MD, MBA. 13:50 “To effect change, we have to unwind what has been wound so tightly and so carefully through medical … education.” 14:13 “It's not a people problem; it's a system problem.” 18:46 What does relationship-based care mean? 22:32 “Everything in pregnancy at least is a trend.” 28:01 How does Jodilyn's practice work with payers? 31:08 EP409 with Larry Bauer, MSW, MEd. 32:24 Why is it important to address the root of this problem in the education space?   You can learn more by emailing Jodilyn at jodilyno@myrvcc.org. You can also connect with her on LinkedIn.   @essntialmidwife discusses improving maternity #patientoutcomes in our #healthcarepodcast. #healthcare #podcast #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Ge Bai, Andreas Mang, Karen Root (Encore! EP381), Mark Cuban and Ferrin Williams, Dan Mendelson (Encore! EP385), Josh Berlin, Dr Adam Brown, Rob Andrews, Justina Lehman, Dr Will Shrank  

Healthcare transparency is essential for patients to make informed decisions, yet price disparities in the industry remain a major issue. In this podcast episode, we explore how financial incentives and contracts between hospitals and insurance companies can misalign the incentives of brokers, employers, doctors, and patients. We discuss the importance of understanding the influence of these incentives and the need for accountability in developing an equitable healthcare system. Through transparent communication and a focus on an equitable system, we can help ensure that patients receive the care they need and deserve.Episode Outline:(00:00:02) Healthcare Transparency(00:04:42) Price Disparity in Healthcare(00:09:37) Health Insurance Incentives(00:14:21) Doctor Compensation Metrics(00:19:05) Incentive MisalignmentQuotes:(00:03:21) The thing that boggles my mind about healthcare is that in most of healthcare, neither the consumer, which in healthcare is the patient, nor the provider of the goods or services, which in most cases is the doctor, neither one of those parties know what the price is going to be until long after the services are already rendered.(00:09:10) You might only be paying a copay or you might only be paying your $200 and $5500 out of pocket that's falling off of your coinsurance. And they have no idea until they get the EOB what the build charges were and what the allowed charge was. So I think they're so disconnected from how much health care actually costs.(00:12:23) But I'm going to put it really bluntly and I think I got this from Dave Chase, this little metaphor here. But imagine for a minute if fire departments only got paid when there was a fire, they would want as many fires to occur as possible. And the bigger the fire, the more money they get.(00:17:22) And not only that, I think to deny that you're influenced by the financial incentives is to deny you're human. I mean, we've operated on financial incentives long before currency even existed.(00:21:08) I challenge you, if you are not already, if you're a consultant, even if you're a patient, if you're an employer, figure out what you can do. What one thing can you do differently to turn that incentive around?Social Post:Are you tired of feeling like you have a healthcare hangover? We've all been there. That's why we created the Healthcare Hangover podcast. We dive into the headaches we've been encountering in the healthcare system that are leaving us feeling a little hungover. In our latest episode, we talk about the importance of healthcare transparency. We heard a story about a patient who was charged $475 for an X-ray at a hospital, when they could have gotten the same X-ray at a chiropractor's office for less than $75. We also spoke with a hernia surgeon who was able to do the same procedure for $7,200 instead of the $20,000 quoted by a local general hospital. Tune in to the Healthcare Hangover podcast to learn more about the importance of healthcare transparency and how it can save you money.Are you curious about how doctors are paid? Tune in to the latest episode of The Healthcare Hangover podcast to find out! From patient volume to RVUs, David Contorno and Emma Fox break down the complex system of doctor pay and how it influences health care decisions. Plus, they discuss how traditional brokers are put in an unfair position and how financial incentives can be used to deliver better outcomes. Don't miss out on this eye-opening episode! #TheHealthcareHangover #DoctorPay #HealthcareAre you tired of the broken healthcare system? Tune in to the latest episode of The Healthcare Hangover to learn how the system was designed to benefit certain people and how you can help turn the incentives around! From the perverse incentives of commission-based compensation to the Cigna CEO's 20 million dollar salary, David Contorno and Emma Fox will take you through the details of the current system and how you can help build an alternative. Don't miss out! #TheHealthcareHangover #BrokenHealthcareSystem #IncentivesBlog Post:The healthcare system is broken, and it's time to start fixing it. In this episode of Healthcare Hangover, hosts David Contorno and Emma Fox explore the lack of price transparency in healthcare, and how providers are taking advantage of patients by charging them more than necessary. Insurance companies make money by renewing plans every year, regardless of how much they pay out, and people often think that more expensive care results in better outcomes, which is not true. Unfortunately, people often cannot afford their out-of-pocket costs, leading to debt or even lawsuits. Insurance companies do not provide any positive benefits to doctors, employers, or patients, and people have been led to believe that they need health insurance to get quality health care, which is false. The hosts also discuss how fire departments operate on a fixed budget, while health care systems make more money the sicker people are. Health insurance companies have a massive workforce that they pay very little to, and they have bonus programs for brokers that are available on their websites. Hospitals are not changing their practices due to lack of consumer demand, and MRF (Machine Readable File) is not human readable, requiring a middleman to translate the data. Additionally, hospitals often put programming on their website to prevent spiders from finding the data. David Contorno and Emma Fox also discuss how cash prices are almost always the lowest prices on hospital spreadsheets, and the disparity between prices for the same procedure from different carriers is outrageous. Commercial carriers pay the highest reimbursement rate to hospitals, and patients are disconnected from the cost of healthcare due to copays and coinsurance. To illustrate this, David Contorno visited a chiropractor for an X-ray of his shoulder and was asked if he was okay with the price before the X-ray was taken. The X-ray cost $75 at the chiropractor's office, but the same X-ray would have cost $475 at Atrium, the hospital system next door. Michael Reinhorn, a hernia surgeon in the Boston area, charges $7,200 for hernia surgery, while a local general hospital charges $20,000. The hosts also compare the healthcare system to the veterinary system, noting that veterinarians often give customers options and prices up front before giving any treatment. Doctors, on the other hand, are typically paid based on two metrics: patient volume and RVU (Revenue Value Unit). Patient volume is the number of patients seen in a day, with some doctors having minimum patient volume requirements of up to 30 patients per day. RVU is a measurement of how much revenue a doctor is helping generate for the health system, often in areas outside of their office. Doctors are incentivized to prescribe opioids to deal with pain, and to send patients to the most expensive care, regardless of whether it is the appropriate treatment. The most likely outcome of back surgery in the US is a second back surgery. Additionally, traditional brokers are paid more when they retain their book of business and cross-sell additional products that benefit the carrier they represent. Healthcare and health insurance employees often think they are doing good, even though the results they keep delivering are bad. The company bills their clients and has a performance bonus for achieving the client's goals of paying less for healthcare. Ultimately, the hosts conclude that people should focus on changing one thing at a time to build an alternative system that is more affordable. The Cigna CEO made 20 million dollars last year, and the sicker people are, the more money they make. It's time to start demanding more transparency and accountability from health insurance companies, and for patients to take control of their own healthcare. We have the power to create a system of trust between providers and patients, and to make healthcare more affordable and accessible.Episode Links:Connect with Emma FoxWebsiteEmma's WebsiteConnect with David ContornoLinkedInWebsiteOther MaterialsThese materials help you promote your podcast. Quotes can be used for audio & video grams or quote cards. Blog and social posts will help your website and social media presence.

What if healthcare as we know it is stealing the American Dream? Join us on this eye-opening episode  as we welcome Dave Chase, creator and co-founder of Health Rosetta, to discuss the vital role of benefits advisors in preventing medical mistakes and saving the US economy.  Learn how Dave's personal journey to understand a tragic misdiagnosis led him to create a movement aimed at transforming healthcare and restoring the American Dream.Together, we explore the origin story of Health Rosetta, how the ACA sparked the journey to change, and how the 2016 election illuminated the need for a drastic overhaul of our healthcare system. Discover how wage stagnation and rising premiums have contributed to economic depression for the working and middle classes over the past 30 years, and why it's time to take action. Uncover the potential of using LEED standards to accredit and certify health plans, and how focusing on quality and affordability could be the key to reducing healthcare spending. Don't miss this powerful conversation with Dave Chase as we work towards restoring the American Dream through healthcare transformation!SPECIAL NOTE: Join Dave and the Health Rosetta team at ROSETTA FEST August 7-9, 2023 in Chicago. Click HERE for more information.

Friends, This is a super interesting and fast paced dialogue about a topic that is poorly understood by most, including healthcare executives and policy experts. The topic is employee health ...

You would think that hospitals with the most money would offer the most charity care—trickle down and all of that. If my health system is big and I have lots of money and profitable commercial patients, I can stuff more dollar bills into the charitable donation balance sheet bucket, right? Except, in general, it's a fairly solid no on that. Let's talk about some of my takeaways from the conversation that I had with Vikas Saini, MD, and Judith Garber from the Lown Institute. During the conversation, there's also mention of a powerhouse of a New York Times article. So, let's circle up on but a few of the more interesting (according to me) reasons why some rich hospitals fail to offer the level of charity care that you might think they could or should: #1: Chasing commercial contracts because they are very profitable means building in areas where there are frankly not a whole lot of poor people. You see hospital chains doing this all of the time and saying at the 2023 JPM (J.P. Morgan) conference that they intend to do more of it, opening up in a fancy suburb with no affordable housing. When this happens, there is just less opportunity to offer charity care. The need for financial aid in that ZIP code is just less. #2: The Ambulatory Surgical Center (ASC) movement, which is weird to say because, in other respects, I'm a big fan. There are a lot of services and surgeries moving out of the hospital into ambulatory surgical centers or just the outpatient setting, and this is going on for a bunch of reasons, including Medicare and employers being very on board with this to save facility fees. But here's a consequence: Surgeons and other docs are now not in the hospital. So, indigent patient shows up in the emergency room and needs an emergency surgery or some intervention. But wait … those physicians and their teams are no longer in the hospital. And now the hospital doesn't have the “capability or the capacity” to serve that patient. I heard from a surgeon the other day, and when he's on call at his hospital, he's getting patients shipped to him on the regular from hospitals in other states. Now, about this “oh, so sorry … we can't possibly help you so we're gonna stick you in an ambulance and take you to another state” plan of action. I called up emergency room expert Al Lewis. He told me that if this “ship 'em out” is being done routinely as a pattern by hospitals who have an ER, you could call it evidence of an EMTALA (Emergency Medical Treatment and Labor Act) violation on several levels. You can't have an emergency room and then routinely not be able to handle emergencies, especially when the emergencies you can't handle always seem to be of a certain kind and for a certain kind of patient. Speaking of violations, one more that reduces the need and level of charity care is canoodling with ambulance companies to take the poor people to some other hospital and the rich people to your hospital, which was allegedly transpiring in New Jersey, based on a recent lawsuit. #3: [play some foreboding music here] This last one is the big kahuna underlying reason why some very rich hospitals may not offer the level of charity care which you'd think they would. This was superbly summed up by Tricia Schildhouse on LinkedIn the other day. She knew a physician leader who would go around saying, “Non-profit and for-profit is a tax position, not a philosophy.” Bottom line, this whole thing boils down to what has been normalized as OK behavior at some of these rich hospitals. You have people in decision-making roles taking full advantage of their so-called tax position to jack up their revenues—revenues which they have no interest in frittering away on charitable causes. Why would they do that when they can use the money to, I don't know, stand up a venture fund or make Wall Street investments? Don Berwick's latest article in JAMA is entitled “The Existential Threat of Greed in US Health Care.” And, yeah … exactly. Back to that New York Times article that we talk about in this healthcare podcast, here's what it says about a hospital in Washington State. It says: “The executives, led by [the hospital's CFO] at the time, devised … a program called Rev-Up. “Rev-Up provided [the hospital's] employees with a detailed playbook for wringing money out of patients—even those who were supposed to receive free care because of their low incomes.” All of this being said, there are hospitals out there who are, in fact, living up to their social contract and serving their communities well with very constrained resources. You also have hospitals just in general working within some really whack payment models that we have in this country, which easily could be a root cause precipitating this suboptimal-ness. Dr. Saini and Judith Garber mention three direct solves for hospital charity shortfalls and also the larger context of the issue. So, there's, of course, better reporting and better auditing, which is pretty nonexistent in any kind of standardized way right now. I also really liked one of the solutions that Dr. Saini mentions on the show: Maybe instead of all the hospitals doing their own charity care thing, they all should pool their money regionally and then put a community board in charge of distributing it. That way, if there is a hospital in an area where the charity care is really needed, even if the rich hospital nearby doesn't have a facility there, they can help fund this care that their larger community really needs—including, by the way, public health needs, which is currently a big underfunded problem. As mentioned earlier, I am speaking with Vikas Saini, MD, and Judith Garber. Dr. Saini is president of the Lown Institute. Judith Garber is a senior policy analyst there. They've studied hospitals from a number of dimensions, not just charity care.   You can learn more at lowninstitute.org and lownhospitalsindex.org.    Vikas Saini, MD, is president of the Lown Institute. He is a clinical cardiologist trained by Dr. Bernard Lown at Harvard, where he has taught and done research. Dr. Saini leads the Institute's signature project, the Lown Institute Hospitals Index, the first ranking to measure hospital social responsibility. The Index, first launched in July 2020, evaluates hospitals on equity, value, and outcomes and includes never-before-used metrics such as avoiding overuse, pay equity, and racial inclusivity. In his role at the Lown Institute since 2012, Dr. Saini led the development of the Right Care series of papers published by The Lancet in 2017, convened six national conferences featuring world-renowned leaders in healthcare, and guided other Lown Institute projects such as the “Shkreli Awards.” Dr. Saini also serves as co-chair of the Right Care Alliance, a grassroots network of clinicians, patient activists, and community leaders organizing to put patients, not profits, at the heart of healthcare. Prior to the Lown Institute, Dr. Saini was in private practice in cardiology for over 15 years on Cape Cod, where he also founded a primary care physician network participating in global payment contracts. He also co-founded Aspect Medical Systems, the pioneer in noninvasive consciousness monitoring in the operating room with the BIS device. Dr. Saini is an expert on the optimal medical management of cardiologic conditions, medical overuse, hospital performance and evaluation, and health equity. He has spoken and presented research at professional meetings around the world and has been quoted in numerous print media, on radio, and on television.  Judith Garber is a senior policy analyst at the Lown Institute. She joined the Lown team in 2016, after receiving her Master of Public Policy degree from the Heller School of Social Policy. Her research interests include hospital community benefit policy, overuse and value-based care, and racial health disparities. She has authored several white papers, journal articles, op-eds, and other publications on these topics. Judith previously worked at the Aspen Institute Financial Security Program, the Midas Collaborative, and Pearson Education. She has a bachelor's degree in American studies and political science from Rutgers University.   06:50 Why does America need socially responsible hospitals? 08:23 What standards are hospitals beholden to with their charitable spending? 08:47 “It's the honor system, essentially.”—Dr. Saini 11:38 What is fair share spending? 13:43 Which hospitals are paying their fair share? 15:05 Why do hospitals that are financially more strapped tend to give back to their communities more? 17:25 Why is it hard for hospitals with the most privately insured patients to do the most for their community? 18:56 “These outcomes … are the outcomes of the [current system].”—Dr. Saini 21:23 “A key problem here is [that] systems have gotten so big.”—Dr. Saini 22:30 What's the solution to fixing the problem with hospital charity care? 23:52 EP374 with Dave Chase. 29:21 What would be the level of acceptance with changing the system as it stands with hospitals?   You can learn more at lowninstitute.org and lownhospitalsindex.org.   @DrVikasSaini and @JudiTheGarber of @lowninstitute discuss #hospitalcharitycare on our #healthcarepodcast. #healthcare #podcast #hospitals Recent past interviews: Click a guest's name for their latest RHV episode! David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari  

This week, I am with my Aventria team on-site at one of our clients. We are holding a full-day workshop to help our client figure out who all across the healthcare industry they will need to get aligned with to achieve greater success in the market and how to handle all of these inevitably conflicting interests strategically and also potentially from a messaging standpoint. I'm one of the subject matter experts who gets to pipe up during the part where we talk about all of these market dynamics, what everybody is up to, and who is going to want what so the client team can do their thing and get paid for it. Anyway, I say all this to say that this week, I am pretty darn busy but also thrilled to encore this episode with Nikhil Krishnan, founder of Out-Of-Pocket, and one of our most popular episodes in the past 12 months. My guest in this healthcare podcast is Nikhil Krishnan, who is the founder of the Out-Of-Pocket newsletter. I was talking with Nikhil, and we identified—or, more accurately, he identified—five business models of digital health. What makes each model distinct is a few factors. If you weren't in the healthcare industry, you'd probably expect that I'm going to say that the biggest factor a business model must hinge on must have something to do with patient outcomes or care or something that has something to do with the hopes and lives of patients. Except no. Mostly, our models do not define themselves by attributes of their patients, except on one dimension: who is paying their bills. Who is paying has enormous downstream consequences that I don't think people outside of healthcare, or even people inside of healthcare sometimes, really appreciate. It's because of all of the perverse incentives. It's a tangled web we weave. For example, let's just say you're a start-up founder trying to cook up your unique selling proposition. You can't just decide you're gonna lower costs and improve patient care as general constructs. Because let's just say you do that—that's your USP (lower costs and improve patient care)—and then you try to sell your thing to Medicare Advantage plans or large provider organizations. Oh, right … Medicare Advantage plans or even commercial ones—they don't care about the total cost of care. Neither do provider organizations unless they take on sufficient risk to care, and many do not. In fact, as came out in that JAMA article the other day, it could be construed that entities such as these carrier health plans have a perverse incentive to see total costs of care go up. So right, you naively (you're the start-up founder again in this case study, don't forget) trot into some administrator's office with a great something or other to reduce total costs of care—and you'll get cast out upon your petard on the quick. Every single day of the year in my world, I see people make this same mistake over and over again: not tailoring their product market fit to any particular market, with the recognition that some in this healthcare industry have a vested interest to see costs going up and some have a vested interest in costs going down. Either way, if we're talking about large organizations here and even some small ones, the money wins over patient care. So sad to have to say that, but listen to EP351 with Dr. Eric Bricker and you'll get all the context you need on that point. Here's the thing, though. I don't know about you, but I can't tell you how many digital health start-ups I run across where I look at their decks or have a conversation with a founder, and I ask who their customer is. Is it employers or health plans or … ? And they don't know. They're gonna figure this out later. I don't get how to successfully do that. I'm indubitably wrong here given all of the pivots I hear about that seem to go OK, but the prospect of completely redefining my operational goals and operations and market positioning at some point in the future seems like a daunting and avoidable prospect. I would be remiss not to mention, however, the number of really good mission-driven healthcare companies out there really trying hard to figure out how to create a sustainable business, a fair profit, while at the same time serving patients really well. There are companies adding value commensurate with the dollars that they come by, and I certainly applaud everything that they are doing. At the same time, given all this, here's a message for all of you VCs and private equity etc—people with money—out there. Let me quote Dr. Vivek Garg here (@vgargMD on Twitter): “If you're financing care delivery without board-level focus on clinical outcomes, you're part of the problem.” So, let's talk about these five business models that health and healthcare start-ups eventually settle themselves into after they figure out who their customer is. Nikhil Krishnan, my guest today, and I discuss how they can be financially viable and if we think they'll actually be able to provide superior patient outcomes. [Trumpets play here] In no particular order, this is what we've got for our five business models: Completely avoiding incumbents, creating a cash-pay ecosystem Better middleware (being the pipes, as I've heard so many times these past couple of weeks) Companies serving incumbents either by being a virtual front door for them or disrupting the competitive landscape somehow Joint ventures Old-school digital health who are now incumbents in their own space My guest in this episode, Nikhil Krishnan, has a bunch of things going on. He might be best known for his newsletter, Out-Of-Pocket Health, which you should certainly subscribe to. He's also working on a healthcare 101 crash course to teach newcomers about the Wild West we call American healthcare. Besides all of this, Nikhil does some early-stage investing. You can learn more at outofpocket.health and with Nikhil's upcoming course.   Nikhil Krishnan is the founder/thinkboi at Out-Of-Pocket, where he's trying to make the business of healthcare more easily understandable and (hopefully) entertaining. He runs a newsletter (yes, yet another one) and an online healthcare community and does some digital health investing on the side. He's “extremely online,” and you can find him firing off obscure healthcare memes plus the occasional insight on Twitter at @nikillinit.   06:20 What are the different models of digital health? 08:05 What are the different motives for cash-pay digital health models? 13:54 “One of healthcare's original sins is that every solution deployed has been a custom solution for the end user.” 14:19 How willing will these companies be to share their data with third parties? 18:07 “I don't think selling tech to large incumbents is going to move the needle.” 21:14 “These companies, most of them are actually getting extra money for the more expensive stuff.” 22:58 How did joint-venture digital health business models come about? 26:37 Why do you see partnerships more on the payer/provider side? 27:29 Who are the old-school digital health companies that could be considered incumbents? 29:36 Why do so many digital health start-ups have a hard time pinpointing who will pay for their services? 32:10 “The ability to go through the idea maze is way faster now.” 34:55 “The field is wide open to help teach people how healthcare works.”   You can learn more at outofpocket.health and with Nikhil's upcoming course.   @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase  

So, a few things to remind everybody. First of all, don't forget EHRs (electronic health records) were purpose built originally for billing. This is no secret. People quite openly have called EHR systems glorified cash registers. If I want to be generous, maybe I would restate this to say that EHRs were designed to document patient interactions. This is what their core architecture was built to achieve. But today, there's a lot that goes on that isn't a traditional patient interaction. First of all, me even calling it, frankly, a patient interaction should give longtime listeners a clue where this is headed. I mean, say you're sitting at home on your couch. I don't know. You're probably not considering yourself a patient. You're considering yourself a person sitting on your couch. However, say you're sitting on your couch and you haven't taken your COPD maintenance therapy. Potentially that is something of clinical significance that maybe should get figured out and noted somewhere—potentially prior to the acute event going down. Or, still talking about things that are relevant to patient health but which don't naturally tuck into an EHR system's native architecture, maybe we have social workers and nutritionists and all kinds of people who are not doctors or nurses or PAs (physician assistants) in this mix. Most of the time, these people don't even have access to the EHR. I mean, what percentage of things that are going to impact a person's health outcomes can be classified as traditional patient encounters that EHRs were designed to document? I mean, you've got your scheduler who wants to tell the transportation company something about a patient. Anything RPM. Where's the caregiver or the family in that garden-variety patient interaction? In sum, what is happening between codes getting written in patient health records? Where's all that information going? I mean, what order set are you gonna use to get all that in and out of the system? Am I saying anything revolutionary that many of you don't already know extremely well? No, I am not. But I am shining the spotlight on it to challenge what might have become a sort of default position at provider organizations today, which is to make the EHR the one ring to rule them all, which might be something to consider revising strategically. My guest in this healthcare podcast, Emily Kagan Trenchard, makes a super point about all of this that I haven't heard made so succinctly or so eloquently. Emily puts it this way: She says just integrating into the EHR as a reflex without contemplation is kind of the olden days. She talks about identifying the core functionalities, the centers of gravity that are needed to bring together providers and patients and everybody else in the mix. Then you find the best systems—call them platforms if you want. But if, at a fundamental level, you have a technology designed for one thing and you're trying to shoehorn it to do something else and this something else is a critical business function, maybe this is something to think about at the highest levels. Of course, it goes without saying that these platforms have to work together (obviously); but you kind of gotta get the right platform for the right job. Now, to make one point clear as glass, what we are not talking about here is cobbling together a bunch of point solutions. What we are talking about is getting the fundamentals, the core architecture here, solidified. Pam Arora talks about this at length in episode 246. She's the CIO at Texas Children's. Pam Arora says that if a health system doesn't get its technology infrastructure rock solid, if that infrastructure is janky in any way, then everything built on top of it will require duct tape and workarounds and probably not go as well as planned. On the show today, Emily Kagan Trenchard continues that theme. She talks about the four platforms that she feels are very necessary to underpin or be the chassis to best support helping providers and others help patients and people in and out of the clinic. She calls each platform a tentpole. These four platforms are: The EHR A CRM (customer relationship manager). And, by the way, when Emily says CRM, she's talking about more than software. It's more like a philosophy or a whole approach around relationship building with patients/people/customers. A cloud platform for data and analytics A data exchange One last takeaway, for me at least. Emily has talked about two basic facts that inform her thinking: (1) Providers and patients alike are increasingly not tolerant of friction. (2) What is easiest is the most likely to happen. Something that we don't get into in this show but certainly bears considering is the larger context here. Yeah, we got Amazon, we got Google—not only what they are doing alone but also what they are investing in. They have platforms that are purpose built to remove friction and to be really, really easy … one-click easy. So, let's talk about the WIIFM (the “what's in it for me?”) here for health systems to get a move on. When Merrill Goozner was on the show a few weeks ago (EP388), he says that when patients and employers and taxpayers start crying uncle on both healthcare prices as well as just bad friction-filled experiences and also when, at the same time, technology and new competitors move in on the supply side, he says what's gonna happen then is older incumbents like hospitals could find themselves getting their lunches eaten. So, probably intuitively as well as intellectually, health systems really getting their technology clearly optimized to support their communities, their patients, and their providers might seem to be mission critical, especially as we contemplate the stuff that Mike Thompson was talking about in episode 389 about how there is increasingly data out there which identifies hospitals who are very inefficiently run. And so, if at a very basic level a hospital has misaligned tech that's requiring a lot of workarounds and stuff, which is another way to say wasting a lot of staff time, having the right technology deployed in the right way will certainly ground efforts to be effective and also help compete with some of these lurking entities who are looking to take a piece of the $3 or $4 trillion healthcare industry in this country—of which hospitals account for something like $1 trillion. And as Eric Bricker, MD, says in episode 351, this is why hospitals have a big red target on their back. Also, I would be remiss not to mention that non–purpose-built, dare I say bad, technology causes bad clinician burnout, which causes bad turnover, which is really expensive. Arshad Rahim, MD, MBA, FACP, talks about this in episode 323. By the way, I interviewed Emily Kagan Trenchard at NODE.Health's Annual Digital Medicine Conference in New York City this past December—always a great conference. Emily is SVP and chief of consumer digital solutions over at Northwell Health. Northwell, in case you haven't heard of this health system, is very large: 21 hospitals, 850 outpatient clinics, 300,000 patients a year. Yeah, it's big. You can learn more at northwell.edu and connect with Emily on LinkedIn. Emily Kagan Trenchard offers a unique perspective from within the American medical system: A spoken-word-poet-turned-healthcare-executive, she is on a mission to remix the human in healthcare, challenging entrenched assumptions about what it means to give and receive care in the digital age. As senior vice president, chief of consumer digital solutions, for New York State's largest health system, Northwell Health, Emily leads teams that push the limits of how we use technology to make healthcare seamless and steeped in humanity while keeping the company competitive at a time of radical change. She is a big believer that innovation is an ongoing process, not just a box to check, and launched Northwell's first UX department to ensure that patient perspectives and needs drove the design of digital tools and systems. Prior to joining Northwell, Emily led Web systems for New York City's Lenox Hill Hospital, where she drove the development of many early consumer health tools, including the first-ever implementation of the Zocdoc scheduling platform for a hospital. Emily holds a master's degree in science writing from Massachusetts Institute of Technology and a bachelor's degree from the University of California at Berkeley.   07:55 How does customer digital solutions fit into the larger technology infrastructure in healthcare? 09:54 “Where else do you have centers of gravity that you should respect in the architecture?” 10:11 “There is a constellation of need here.” 11:51 “We interact with way more than just patients.” 14:28 “We have to be able to understand the network of relationships in a population.” 15:11 How do EHRs and CRMs interact as two tentpoles in healthcare? 17:32 “The question is, where does a human being work?” 19:54 How are patients staying on a nonfragmented care journey in a proactive way? 23:46 “Anybody who's a consumer of our digital offerings has a relationship with us.” 29:33 “The medicine is being practiced not only on our physical bodies but on our digital bodies.” You can learn more at northwell.edu and connect with Emily on LinkedIn.   @ektrenchard of @NorthwellHealth discusses #EHRs and #CRMs on our #healthcarepodcast. #healthcare #podcast #EHR #CRM   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373)  

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

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)    

For the past few shows and in a few coming up, we are circling our wagons around a theme: In healthcare in this country, there are two teams. One team is employers, taxpayers, patients … those trying to keep healthcare prices down. Then on the other team, we have those looking for healthcare prices to continue to go up, meaning, as just one example, some health systems and some hospitals. There was a New York Times article recently, and Peter Hayes wrote an interesting comment about it on LinkedIn. He wrote: “This article is troubling on so many levels and clearly demonstrates that patient health and well-being are not the top priority of many in healthcare leadership in our hospitals. Unfortunately, it is much more about patient revenue than patient health. … The non-profit status of our health facilities is a huge hidden tax and wealth transference from every taxpayer that is estimated to be about $39 billion annually.” Look, for sure, not talking about everybody in healthcare leadership here, and increasingly I'm kinda thinking we need to maybe have more than one word for hospitals and their leadership because lumping them all together into a homogenous blob is really unfair to those rural and safety net organizations contending with all kinds of adversities—which is very, very different in circumstance to those so-called “well-resourced” hospital chains in suburban markets really raking in the cash and virtue signaling in very well-resourced press campaigns. And the irony of this whole thing is that a reason hospitals (that want to) get away with doubling down on profit-centric business models is actually their nonprofit status. This is a major loophole. If you are a nonprofit, you get to be excluded from some of the powers of the FTC (Federal Trade Commission), for example. But then there's also the lack of financial discipline, as Mike Thompson puts it in the show today. These nonprofit organizations have never had to run efficiently. They have never been asked to justify the new building or the other adds to their infrastructure that ultimately increase their costs of doing business in ways that, on the whole, might not benefit patient care. And I say “might not benefit patient care” fairly confidently because there is absolutely no correlation between high prices and high quality in healthcare. In fact, it can just as easily be the opposite. But if you overbuild and you buy too many MRI machines or whatever, then you gotta feed the beast. And then the downward spiral starts, and the anticompetitive, financially toxic behavior really kicks into high gear—which, again, is tough to regulate because our laws and legislation expect nonprofits to, you know, behave like nonprofits. In this healthcare podcast, I am thrilled to speak with Mike Thompson, who is the CEO and president of the National Alliance of Healthcare Purchasers. Interestingly, Mike is an actuary by background; and I am sure that that has come in handy as more and more data is becoming available for purchasers and also regulators. The National Alliance has created a playbook to help employers get a fair price from hospitals. In short, the playbook's five strategies to do so include (1) looking up what the fair commercial price is for your local hospital, which is really easy to see if you go to dashboard.sagetransparency.com. This Sage Transparency dashboard was created by the Employers' Forum of Indiana. Not to drown you in acronyms, but the Sage Transparency dashboard very elegantly combines RAND data showing what hospitals are actually charging employer plans and compares that to what's called the NASHP commercial break-even price. NASHP is the National Academy for State Health Policy, who crunched a lot of numbers to figure out this commercial break-even price. Once you know the fair commercial price for hospitals in your area, then one way to go could be (2) using an RBP (reference-based pricing) strategy and paying based on the fair commercial price plus a markup. Another strategy is to (3) start monitoring your ASO/TPA (administrative services organization/third-party administrator) carefully and see that they are paying this fair price and getting performance guarantees to hold them accountable to do so. Yet another strategy is to (4) gang up with other employers in coalitions, which is often necessary, given how much market power some of these hospitals have consolidated and all the anticompetitive practices they've managed to tuck into their FTC-exempt quiver. And last is to (5) regulate through legislation. One point that Mike makes very clear is that if nonprofit hospitals cannot remain true to their mission and if they are also not subject to market dynamics, that's a lose-lose for their communities. At that point, a very viable option is to regulate them like utilities. This is also what I talk about next week with Chris Skisak and Gloria Sachdev. The sad part about this whole thing is that hospitals and communities really should be sitting on the same side of the table working together to improve the health and well-being of their communities. And that should include—according to me, at least—keeping financial toxicity in check, especially just given everything we know for sure about how financial toxicity negatively impacts patient health. Oh, hey, here's a thing: Turns out I had a fever when I recorded this show, so yeah, Mike deserves a little extra kudos for very eloquently just going with it when occasionally my questions sort of ended without, you know, actually asking a question. You can learn more at nationalalliancehealth.org. Michael Thompson is the president and CEO of the National Alliance of Healthcare Purchaser Coalitions (National Alliance), the only nonprofit, purchaser-led organization with a national and regional structure dedicated to driving health and healthcare value across the country. Prior to joining the National Alliance, Mike was a Principal at PricewaterhouseCoopers (PwC) for 20 years. He is a nationally recognized thought leader for business health strategies and health system reform. Mike has worked with major employers and other stakeholders on sustainable cost reduction, integrated health, wellness and consumerism, retiree health, private health exchanges, and health reform. Known for developing and promoting collaborative cross-sector health industry initiatives, Mike participated on the steering board of the World Economic Forum's “Working toward Wellness” initiative and co-founded the Private Exchange Evaluation Collaborative. Prior to PwC, Mike served as an executive with diverse roles with Prudential Healthcare for over 17 years. Mike is a Fellow of the Society of Actuaries, serving on the Health Practice Council, and chairs the Medicare Sub-Committee of the American Academy of Actuaries. He is board president of the Innovation and Value Initiative. He is also widely recognized as a leading national advocate for mental health and well-being and was past president of the New York City chapter of the National Alliance for Mental Illness. 05:37 Check EP372 with Cora Opsahl; EP358 with Wayne Jenkins, MD; EP388 with Merrill Goozner; and EP346 with Peter Hayes for a deep dive. 05:48 Why should an employer health plan be concerned about how much area hospitals are spending? 07:01 How are hospitals quantifying their prices? 08:10 “I think we're not paying a fair price is the end game.” 10:45 How do we bring rigor back into the market? 11:12 What is NASHP? 15:10 What does the NASHP commercial breakeven take into account? 18:24 Why are hospitals conflicted when it comes to building a health system based on value and health? 20:17 Why is the onus on hospitals to defend the way they've spent the money they have? 21:58 “Where there are market dynamics, we typically see prices in that fair price range.” 25:06 What can employers do from a market standpoint, a program design point, and a policy standpoint? 27:11 What is the National Alliance of Healthcare Purchaser Coalitions playbook? 30:15 Why is changing the dynamics in the press important to changing hospital pricing? 33:02 How fundamental is the employer's role in making sure that they're paying a fair price for the healthcare services their employees are receiving?   You can learn more at nationalalliancehealth.org.   @IWLMikeT of @ntlalliancehlth discusses #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #hospitals #healthcarepricing   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371)

HRRP stands for Hospital Readmissions Reduction Program, by the way. I wanted to encore this episode with Dr. Rishi Wadhera because it's a great representation of a common root cause reason why quality metrics sometimes don't end well in real life. This root cause is otherwise known as Goodhart's Law, and we dig into Goodhart's law later on in this healthcare podcast. But the actual and ultimate impact of HRRP is also a pretty good representation of the consequences, what happens, when you create a blunt-force policy that assumes hospitals with very different circumstances are the same. Before we kick in to the episode, I asked Dr. Wadhera, my guest today as aforementioned, if there'd been any updates regarding HRRP since this show originally aired last year; and he told me that two key pieces have come out this past month in JAMA journals calling out CMS (Centers for Medicare & Medicaid Services) to move on from/retire this policy: A Decade of Observing the Hospital Readmission Reductions Program—Time to Retire an Ineffective Policy Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns? Thanks so much to Dr. Steve Schutzer and also BoneDoc66 for your really nice reviews this past month. So appreciated … thank you so much! And here is your encore. Today's guest is Rishi Wadhera, MD, MPP. Dr. Wadhera authored a retrospective analysis in the BMJ about the HRRP, which we will talk about in this healthcare podcast. Dr. Wadhera is a cardiologist at Beth Israel Deaconess Medical Center. He also has a master's in public policy at the Harvard Kennedy School of Government and also a master's in public health from the University of Cambridge. But here's the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this healthcare podcast and which my nerd heart could not love more: Goodhart's Law. This law is the root of so very many problems. Goodhart's Law is this (which I learned from Dr. Wadhera): “When a measure becomes a target, it ceases to be a good measure.” In other words, when we set a goal, people will try to take a shortcut to the goal, regardless of the consequences. And sometimes the consequences, paradoxically, are to do worse at the goal. Maybe because bean counters and admins and maybe even goal-oriented clinicians themselves will go right to the end goal, inadvertently skipping a whole bunch of (it turns out) rate-critical steps. For example, teaching to the test may not lead to students who deeply understand a subject. And anyone trying to achieve value-based care success, improve quality, form collaborations, or make sales might want to remember that old proverb, “Sometimes the shortest way home is the long way around.”   You can learn more at Dr. Wadhera's Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site.   Rishi K. Wadhera, MD, MPP, MPhil, is an assistant professor of medicine at Harvard Medical School, a cardiologist at Beth Israel Deaconess Medical Center (BIDMC), and the associate program director of the cardiovascular medicine fellowship at BIDMC. He is also health policy and equity researcher at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. Dr. Wadhera received his MD from the Mayo Clinic School of Medicine as well as an MPhil in public health as a Gates Cambridge Scholar from the University of Cambridge. He completed his internal medicine residency and cardiovascular medicine fellowship at Brigham and Women's Hospital in Boston. During this time, he also received a master's in public policy (MPP) at the Harvard Kennedy School of Government, with a focus on health policy. Dr. Wadhera's research spans questions related to healthcare access, quality, and disparities, as well as understanding how local, state, and national policy initiatives impact care delivery, health equity, and outcomes. Dr. Wadhera has published more than 80 articles to date, and he receives research support from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health (NIH)   03:30 What was the Hospital Readmissions Reduction Program intended to do? 05:22 Why did the Centers for Medicare & Medicaid (CMS) think some readmissions were preventable? 06:02 “The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge planning, transitions of care, and post-discharge follow-up and care.” 06:58 How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? 08:16 “The 30-day readmission measure—it's an incomplete measure.” 11:48 “I think patients … are smart, and they know what's going on.” 13:34 “What's happening is, we're just increasing the number of times they need to come back to the ER within that 30-day period.” 13:55 “The weird thing about the HRRP is that when it evaluates hospitals' 30-day readmission rates, it's a yes-no phenomenon.” 15:03 “What CMS does is, it risk adjusts … and that is what we should be doing.” 18:30 “This program has been incredibly regressive.” 19:04 “Poverty, neighborhood disadvantage, housing instability—these factors are out of hospitals' control.” 21:50 “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.” 22:06 “It just makes no sense to take resources away from hospitals.” 22:32 EP295 with Rebecca Etz, PhD. 23:47 What's the way to improve quality of care globally? 25:37 “CMS's approach to improving quality of care has really anchored … [that] to payment.” 26:08 “It's time for us to rethink what our approach to quality improvement should be.” 29:22 “Policy makers have an obligation to rigorously test the impact of these types of policies before they roll them out nationally.” 31:41 Can you scale healthcare nationally?   You can learn more at Dr. Wadhera's Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site.   @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission What was the Hospital Readmissions Reduction Program intended to do? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission Why did CMS think some readmissions were preventable? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge planning, transitions of care, and post-discharge follow-up and care.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “The 30-day readmission measure—it's an incomplete measure.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “What CMS does is, it risk adjusts … and that is what we should be doing.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “It just makes no sense to take resources away from hospitals.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission What's the way to improve quality of care globally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “It's time for us to rethink what our approach to quality improvement should be.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission Can you scale healthcare nationally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission   Recent past interviews: Click a guest's name for their latest RHV episode! Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370)

This show was one of the most popular episodes in the past 12 months. So, here it is again for your listening pleasure. Mostly this whole episode is about the so-called “Big Three” PBMs that provide between the three of them pharmacy benefit services for 95% of insured Americans. PBM stands for pharmacy benefit manager, and the Big Three PBMs being ESI, otherwise known as Express Scripts; OptumRx, which is a part (a big profitable part) of UnitedHealth Group; and then also CVS. Yes, CVS is not just for your retail pharmacy needs; they are also a huge pharmacy benefit manager. Now, we get to the GoodRx part of our story. If you don't know how GoodRx works, I would strongly encourage you to go back and listen to “An Expert Explains” with Dr. Ge Bai from last year (AEE13). That said, here's the super short semi-reductive version to keep us all level set here. If you already know how GoodRx works, you can skip forward about four minutes. So, first of all, let's all understand that GoodRx's business model only exists because the pharmacy supply chain dominated by these three big PBMs that we just talked about is such a cluster. GoodRx profits from that dysfunction. So, as I said, here's the short version of how they do that. It all hinges on so-called spread pricing, and this is what I mean by that. Patient goes into pharmacy with a prescription for generic drug X. The patient has insurance—good news! Pharmacist checks the computer and sees that this patient should be charged, I don't know, $50 for drug X. The patient's insurance carrier picks up, say, $30 of the $50 cost; and the patient is left with, say, a co-pay of $20. Who did that little math there in the computer? The PBM (the pharmacy benefit manager) did that math. That's their thing, these PBMs. They adjudicate claims. That's what this math is called. Anybody who goes into a pharmacy with a prescription, it's the PBM on the back end who figures out how much the patient owes and how much their insurance will pay and what the patient responsibility is, etc. Goodness, you might say. How much are the PBMs being paid to perform this useful service? Turns out, it's free. That's right … the Big Three PBMs do all this adjudication for free. No charge to plan sponsors. Isn't that nice? Except it's actually not free if you dig into it. The PBM is certainly getting paid by means of arbitrage. They're taking a little something something out of the middle of every single transaction. Here's what that looks like in the example aforementioned. Recall the patient's insurance paid $30, and the patient themselves paid $20. The question is, how much did that drug cost the PBM? Remember, that's commerce: Buy low, sell high, and all that. You buy something, and then you sell it for more than you bought it for. OK, so we're talking about a generic drug here. They're cheap (usually). So, let's just say drug X costs, I don't know, $5. The PBM pays the pharmacy $5 for that generic script—and you can see how much money the PBM just made right there. The patient and their plan sponsor got charged $50, and the PBM's cost of goods was $5. Multiply that profit margin by the billions of generic prescriptions in this country that run through insurance, and you have a tidy little business model there. UHG, the parent company of OptumRx, made $24 billion in profit in 2021. Not all of that was from generic drug arbitrage (ie, taking advantage of spread pricing), but some of it was. And $24 billion is an awfully big amount when you consider whose paychecks all those pennies were lifted from. PBM services are anything but free. PBMs are collecting massive windfalls in the so-called spread between what the patient and the plan pay and what the PBM is actually buying those drugs for. Here's another wrinkle: When a PBM contracts with a pharmacy, part of their contractual terms is that the pharmacy's list price for drugs cannot be lower than a certain amount usually having something to do with the PBM's rates. So, pharmacy list prices become artificially high as a result, meaning that cash-pay patients who just wander into a pharmacy and try to pay cash pay an artificially high price. Into this mess swoops GoodRx with a killer idea. They see all that money on the table that PBMs are cleaning up in that spread. They want a piece of that action. And in the beginning, PBMs were fully on board with this. They were fully on board because the market GoodRx was going after was the uninsured market, meaning untapped turf for PBMs. And because PBMs make so much money off of each transaction, PBMs are always hungry for more transactions (the Big Three PBMs, anyway). They love more transactions. The more more more with the transactions, the more more more with the money. So, GoodRx goes to the PBMs and says, “Hey … if a cash-pay patient shows up in a pharmacy, what price would you charge them for you to adjudicate that claim? You know how much money you have to pay the pharmacy, so what can the patient price be? What spread are you willing to accept? GoodRx will take a little off the top, but you can keep your spread on this new frontier of patients that you haven't historically had access to because … uninsured. Oh, by the way, we, GoodRx … we're gonna go around to all your competitors, too (just saying)—the other two PBMs—and we're gonna show their prices, too, in our GoodRx app at different pharmacies. So, you're gonna have to compete with other PBMs in this model.” This is why GoodRx cash prices for generics are so very very often less than what the patient will pay if they use their insurance. In the GoodRx app, PBMs have competition. So, by not using their insurance, patients often pay less for generic drugs—which, by the way, are 90% of the scripts written in this country—and also, as an added bonus, patients don't have to jump through all the weird and arduous prior auths or step therapies or other hurdles that a PBM might toss in the mix. So, from a patient perspective, using GoodRx could save money, save time, and you could get your drugs faster because you don't have to wait around for some prior auth to go through. But this was not what PBMs had originally thought they were signing up for. They were working with GoodRx to gain new market share from the uninsured market, not lose market share to more and more patients forgoing their insurance, meaning forgoing shelling out to the PBM their spread on the transaction. Cue my conversation today with Dr. Ge Bai. Ge Bai, PhD, CPA, is a professor of accounting at Johns Hopkins Carey Business School and a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. In this healthcare podcast, Ge Bai and I discuss the reactions of the Big Three PBMs to consumers getting all consumer-y when it comes to buying their generic drugs—despite the fact that, in my interview with Dr. Sunita Desai (EP334), she said that studies have shown that 67% of patients are unaware that they might be able to get a better price by not using their insurance and shopping around on GoodRx or Amazon or at a cost-plus pharmacy like Blueberry in Pittsburgh or Mark Cuban's new thing. Despite that, it means 33% (one-third) of patients are aware that they can price shop and potentially get a better price not using their insurance on generic drugs; and apparently, it's making some people at some PBMs nervous. Check the ESI (Express Scripts) blog post about their new prescription benefit that automatically applies discounts. Hmmm … sounds like a defensive play to me? What do we make of this? That's my first question to Dr. Ge Bai in this episode. Also, if you're really intrigued by generic drug goings-on, go back and listen to the show with Dr. Steven Quimby (EP344) when you have a chance. It's about the high cost of generic drugs, and we go deep into supply chain machinations.   You can learn more on Ge's Web site at Johns Hopkins University. You can also connect with her on LinkedIn. Ge Bai, PhD, CPA, is professor of accounting at the Johns Hopkins Carey Business School and professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on healthcare pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies.   08:39 What is ESI doing by automatically applying discounts to generic drugs? 09:53 Why are PBMs losing money when consumers don't use their benefit? 10:40 “GoodRx disrupted the ongoing game.” 10:58 How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? 12:07 Amazon pricing versus GoodRx pricing. 12:44 How much money is a PBM really making? 13:54 EP344 with Steven Quimby, MD. 14:24 EP334 with Sunita Desai, PhD. 14:37 How is future fear playing into the PBM business model? 16:49 Is there a negative consequence to subtracting from the bottom line in a PBM model? 17:44 “I think to have strong PBMs does not mean necessarily bad things for patients.” 19:33 What happens if everyone uses Amazon for drugs? 22:33 If every PBM gets their own discount cards, what will happen? 25:32 “We are actually witnessing a potential sea change.” 26:19 How do cost-plus pharmacies factor into the current market? 29:09 Is a profit shortfall inevitable? 29:28 “PBMs have to give a slice of their profit back to consumers. That's just reality.” 30:05 Can anything be done on the PBM side to generate a higher margin in the generic space? 31:34 “Naive plan sponsors are a big problem.” You can learn more on Ge's Web site at Johns Hopkins University. You can also connect with her on LinkedIn.   @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing What is ESI doing by automatically applying discounts to generic drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Why are PBMs losing money when consumers don't use their benefit? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “GoodRx disrupted the ongoing game.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Amazon pricing versus GoodRx pricing. @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How much money is a PBM really making? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How is future fear playing into the PBM business model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Is there a negative consequence to subtracting from the bottom line in a PBM model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “I think to have strong PBMs does not mean necessarily bad things for patients.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing What happens if everyone uses Amazon for drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing If every PBM gets their own discount cards, what will happen? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “We are actually witnessing a potential sea change.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How do cost-plus pharmacies factor into the current market? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Is a profit shortfall inevitable? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “PBMs have to give a slice of their profit back to consumers. That's just reality.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Can anything be done on the PBM side to generate a higher margin in the generic space? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “Naive plan sponsors are a big problem.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Recent past interviews: Click a guest's name for their latest RHV episode! Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman

If you want to keep listening, follow and subscribe to Everyone Hates Healthcare, please CLICK HERE The healthcare system may be broken in many ways, but let's talk about some of the existing tools out there that are trying to fix it.  In this episode of Everyone Hates Healthcare, Michael Swartz has a very insightful exchange with Dave Chase, creator, founder, and leader of Health Rosetta. In his late thirties, Dave witnessed how broken healthcare was after a complete system failure led to the passing of one of his friends. He created the Health Rosetta framework to guide public and private employers to reduce their health benefits costs and improve the quality of care for plan members. Listen to this episode to learn more about the Health Rosetta approach to improving health benefits!

The healthcare system may be broken in many ways, but let's talk about some of the existing tools out there that are trying to fix it. In this episode of Everyone Hates Healthcare, Michael Swartz has a very insightful exchange with Dave Chase, creator, founder, and leader of Health Rosetta. In his late thirties, Dave witnessed how broken healthcare was after a complete system failure led to the passing of one of his friends. He created the Health Rosetta framework to guide public and private employers to reduce their health benefits costs and improve the quality of care for plan members. Listen to this episode to learn more about the Health Rosetta approach to improving health benefits! Click this link to the show notes, transcript, and resources: outcomesrocket.health

We have done three inbetweenisodes so far on healthcare stakeholder collaboration. In sum, there are two major issues that patients have with our healthcare industry, and both can only be solved for if healthcare stakeholder collaboration happens: Patients falling into care gaps and winding up with bad downstream consequences Patients not being able to afford their care This show, we are moving on to talk about an actionable solution here to the care gap problem—the very ubiquitous issue of patients with some pretty serious health issues who remain either undiagnosed or not on optimal treatment or follow-up. Our team at Aventria Health has a big success story that I would love to share relative to care gaps and how to think about solving for them at the local, regional, and national level. Spoiler alert here: What we're talking about in this healthcare podcast, which we call our Groundswell Solution™, improved the usage of best-practice clinical guidelines for patients with end-stage liver disease by 23% nationally. Also keep in mind that what is fast becoming a major factor in developing liver disease is obesity, and the incidence of liver disease is growing. As aforementioned, we are talking about an Aventria Health Group Groundswell Solution, which is the idea of getting diverse stakeholders who are enthusiastic to be empowered as part of a team to help solve for gaps in care and really improve patient outcomes. It definitely takes a village, and if we can find ways where different organizations can work together to contribute and leverage strengths along shared priorities, then great things can really happen. Before we kick in to the show here, let me bring up the miracle of the commons. This is cool. This was a term that was coined by Elinor Ostrom. Ostrom, by the way, won the Nobel Prize for this work. She saw how humans have such an amazing capacity to work together through what she called design principles and come up with some really unique and inspiring solutions that benefit everybody. You can connect with Stacey and Dave on LinkedIn. If you are interested in contributing to Groundswell, please complete this short questionnaire.  Dave and Stacey are co-presidents of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. They are also co-presidents of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. 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. Dave is a 30-year veteran helping clients work at the intersection of payers, providers, pharmacy, Pharma, and medical device companies. He is an accomplished strategist, providing innovative customer marketing, access, quality, and health intervention solutions for large clients and has directed the development of numerous industry-leading campaigns in primary care and specialty markets. Dave has helped dozens of clients achieve top rankings in their respective categories. He is also an active member of the Pharmacy Quality Alliance.   03:03 How can areas of improvement be flagged in such a fragmented patient care journey? 04:06 What is “the miracle of the commons”? 04:54 How is the miracle of the commons being used at Aventria and QC-Health? 07:51 What is Groundswell, and how does it utilize the miracle of the commons? 11:13 “Is the answer, then, to drive more knowledge and more awareness?”—Dave 11:35 “What about using technology to provide curated, highly targeted information that can support them at the point of care?”—Dave 13:25 “You want to identify where these gaps are across the full spectrum of the journey.”—Dave 15:08 “This is something that is not commonly happening on its own.”—Dave 16:40 “Done in the right way, people are excited … to improve care and improve outcomes.”—Dave 18:50 “Our aim is really to meet people and teams where they are.”—Stacey 19:35 “You don't have to know how or why or where—merely that I think this outcome is not what it could be. That's the place to start.”—Dave 20:01 “You have to understand the different goals of the different stakeholders.”—Dave 21:14 “If we can do the right things the right way, then we can serve many masters.”—Dave   You can connect with Stacey and Dave on LinkedIn. If you are interested in contributing to Groundswell, please complete this short questionnaire.    Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast How can areas of improvement be flagged in such a fragmented patient care journey? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast What is “the miracle of the commons”? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast How is the miracle of the commons being used at Aventria and QC-Health? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast What is Groundswell, and how does it utilize the miracle of the commons? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “Is the answer, then, to drive more knowledge and more awareness?” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “What about using technology to provide curated, highly targeted information that can support them at the point of care?” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “You want to identify where these gaps are across the full spectrum of the journey.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “This is something that is not commonly happening on its own.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “Done in the right way, people are excited … to improve care and improve outcomes.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “Our aim is really to meet people and teams where they are.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “You don't have to know how or why or where—merely that I think this outcome is not what it could be. That's the place to start.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “You have to understand the different goals of the different stakeholders.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “If we can do the right things the right way, then we can serve many masters.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282)    

In this healthcare podcast, I have Merrill Goozner on the show talking about his prognostications for the future of healthcare in this country and how, realistically, it could be engineered so that the healthcare industry rightsizes itself relative to our GDP. Merrill offers three glide paths to this end. Okay … so, let's break this down some. First, Merrill talks about the full impact of huge numbers of patients/people in this country who are scared to seek medical attention. They are afraid to play the game at the end when the bill comes in the mail and they open it up having no idea what it is going to be. It's a magical mystery guessing game of luck and chance where losers go bankrupt. This is not a victimless situation we have going on here in this country. All these deaths of despair and life expectancy going down … this is unprecedented. So now, we're level-set on the stakes. Interestingly, Merrill plots out the aspiration for healthcare spending in exactly the same way that David Muhlestein, PhD, JD, did in episode 364. The goal, according to both of them, isn't to reduce healthcare spending per se. That would be nie near impossible to pull off in the real world, but we could work on holding healthcare cost increases below the rate of GDP growth. Optimal might be healthcare costing, say, 13% of GDP like it does in Switzerland instead of upwards of 20% ($1 out of $5) getting stuffed in the pockets of a healthcare entity or their shareholders. Fifty percent of that, by the way, is being paid for by the government, the other 50% largely coming out of the wages of employees either directly or indirectly. Okay … so, what is the lightning-in-the-bottle moment where we clip in for this journey toward rightsizing healthcare prices? Merrill says it's a combo of patients and employers and taxpayers crying uncle at the same time that technology and new competitors move in on the supply side and start to chip away at older incumbents like hospitals, especially hospitals who have broken their social contract with their communities—and there I'm paraphrasing some terminology Vikas Saini, MD, uses in an upcoming episode on hospitals and their embarrassing levels of charity care. So, it's harnessing forces on the demand side of the equation and on the payment side of the equation, coupled with goings-on on the supply side. With all of this going on, Merrill says that, in this crucible of transformation, we could get better care for lower costs. To accomplish that, he says step 1 is for the team for healthcare costs going down—employers taxpayers, government policy makers—gang up, create a value alliance, and work together. These allies then tell the healthcare industry, “Look, gang … ixnay on the growth rates you've been accustomed to in the past. Period. You are going to need to deal with that, so get used to it.” That is kind of where all of this starts. Merrill mentions three glide paths that will help up get from here to there, and he names the three: Accountable care—essentially putting providers at risk, giving them budgets that they are responsible to work within Paying for value. We have PCPs who deliver a lot of value. We should pay 'em more. We should also put docs on salary like they do at Mayo and some of these other leading Centers of Excellence. All-payer pricing, which we do get into. They have this now in Maryland. It's basically when everybody pays the same price for the same service. Merrill says this all kind of rolls up into removing the incentives that reward low-value care. That can be really expensive. I'm paraphrasing here. I'm sure for many of you, Merrill Goozner needs no introduction. He's been the editor in chief of Modern Healthcare. He wrote a book on the drug industry. He was a reporter for many years before that and also did public interest work. Thank you to Hugh Sims, MD, MBA, for his support and insight! You can learn more at GoozNews. You can also read his book on the drug industry, The $800 Million Pill. Merrill Goozner served as editor in chief of Modern Healthcare from 2012 to 2017 and, as editor emeritus, continued to write the magazine's weekly column until April 2021. In October 2020, he launched GoozNews.substack.com, where he continues to write about healthcare, the environment, and other subjects. Prior to joining Modern Healthcare, his journalism career spanned nearly 40 years as an editor, writer and journalism educator. In 2004, he authored The $800 Million Pill: The Truth Behind the Cost of New Drugs. He previously served as a foreign, national, and chief economics correspondent for the Chicago Tribune (1987-2000) and a professor of journalism at New York University (2000-2003). He has contributed to numerous lay press and scientific publications over the course of his career, ranging from the New York Times to the Journal of the National Cancer Institute. He earned his master's degree in journalism from Columbia University in 1982 and his bachelor's degree in history from the University of Cincinnati in 1975. The University of Cincinnati named him a Distinguished Alumni in 2008 and inducted him into its Journalism Hall of Fame in 2016. 06:24 How is the rise of the high-deductible plan affecting the nation's health? 07:20 What is one of the big issues not being discussed in America today? 08:33 What kind of tipping point is in store for hospitals in this decade? 09:01 What two trends are we going to see in healthcare in the coming decade? 10:50 What are the ways in which the changes in healthcare go well, and what pitfalls do we need to look out for? 11:14 “[This] is about what is sustainable and what is not sustainable.” 12:35 “Healthcare is misnamed. It's sick care.” 13:12 Why do we need to talk more about who gets sick in this country? 13:51 “Pricing is part of the problem, but volume is the other part [of the problem].” 15:40 “The world is gonna change, you're gonna change, and we're gonna provide you a glide path … because this is what we need as a society.” 17:20 What should be the overall goal for healthcare spend? 18:45 EP364 with David Muhlestein, PhD, JD. 19:40 Why do we need to address physician pay? 25:31 Why does the single pricing system create equality? 30:11 EP363 with David Scheinker, PhD. 30:34 EP370 with Erik Davis and Autumn Yongchu. 30:55 What are the three glide paths for the future of healthcare? You can learn more at GoozNews. You can also read his book on the drug industry, The $800 Million Pill.   @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast How is the rise of the high-deductible plan affecting the nation's health? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What is one of the big issues not being discussed in America today? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What kind of tipping point is in store for hospitals in this decade? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What two trends are we going to see in healthcare in the coming decade? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What are the ways in which the changes in healthcare go well, and what pitfalls do we need to look out for? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “[This] is about what is sustainable and what is not sustainable.” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “Healthcare is misnamed. It's sick care.” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast Why do we need to talk more about who gets sick in this country? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “Pricing is part of the problem, but volume is the other part [of the problem].” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “The world is gonna change, you're gonna change, and we're gonna provide you a glide path … because this is what we need as a society.” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What should be the overall goal for healthcare spend? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast Why do we need to address physician pay? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast Why does the single pricing system create equality? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34)  

Here's a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean success in all of its financial glory—because they have experience and the scale and also the specialized departments who keep track of all kinds of intricacies that are rate critical to MA success. Specifically, things Betsy Seals talks about as critical success factors, for example, are having relationships with brokers and health systems and other provider organizations. She also makes it clear how much local market knowledge is necessary. A benefit design working great in one local market might be a medical trend disaster in another area with different levels of social determinants of health (SDoH) or different disease patterns, so scaling into new areas isn't a matter of just cutting and pasting. History has shown it's easy enough to go down in a flaming ball of unanticipated medical trend and/or OIG/DOJ scrutiny. So, this is one thing that big MA carriers can get right and potentially, for sure, benefit patients in their plans. Now I say this knowing full well that there's a brouhaha afoot in which there are some who are really pro-MA and there are some who are really not. In this show with Betsy Seals today, we do not get into this (ie, Do patients in MA plans fare better than patients in traditional Medicare?). But I have a point to make, and I'm just gonna make it here. Like most “Is this better than that?” questions in healthcare, there is not one answer; and anyone running around espousing pretty much anything as a broad-stroke holy grail is pretty much full of it—and I would say that as a general statement. Whether MA is better than traditional Medicare depends on who the patient is and also which MA plan we're talking about here. So, starting on the “not a fan” side of the house, Wendell Potter has said (with evidence) that if a patient is toward the end of his or her life or acutely ill or needs to go to an NCI-designated cancer center, it could easily be deduced that traditional Medicare is going to be better. On the other hand, there seems to be evidence, including a recent JAMA article by Ravi Parikh, MD, MPP, and Ezekiel Emanuel, MD, PhD, that concludes MA produces a 22% to 26% reduction in costs compared to MSSP (Medicare Shared Savings Program) arrangements. And this is across just a general patient population of all age ranges, if I'm reading the study right. The great results that are discussed in that JAMA article are what can happen when payers and providers align to tackle SDoH and preventative stuff and are willing to go out into the community to curb potentially avoidable downstream acute events. David Carmouche, MD, by the way, on episode 343 talked at length about this. But there are variables here, and let me mention one of them: how good the Medicare Advantage plan is at risk-based contracting with physician groups. How good are they at putting patients into accountable relationships with provider organizations who are getting paid to keep patients healthy, meaning the MA plan is offering budget-based prospective payment contracts to physician groups? This is the case in that Ochsner/JAMA article example that Dr. David Carmouche was talking about. Ochsner, the health system in Louisiana, and MA plans were working together; and both assumed risk for this population. Susan Dentzer, president and CEO over at America's Physician Groups (APG), does a great job at covering a bunch of these topics on the Race to Value podcast. Another thing that will impact care quality is how good the plan leadership is at balancing patient care and shareholder demand for profit. Bottom line, it is not productive to be indiscriminately pie-eyed about pretty much anything in healthcare or throw babies out with bathwater on a regular basis. As Ge Bai, PhD, CPA, has said on this show (and others have said), there's no angels and no devils in healthcare. Everybody is some combination of both. And, in general, the only reason anybody does anything in healthcare is because it appeals to their self-interest. So, not working with some other healthcare stakeholder because we perceive them as greedy or “industry” or whatever is gonna mean that nobody is working with anybody. Just keep your eyes wide open, check the math, and in your contracts, get actual dollar amounts and not discounts. In this healthcare podcast, as mentioned a few times now, I am speaking with Betsy Seals. Betsy Seals is CEO and cofounder of Rebellis Group, a managed care consulting firm working with Medicare Advantage plans. Oh, and one acronym alert before we dive in here: SNP stands for special needs plan. A special needs plan is a Medicare Advantage coordinated care plan that is specifically designed to provide targeted care and limit enrollment to special needs individuals. So, a special needs individual could be any one of the following: An institutionalized individual A dual eligible, meaning somebody who has Medicare and Medicaid An individual with a severe or disabling chronic condition, as specified by CMS SNPs are becoming a bit of thing in the MA space this year, and Betsy talks about this trend. You can learn more at rebellisgroup.com. Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 06:16 Is Medicare Advantage still a cash cow? 06:42 Why should Medicare Advantage be the most lucrative line of business? 07:07 “If there weren't a lot of money in it, nobody would do it.” 07:29 What should you know before jumping into the Medicare Advantage market? 14:04 What issues do upstarts overlook when getting into Medicare Advantage? 17:07 What is one of the next areas that Betsy thinks CMS will crack down on? 18:24 “Look at the data.” 19:53 “I think there's a lot of lessons that you could see over the past years in the industry.” 20:52 “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” 21:02 Why don't common business models always work in healthcare businesses? 22:29 What are the new key trends coming out of the Medicare Advantage space? 26:04 Why is it important to bring in your clinicians when entering a dual market? 27:52 What's going on in the chronic conditions space? 32:14 What's necessary to the infrastructure with any kind of SNP product? 32:56 What's Betsy's forecast for the future of Medicare Advantage? You can learn more at rebellisgroup.com. @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Is Medicare Advantage still a cash cow? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why should Medicare Advantage be the most lucrative line of business? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “If there weren't a lot of money in it, nobody would do it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What should you know before jumping into the Medicare Advantage market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What issues do upstarts overlook when getting into Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What is one of the next areas that Betsy thinks CMS will crack down on? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “Look at the data.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “I think there's a lot of lessons that you could see over the past years in the industry.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why don't common business models always work in healthcare businesses? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What are the new key trends coming out of the Medicare Advantage space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why is it important to bring in your clinicians when entering a dual market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's going on in the chronic conditions space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's necessary to the infrastructure with any kind of SNP product? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's Betsy's forecast for the future of Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter

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

Brendan McPhillips was the campaign manager for John Fetterman's general election campaign, helping guide it to a win over Dr. Oz in the cycle's most chaotic and closey watched Senate race. In this conversation, Brendan talks his path to politics that started in a community college in conservative Southern California and includes running Iowa for Buttigieg in the 2020 primaries and working as Biden PA State Director in the general election. And, of course, we go deep on Brendan's time with Fetterman...from meeting him over a decade ago, running his '16 Senate race, taking the helm of Fetterman 2022 this spring...the candidates, the stroke, the message, the attacks, the debate, and the win. IN THIS EPISODE…Brendan's path from conservative Southern California to working in Democratic politics…Brendan runs Iowa for Pete Buttigieg in the 2020 primaries…Brendan crosses paths with John Fetterman over a decade ago…The Brendan McPhillips 101 on how to run a race in Pennsylvania…Brendan's take on the Fetterman dominant primary win…Brendan takes the helm as manager on the heels of the primary win & health scare…Brendan breaks down the case the campaign made against Dr. Oz…How the campaign beat back the “soft on crime” attack…Brendan weighs in on the Mastriano Effect on the Senate race…Brendan takes aim at grifting Democratic Scam PACs…Deep inside the Fetterman vs Oz debate…Brendan's expectations heading into Election Day…and his analysis of the 5-point Fetterman win…Brendan's take on Pennsylvania's status as a swing state heading into 2024…Lessons other campaigns can learn from the Fetterman win…AND Amtrak tours, annoying naysayers, Val Arkoosh, Tony Baker, Joe Biden, Bob & Barbara's, George W. Bush, carbon copies, James Carville, Bob Casey, Dave Chase, crazy kitchen cabinets, dive bars, gas bills, GED classes, Andrew Gillum, Lindsay Graham, grocery clerks, HQ Analytics, Ben Halle, hard-ass bouncers, hucksters, Bill Hyers, interesting dudes, Iowa steak frys, Johnstown, Rebecca Katz, Conor Lamb, Malcolm Kenyatta, media buyers from DC, mega churches, Middle Seat, the New Jersey State Hall of Fame, Notre Dame, Barack Obama, old adages, off-track betting, phone trees, Ed Rendell, resident gofers, Mike Schmuhl, Rick Scott, Josh Shapiro, The Situation, Snookie, special sauce, South Bend, the Susquehanna, Temecula, thrilling the DCCC, the Turf Club, UFCW, VFW halls, weirdos, wild rides...& more!

A Fiduciary's Guide to Data Analytics with Agility Innovation Partners. This episode is a follow-up to my video "The Consolidated Appropriations Act 101 - Comply or Die?" The Consolidated Appropriations Act, otherwise known as the CAA, established protections for consumers related to surprise billing and transparency in health care. Upcoming fines can and will be heavy, amounting to $100/day PER EMPLOYEE, which is substantially greater than the fines hospitals receiving for being non-compliant, which was only $300 total day. In this Episode - Part 2 - we focus on an employer's fiduciary responsibility now that they have access to claims and pricing data due to the CAA regulation, and the power of using an innovative Data Analytics platform to make sense of it. Agility Innovation Partners helps offer a data analytics platform with "at-scale pricing" to small-to-mid-market brokers who may not have the leverage on their own. They also offer consulting after the decision to purchase a data analytics platform called Innovu, so that consultants can make sure they maximize the ROI on their investment. Innovu also offers a CAA fiduciary tool stack with benchmarking against 4 million lives for plan design, claims cost, plan design etc, so that an employer can determine if they are paying reasonable cost for care and are compliant. If not, now they know and can take action! Here is a recent article covering the CAA in greater detail, and outlining the employer obligation to be compliant. Hat's off to Dave Chase, co-founder and CEO of Health Rosetta for bringing it to my attention! https://docket.acc.com/erisa-covered-companies-must-disclose-health-plan-costs --- Support this podcast: https://anchor.fm/spencer-harlan-smith/support

This episode was one of the most popular episodes in the past 12 months. Since it aired, there was a show with Kevin Schulman, MD (EP366), that added some context, which I would recommend, and also one with David Muhlestein, PhD, JD (EP364). Those two shows and this one are a good three-pack. And hey, here's something new that we're going to try out. Coming up in December, Dr. Bricker and I will host a smallish virtual chat to discuss the topics covered in this episode. It will be a conversation, not a presentation, so therefore the “why” behind the “smallish.” If you are kinda thinking this is something that you'd like to do, go to our Web site and scroll down to the “Join the Relentless Tribe.” When we get our act together, we'll send out the details for how to sign up in a future email. I'm thinking it will be very cool to get a chance for the great people who support our show enough to actually get a weekly email to talk amongst ourselves! In this healthcare podcast, I'm speaking with Eric Bricker, MD, about how so many entities in healthcare are getting up in other people's business and swimming in other people's traditional lanes. We kick off the conversation talking about the payer, PBM, and hospital system horizontal consolidation that has transpired over the past decades (that's plural). Horizontal consolidation is pretty much the easiest way to decimate all competition in your own swim lane so that you can charge more and not worry so much about patient/customer/member experience because the patients/customers/members have no better alternative. They effectively have nowhere, or few other places at best, to go if they leave you. So, what's the impact of horizontal consolidation? Commercial insurance costs have gone up 4x the rate of other benchmark goods and services. Let's spend a moment, shall we, on the human impact of all this extreme consolidation. The impact is your sister, your neighbor, your son, your friend. So many feel so much pressure financially in our country today because of healthcare costs. Even families earning significantly more than median household income are forgoing care because of costs. This was in a recent paper. (The authors are Alyce S. Adams, Raymond Kluender, Neale Mahoney, Jinglin Wang, Francis Wong, and Wesley Yin.) But the direct observable financial toxicity resulting from high healthcare patient costs is really only the tip of the iceberg here. As Dave Chase from Health Rosetta has said a million times already, high healthcare costs have a multitude of effects on employers, big and small. One big one is, if healthcare costs more, then there's less money for salaries. Dave, citing lots of evidence, has long attributed wage stagnation in this country to accelerating healthcare costs, which became even more rampant during periods of industry consolidation. Dave Chase leads Health Rosetta, by the way. Here's another human toxicity: Listen to episode 337 with Oliva Webb on the impact on her life as a result of the undeniably and unquestionably common non-excellent treatment by the PBMs and SPPs that she has to deal with. Because, as Dr. Bricker also says, no competition means basically not a whole lot of concern about patient experience. Why should a for-profit business spend money to improve something when there's nothing really to be gained for them financially to do so? I mean, the best a patient can do most of the time is hop from the frying pan into the fire. That's what happens when there's no competition or no real competition. Also consider the burned-out clinicians who have to get stuck in the middle of this nobody-really-cares-at-the-monopoly customer service paperwork quagmire. By the way, here's a sidebar that might come as a surprise to some people, but please take this in the spirit with which it's intended. All of us innovators and lifelong learners, we want to update our beliefs when the facts show us an updated conclusion. So, I have learned that all of this consolidation was going on long before the ACA (Affordable Care Act). My point here is to please look into this well-documented trend line before reflexively tweeting that the ACA drove consolidation. Dr. Bricker and others like Dr. Mai Pham have told me that, in their opinion, low interest rates, cheap debt, and a desire to eliminate competition are wildly powerful drivers of consolidation. Anyway, about eight minutes into the interview with Dr. Bricker, if you're one of the ones who knows all you care to know about horizontal consolidation, we get into vertical integration, vertical consolidation—and this is where things get interesting. And when I say interesting, I mean it in a “we live in interesting times” kind of way. The vertical consolidation conversation segues into whose swim lane that the digital health and other innovators or, dare I say, disrupters are diving into and whose lunch they are aiming to eat. Dr. Bricker probably needs no introduction. He is the force behind AHealthcareZ, which you can find online, on Twitter, YouTube, and LinkedIn. He has worked as a clinician, in healthcare finance. If that weren't enough, he's also been an entrepreneur—a very successful entrepreneur, I might add. He started one of the first healthcare navigation firms. You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn.   Eric Bricker, MD, is an internal medicine physician and former cofounder and chief medical officer of Compass Professional Health Services. Compass is a healthcare navigation service that grew to 2000+ clients, including T-Mobile, Southwest Airlines, and Chili's/Maggiano's restaurants. Compass was acquired by Alight Solutions in July 2018. Alight is a 10,000-person employee benefits and HR outsourcing company that separated from Aon in 2017. Dr. Bricker has since started AHealthcareZ.com, with 300+ healthcare finance videos with approximately 120,000 views per month across all platforms. In 2022, he became medical director of SimplePay Health, an alternative health plan that empowers employees with high-quality care, concierge support, and easily understood payment. He is also the author of Healthcare Money Campfire Stories.   05:50 What is this “megatrend” happening in healthcare right now? 07:11 How has consolidation changed the healthcare landscape? 09:41 What is vertical integration within healthcare? 11:07 Why doesn't inorganic growth benefit patients? 12:52 “What is best for the patient does not necessarily make the most money.” 14:02 “It's not that it's above the law … it is just intentionally obscured.” 18:16 “Healthcare is glacial. It is slow.” 22:36 “The largest source of healthcare costs is hospitals.” 25:00 EP330 with John Marchica. 28:20 “What have the historical priorities been of the administrators of those hospitals?” 28:35 “Every hospital CFO knows that they need sick people.” 29:21 EP343 with David Carmouche, MD. 30:01 “The payment change has to come first.” 31:19 “The money wins.” 33:16 “You've got to put the financial incentives in place … to make people actually behave the way that they should.”   You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn.   @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth What is this “megatrend” happening in healthcare right now? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth How has consolidation changed the healthcare landscape? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth What is vertical integration within healthcare? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth Why doesn't inorganic growth benefit patients? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “What is best for the patient does not necessarily make the most money.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “It's not that it's above the law … it is just intentionally obscured.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “Healthcare is glacial. It is slow.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The largest source of healthcare costs is hospitals.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “What have the historical priorities been of the administrators of those hospitals?” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “Every hospital CFO knows that they need sick people.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The payment change has to come first.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The money wins.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “You've got to put the financial incentives in place … to make people actually behave the way that they should.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman  

The Consolidated Appropriations Act 101 - Comply or Die?   The Consolidated Appropriations Act, otherwise known as the CAA, established protections for consumers related to surprise billing and transparency in health care. Upcoming fines can and will be heavy, amounting to $100/day PER EMPLOYEE, which is substantially greater than the fines hospitals receiving for being non-compliant, which was only $300 total day.  The goal for employers immediately is not to be perfect by 12/27/22, but to at least show that they made a good faith effort to be compliant. The price transparency component is where the opportunity lies for employee benefits brokers and their employers to uncover the source of their high cost claims, and then take appropriate fiduciary responsibility in order to pay more appropriate unit costs for healthcare.  While there is a cost associated with ensuring you are compliant, the opportunity to retain and win new business for consultants is massive. Right now, opaque network contracts make it difficult for healthcare consumers to know the cost of care prior to receiving it, and it is nearly impossible to make an informed decision as a patient.  The CAA will have a dramatic impact on Americans' ability to price shop on where to go for care, as well as their ability to plan for their out of pocket expense(s). The goal of the CAA is simple: People should be able to know the price ahead of time, shop using that price as well as quality of care metrics, and then they shouldn't be slapped with a giant, surprise balance bill afterward. At the end of the day, the goal is to allow people to have the tools to shop for healthcare the way that they do so for any other product or service. Here is a recent article covering the CAA in greater detail, and outlining the employer obligation to be compliant.  Hat's off to Dave Chase, co-founder and CEO of Health Rosetta for bringing it to my attention! https://docket.acc.com/erisa-covered-companies-must-disclose-health-plan-costs --- Support this podcast: https://anchor.fm/spencer-harlan-smith/support

First of all, let me thank those of you who have left a podcast review in 2022. There was one from Best Healthcare Podcast Around on Apple Podcasts the other day that thanked Relentless Health Value for being singularly responsible for providing a 400-level education in so many complex areas of healthcare, which I personally really appreciated because we aspire to be a master class in healthcare industry strategy, such that those looking to do right by patients understand the dynamics well enough to succeed. This also echoed a review from February of this year that said that Relentless Health Value distills complex healthcare issues into a highly intuitive and highly accessible narrative that helped the reviewer's Fortune 500 company get everybody in the C-suite the understanding needed to confidently make some pretty key healthcare-related decisions. Thanks so much to those of you who left a review for taking the time. As I have said on earlier shows, we really have a Relentless Tribe here working hard to make the healthcare industry in this country much more accountable to the patients that we serve. And you leaving a rating and a review might be the best thing that you can do if you're into helping us achieve our mission, because the ratings are so entwined with helping others find the show. If you consider yourself a listener who has gained value from this show and you haven't yet left a review or a rating, could I ask that you do me a favor and do so? If you don't know how to do that, there are instructions here for how to do so. *** In this healthcare podcast, I am talking with Al Lewis. Al has been on the show before. One thing I did not realize about Al is that he went to Harvard Law School. Today we are discussing using the Quizzify Consent Form in the emergency room. This Quizzify Consent Form quite simply gives patients convenient ways to remember the exact and specific words they need to write on any financial forms they are presented with and told to sign in the emergency room. These words negate a hospital system or ER staffing firm's claims that the patient agreed in a blanket statement to pay whatever they are charged. In the past (ie, before the surprise billing legislation that went into effect at the beginning of 2022), this Quizzify Consent Form helped prevent the old $11,000 COVID test somebody got in the emergency room or the million-dollar heart attack. For more on the legislation itself, listen to the show with Loren Adler (EP307). While it is far from perfect in a few respects, on the whole, the No Surprises Act is good for patients. It's been terribly bad news, however, for certain private equity–backed ER staffing organizations who used surprise billing as a business model, meaning specifically—and maybe there's others, but Team Health and Envision are certainly the big dogs here. This wasn't any sort of cloaked-in-the-shadows secret, by the way, as far as business models for these two entities. I recall one of them saying without equivocation that the No Surprises Act would be very detrimental to their business. And it turns out, they were right. Here's from Fierce Healthcare, quoting Moody's: “Envision ‘faces significant social risk' due to ‘significant negative publicity relating to the patients … receiving surprise medical bills' and will remain financially challenged by the No Surprises Act.” Moody's downgraded Envision's corporate debt, suggesting that they are at risk of going bankrupt over the next 12-18 months. To further attenuate my sympathies, both of these companies, Team Health and Envision, cut doctors' pay during the first COVID-19 wave while simultaneously spending millions on political ads to protect surprise billing practices. Anyway, sad … not sad. Getting back on track here, the good news in all of this is that patients don't have to worry about surprise bills either by private equity–backed entities or just your run-of-the-mill hospital down the street who, pre–No Surprises Act, were not opposed to a little surprise billing action of their own or not opposed enough to do anything about out-of-network docs sending these bills in a lot of cases. But the No Surprises Act doesn't make going to the ER a safe space from a financial standpoint for patients or their employers, and this is what I talk about today with Al Lewis. This whole conversation reminded me of something that David Contorno has said more than once: Every hospital bill, every physician bill is a surprise bill if the patient does not know ahead of time what the charges will be. You've listened to this podcast before and heard guest after guest talk about how payers … frankly not so good at negotiating with hospitals, most of whom have emergency rooms. (Listen to EP346 with Peter Hayes, for example.) If you're a patient and you go to the ER, you're gonna see this lack of great negotiating in all of its glory. So, for example, if a payer “negotiated” $10,000 for an emergency MRI or CT scan or some other test or service and the patient has cost sharing, yeah, that patient just got hit with a very, very big bill. Or the whole upcoding thing. This whole thing is what I talk about with Al Lewis today: post–No Surprises Act, what's happening in emergency rooms and how can we protect patients/members/employees from excessive financial toxicity that is still rampant when it comes to going to the emergency room in many cases. Al talks about how the employers can really help employees and members protect themselves from profiteering hospitals or physician staffing companies the patient doesn't even realize are gonna be sending bills. You can get and learn more about the Quizzify Consent Form as well as Quizzify's Doctor Visit PrepKits here. Another episode along these lines to listen to is EP328 with Marshall Allen. You can get the free version of the card by emailing al@quizzify.com. You can also connect with Al by emailing al@quizzify.com, visiting the Web site at quizzify.com, on LinkedIn, or on Twitter at @quizzify and @whynobodybeliev.   Al Lewis wears multiple hats, both professionally and also to cover his bald spot. Hat #1: Employee Health Literacy. He is the founder and “quizmeister-in-chief” of Quizzify, whose mission is to help companies teach their employees to utilize health care services appropriately, using a format best described as “Jeopardy meets Choosing Wisely meets Comedy Central.” Quizzify is the only vendor authorized to display the Harvard Medical School “Veritas” shield and has received excellent reviews from users. Quizzify is also well known for its ER Sticker Shock Prevent Consent, which has been endorsed by Dr. Marty Makary and Dave Chase, among others. It can be taped to an insurance card, used as a stand-alone card, or downloaded into your Apple or Google Wallet and will “pop up” when you enter an ER. It limits ER bills (both in- and out-of-network) to 2x Medicare, which is less than half of most “negotiated” rates. His quiz-specific background includes authorship of the best-selling Newsweek Presents the Ultimate Trivia Game, which Games magazine lauded as having the best questions of any trivia game; hosting two quiz shows on Boston network affiliates; and appearing on Jeopardy. Hat #2: Outcomes Measurement. As an author, his critically acclaimed category best-selling book on outcomes measurement, Why Nobody Believes the Numbers, chronicling and exposing the innumeracy of the health management field, was named digital health book of the year in Forbes. Cracking Health Costs, written in conjunction with Walmart alum Tom Emerick, was also a trade best seller. He was the cofounder of the World Health Care Congress's Validation Institute. His expertise in outcomes measurement got him named one of the unsung heroes changing healthcare forever. He graduated Phi Beta Kappa with honors from Harvard, where he taught economics as well. He also graduated from Harvard Law School, albeit with no honors that time—other than winning their annual trivia contest, of course. 06:34 What is the evolving problem around surprise bills? 07:08 What are the two issues with the No Surprises Act? 9:13 Why are ER bills in network still so high? 17:27 How does the Quizzify Consent Form work for patients with insurance who unexpectedly visit the hospital? 20:50 “They're basically saying, ‘We don't abide by federal law.' Good luck with that.” 22:20 “The better question is, why aren't other vendors copying it?” 23:56 How would Quizzify affect the hospital bottom line if employers start utilizing it as part of their employee healthcare? 27:35 Is there any potential downside to Quizzify? You can get the free version of the card by emailing al@quizzify.com. You can also connect with Al by emailing al@quizzify.com, visiting the Web site at quizzify.com, on LinkedIn, or on Twitter at @quizzify and @whynobodybeliev. @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast What is the evolving problem around surprise bills? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast What are the two issues with the No Surprises Act? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast Why are ER bills in network still so high? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast How does the Quizzify Consent Form work for patients with insurance who unexpectedly visit the hospital? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast “They're basically saying, ‘We don't abide by federal law.' Good luck with that.” @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast “The better question is, why aren't other vendors copying it?” @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast How would Quizzify affect the hospital bottom line if employers start utilizing it as part of their employee healthcare? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast Is there any potential downside to Quizzify? @whynobodybeliev of @Quizzify discusses #erbilling and the #nosurprisesact on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas    

David is joined by Anna Staver of the USA Today Network's Ohio Bureau to talk about the key races and what the voting results that come in early evening on election night will tell us about how the night is going to go  Then, Dave Chase, campaign manager for Tim Ryan for Ohio, on why Ohio voters are aligned with his candidate's views - and the importance of getting as many Republican and Independent voters to cross-over, even in areas Ryan might not win. To learn more about listener data and our privacy practices visit: https://www.audacyinc.com/privacy-policy Learn more about your ad choices. Visit https://podcastchoices.com/adchoices

If you listened to the show with Dan O'Neill (EP359), you would know this already. But let me tell you: If you're a provider, even a provider very confident in your office's ability to confer better patient health, you will still have a super hard time getting off the fee-for-service (FFS) hamster wheel. Why? Because it's hard to find payer contracts out there which will reward you (the provider) for actually taking care of your patients and to be accountable for the value of healthcare that you deliver. This is a tangled web we weave because, despite some payers offering risk-based contracts, a lot of times there's some IPA (independent physician association) or other “holder of the actual payer contract” who does not pass along these contract terms. These IPAs or health systems even sometimes just keep paying docs or provider offices FFS even if they themselves have a risk-based or capitated or value-based-of-any-kind agreement. If I actually kept track of the issues raised in the emails I receive from docs, there's one thing that I would likely find amongst the most frequently cited points of consternation: Physicians or practices or CINs (clinically integrated networks) or ACOs (accountable care organizations) want contracts where they can do right by patients. These are the good docs. These are the ones burned out and suffering from moral injury because physicians, PAs (physician assistants), nurses, clinicians who actually follow up and coordinate care and spend time making accurate diagnoses instead of cramming in more procedures … these are the clinicians who want to do the right thing and are also the ones who are getting dinged on performance reports and paid less. Bottom line here, for a physician practice to transform itself from an FFS machine cranking out volume but not necessarily health or care, the office has to have a high enough percentage of their patients in value-based arrangements to make it actually feasible to transform. It is only when they hit a tipping point of enough volume, enough patients in risk-based contracts that they can afford to be accountable for their results. At that point, yeah, everybody wins—doctors, patients, actually the entire community wins because when a local practice transforms, all of their patients tend to benefit at some level from the new processes and procedures and standardizations and pop health systems that get put in place. So, let's move forward with this with all haste, shall we? Why aren't we? What's the problem here? Well, there are lots of problems, don't get me wrong. But a big one is self-insured employers on the whole are not offering any sort of accountable care arrangements to the providers in their community. This is 150 million patient lives we're talking about here—a huge chunk of many providers' patient panels. Self-insured employers have a really big opportunity to level up the care in their whole community due to the spillover effect when a provider practice transforms itself because it has enough patients to do so. But these employers are stuck. They are paralyzed. They are doing the same thing this year that they've done last year, and therefore their whole community is equally stuck in a smorgasbord of suboptimal FFS goings-on. So, offering accountable care contracts is one thing (a very big consequential thing) that is also one of the five things self-insured employers can do to improve employee health that I talk about in this healthcare podcast with Dan Mendelson. Dan Mendelson, my guest today, also wrote a Forbes article listing out these five things. Here are all five things that Dan mentions in one handy list: Expand availability of accountable care models to improve the care experience, quality, and affordability at a local level. For a deep dive on this, listen to the show with Dave Chase (EP374). Invest in the data access needed to assess health outcomes. For a deep dive on this, listen to the show with Cora Opsahl (EP372). Align employees' health benefits with pop health outcomes. For a deep dive on this, listen to the show with Mark Fendrick, MD (Encore! EP308). Prioritize care models that can meet employees wherever they are. For a deep dive on the DEI (diversity, equity, and inclusion) aspect of this, listen to the show with Monica Lypson, MD, MHPE (EP322). Make care navigation a central part of the benefits package and experience. I am looking for an expert to take a deep dive on care navigation who does not work for a care navigation company. Hit me up if you know someone (again, who does not work for a care navigation company). My guest today, Dan Mendelson, is CEO of Morgan Health at JPMorgan Chase. He previously founded Avalere Health. Before that, Dan served as associate director for health at the Office of Management and Budget. Besides exploring the why and the what for each of the five things employers should do right now, I also wanted to find out from Dan what's going on at Morgan Health and how they are looking to help self-insured employers who want to do these five things actually do them.   You can learn more at the Morgan Health Web site. Dan Mendelson is the chief executive officer of Morgan Health at JPMorgan Chase & Co. He oversees a business unit at JPMorgan Chase focused on accelerating the delivery of new care models that improve the quality, equity, and affordability of employer-sponsored healthcare. Mendelson was previously founder and CEO of Avalere Health, a healthcare advisory company based in Washington, DC. He also served as operating partner at Welsh Carson, a private equity firm. Before founding Avalere, Mendelson served as associate director for health at the Office of Management and Budget in the Clinton White House. Mendelson currently serves on the boards of Vera Whole Health and Champions Oncology (CSBR). He is also an adjunct professor at the Georgetown University McDonough School of Business. He previously served on the boards of Coventry Healthcare, HMS Holdings, Pharmerica, Partners in Primary Care, Centrexion, and Audacious Inquiry. Mendelson holds a Bachelor of Arts degree from Oberlin College and a Master of Public Policy (MPP) from the Kennedy School of Government at Harvard University.   05:53 Why did Dan direct his article about health benefits at CEOs? 06:56 What does an accountable care model mean to a self-insured employer? 08:50 “This alignment of value will never work … if the 150 million Americans … getting their health insurance through their employer are not also aligned in the same way.” 12:21 “We're offering them a higher level of service.” 12:32 “Everything that we do is intended to be scalable and not just for us.” 13:01 “We have an obligation to do better for our employees.” 15:44 “Employers need to understand, the only way to get outstanding care is locally.” 18:21 Encore! EP206 with Ashok Subramanian and EP358 with Wayne Jenkins, MD. 19:10 Why is getting quantitative metric data important? 19:42 Encore! EP308 with Mark Fendrick, MD. 21:50 “This is a much broader vision of accountable care than … primary care.” 23:41 “Until everything is aligned, the employer is just not going to be providing an optimal product.” 24:32 “There are substantial issues with … health equity, and employers are paying for the care of 150 million Americans in this country.” 26:15 Is digital health access important for creating meaningful relationships between patients and providers? 30:43 What is the myth that employers need to tackle? 31:10 Why is care navigation important for employees? 32:37 EP334 with Sunita Desai, PhD. You can learn more at the Morgan Health Web site. @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast Why did Dan direct his article about health benefits at CEOs? @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast What does an accountable care model mean to a self-insured employer? @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “This alignment of value will never work if the 150 million Americans getting their health insurance through their employer are not aligned in the same way.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “We're offering them a higher level of service.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “Everything that we do is intended to be scalable and not just for us.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “We have an obligation to do better for our employees.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “Employers need to understand, the only way to get outstanding care is locally.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast Why is getting quantitative metric data important? @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “This is a much broader vision of accountable care than … primary care.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “Until everything is aligned, the employer is just not going to be providing an optimal product.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast “There are substantial issues with … health equity, and employers are paying for the care of 150 million Americans in this country.” @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast Is digital health access important for creating meaningful relationships between patients and providers? @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast What is the myth that employers need to tackle? @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast Why is care navigation important for employees? @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein

Here's a Milton Friedman quote: “There is one and only one social responsibility of business—to use its resources and engage in activities designed to increase its profits so long as it [that entity] stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud.” Okay, so this is Friedman, Milton Friedman, pretty much the most influential advocate of free market capitalism, stating quite clearly that an entity's greatest responsibility lies in the satisfaction of its shareholders. His nod to social responsibility or ethics of any kind comes at the end there, where he says that for free market capitalism to function, there must be open and free competition and no fraud. So, let's compare this to what's going on in the payer space in the healthcare industry. First off, there was just a chart in the New York Times the other day where pretty much every major payer except one got a check in a box for being accused of fraud. Interestingly, if you look in the comments section of that article, people posted links where that one outlier was being accused of fraud. So, I'm not sure what's up with that, but yeah, let's just conclude that there's fraud in the payer space. On to Friedman's requirement for open and free competition. As we all know, there are a few very powerful, very big, consolidated entities who control the vast majority of the market with both regulatory capture as well as the capital to continue to buy more and more adjacent businesses, as well as any threatening upstarts and just close them down. As I often hear said, we're gonna wind up with single-payer healthcare but maybe not the single payer most people are thinking of. If anyone thinks that in the highly consolidated payer space there is open and free competition, send me a note. I'd love to hear from you. I mean, even if what I've just said is 50% or 75% true, we're still outside of Friedman's definition of functional free market capitalism in the payer space. I wanna shift gears now to discuss the rules of the game, and this is really the topic of today's podcast. Friedman said in that quote above that there are rules of the game that entities abide by. Therefore, these rules of the game are inarguably consequential. And in this healthcare podcast we're talking about how these rules of the game echo when it comes to payers—companies that are publicly traded on Wall Street with shareholders. So, that's your spoiler for where this episode is headed. But before we go there, let me just say one or two things to the many listeners who I would consider certainly part of our Relentless Tribe who also work for payers. If you work for a payer, you have a few options. One of them is to do as much social good as you can to offset even a little piece of the not so good going on. The other is to help those working elsewhere in the organization to understand the full impact of their actions and the hope that they figure out a way to be less financially toxic to members. You have already taken the first step, because simply by listening to the show, you see the problems with clear eyes. The larger question, though, is this: Is it possible to do well by doing good vis-à-vis leveraging the power of market forces to efficiently help patients, even if shareholders are demanding otherwise? Well, it ain't working out so great so far, just comparing us to the rest of the world. But the more white hats we have, the better. So, keep advocating for patients in the belly of the beast, and there's always a whistle around to blow should it come to that. Meanwhile, let's focus our clear eyes on where we are from a patient's eye view—just briefly here, because we've discussed this all before in great depth. Here's some stats to a Commonwealth Fund issue brief. In the first half of 2020, first quarter, one out of four adults in employer plans were functionally uninsured due to high out-of-pocket costs or high deductibles. Listen to the show with Wayne Jenkins, MD (EP358), for a deep dive on the human consequences of having insurance but not being able to afford to use it. We're in a place in this country where the majority (67%) of adults who reported medical bill or debt problems was insured when that care was provided. That's from Kaiser Family Foundation. There's 100 million Americans with medical debt. These numbers are staggering. What's the why with all of this? It's our dysfunctional healthcare benefits market. Listen to the show with Kevin Schulman, MD (EP366), for more on this at the systemic level. But today we're talking about one entity in this dysfunction, which are payers, insurance carriers. I invited Wendell Potter on the show to ask him to explain how for-profit payers contribute to our dysfunction, creating inequality and wage stagnation. You see this happening as well as I do, right? On one hand, we have entities claiming all kinds of worthy and beautiful things in press releases and maybe even doing pilot programs—pilots, which are great, and I wish they did more of them and scaled them more broadly, but then premiums go up the following year … again. Being blunt here, it's hard to attain broad success in improving health outcomes or improving disparities in care when getting and/or using their healthcare benefits is toxic financially and disproportionately impacts lower-income communities. The reality is, private payers have not been able to bring costs of care down. What they have done instead is settle more and more out of pockets with patients or with taxpayers or with employers. Speaking of more and more out-of-pocket costs, although this is not the focus of the show, I am not giving consolidated health systems a pass here, obviously. But in this episode, we're focusing on why payers behave as they do contributing to the dysfunctional healthcare benefit system in this country. I could not have been more thrilled to have an opportunity to speak with Wendell Potter. His name most likely precedes him. But in brief, for much of his early career, Wendell Potter was a health insurance executive. After 20 years, he left his job after a crisis of conscience. Wendell testified before then-Senator Rockefeller's Commerce Committee at a hearing about how healthcare companies actually operate. From there, he went on to write books and ultimately to start the Center for Health & Democracy.   You can learn more by following Wendell and signing up for his newsletter at wendellpotter.substack.com. Wendell Potter has more than four decades of experience as a communications professional, including a career as a reporter and a communication executive at the country's largest health insurers. After seeing firsthand how strategic PR and lobbying are used unfairly to tilt the scales toward corporate interests against the people's interests, Wendell left his corporate career to advocate for meaningful healthcare reform. He made headlines in 2009 when he disclosed in Congressional testimony how insurance companies, as part of their efforts to boost profits, have contributed to spiraling healthcare costs and the growing number of Americans without health insurance. Since then, he has spoken at more than 200 public forums and authored the award-winning New York Times bestseller Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans. He is also the author of Obamacare: What's in It for Me? What Everyone Needs to Know About the Affordable Care Act. His latest book, which he wrote with Nick Penniman, is Nation on the Take: How Big Money Corrupts Our Democracy and What We Can Do About It. Wendell leads two nonprofit advocacy organizations, Business Leaders for Health Care Transformation and the Center for Health & Democracy that convenes the Lower Out-of-Pocket NOW Coalition that pushes for reforms that lower and cap out-of-pocket costs in the United States.   07:01 What is the medical loss metric? 10:04 “The reality is, insurers have been jacking up premiums … for a long time.” 11:19 “It's a short-term game.” 14:10 “You're seeing that these companies are not doing a very good job … of controlling costs because they don't have the incentive.” 16:37 Why are payers hammering the individual PCPs? 17:40 Why does a Wall Street publicly traded payer care what their medical cost is as long as their premiums are higher? 20:07 EP366 with Kevin Schulman, MD. 22:32 How do payers ensure that they're controlling utilization? 25:40 “It's death by a thousand cuts.” 31:42 “Just like independent practice physicians are endangered, so are community pharmacists.” 33:11 Who runs our healthcare system? You can learn more by following Wendell and signing up for his newsletter at wendellpotter.substack.com.   @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers What is the medical loss metric? @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers “The reality is, insurers have been jacking up premiums … for a long time.” @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers “It's a short-term game.” @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers “You're seeing that these companies are not doing a very good job … of controlling costs because they don't have the incentive.” @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers Why are payers hammering the individual PCPs? @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers Why does a Wall Street publicly traded payer care what their medical cost is as long as their premiums are higher? @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers How do payers ensure that they're controlling utilization? @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers “It's death by a thousand cuts.” @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers “Just like independent practice physicians are endangered, so are community pharmacists.” @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers Who runs our healthcare system? @wendellpotter of @cforhd discusses #healthcareshareholders on our #healthcarepodcast. #healthcare #podcast #healthpayers   Recent past interviews: Click a guest's name for their latest RHV episode! Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker

The show on direct contracting with Doug Hetherington (EP367) and also the one with Katy Talento (EP350), both of these experts have said that if an employer direct contracts with a provider organization, in general, the employer gets about 20% savings over the status quo. This makes sense—just cut out the middleman with an MLR (medical loss ratio) of plus or minus about 15% and you're at three-quarters of the way there. You might be thinking, “Well, maybe not so fast here, because then wouldn't FFS (fee-for-service) rates go up? Is it not Slide 1 on most carriers' sales decks how great they are at leveraging their vast buying power to negotiate discounts with hospitals?” Hmmm … if you think this, you're about to be shook. Turns out, carriers are not so good at negotiating rates with hospitals. For more on this topic, follow Leon Wisniewski on LinkedIn. Or check out an article entitled “Hospital prices vary widely, often higher with insurance than cash, The New York Times finds.” The big concerns for employers looking to direct contract, I think, are going to be threefold. And right now, I'm just speaking in general. This has nothing to do with the conversation that follows. But I think the three big concerns are this: Let's say the employer gets actual fee-for-service rates that are 20% less than average carrier negotiated rates. So, great … but will utilization go up if the wolf is watching the henhouse, so to speak? Especially if PCPs are owned by the hospital system and incented, as many are, to drive downstream utilization. It's been estimated that PCPs can drive $1,000,000+ of revenue when they refer in network to profitable service lines. What happens when this is unfettered, meaning no third party to do prior auth stuff for utilization management, for example? Some employers, for sure, could and certainly do hire a third party to do utilization management; but sometimes one of the contractual requirements of a health system direct contract is an easing of, let's just say, at least the most aggressive PA (prior auth) requirements. So now, all of a sudden, are more plan members getting more services that, even at a 20% discount, add up to a greater total spend? A counterpoint: I've heard more than one person who would know say that most PA programs don't actually do a whole lot except defer spend at best. Here's a quote from Scott Haas. He said, “The only value I have observed of the prior authorization process is the accumulation of data that is required of the stop-loss industry to establish known risk for them to laser risk. Cost shifting at its best. Other than that, I have rarely observed value to the patient, provider, or the plan sponsor.” One thing I am noticing is that those providers offering direct contracts are aware of this whole line of questioning and fear of the health system driving overutilization because incentives and might be doing things (the health system looking to direct contract) to mitigate those fears. Some are discussed later in this podcast. So, I don't know about whether plan sponsor spend would net-net go up if you get rid of PAs and profit-driven utilization management or go up enough to offset all of the admin costs and care gaps that crappy prior auths or prior auth processes slam patients and providers with. Big concern for employers (besides even if the price goes down will utilization go up—and then what's the net effect of that?): Will the provider's PPO (preferred provider organization) network be too narrow if I go with a direct contract with a health system, either legally running afoul of network adequacy rules or run afoul of employees just getting pissed off because their doctors are no longer in network? I guess there's a bunch of ways you can do things if you are a plan sponsor that might mitigate this, but I could still see it certainly being a concern. By aligning the plan sponsor with the provider, including getting all the data and just from a pop health perspective being able to align around priorities, does care quality, preventative care stuff, social determinants of health, and equity concerns … does this stuff actually start to improve patient health? There are plenty of examples—some that Nick Stefanizzi talks about in this podcast, including a great one with Whole Foods—where this is certainly the case. But as we in healthcare all know, not all cases are the same. As soon as any party in the mix starts trying to maximize their revenue with little regard to its impact on patients and clinicians, things can go south. For example, just speaking in general here, but I might bring up the whole “remember consolidating health systems?” They promised all kinds of care quality improvements as a result of owning the entire patient journey and consolidating data and … yeah, not so much with that. As we know, hospital systems who consolidated have no greater or better quality on the whole as unconsolidated health systems, despite the fact that their prices went up a lot. Now, I just have to say, this is not a parallel situation. When the health system consolidated, it was just providers consolidating, which may have actually exacerbated relationships with plan sponsors and payers as opposed to driving greater alignments. So, as I said, not a parallel situation. I think the point that I'm making is just because better patient care is theoretically possible doesn't necessarily mean it will happen when there are profits at stake. However, when incentives do align and true collaborations can occur amongst payers and providers or amongst any of the other stakeholders along the patient journey … yeah, some great stuff can happen. As I mentioned earlier, I am talking with Nick Stefanizzi, who is CEO over at Northwell Direct, which is Northwell's stand-alone, for-profit entity looking to direct contract with employers and their TPAs (third-party administrators). The board of Northwell, meaning the tax-exempt hospital system mother ship, that same board also oversees Northwell Direct. Northwell Direct has two main categories of product offerings. One is that they offer on-site and virtual clinics for employers. The other is that they offer a network to direct contract with. According to Nick Stefanizzi, a health system can offer significant price reductions because—and this mirrors a lot, as I mentioned earlier, what Doug Hetherington (EP367) and Katy Talento (EP350) said in earlier episodes—you can get rid of a ton of administrative burden that payers place on hospital systems, plus you get rid of the middleman carrier profit margins, plus the health system can drive additional volume, I'm assuming to profitable service lines with profitable commercial patients … patients who are profitable despite the 20% cut because, yes, commercial rates are still way higher than Medicare even if you cut 20% off the top. It's also, as Nick talks about in this episode, more possible to do value-based things and care for populations because there's plan sponsor/provider alignment and far better data capture.   You can learn more at northwelldirect.northwell.edu. Nick Stefanizzi is the chief executive officer of Northwell Health's direct-to-employer organization, Northwell Direct, which supports businesses through a full spectrum of customized employer health services. Prior to joining Northwell Direct, Nick served as chief administrative officer and later as interim chief executive officer of Formativ Health, a for-profit joint venture aimed at enhancing the patient and provider experience of and access to care. Nick also spent over eight years in various leadership roles within the Northwell Health system, focused on human resources (HR), organizational effectiveness, talent management, and HR technology. He was a leader within the health system's ambulatory network of over 450 physician offices and ambulatory locations, where he was responsible for the direct development, coordination, and administration of central administrative services, as well as the integration of the health system's network of clinical joint ventures. He also served as the chief of staff for the health system's chief information officer. Nick received a degree in international relations from Boston University and his MBA in healthcare administration from Hofstra University.   07:22 What do Northwell Health's main services look like? 08:05 How does Northwell Health save their clients 20%? 12:53 “Look, it is a selective network.” 13:22 What are the factors that allow Northwell Health to provide this 20% discount? 13:36 How does getting rid of the payer help the patient and provider relationship and reduce costs? 17:00 Why Northwell Health is selective, not narrow, in their network. 18:28 How does Northwell Health operationalize their direct network? 19:39 “Communication and change management and engagement.” 22:17 “Providers also want to be a part of this. They also have ideas.” 23:04 Where does the TPA fit into this model? 25:05 EP127 with Kris Smith, MD, MPP. 25:54 What are Northwell Health's must-haves for their TPA partners? 30:27 What's different about Northwell Health's approach?   You can learn more at northwelldirect.northwell.edu.   Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What do Northwell Health's main services look like? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems How does Northwell Health save their clients 20%? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems “Look, it is a selective network.” Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What are the factors that allow Northwell Health to provide this 20% discount? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems How does getting rid of the payer help the patient and provider relationship and reduce costs? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems “Communication and change management and engagement.” Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems “Providers also want to be a part of this. They also have ideas.” Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems Where does the TPA fit into this model? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What are Northwell Health's must-haves for their TPA partners? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems What's different about Northwell Health's approach? Nick Stefanizzi of @NorthwellHealth discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #healthsystems Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar  

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

I saw a Tweet from Farzad Mostashari, MD, the other day; and I'm gonna rewrite it in the context of today's show: This is why we can't have nice things! As soon as someone comes up with something that might accomplish some good things when done in moderation and with good intent, it gets exploited for revenue maximization. I have to admit, this conversation with Aaron Mitchell, MD, MPH, and actually the one with Mark Miller, PhD (EP380), from two episodes ago were both kind of painful for me—and let me tell you why. It's the same reason I find conversations painful about hospitals or leading cancer centers or even some self-insured employers and EBCs (employee benefit consultants): It hurts my heart when some percentage of healthcare industry peeps who have the opportunity to produce so much good in the world instead choose to do stuff that is financially or otherwise toxic. But let me get to the point of today's show. Dr. Aaron Mitchell and I are talking about conflicts of interest (COI), and we're talking about COI in the payments that are made from Pharma to physicians. COI might mean when physicians are paid in a way that skews their clinical decision-making. Nobody wants to be the patient of a physician with skewed decision-making, after all. That's the “why” of this whole discourse. Now, let's get into two important points re: skewed decision-making. Any payment that skews decision-making is, in fact, considered no bueno by the current writing of the AKS, the anti-kickback statute. Second, almost any payment, direct or indirect, turns out, skews physician decision-making. It's not just getting paid the big bucks to make a speech or consult or whatever. Getting a modest free lunch can also have the same effect. Prescribing is affected. That's what the data show and what the recent paper that Dr. Aaron Mitchell and his colleagues published in the Journal of Health Politics, Policy and Law articulates. Their paper is titled “Industry Payments to Physicians Are Kickbacks: How Should Stakeholders Respond?” So, hmmm. Much to cogitate upon in what I just said, which is what the conversation with Dr. Aaron Mitchell that follows is all about. But let me offer up a few spoilers and maybe some additional thoughts. First of all, some “Are payments COI and kickbacks?” contemplations are pretty black and white. We start out the conversation in this healthcare podcast talking about the recent Biogen incident, I guess I'll call it, which is sadly not an outlier. Biogen never admitted any wrongdoing here. But if what they are accused of doing is true, this could be considered not a gray area. This is black-and-white COI—unquestionably should not happen. But where things get a little bit more open to interpretation and require some consideration and thoughtfulness is if we're trying to weigh the gray in the middle between black and white. Here, what needs to be thought through is the aggregate good versus the aggregate bad of Pharma paying physicians to do stuff or buying things for them. If Pharma needs help during its clinical trials to figure out a breakthrough therapy and they want to talk to leading experts in a specialty, that's maybe a good thing so that they can get a drug that actually works well for patients. So is—and this is me talking, not Dr. Mitchell—but I could see that Pharma helping to figure out ways to educate clinicians about the best ways to help patients suffering with real diseases that nobody else is making any effort to do anything about at a national scale … it could help humans live better lives if Pharma takes the advice of the right thought leaders and helps to disseminate their teachings. Maybe physician societies could fill this role, but a lot of times, who needs educated are not the actual doctors in the society in question. It's other doctors the patient is seeing who don't realize the root cause is a GI problem or CKD (chronic kidney disease) until the patient needs a liver transplant or “crashes” into dialysis in the ER. But irrespective of the validity of my musings here, the point is to quantify the in-aggregate “good” that might happen as a result of Pharma paying appropriate clinical experts appropriate amounts. Contrast that aggregate good against some not so good. Study findings that Pharma can drive up not only Rx's (prescriptions) for its own drugs but also drugs in general when they buy stuff for doctors or pay doctors. Patient populations get overmedicated when compared to a baseline as a result. Too many patients get diagnosed and treated for some condition that they may not actually have. Too many expensive me-too drugs get prescribed at big unnecessary costs to patients, taxpayers, and employers. When I say costs to patients, by the way, I also might be implying a clinical overtone here as much as a financial one, because there's almost no drug that comes without side effects. So, what are some solutions that Dr. Aaron Mitchell mentions in this episode, or I that bring up, if we are trying to steer physician payments into the aggregate good zone and out of the bad COI zone? Here we go, and these are not necessarily in the order in which they are discussed: Keep an eye on practice patterns and overall costs. This might make physicians aware when their clinical decision-making is getting swayed, so to speak. Get payers involved. Listen to this whole episode for the “how” and “why” here, but if anyone has a visceral reaction to this, here's one possible positive from a physician standpoint: It could be a way to get rid of a lot of PAs (prior auths). If a doc's practice pattern is average, on trend, and/or they do not take industry dollars, then they get what amounts to a PA gold card. With that carrot, a doc may have less inclination to let their prescribing decisions sway and/or take pharma dollars. The federal government can get involved in a few ways that Dr. Mitchell talks about. One of them is a direct ban on all payments. Or maybe they could just clarify what is okay and what is not okay, since what is listed as COI in the current AKS is also currently considered an industry norm. Asking providers themselves to pay attention and self-regulate and to, for example, not accept speaking gigs where they are paid to talk to an empty room or “consult” on topics that really they should know they're not thought leaders in. You can learn more at Dr. Mitchell's personal profile on the Memorial Sloan Kettering Cancer Center Web site. You can also connect with Dr. Mitchell on Twitter at @TheWonkologist. Aaron Mitchell, MD, MPH, is a practicing medical oncologist and health services researcher. He is an assistant attending at Memorial Sloan Kettering Cancer Center in the department of epidemiology and biostatistics. His research focuses on understanding how the financial incentives in the healthcare system affect physician practice patterns and care delivery to cancer patients. He cares for patients with prostate and bladder cancer. 07:32 How does the recent whistleblower case serve as a good example of what shouldn't be permissible in Pharma? 11:23 “There's a little bit of a disconnect between what the law currently says and maybe the ideal world that we would want.” 11:56 Dr. Aaron Mitchell's paper in the Journal of Health Politics, Policy and Law, titled “Industry Payments to Physicians Are Kickbacks: How Should Stakeholders Respond?” 14:37 How should stakeholders react to this new legislation? 17:56 What is the aggregate benefit versus risk of these payments to doctors? 19:53 BMJ paper by Tyler Greenway and Joseph Ross. 23:51 What should providers and the federal government be doing in light of this new legislation? 29:07 “It's just always so much harder to get to the outcomes because there's so much more that happens in between the clinical decision and then what the patient's outcome is down the road.” 30:42 Will innovation be stifled with this new crackdown on kickbacks? You can learn more at Dr. Mitchell's personal profile on the Memorial Sloan Kettering Cancer Center Web site. You can also connect with Dr. Mitchell on Twitter at @TheWonkologist. @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth How does the recent whistleblower case serve as a good example of what shouldn't be permissible in Pharma? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth “There's a little bit of a disconnect between what the law currently says and maybe the ideal world that we would want.” @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth Dr. Aaron Mitchell's paper in the Journal of Health Politics, Policy and Law, titled “Industry Payments to Physicians Are Kickbacks: How Should Stakeholders Respond?” @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth How should stakeholders react to this new legislation? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the aggregate benefit versus risk of these payments to doctors? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth What should providers and the federal government be doing in light of this new legislation? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's just always so much harder to get to the outcomes because there's so much more that happens in between the clinical decision and then what the patient's outcome is down the road.” @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth Will innovation be stifled with this new crackdown on kickbacks? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360)

It's been said that healthcare in this country will not be transformed because of some incremental government policy, nor will this industry transform because of some tech company who techs the crap out of healthcare. It's been said that the only way the healthcare industry in this country is going to fundamentally change is vis-à-vis a seismic shift in the way Americans view the healthcare industry in their understanding of what is going on and the extent to which it directly impacts lives. You and I, all of us, have heard pundits say every year for a decade (at least) that this revolution is a-comin' and that this year … no más. Americans cannot afford to pay any more in premiums or out of pocket. We have reached the brink. And year after year, we've discovered that, in fact, Americans as patients, members, and taxpayers can pay more and are willing to do so. Well, maybe right now we are actually cresting the chop. Medicare can now negotiate drug prices legislation. Maybe it's a bit of a watershed moment here. In this healthcare podcast, I'm talking with Mark Miller, PhD, EVP of healthcare at Arnold Ventures; and this is what we talk about today: the why now—the why, all of a sudden, after years of talking and griping and nothing happening, how right now, what constellation of factors transpired that enabled Medicare drug price negotiation to become law. You need to listen to the show to get the context, but here's the seven main reasons by my counting that Mark Miller talks about in this episode: The sensitivity of the public to just healthcare costs in general, Pharma being an easy-to-spot component of those healthcare costs Sensitivity of policy makers to Pharma's R&D claims, and non-industry-sponsored information coming out that tempers some of those research and development claims that Pharma has been making Sensitivity that innovation isn't a homogenous broad stroke when it comes to new drugs. There's a difference between breakthrough innovations versus me-too-type drugs. Consider some new combination drug that's, I don't know, two generics and costs $2000 a month. There's eyes on that kind of stuff, and if Pharma's reputation travels in an industry-wide block, this compounds our #3 point here. Sensitivity of innovation in the future versus people getting access right now to today's innovations. If too many people (ie, voters) can't get access to today's meds, it's a reach to expect them to worry too much about their future selves where, in all likelihood, they are thinking that they still wouldn't have access to the drugs. The landscape shifted, but pharma talking points did not—and the result was labeled “tone deaf” by some. Voters wanted aggressive actions as a result of the aforementioned constellation of factors, and a majority of Congress people responded and either voted yes or didn't protest overly hard, even if they didn't. Patient voices became more sophisticated. While they still might have issues with PBMs (pharmacy benefit managers) and/or insurance carriers, there's a growing perception that the story here is more nuanced and Pharma is in that mix. This is what we talk about in this episode: the why now, exactly and specifically. So thrilled to have had this conversation with Mark Miller, who has had, and continues to have, such a storied career. In brief, Mark Miller ran MedPAC (Medicare Payment Advisory Commission) for 15 years. That's a big deal. He also has held other roles at CMS and the Urban Institute. Now, Mark is at Arnold Ventures, as aforementioned, which is a philanthropic organization. He oversees Arnold's work in healthcare. One last thing: The legislation that just passed also includes a few other parts that impacts drugs. A big one is limiting the catastrophic Medicare Part D out-of-pockets to beneficiaries to $2000. And then there's also an inflation rebate. So, there's a rebate back to Medicare if Pharma raises its prices faster than the inflation rate. You can learn more at arnoldventures.org.  Mark E. Miller, PhD, leads Arnold Ventures' work to lower the cost and improve the value of healthcare. He has more than 30 years of experience developing and implementing health policy, including prior positions as the executive director of the Medicare Payment Advisory Commission, assistant director of Health and Human Resources at the Congressional Budget Office, deputy director of health plans at the Centers for Medicare and Medicaid Services, health financing branch chief at the Office of Management and Budget, and senior research associate at the Urban Institute. 04:45 Why did Medicare's ability to negotiate on drug pricing happen now? 06:35 What's different about the drug market today that allowed Medicare to gain the ability to negotiate drug pricing? 12:08 How has innovation played into drug price negotiations? 12:40 “If you limit profits, you can end up limiting innovation.” 14:03 Why was the distinction between more drugs and innovative drugs important to changing the landscape of the drug market? 15:49 More versus new and future versus now in the drug market. 19:59 “As the landscape was shifting, Pharma didn't shift with it.” 23:00 How did voters change the landscape in drug pricing? 24:39 “Pharma did not have exclusive control over the patients' voice.” 29:59 “The industry would largely like to just stick with the patents that they have.” 30:16 “Of course, it's competition that ultimately drives innovation.” 31:30 “This is an exquisitely complicated market.” You can learn more at arnoldventures.org.   @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast Why did Medicare's ability to negotiate on drug pricing happen now? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast What's different about the drug market today that allowed Medicare to gain the ability to negotiate drug pricing? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast How has innovation played into drug price negotiations? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast “If you limit profits, you can end up limiting innovation.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast Why was the distinction between more drugs and innovative drugs important to changing the landscape of the drug market? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast More versus new and future versus now in the drug market. @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast “As the landscape was shifting, Pharma didn't shift with it.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast How did voters change the landscape in drug pricing? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast “Pharma did not have exclusive control over the patients' voice.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast “The industry would largely like to just stick with the patents that they have.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast “Of course, it's competition that ultimately drives innovation.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast “This is an exquisitely complicated market.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins  

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 (pharmacy benefit managers). We're talking about brokers and EBCs (employee benefit consultants). 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 last December (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. Maybe they are happening right now to you if you haven't gotten the disclosures from your EBC or broker. 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 last year.   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 has been on this podcast before talking about PBMs, and in this episode he delivers, talking about the shenanigans of some brokers and how the jig is now up. AJ 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.   You can learn more at cap-rx.com and find resources through law firms. Anthony J. “AJ” Loiacono is the co-founder and CEO of Capital Rx, one of the fastest-growing health technology companies in America. He has over 20 years of experience in pharmacy benefits, finance, and software development. AJ's mission is to create the first efficient market for prescription prices and provide employer groups with the highest standard of patient care. AJ has spent his career studying the pharmaceutical supply chain and producing engineering solutions that have continually redefined the pharmacy benefit industry to achieve this goal. Prior to Capital Rx, AJ was a co-founder of Truveris, where he served for eight years as CEO, CIO, and board member, leading the company to record growth (Deloitte FAST 500 and Crain's Fast 50). Before 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, and successfully sold the company to Chrysalis Solutions in 2007. AJ is a graduate of Manhattanville College, where he studied finance while playing varsity soccer and rugby. 06:03 Who can get in trouble for mismanaging employee funds? 06:31 Who can begin the cycle for annual review? 07:53 “When you talk about conflicts of interest, they're everywhere.” 13:17 “You're paying for access.” 13:38 Why is it important to request that they disclose direct and indirect compensation? 14:08 What are the layers to these hidden fees and compensations? 18:17 What is a reasonable fee for a good plan admin? 19:32 “I think people need to step back and say, ‘How many different ways are they getting compensated?'” 24:57 “The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.” 25:13 “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.” 28:14 “You can't win if you can't even pay the house fee to come in.” 31:42 Why do you need to ask for disclosure, and what do you need to ask specifically? 32:27 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 Who can get in trouble for mismanaging employee funds? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth Who can begin the cycle for annual review? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When you talk about conflicts of interest, they're everywhere.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You're paying for access.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is it important to request that they disclose direct and indirect compensation? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the layers to these hidden fees and compensations? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is a reasonable fee for a good plan admin? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think people need to step back and say, ‘How many different ways are they getting compensated?'” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth “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.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You can't win if you can't even pay the house fee to come in.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why do you need to ask for disclosure, and what do you need to ask specifically? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are some of the characteristics of a good plan consultant? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova

Okay, so … telehealth for Medicare patients. Currently, there's payment parity, meaning a clinician gets paid the same amount for a Medicare patient visit regardless of whether that patient comes in the office or has a telehealth encounter. Right? Or did that end already? And if it didn't end, how much longer will payment parity continue? Also, is it the same for commercial and Medicaid patients? Congress makes rules for Medicare patients, but is it Congress that makes the rules for commercial and/or Medicaid telehealth reimbursement rates? Or how do those reimbursement decisions get made? What about the doing telehealth across state lines thing … the idea that if I'm a doc in New York, I can take a telehealth appointment with a patient in Arizona even though I am technically not licensed in Arizona? And who's in charge of that? Yeah, I went into today's conversation with Josh LaRosa, VP at Wynne Health Group, with a lot of questions. As you may suspect, this program is about telehealth. But just to level set on what we're not talking about, this interview does not dissect the “should we use the telehealth or should we not” question; and it does not get into best practices or equity concerns. For that info, listen to the show with Christian Milaster (EP320) or Liliana Petrova (EP357) or Ali Ucar (EP362) or Ian Tong, MD (EP347).  Also, we are not talking about the politics, per se, of who's for telehealth and who's against it. We also aren't drilling too far into the telehealth fraud cases that are coming to light right now, but of course we cannot resist talking about them a little bit. So, let me tell you what Josh LaRosa and I are, in fact, talking about in this healthcare podcast. We're specifically discussing the near-term future of CMS reimbursement for telehealth and the allowed so-called “flexibilities” for telehealth. We talk about a few of the why's behind why are policy makers doing some of the stuff that they are doing. And then we chat about the when, how long some of the new flexibilities and reimbursements that were permitted originally during the pandemic will continue. We touch on the Cerebral incident (I guess maybe you'd call it) and the potential DEA or legislative actions that may result from that as well. An interesting point that we dig into for a couple minutes is this one: Do not forget that the whole telehealth reimbursement debate (do I wanna call it?)—Should we cover it? Should we not cover it? And for how much?—this whole debate is part of a bigger debate. A much bigger debate, actually: the fee-for-service vs the not-fee-for-service debate. That's the larger context of all of this, and I think it's often overlooked. Nobody anywhere is limiting how often a practice who wants to use telehealth as part of some kind of risk-based or capitated thing can use telehealth. Why? Because in a capitated or bundle arrangement, from a Medicare trust fund perspective at least, telehealth visits are not equivalent to additional spend or additional volume. In a non-FFS environment, there's little chance of fraud also, really. Also, patient safety—arguably, probably—becomes much more of a practice concern. It gets a lot less rewarding to do unsafe things over telehealth when you don't get automatically paid to do them … and also paid to fix the problems that resulted from the unsafe things, which is the perverse beauty of FFS that we're all so familiar with. Acronym alert! PHE stands for public health emergency. A public health emergency is the thing the government declares, for example, during a pandemic. You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.   Josh LaRosa, MPP, is a vice president at Wynne Health Group, focusing primarily on regulatory affairs with a focus on the US Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS). His interests lie in delivery reform and innovations in payment and care delivery models. Josh also supports the firm's Public Option Institute, which studies the emergence of public option programs at the state level. Prior to Wynne Health Group, Josh consulted for the CMS Innovation Center, where he worked to implement, monitor, and spread learning garnered from the center's high-profile demonstration projects, most recently including the national primary care redesign effort, Comprehensive Primary Care Plus (CPC+). Josh holds a Master of Public Policy from the University of Virginia's Frank Batten School of Leadership and Public Policy. He also completed his undergraduate studies at the University of Virginia, graduating cum laude with a BA in political philosophy, policy, and law. 04:09 What is the story with telehealth policy right now? 06:08 What kind of flexibilities did HHS allow with telehealth after the pandemic? 09:46 Are we still under these pandemic flexibilities for telehealth? 12:15 Why isn't the government just making greater access to telehealth permanent? 18:24 How does telehealth lend itself to the risk of overspending when dealing with an FFS model? 21:13 Does telehealth fit into the new CMS fee schedule? 22:55 How do states factor into the future of telehealth? 24:40 What is Arizona doing specifically to improve and ensure the future of telehealth? 30:56 What's next in store for telehealth at the congressional level? You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.   @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the story with telehealth policy right now? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What kind of flexibilities did HHS allow with telehealth after the pandemic? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are we still under these pandemic flexibilities for telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why isn't the government just making greater access to telehealth permanent? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth How does telehealth lend itself to the risk of overspending when dealing with an FFS model? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Does telehealth fit into the new CMS fee schedule? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do states factor into the future of telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is Arizona doing specifically to improve and ensure the future of telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's next in store for telehealth at the congressional level? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai  

Cultra is Chillin' with Dillon! Dave Dillon is a quality human being and he's YouTube famous- over 67,000 subscribers can't be wrong! Dave offers sharp insight on trail running and stellar product reviews, all delivered in a professional and matter-of-fact manner in HD. So What Watch should you buy? Tune in to find out about this plus latest news on some FKT's and other dank beta. Chase the summit YouTube podcast website   North Shore Surfing Film Offspring   

Late in May of this year, three-ish months ago, I did an inbetweenisode that explores the “why with the no collaboration” amongst healthcare stakeholders and what the lack of collaboration signifies. That episode got a lot of traction and engagement.   This episode that follows is a pretty good approximation of a presentation that I made at the MTVA (Moving to Value Alliance) symposium that happened in Connecticut this past June. If you listened to the earlier show about collaboration, this one is slightly different, shorter, and more to the point. So, let's start here: When you listen to any patient with a chronic condition talk about their challenges with the healthcare industry—and yes, if a patient has a chronic condition, more often than not, that is what they will talk about, their challenges … I went on Twitter just now, and it took me literally 13 minutes to collect what I'm going to say are 300+ Tweets written by patients and their caregivers complaining about their chronic care journey. That's the sad part. I don't mean to kick this off talking about problems; however, if you're gonna solve for something, it is important to understand what problem you are solving for. You do not want to be a solution looking around for a problem. So, let's fix this, this rampant problem problem that chronic care patients seem to have. Many of the patient challenges in the 300 Tweets that I just collected can be grouped into two major categories. And these two major challenge groups can really only be solved for with collaboration amongst healthcare stakeholders. So, let's dig in here. The first major patient challenge is what I'm gonna call the care gap problem. I was talking to someone at a provider organization the other day, and she had 8000 known care gaps with patients and [insert overwhelm here]. And these were just the care gaps that showed up on somebody's radar because they added up to a quality metric, which is sometimes the definition people use for what is a care gap. But if we think about all the other holes in patient care, the typical care gaps that are identified probably come not even close to the total number of actual care gaps: patients who can't see their specialist because they can't get ahold of their records from the local health system or no coordination of care. Coordination is probably another synonym for collaboration. This is a huge deal. People literally die because their clinician cannot get their biopsy results or whatever from somebody else. That's a care gap as deep as a grave. Or patients who keep showing up in the ER because they aren't getting the help or the meds or the accurate diagnoses or the treatment plan that they need to stay out of the ER ... My grandfather had heart failure. At the end of his life, he was probably in the ER once a month. It was sad and painful and expensive and totally unnecessary. But his PCP didn't seem to be collaborating with the specialists, and the ER I don't think was telling anybody what was going on. Right? Or patients who can't get a drug they need approved by their insurance, so they wind up in crisis. Crappy prior auth processes create care gaps. All of these things are gaps in care. Carly Eckert, MD (EP361), was on the podcast; and she made a crucial point for me. In fact, I tried to get her to come on the podcast originally to talk about care gaps and closing care gaps; but she categorically refused. Chronic care management, she said, should not be a game of whack-a-mole. It may be better than nothing, a game of whack-a-mole; but it is certainly not ideal.   Chronic care management by care gap is like cooking with a fire extinguisher. If we want to eliminate care gaps for reals, let's just not have care gaps. So, how do you go about not having care gaps, then? The goal should be to craft a non-fragmented patient journey. Let's figure out what a great care journey looks like ahead of time and then try to keep the patient on it. That is the best way to eliminate care gaps: proactively. You don't have them. Immediately, because I am a person of action, I went into my filing cabinet; and I actually found an example of a patient journey map amongst my papers that I had worked on years ago. You have probably seen one of these and may have some of your own patient journey maps tucked away in a binder in your office somewhere. Most people have them. There are a few things that they all have in common, irrespective of the disease state or the organization or anything. The things that they have in common are they are complicated flowcharts with a lot going on. Besides just being complicated, the other thing that patient journey maps all have in common is that there are multiple parties mentioned with roles in that patient journey. You're gonna have a PCP, a specialist or two, a hospital, a payer, a pharma company more than likely, a PBM maybe, maybe a community organization … Here's a quote that kinda sums that up from Dr. William Bestermann: “Improving chronic disease management is an enormous problem that requires multiple stakeholders coming together to combine new science, new systems, and new payment models in a comprehensive solution. No one person or organization can make progress that matters. The problem is too big.”   Is this obvious? I think it's pretty obvious. But yet, collaboration in general at the organizational level is less than common. With uncommon exceptions, you not only don't have multiple providers working together but—heaven forbid!—you have payers and providers or other entities working together. But just taking this back to the thrust of this conversation, the first major patient challenge can only be solved for with collaboration to create a non-fragmented patient journey, which reduces care gaps by avoiding care gaps in the first place. So, collaboration is a rate critical for a non-fragmented patient journey to eliminate care gaps that patients have big issues with. So now, let's move on now to the second big problem category that chronic care patients were Tweeting about in those Tweets that I collected: They can't afford their care. This crisis of affordability is a huge patient challenge that, it's not the only thing, but we can't solve for it without being collaborative, without having collaborative relationships along the patient journey. I don't really want to get into how much healthcare prices have skyrocketed, but healthcare prices have been inflating at 4x the cost of everything else. This causes mental health issues; it causes stress. There's a show with Wayne Jenkins from Centivo where we dig into this deeply. Listen to EP358.   It is inarguable at this point that financial toxicity is clinical toxicity. I have a folder on my computer where I chuck references for this statement, and at this point, I probably have 400 studies and articles that all say the same thing in different ways with different patient populations. Most of these patients are insured. By the way, just because you have insurance doesn't mean that you can afford to use it. And patients who cannot afford their care have worse clinical outcomes. Period. End of sentence. Minor sidebar because I was really like head exploding emoji this morning: I saw somebody in a forum today lashing out at patients suffering with crippling medical debt saying that these people really should take some personal responsibility for the financial choices that they have made. WTH? The entity not taking responsibility for people losing their life savings and their homes simply because they had the fortune of getting sick or injured, the entity that should be taking some responsibility here is a broken, profit-driven healthcare industry. Let me just add some fidelity to what I mean when I say “the healthcare industry,” which really should take some responsibility here for the financial toxicity that they themselves are creating. Consider that a lot of medical debt is of a balance bill nature and the people being pursued generally signed a contract which they did not understand the consequences of, because most of them had “insurance” and they certainly weren't given a quote up-front so that they could make a rational economic choice. So, let's add some fidelity: How do we make healthcare more affordable? Or how do we make the charges not a complete surprise at a minimum? How do we do that? Lots of ways, big and small, are required; but let's talk about one of them: Navigate patients to high-quality providers charging a fair price. Navigate patients to providers who do not do low-value things and who have practice patterns that are aligned with evidence-based medicine (ie, get employers and providers to direct contract, especially in non-FFS ways, especially as it relates to primary care where there are measurable outcomes or quality). ACOs or CINs (clinically integrated networks) who know how to refer to high-value specialists or hospitals is another example of a collaboration that can help with affordability. Some health plans and TPAs (third-party administrators) are starting to get really data-driven about how they go about this. Point being, to coordinate care to or amongst high-value providers, multiple parties have to be involved (ie, collaboration). So, in sum, we talked about two common and major patient problems, which are probably not a surprise to anyone listening. The two are a lack of coordinated care (patients falling into gigantic care gaps) and then also a lack of affordability. We know how to solve for both of these issues. Defragment care and steer patients to high-quality provider organizations/hospitals/CoEs with competitive prices. Collaborate in these two ways. So, why are so few doing it, then? You can always count on me to say the quiet part out loud, so here we go: The business model of most, many, lots of healthcare organizations, both for-profit and tax-exempt, is revenue maximization. As Kevin Schulman, MD, said on the podcast (EP366), it's not A or B; we have a dysfunctional healthcare benefits system in this country.   But nonetheless, if we want to identify a root cause for why with the no interoperability, why with the info blocking to prevent network leakage, why with the no collaboration … it's not a technical problem at its core. It's not a HIPAA concern, really, at its core. It's a business case problem. And I don't say this as any sort of castigation. I say this because it's actionable information. Tiptoeing around a thing that we all know just clutters our ability to come up with a solution that is actually going to work. Really understanding a pretty big root cause behind why needed collaborations don't happen is necessary. This level of introspection is required for those who are mission driven to find others who are similarly mission driven to get a collaboration over the line. But the good news is success stories abound. It's my belief the healthcare industry won't be transformed in one giant turn of some flywheel. It's gonna be transformed one local market at a time. And there's a lot of great stuff happening in local markets. Listen to the show with Dave Chase (EP374) for a bunch of examples. There's a show with Cora Opsahl (EP372) that has some great examples of this. There's the one with Doug Hetherington (EP367). We also have a show coming up in October with Nick Stefanizzi from Northwell Direct.   All of these great examples are stakeholders harnessing the power of collaboration to defragment patient journeys and get patients into high-value care settings so that the overall cost of care is in range for employers, taxpayers, patients, and American families. I'm so excited, honestly, about that because the healthcare industry is a legacy that we will leave behind to children and grandchildren. I have a vision in my head about what I want the healthcare industry to look like in 25 years. Maybe you do, too. Listen to the show with David Muhlestein, PhD, JD (EP364), for more on that. But the point is, if this vision is going to come true, we need to—like, right now—start building the roadmap to get to that goal. And a lot of this involves facilitating collaboration. Actually collaborating, for reals. There's real momentum behind that in organizations such as the Moving to Value Alliance in Connecticut, where I originally gave a version of this same talk. Thanks, by the way, to Steve Schutzer, MD, for moderating the collaboration panel that I was a part of at aforementioned MTVA symposium. Not only is he a great moderator, but he also has done a great service for patients through his ability to get a whole bunch of surgeons—who are pretty competitive as a general rule—to collaborate and form a Center of Excellence. 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. 01:41 What are the two major patient challenges in chronic patient care that can only be solved by collaboration? 01:56 What is the “care gap” problem? 03:19 “Crappy prior auth processes create care gaps.” 03:25 EP361 with Carly Eckert, MD.  04:00 How do you eliminate care gaps proactively? 06:46 EP358 with Wayne Jenkins.  08:21 What is one way to make healthcare more affordable? 09:49 Why aren't more healthcare entities collaborating? 10:04 EP366 with Kevin Schulman, MD.  11:13 EP374 with Dave Chase. 11:18 EP372 with Cora Opsahl.  11:22 EP367 with Doug Hetherington.  11:25 Upcoming episode with Nick Stefanizzi. 12:00 EP364 with David Muhlestein, PhD, JD.   For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast What are the two major patient challenges in chronic patient care that can only be solved by collaboration? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast What is the “care gap” problem? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “Crappy prior auth processes create care gaps.” Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast How do you eliminate care gaps proactively? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast What is one way to make healthcare more affordable? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Why aren't more healthcare entities collaborating? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan    

I wanted to resurface this episode because when it originally aired over a year ago, the topic may have been ever so slightly ahead of its time. Look, here we are right now with everybody trying to do three big things relative to measuring PCP (primary care provider) performance: Come up with a fair measure for PCP performance. Account for diverse populations with diverse risks so that some docs don't get dinged because their patient populations have lots of comorbidities or behavioral health challenges or live in food deserts, or any one of the other social determinants of health. Not make measuring performance a total procedural nightmare. Right? We want fair measures, we want to account for equity issues essentially, and we want this whole measurement fandango to be as easy as possible. Enter Rebecca Etz, PhD, and The Larry A. Green Center with a really well-validated “instrument,” as she calls it, to measure primary care performance. I can think of more than one PCP frankly right off the top of my head who would be thrilled to be measured using this methodology. Even more so because it's one thing that's simple and not a jumble of numerators with various mix-and-match denominators. PCPs are really important to population health. Primary care is the foundation of any well-functioning health system, I am sure many listening to this podcast know well. For the Triple Aim to happen, patients really need access to robust primary care. This has been affirmed by almost anyone who looks into it. And yet, in this country, our system sort of anemically supports our primary care colleagues. As a general statement, poking and prodding and procedures are compensated at a far higher rate than anything requiring cognitive services. What a PCP or a pediatrician mainly does all day is really cognitive. It's listening and thinking and counseling and coordinating. But here is maybe an underappreciated point: If we're going to measure PCP performance, then we need the right measures to measure that performance. You might be doing this measurement as a basis for incentives or maybe for continuous improvement programs. Either way, if you don't have the right measures, then maybe great primary care is under-rewarded or your continuous improvement process is counterproductive—you're incenting the wrong things, you get the wrong activity. And to add to that, PCPs (ie, practices) can spend upwards of $40,000 a year of uncompensated time trying to add and subtract and tote up the difference in all these varied and potentially inapplicable measurement standards coming at them from all manner of directions. My guest in this healthcare podcast is Rebecca Etz, PhD. Dr. Etz and the team over at The Larry A. Green Center have worked hard to create a set of 11 performance measures for primary care. These measures went through the wringer as far as their creation and validation. These 11 measures take into account what patients want, what primary care clinicians (including pediatricians, nurse practitioners, and others) think is most important and possible to provide, and what payers want to pay for. These 11 measures are aligned across the three stakeholders, and they are actionable. Rebecca Etz, PhD, is associate professor of family medicine and codirector of The Larry A. Green Center, which is in Richmond, Virginia, at the Virginia Commonwealth University. You can learn more at green-center.org.   Rebecca S. Etz, PhD, is an associate professor of family medicine and population health at Virginia Commonwealth University (VCU) and codirector of The Larry A. Green Center—Advancing Primary Health Care for the Public Good. Dr. Etz has deep expertise in qualitative research methods and design, primary care measures, practice transformation, and engaging stakeholders. Her career has been dedicated to learning the heart and soul of primary care through three main lines of inquiry: (1) bridging the gap between the business of medicine and the lived experience of the human condition, (2) making visible the principles and mechanisms upon which the unique strength of primary care is based, and (3) exposing the unintended, often damaging consequences of policy and transformation efforts applied to primary care but not informed by primary care concepts. As a member of the VCU Department of Family Medicine and Population Health and previous codirector of the ACORN practice-based research network, Dr. Etz has been the principal investigator of several federal and foundation grants, contracts, and pilots, all directed toward making the pursuit of health a humane experience. Recent research activities have included studies in primary care measures, behavioral health, simulation modeling, care team models, and adaptive use of health technologies. Dr. Etz currently leads the fielding of a weekly survey regarding the response to and impact of COVID-19 on US primary care practices. She also serves on the National Academies of Medicine consensus study, “Implementing High-Quality Primary Care.” 04:58 Why is primary care one of the “best-kept secrets” of better health outcomes? 09:45 “Measures are a form of communication.” 09:58 “If the way that you are assessed does not actually match up with the work you do or what you find to be important, it's pretty demoralizing.” 12:48 “It is the outcome of healthcare, but it is not the same thing as quality.” 17:18 “It creates a financial incentive to hit a target by any means necessary.” 18:53 “We incentivize people to have good outcomes, and what that means is that electronic medical records are no longer simply databases that tell us what the health of the population is. They are databases that tell us what is the optimal picture that a clinician is able to paint of their patients.” 21:54 “Primary care is a relational field.” 23:02 “How does this relate to cost and utilization?” 27:45 How has the measure of PCPs in the time of COVID held up? 28:03 What measure performs worse in the time of COVID? 29:59 EP270 with Dave Chase and EP272 with Guy Culpepper, MD.  You can learn more at green-center.org.   Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp “Measures are a form of communication.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp “If the way that you are assessed does not actually match up with the work you do or what you find to be important, it's pretty demoralizing.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp “It is the outcome of healthcare, but it is not the same thing as quality.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp “It creates a financial incentive to hit a target by any means necessary.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp “Primary care is a relational field.” Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp How has the measure of PCPs in the time of COVID held up? Rebecca Etz of @GreenCenterOrg discusses #primarycare performance on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #pcp   Recent past interviews: Click a guest's name for their latest RHV episode! Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes  

This encore episode seemed really apropos at this moment in time, since we've just basically published a course in the specialty pharmacy ecosystem, including who all of the various stakeholders are and what their vested interests are. Weirdly, in many of the episodes in the series/course, you'll find the word patient in short supply. And that's not a weird oversight in our podcast production. It is actually an egregious oversight in the specialty pharmacy market, an oversight with real human consequences, which I talk about with Olivia Webb in this encore. Check out a playlist of all of the specialty pharmacy episodes that comprise our series here.   If you listen to them all, let me know; and also let me know what you think and, I don't know, maybe we'll create a special certificate for you because at that point you will know more than 99.9% of the industry (even industry insiders) if you listen to the whole thing. Here's the cold hard truth: The whole specialty pharmacy operational model is not built to serve patients, a fact that becomes crystal clear when you're a patient. Instead, the specialty pharmacy model is, rather, pretty blatantly dedicated to the power struggle for revenue and captive patient populations. It's war between providers and the whole PBM/insurer/specialty pharmacy vertical consolidations. Employers and pharma manufacturers are, of course, on the battlefield as well. What is a drug that qualifies to be a specialty pharmacy drug? Usually, these drugs are complicated to store, dispense, to use, and/or they're expensive—generally, really expensive. Lots of zeros, completely unaffordable to pay cash for them as an individual. No one is using a GoodRx card and not using their insurance to pay for these puppies. They can cost as much as a house. Biologics, for example, usually considered specialty drugs—lots of cancer and immunology therapies, injectable medications, IV/infused medications—all these are usually considered specialty drugs. There's no one definition of a specialty drug. It's more that someone somewhere decided to not run the drug through your traditional retail pharmacy for any number of reasons. The problem with the current status quo, wherein the patient gets tossed around while everybody fights over them, is that some basic needs are not being met—like if a patient asks the person administering the drug maybe even a pretty simple question about the drug or its side effects. It's way more likely than it should be that the nurse or whomever doesn't know the answer. Not knocking nurses here at all but definitely knocking a system that allows that to happen. I mean, really now. We're injecting a six-figure therapy in someone's arm that will impact their body in a myriad of maybe frightening ways, some of which are a problem and some of which are not. Said another way, there's a really good financial and clinical use case for making sure that we're patient-centric at a specialty pharmacy point of service—if you care about the patient and cost efficiency, that is. But I guess therein lies the root cause of the trouble. In this healthcare podcast, I'm talking with Olivia Webb about what it would take and be like to create a “patient-first specialty pharmacy,” as she has coined the term—a specialty pharmacy dedicated to patients not only having a half-decent experience but also one that might actually create better patient outcomes. Olivia Webb is author of the Acute Condition newsletter. I would certainly recommend subscribing. One last thing: If you're following the whole PBM/insurer/specialty pharmacy vertical integration skullduggery, keep an eye on a bunch of lawsuits against these combined entities (three examples here, here, and here) alleging that they are doing some not super upright and honest things with their massive market power. (Say it isn't so!) You can learn more at acutecondition.com.  Olivia Webb is a healthcare strategist and writer. She publishes the newsletter Acute Condition, as well as working on other content across the healthcare and biotech ecosystem. She previously worked at Massachusetts General Hospital and Advisory Board Company. 04:43 Why did Olivia start thinking about a patient-centric specialty pharmacy? 06:05 “There's really no layer on top of it to make it look nice.” 06:55 “You're kind of dealing with this vertical stack that doesn't really deal with patients frequently.” 07:07 Is the specialty model more patient friendly or less? 07:39 What would a patient-centric specialty pharmacy look like? 08:29 “There's a lot of fragmentation; there's a lot of friction.” 08:42 What's unique to specialty pharmacy prescriptions? 11:09 Why can infusion centers be a high-drama place? 12:44 What's “the question” around specialty pharmacy? 13:11 Who has the vested interest in ensuring patients take their medications correctly in specialty pharmacy? 15:08 “It's really just a unique area of healthcare where the people that I think of as the good guys and the bad guys completely flips.” 16:34 Why might the time be ripe for disruption in the specialty pharmacy area? 20:26 “There's no one with a clear incentive to cap the prices.” 20:39 What are the barriers in specialty pharmacy? 21:01 “The patient just isn't at the center, the financial incentive, in any direction.” 29:44 “I think people who are designing these things need to see how patients are actually doing it.” 30:13 “I think there's a lot of money here; I think this market is going to only increase in size.” 30:32 “I think you need scale.” 30:42 AEE15 with David Carmouche, MD, of Ochsner.   You can learn more at acutecondition.com.  @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why did Olivia start thinking about a patient-centric specialty pharmacy? @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “There's really no layer on top of it to make it look nice.” @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You're kind of dealing with this vertical stack that doesn't really deal with patients frequently.” @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is the specialty model more patient friendly or less? @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What would a patient-centric specialty pharmacy look like? @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “There's a lot of fragmentation; there's a lot of friction.” @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's unique to specialty pharmacy prescriptions? @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why can infusion centers be a high-drama place? @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's “the question” around specialty pharmacy? @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why might the time be ripe for disruption in the specialty pharmacy area? @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's really just a unique area of healthcare where the people that I think of as the good guys and the bad guys completely flips.” @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The patient just isn't at the center, the financial incentive, in any direction.” @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think people who are designing these things need to see how patients are actually doing it.” @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think there's a lot of money here; I think this market is going to only increase in size.” @OliviaWebbC of the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353)  

Members taking specialty drugs represent about 2% of any given employer's population but often consume as much as 30% of an employer's total cost of care. As Pramod John, PhD, in EP353 has said, this isn't just small companies we're talking about here. Some of the largest employers in the US are dropping big bucks on specialty drugs, and they are obviously overpaying and don't need to.  No employer or plan really need pay any more than the pharmacy's acquisition price plus a reasonable professional fee. But so many employers pay way more than that. Let's just keep in mind that specialty pharmacy spend extends beyond just pharmacy spend. Medical claims for pharma drugs that are infused, for example, can be more than 50% of an employer or plan's specialty pharmacy spend. What I'm talking about now is buy and bill–type stuff where a hospital or physician practice bills for an infused pharmaceutical product under a patient's medical benefit. Listen to EP370 with Autumn Yongchu and Erik Davis about how some hospitals, for example, are managing to charge employers 6x the cost of specialty meds to infuse them and also EP365 with Scott Haas about PBM shenanigans.   So, currently, specialty pharmacy spend is big; but it's grown bigger every single year. Every year, employers and the government/taxpayers alike spend more and more on these really expensive drugs. As you can see, there are billions and billions of dollars on the specialty pharmacy table here. Also, as you certainly know if you've listened to the recent series of specialty pharmacy shows that we've done lately, it's kind of a war out there.   There are multiple healthcare industry stakeholders trying to capture all of the money. If you can get your hands on a specialty pharmacy patient and manage their care—or, probably more pointedly, manage to bill for their care—it can be incredibly profitable. This show kind of wraps up some loose ends for me. In this healthcare podcast, I'm speaking with Mike Baldzicki, who is chief brand officer over at AscellaHealth. A majority of Mike's background is in specialty pharmacy infusion, capabilities with an array of different healthcare companies. So, he is a great guy to wrap up some of these loose ends with. On the show today, we discuss how many/the percentage of self-funded employers who have taken their specialty pharmacy business from the “Big Three” or “Big Five” PBMs, how many of them have actively started steering their members and managing their benefit carefully. I talk with Mike about what these employers are doing and how they are doing it. From there, the conversation, of course, naturally flows into preventing hospitals from rapaciously buying and billing, which then segues into a discussion about hospital strategy … because if you can't do your buy-and-bill thing for a whole bunch of your patients, then it makes sense for you to do two things strategically: (1) stand up your own specialty pharmacy and/or (2) set up your own network of infusion centers. Mike and I talk about this. We also discuss how much trying to get a specialty pharmacy drug sucks for most patients, which I deeply investigated in EP337 with Olivia Webb.   Also in this episode, you can hear me contend that maybe if Pharma and payers enter into outcomes-based contracts, maybe patients would be better served. It's kind of the pharmacy version of the whole “let's pay for value, not volume” thing. I ask Mike how many pharma outcomes-based contracts are out there in the wild, for reals. All of this and more … but you gotta listen to the podcast. Oh, by the way, acronym alert: SPP stands for specialty pharmacy provider. You can learn more at ascellahealth.com.   Michael J. Baldzicki, CRCM, is chief brand officer (CBO) at AscellaHealth. As CBO, Mike supports the AscellaHealth Family of Companies comprehensive business strategy to increase brand awareness, boost perceived value, and improve lines of services in the marketplace. He is responsible for oversight of their Family of Companies based on sales and marketing to finance, client services, and specialty pharmacy strategies throughout the organization that drive strategic business initiatives. Within his roles, he enhances the success of the strategic projects and applies business development, contract negotiations, network advancement, and marketing and outreach strategies that cultivate opportunities for AscellaHealth and their Family of Companies. With more than 24 years of experience, Mike held roles in senior executive management within the specialty pharmacy supply group, pharmaceutical and biotech industry of managed markets, group purchasing organizations, specialty wholesale, and integrated delivery networks. He assumed roles within the pharmaceutical organization such as Bristol Myers Squibb, Enzon BioTech, Novo Nordisk, Baxter BioScience, as well as roles within the distribution channel of AmerisourceBergen specialty groups, BioMatrix Specialty and Infusion Rx, Diplomat/BioRx Specialty Pharmacy, CareCentrix Medical Infusion, Asembia GPO, Axelacare Infusion, to other manufacturer and specialty pharmacy home infusion companies. Mike is active in the biotech community and is council advisor of the Council of Strategic Healthcare Advisors (CSHA), an advisor/faculty member of the Academy of Managed Care Pharmacy (AMCP) for Specialty Pharmacy Advisory Group & Biosimilars Partnership Forum, NCPDP Specialty Pharmacy Stakeholder Action Group, Self-insured Institute of America (SIIA) advisor, National Alliance of Healthcare Purchaser Coalitions, and was 2014 Editorial Board Member for Specialty Pharmacy Times. Mike holds a bachelor's degree in business management and a Certificate in Clinical Research Compliance and Management (CRCM). He has completed programs in leadership development at Harvard University, Brooks Group, Miller Heiman Account Management, and MD Anderson Center Cancer Courses. 04:27 Is it a conflict of incentives to worry about the cost of million-dollar pharmaceuticals? 06:24 “Really, does it make sense to carve up my specialty pharmacy benefit … away from my typical PBM model?” 06:48 What's the trend line with moving away from the big PBMs? 07:20 Specialty pharmacy episodes.07:53 How does a small PBM contract with Pharma? 08:34 EP365 with Scott Haas.10:15 EP337 with Olivia Webb.11:32 “We're still lacking the overall insight to data.” 12:15 “When you have insight and good data, then you can start really driving the plan language and cover requirements.” 13:07 “It is a frustrating game because … the large PBMs that have traditionally managed an employer's spend … doesn't give them the data that's needed.” 13:48 What's going on with outcomes-based contracts? 14:16 What's the importance of aligning reimbursement around value instead of volume? 14:57 “The issue is, how real is the data?” 19:24 EP370 with Erik Davis and Autumn Yongchu.20:36 Are hospital-based specialty pharmacies teaming up with big PBMs? 22:01 “It's market ownership.” 29:17 EP369 with Keith Hartman, RPh.30:43 “These are real scenarios that are happening in the self-insured planned sponsor market.” 30:59 “Employers really should start recognizing organizations that take more of an integrated and thoughtful approach.” You can learn more at ascellahealth.com.   Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast Is it a conflict of incentives to worry about the cost of million-dollar pharmaceuticals? Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “Really, does it make sense to carve up my specialty pharmacy benefit … away from my typical PBM model?” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast What's the trend line with moving away from the big PBMs? Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast How does a small PBM contract with Pharma? Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “We're still lacking the overall insight to data.” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “When you have insight and good data, then you can start really driving the plan language and cover requirements.” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “It is a frustrating game because … the large PBMs that have traditionally managed an employer's spend … doesn't give them the data that's needed.” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast What's going on with outcomes-based contracts? Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast What's the importance of aligning reimbursement around value instead of volume? Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “The issue is, how real is the data?” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast Are hospital-based specialty pharmacies teaming up with big PBMs? Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “It's market ownership.” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “These are real scenarios that are happening in the self-insured planned sponsor market.” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast “Employers really should start recognizing organizations that take more of an integrated and thoughtful approach.” Mike Baldzicki of @AscellaHealth discusses #specialtypharma, #PBM, #hospitals, #employers, and #pharma on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352)  

Interoperability. Let's just review a few key points that probably everybody listening knows but certainly bear repeating because they matter. I don't want to dig into the technical or regulatory details of interoperability. That is above my pay grade. But I want to talk about the really important stuff that maybe doesn't get talked about a whole lot because you say the word interoperability and it's like the magic word that transports the unwary into the land of shadow and smoke and mist. It's like a self-published YA (young adult) novel half the time. But let's start here: First of all, consider that a lot of healthcare these days is conceived of as a scattering of micro-moments. It's not even like we think of patients one at a time. We think about patients one ICD-10 code at a time. And we think about those ICD-10 codes in 20-minute increments whenever a patient happens to show up in clinic. The average Medicare patient these days sees five specialists and more than one PCP a lot of times. So, we're not only breaking that patient down into codes per minute or something, but this is further broken down by clinician or practice. Now consider that everybody knows—and when I say everybody knows, I mean it's inarguable at this point—health happens at the whole-patient level, at the whole-person level, more accurately. It happens at the community level: 80% of patient outcomes are going to derive from what that patient does when they leave the office and whether they are able to and health literate enough to construct a reconciled treatment plan for themselves from the bits and pieces of information they've received scattered all over the place. You know in Star Trek when someone gets into the transporter to beam down to a planet and their whole body splinters into a gazillion little pieces? That's how our healthcare industry treats patients. They are frozen in that moment and rarely, if ever, become whole on the other side. So, when we talk about interoperability, what we're really talking about is a means to an end. What we are discussing is creating the ability to treat the whole patient or—Heaven forbid!—consider the whole community because we have enough data that we can accurately and adequately see the whole picture. We are able to avoid prescribing a treatment that is dangerous to the patient, inefficient, duplicative, or low quality—which is what happens over and over again. It's no amazing surprise that our healthcare industry wastes $1 in $4 we spend and doesn't net outcomes that are great in almost any respect when compared to other countries. Let me say this more bluntly, as if that wasn't already pretty blunt: If I don't know relevant and important details about my patient, then I cannot consistently deliver care that is high quality, safe, or cost conscious due to service duplication or uncoordinated care. I mean, how is anybody supposed to deliver evidence-based care when a lot of evidence may or may not be missing? So basically, without interoperability piping in the right patient information, I cannot succeed in any risk-based arrangement, right? If care provided is consistently lower quality, uncoordinated, unsafe, or inefficient, how am I supposed to optimize my care delivery? Said another way, interoperability is essential for anybody who wants to succeed in a value-based arrangement. I need all the data on my patients, and I need it in a way that I can separate the signal from the noise. Of course, getting 40 pages of duplicative SOAP (subjective, objective, assessment, and plan) notes that are semi-accurate and that no one bothers to look at is just unhelpful. Quick counterpoint: FFS (fee for service) loves siloed data. You know how much money everybody talks about could be saved if we eliminate duplicative services? Well, that's how much some fee-for-service health system is gonna lose if you make it easy for clinicians to see that the patient already got that CAT scan. So, in sum, interoperability is essential to high-quality, safe, and efficient care. A mark of a health system or provider practice who is really committed to patient outcomes is going to be their commitment to share data. The world has moved from a “Hey, you're permitted to share data if you really want to” to a “You are obligated to share your data.” And right now, I am loosely quoting Micky Tripathi, PhD, MPP, who is the ONC's (Office of the National Coordinator for Health Information Technology) national coordinator and also the guy in charge of TEFCA (Trusted Exchange Framework and Common Agreement) and implementing the provisions against information blocking that was in the Cures Act Final Rule last year. In this healthcare podcast, I am speaking with the perfect person about interoperability, and that would be Lisa Bari, who is the CEO of Civitas Networks for Health, which is a national collaborative working to improve interoperability in this country to improve health. Since interoperability is a huge topic, what I wanted to understand from Lisa most particularly are: Who are the current roster of players in the interoperability space? Like, what is going on there? Lisa told me that there are four main groups of interoperability folks—EHR (electronic health record) systems; APIs (application programming interfaces); HIEs (health information exchanges), both profit and nonprofit; and then others like clearinghouses, etc—which we talk about in some detail in this episode. We also discussed Larry Ellison's bold proclamation that Cerner is going to build one national medical records database. It's almost like Larry made it through the “welcome to the healthcare briefing” packet that his team gave him and immediately concluded that the interoperability problem is a technology problem, not a business case, fee-for-service, workflow, no universal ID, human, organizational, or government problem. Lisa adds some fidelity there.  Also, TEFCA … we talk about what it is and what it's not. Short version: It's a framework so that no one can say they won't share data lest they get in trouble in some way. At the same time, it's not gonna solve, as Lisa puts it, “the last mile of interoperability,” meaning it's not going to put the right information in the right clinician's hands at the right time. It just governs getting data from one organization to another organization but kinda has nothing to do with the clinical workflow, so to speak. The Civitas Networks for Health annual conference, by the way, is coming up on August 21-24 if you are interested in going.  You can learn more at civitasforhealth.org.  Lisa Bari, MBA, MPH, is the inaugural CEO of Civitas Networks for Health, a national nonprofit member- and mission-driven organization that was previously known as the Network for Regional Health Improvement and the Strategic Health Information Exchange Collaborative. Civitas counts over 100 multi-stakeholder-governed regional health improvement collaboratives and health information exchanges as members and creates national opportunities for education and community building between its members, policy makers, and business partners. Their upcoming conference (August 21-24, 2022, in San Antonio or via livestream) focuses on the theme of data collaboratives and information exchanges creating the critical infrastructure for health equity. Previously, Lisa was the health IT and interoperability lead at the CMS Innovation Center, working on primary care innovation model policy, and additionally has a background in health IT marketing and strategy. She holds an MBA from Purdue University and a Master of Public Health in health policy from the Harvard TH Chan School of Public Health and serves on the boards of directors of HealthCare Access Maryland and the Zorya Foundation.  06:30 How does value-based care depend on interoperability? 07:38 Why is it really important to exchange information at the right time with the right purpose? 08:00 What is one of the easiest low-hanging fruit to achieve in value-based care? 09:42 What are the four kinds of companies getting into the interoperability space? 11:51 “As we know, there's sort of technical interoperability … and then there's semantic interoperability.” 12:59 Where are we right now with EHR basic interoperability? 15:33 Who should ACOs hire to get the right data at the right time? 17:00 Why is it important to delineate the different types of HIE? 22:09 What can ACOs assure with interoperability? 22:59 Is the demand among ACOs for interoperability there? 24:04 “If you're in value-based care, you better care about what's happening outside of the healthcare setting.” 24:36 EP108 with Chris Klomp.26:25 “Every couple of years, someone talks about creating the ultimate database to rule them all. … It hasn't happened yet, and I don't think it's going to happen.” 26:56 “The difficult thing about healthcare data … interoperability … is an organizational and a governance problem.” 28:49 “You've gotta start with the incentives … and then you do have to say … ‘We are not gonna hoard any more data.'” 29:10 What is TEFCA, and how does it fit into this interoperability conversation? 32:17 “I think partners are trying to solve for value and outcomes.” You can learn more at civitasforhealth.org.  @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth How does value-based care depend on interoperability? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is it really important to exchange information at the right time with the right purpose? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is one of the easiest low-hanging fruit to achieve in value-based care? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the four kinds of companies getting into the interoperability space? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth “As we know, there's sort of technical interoperability … and then there's semantic interoperability.” @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth Where are we right now with EHR basic interoperability? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth Who should ACOs hire to get the right data at the right time? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is it important to delineate the different types of HIE? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth What can ACOs assure with interoperability? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is the demand among ACOs for interoperability there? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you're in value-based care, you better care about what's happening outside of the healthcare setting.” @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Every couple of years, someone talks about creating the ultimate database to rule them all. … It hasn't happened yet, and I don't think it's going to happen.” @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The difficult thing about healthcare data … interoperability … is an organizational and a governance problem.” @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You've gotta start with the incentives … and then you do have to say … ‘We are not gonna hoard any more data.'” @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is TEFCA, and how does it fit into this interoperability conversation? @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think partners are trying to solve for value and outcomes.” @lisabari of @civitas4health discusses #interoperability on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker

With us is Karen Simonton, Director of Strategic Alliances for the OrthoForum, an organization that connects the nation's largest orthopaedic groups through benchmarking, advocacy, innovation, and networking. Karen shares the provider's perspective as to how providers are reacting to or driving some of the trends and changes we are experiencing in MSK care delivery. Karen will share some of the challenges that these physicians face today, what their thinking is on value-based care and digital MSK.   Show notes: Books Karen is reading: Thank You For Being Late: An Optimist's Guide to Thriving In The Age Of Accelerations; CEO's Guide To Restoring The American Dream by Dave Chase and The Bible.

Medicare Advantage (MA), otherwise known as the “money machine,” is often the most profitable parts of many payers' business lines. Medicare Advantage plans can make a lot of cash if they are good at what they do. Look at any of these large, consolidated carriers' financial statements to get the magnitude of that statement. Also, in 2022, Medicare Advantage plans have enrolled 28 million participants between them, which represents 45% of all Medicare beneficiaries. This marks a three-point improvement in penetration over 2021 and a total program enrollment growth of 9%.   All of this is not a secret. So, what's happening right now is that this administration is looking carefully at Medicare Advantage plans and what they have been up to. We have had an amping up of government oversight, including regulatory actions and program audits. In this healthcare podcast, I am speaking with Betsy Seals, who is CEO and cofounder of Rebellis Group, which is a managed care consulting firm working with Medicare Advantage plans. Betsy says (and this is what we talk about in the interview) that there's three main areas that the government is currently scrutinizing: Sales and marketing. There have been these third parties, it seems, these field marketing organizations who were hired to do marketing and sales for some of the Medicare Advantage plans. And because they were third parties, it seems that many of them felt themselves to be excluded from CMS (Centers for Medicare & Medicaid Services) regulations and able to basically mislead prospective members with sales pitches that were highly suspect. Betsy gives some examples of these, and when you hear them, you will see why CMS is cracking down. Recouping improper payments is another area that CMS is all over. Interestingly, as Betsy Seals says in this interview, this might be one area where the government is actually ahead of private sector plans from a technology and analytic standpoint. CMS seems to have better analytics capabilities and is better at detecting fraud schemes and improper payments than the plans themselves. These plans are not sophisticated enough to notice stuff that CMS detects when it gets ahold of the plan data. But as unusual as this situation is where the government is ahead of the business sector, I can't say I'm shocked. We have had one guest on this show after another talking about just how far in the past some of these health plans are lagging. Dan O'Neill probably said it most eloquently and notably (EP359).   But I digress. So, recouping improper payments has the eye of CMS. This means two things largely. It means finding “outlier” codes that some MA plan paid for but which are clearly errors and should not have been paid. Another improper payment is when plans themselves do a little fancy upcoding so that they make more money than they should in their risk-adjustment payments. This has gotten some major attention lately. Let me quote from an OIG (Office of Inspector General) report:   “Our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs [health risk assessments] to maximize risk-adjusted payments. We found that 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.” The sneaky idea here to get more money than they should from taxpayers is that someone somewhere puts down that a member has major depressive disease because someone somewhere said they did. But the patient clearly doesn't have major depressive disease because they aren't getting any treatment for it and nothing anywhere would indicate that they are suffering from a major depressive disease. So, the plan winds up getting more money from the government to care for a patient who is suffering from major depressive disease, but the patient doesn't require any additional care because they don't have major depressive disease. It's a great way to make some dollars for shareholders that is coming right out of the pockets of taxpayers. In sum, the #2 area of additional oversight is recouping improper payments either from paying claims that should not have been paid for or by wild upcoding. This is just kinda like the general sort of compliance oversight that CMS does, meaning grievances and appeals and formulary administration and models of care for SNP plans (special needs plans), compliance program effectiveness—normal stuff like this—which will be interesting given all of the articles coming out right now about how patients on Medicare Advantage plans are less likely to get more costly diabetes treatments and how often there's denials for cancer care or NCI cancer centers aren't covered, etc. One point of note here that's kind of thought-provoking on a few levels: If you're an MA plan, it is super important for you to get members in for their annual screenings. For one, CMS requires that you document diagnoses each year; and you need to do this to reduce the chances that CMS will question a treatment being paid for because there's no underlying diagnosis to support it—and these diagnoses must be re-upped every year. Recall what I was just talking about re: improper payments and fraud schemes. If a patient isn't diagnosed with something, then why are taxpayers paying for its treatment? Also risk adjustment ... if you wanna upcode, it's not a bad idea to have a diagnosis documented in multiple different ways so that when the OIG/CMS/DOJ comes knocking, you can have your ducks in a row. Getting patients in for their annual screenings is how you can safely upcode. Further, one more reason why getting patients in for annual screenings matters to MA plans, member experience counts for an increasing piece of star ratings. Patients who never see their doctor and never interact with the plan don't usually give the plan they have nothing to do with stellar marks—and besides that, these members are tough to retain. Last big deal for an MA plan to get members in for their annual is this is when the doc gets into screening for care gaps, which is also part of star measures. All this about annual screenings is a bit of a sidebar, but it is kind of interesting to contemplate as we get into the conversation today about government oversight. (For a meme on this topic, check out this Tweet from Rik Renard.) My guest, as I mentioned earlier, is Betsy Seals. Listen to our conversation about how MA plans are in the hot seat right now. Later in the fall, Betsy will be coming back to talk about trends in the Medicare Advantage marketplace. You can learn more at rebellisgroup.com.   Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 08:15 What's happening with sales and marketing in the healthcare industry? 11:04 What's happening with the focus on recouping improper payments? 13:32 “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” 15:39 Are improper claim payments an administrative problem, or something more intentional? 16:20 “The health plan has a responsibility to catch those issues.” 20:10 What are specialty pharmacy prescriptions being scrutinized for? 22:12 “If this is where CMS is headed … the health plan should've already been doing this.” 23:58 Why do you see a bigger focus on social determinants of health? 25:54 Do these health plan audits actually have any teeth? 27:01 What is the biggest penalty a health plan can face from an audit? 29:57 “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” You can learn more at rebellisgroup.com.   @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with sales and marketing in the healthcare industry? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with the focus on recouping improper payments? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are improper claim payments an administrative problem, or something more intentional? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The health plan has a responsibility to catch those issues.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are specialty pharmacy prescriptions being scrutinized for? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If this is where CMS is headed … the health plan should've already been doing this.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why do you see a bigger focus on social determinants of health? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Do these health plan audits actually have any teeth? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the biggest penalty a health plan can face from an audit? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento  

So, let's put the last, I don't know, 300 episodes of Relentless Health Value into perspective here. The USA wastes about $1.5 trillion a year on some combination of paying way too much for low-value care, fraud, and waste—$1.5 trillion down the drain. As my guest, Dave Chase, says in this healthcare podcast, if this was a country, what we waste would be the 11th biggest GDP in the world. We could call it Healthcare-istan. Meanwhile, outcomes aren't anything to brag about on the world stage, and 41% of American adults have medical debt in this country. Also, all across the country, people making all kinds of healthcare decisions to save money that are clinically toxic. Financial toxicity is clinical toxicity, right? You know this already. You listen to this show. I just saw yet another study the other day—actually this one about cancer outcomes and how they are appreciably worse when patients are worried about how much money their treatment will cost. And a lot of people in this country—many people with a Part D plan, commercial insurance with big deductibles—there's a lot of people in this country who cannot afford tens of thousands of dollars in out-of-pocket spend every year. But let's change gears and talk about some good stuff, some inroads that are being made. Let's talk about Rosen Hotels for a moment. Rosen Hotels is a bright spot, for sure, in all of this. They are a leading indicator of what is possible. Rosen Hotels, which is a hotel chain in Florida, they saved over $450 million in healthcare costs and have healthier, happier employees. They spend 55% less per capita on health benefits despite having an employee population with significant health challenges. They saved so much money that Rosen was able to set up a scholarship fund so that not only kids of employees (and employees themselves) but also kids in the community can go to college. Turnover there is lower. Retention is higher. Employees are healthier. I mean, the ROI of a CEO and a CFO getting engaged and taking back control over their health benefits from third parties? It's huge. Check out this article about Rosen and also Dave Chase's TED Talk about Rosen.   My guest today, Dave Chase, says that what they did at Rosen Hotels was actually an inspiration for Health Rosetta, which is the organization that he founded to help employers take control of the out-of-control dysfunctional health benefits market in this country. Dave Chase says that the Health Rosetta community knows something that most don't (yet). Dave Chase has said that healthcare is fixed/fixable. He said that healthcare actually isn't expensive. Clinicians only receive $0.27 of every $1 that's ostensibly spent on healthcare. What is expensive is price gouging, profiteering, administrative bloat, fraud, and inappropriate treatment. And Dave Chase has also said that we're already investing more than enough money to not only fund world-class healthcare for everyone but also take all that money from Healthcare-istan and fund what drives 80% of health outcomes (ie, income, education, career opportunities, and clean air and water). There's so much money that is being wasted in healthcare. But all of this other stuff could be funded if we simply pay what we should be paying. (See Dave Chase's LinkedIn post to learn more about this.)   Health Rosetta currently has about five million lives stewarded through plans managed by their Health Rosetta advisors. That's probably another bright spot right there—five million lives. Another bright spot is the work of the Nuka System in Alaska. Listen to EP312 with Douglas Eby, MD, MPH, CPE. The Nuka System has won award after award for being one of the best health systems in the country, and it serves a challenging patient population for less money than most Medicaid plans.   So, here you have two entities, Rosen Hotels and the Nuka System, dealing with (on a good day) patient populations with multiple chronic conditions, high maternal mortality … At Rosen, 56% of their pregnancies are categorized as high risk, which not only has generational human consequences, of course, but is also a notorious budget-buster, as Dave Chase has said. There's substance abuse issues. These are patient populations who are doing appreciably better and cost far less than if they were covered by almost any other health plan in this country. Here's yet one more bright spot example company, and that's Pacific Steel. During our conversation, Dave Chase mentioned that the CFO of Pacific Steel said that when they went from spending $8 million in health benefits a year to spending under $3.5 million—basically cutting their healthcare costs in less than half—the CFO said that in order to make that same amount of net income, Pacific Steel would have had to raise their top-line sales revenue by 25% to 30%. So, okay … you're a CEO, and here's your choice to appease your shareholders or make your own bonus. Option A: Go out right now and figure out how to sell 30% more. Or Option B: Get your healthcare house in order, which may also improve retention if you do it right. To me, this doesn't seem like a head-scratcher. Two things that Dave Chase also brought up during our conversation that I thought were thought provoking. First, change is happening regionally and seems to adhere to the so-called “rule of three,” meaning that if three employers have worked with a qualified employee benefit consultant (EBC) and really fixed up their health benefits, then a cascade will start in that region. And secondly—and I never thought about this before—we spend over $4 trillion through various health plans (employer, ACA, Medicare, Medicaid), and yet have little to no objective mark of value for how good any given health plan is. The closest thing, as Dave Chase says, might be Medicare Advantage Star Ratings. To address this problem, Health Rosetta invested seven figures to build a Plan Grader™. This really helps employers make sure that the plan they put in place is a win-win the whole way around. You can learn more at healthrosetta.org or by emailing Dave at dave@healthrosetta.org.   Dave Chase leads the mission for Health Rosetta, which is to empower community-owned health plans (COHPs) with the vision of COHPs everywhere. Health Rosetta's purpose is creating and reinvesting the Health Rosetta Dividend (ie, redeploying the currently wasted $1.5 trillion in healthcare to a higher and better use—the social determinants of health such as income, better food, etc). Health Rosetta makes health plans local, organic, and sustainable transforming health plans from the number one driver of inflation, poverty, and bankruptcy to drivers of well-being and wealth. Health Rosetta ends the 30-year heist of stolen income from the working middle class. Health Rosetta plans have restored the American Dream for tens of thousands of people, giving them raises/bonuses and healthcare they can access without fear of bankruptcy. Individuals that had sky-high deductibles and co-pays no longer have that as a barrier (typically they are $0). School districts that once couldn't give teachers raises or had to have school levies to pay for music, art, and sports programs now have the funds (due to healthcare savings) to pay teachers more, have bigger class sizes, avoid cutting extracurricular programs, and more—all while giving teachers much better care outcomes. Health Rosetta's Plan Grader™ assesses the 40 most important attributes of a health plan “prescribing” proven strategies to transition into local, sustainable, world-class health plans. Health Rosetta community's transparency set a new industry standard and became the law of the land due to changes in laws that represent the largest change in employee health benefits since 1943. Through best-selling books, writing for various media outlets, TED Talk, and TV/film, Dave has reached over 10 million people with the goal of engaging, equipping, and empowering a broad grassroots movement designed to restore hope, health, and well-being to our communities. Dave received the Health Value Awards' Lifetime Achievement for Health Benefits Innovation at the World Health Care Congress. Prior to Health Rosetta, Dave cofounded Avado, which was acquired by and integrated into WebMD/Medscape, and founded Microsoft's $3-billion, 28,000-partner healthcare ecosystem. Outside of work, Dave coaches the next generation of leaders as a high school track and cross-country coach of state champion teams and individuals. Dave was a PAC-12 800 meter and 4×400 competitor. Most importantly, devotion to faith, family, and friends underpin a desire to be a servant leader to the five million lives (and growing) stewarded through the Health Rosetta community. 06:57 Why did Dave Chase start Health Rosetta? 07:42 EP312 with Douglas Eby, MD, MPH, CPE.07:51 How does Health Rosetta deem which health plans are succeeding? 11:07 What are the most important areas and factors for grading health plans? 11:22 EP365 with Scott Haas.11:38 “That $1.5 trillion of waste, how is that possible? Well, it's all codified in the contracts.” 12:18 “You can't manage what you can't measure.” 16:59 “What could be more disruptive than 30 years of wage gains stolen by the status quo health plans?” 17:39 “This is the last major area to modernize inside of corporate America.” 18:15 “This is not small dollars; there's a tremendous opportunity.” 19:04 “Go back to PBM. That's the first thing that starts to get at the care delivery side.” 21:52 “Can we even call it primary care if you can't get in to that doc for weeks?” 25:03 Where does Health Rosetta get their data to assess health plans? 27:00 Who are these self-insured employers, typically? 29:48 “3.5% [is] where the market flips.” 31:57 EP367 with Doug Hetherington.32:03 EP350 with Katy Talento.33:13 “We like to fetishize big in this country.” You can learn more at healthrosetta.org or by emailing Dave at dave@healthrosetta.org.   @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth Why did Dave Chase start Health Rosetta? @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth How does Health Rosetta deem which health plans are succeeding? @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the most important areas and factors for grading health plans? @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “That $1.5 trillion of waste, how is that possible? Well, it's all codified in the contracts.” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “You can't manage what you can't measure.” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “What could be more disruptive than 30 years of wage gains stolen by the status quo health plans?” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “This is the last major area to modernize inside of corporate America.” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “This is not small dollars; there's a tremendous opportunity.” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “Go back to PBM. That's the first thing that starts to get at the care delivery side.” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “Can we even call it primary care if you can't get in to that doc for weeks?” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth Where does Health Rosetta get their data to assess health plans? @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth Who are these self-insured employers, typically? @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “3.5% [is] where the market flips.” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “We like to fetishize big in this country.” @chasedave of @HealthRosetta discusses #healthplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33)  

In this healthcare podcast, I am speaking with Cora Opsahl, who directs the 32BJ Health Fund. Important to know about Cora's background is this: In previous roles, she's worked deep in the inner workings of the healthcare industry. So, she came to 32BJ armed with a BS meter that is finely tuned, which is, unfortunately, an essential skill for anyone trying to help the patients and members relying on them to successfully navigate the healthcare industry. So sorry to have to say that, but employers and unions, your employees and members need your help. If you do not help them, then your employees can find themselves defenseless against so many pit traps of financial toxicity and also clinical decision-making that is not made by patients and their clinicians in the service of improving patient outcomes but made by some other party in the service of financial maximization. It is really frightening what goes on in some cases. I really appreciated this interview with Cora Opsahl, which will be two shows, this week and next week. This whole conversation has been really a big bright spot for me and will provide hope, I think, for any employer/union who is seeking ways to protect their members and patients, the ones on their plans and therefore under their aegis and whom they have a fiduciary responsibility to look out for. It also should be a bright spot for dedicated clinicians out there suffering under the weight of moral injury because you are expected to do things that you know are not in your patient's best interest—or not do things, as the case may be. This whole conversation should put on notice health systems and others who have been really taking advantage of employers who are asleep at the wheel. Change is always really, really slow—until it hits a zeitgeist and then it's not slow anymore. I just attended the MTVA (Moving to Value Alliance) in Connecticut last month, and there were 30 employers there listening and learning. I hear similar numbers from business coalitions across the country penetrating their local markets (Houston, Indiana, for example). Also, spoiler alert, upcoming conversations with Dave Chase will continue this “yeah, there's good things happening out there” theme. So, let's start here with a little bit more about the 32BJ union and their Health Fund that we'll hear about in this episode. 32BJ represents about 200,000 members. They are mostly in residential and commercial real estate—so, for example, your doormen, your maintenance workers, your security, your cleaners, amongst others. Members are in about 11 states, but a lot of them are in the New York City metro area. These union members who are in the fund work for over 5000 different employers. The 32BJ Health Fund has zero-dollar premiums. Also, employees have no premium contribution. Wowza on that point—that's a huge benefit. Here's one more thing that I'm gonna say about the 32BJ Health Fund overseen by Cora Opsahl, my guest today. Let's talk about their amazing leadership, because I do not, nor should anyone else, take exceptional leadership for granted. We have had one guest after another on this podcast who, when asked what it takes to actually attain value for plan members or attain the quadruple aim, what it takes to navigate and overcome bureaucracy and inertia, every one of those thought leaders asked the “What does it take?” question came back with the following included in their list: It takes leadership. Real leadership. The mark of an exceptional leader is one who can conceive of a big mission statement, a goal to deliver better for their members at lower costs, and also the chops and determination to operationalize that vision. This operationalization requires brainpower and relentless dedication to untangle the deliberate opacity that some current healthcare stakeholders absolutely rely on as a business strategy. It takes work to get to the bottom of and disarm some deliberately labyrinthine and noncompetitive contract terms. Let me just pause for a beat on these basically egregious contract terms. Certain healthcare stakeholders seem to consider it somehow their birthright and their privilege to demand that employer and union customers sign on some pretty insane dotted lines—to the detriment of members and employees. By the way, if anyone is thinking CAA right now, I'm right there with you. Talking about the new Consolidated Appropriations Act that went into effect late 2021, and it's gonna take a lot of C-suite executives by surprise when they're named in class action lawsuits. So, there is another impetus to question bad contract terms if anyone at an employer or union needs an additional reason besides the health and safety of employees and members to justify getting their healthcare house under control. For more on the CAA, the Consolidated Appropriations Act, listen to the show with Christin Deacon (EP342).   But as I mentioned a moment ago, we are breaking this conversation up into two power-packed episodes. This first one gets into everything that the 32BJ Health Fund does with their data. They have lots of data. They demand it. Next week's show gets into their unprecedented decision to kick a major local health system out of their network. This decision was also a data-driven decision, but it's a whole other conversation, which is why it is now a whole other episode. So, besides kicking out overly expensive health systems from their network, here's other things that 32BJ is currently doing with their data and which other employers and unions may get a few ideas from. If you have the data, you (like 32BJ) can use it to: Make smart benefit decisions that are validated, not just guesses. Before you decide to do something (add a wellness program etc), be able to model it accurately for how much it will actually cost you—which, spoiler alert, is most of the time not what the vendor will estimate. You have way more data than the vendor does, so you can certainly use it to great effect in this way. Make sure that the right members are being communicated with so that benefit designs are successful. As Ashleigh Gunter said in EP368, success when changing benefit designs has a lot more to do with communication than many realize. Create dashboards for leadership that may show trend lines, for example, which could be very helpful to ensure that the fund doesn't run out of money etc … little things like that. Figure out how much the fund is spending on various procedures and where. There's all this talk right now about the crazy variability of prices for the same exact service in the same local market. At one hospital, a colonoscopy could literally cost $10,000; and in another hospital—same quality, same basically everything—that same colonoscopy will be $2000 or $3000. I mean, there's a 500% delta or something in some of these cases. Ensure that if a vendor said they were going to do something, that they are actually doing it. This is especially meaningful for point solutions because of the whole squeezing the balloon thing. I can save money in a silo, and you won't realize that those dollars are getting transferred elsewhere unless you are doing your own math. This is a big deal if you start thinking about how pharmacy benefits are typically siloed from medical benefits. So, if I'm a pharmacy benefit manager, I can talk about how much I'm saving by denying patients drugs without consideration of the medical downstream implications of that. Ensure you're not paying a bill and writing a check for more than the bill was for, which is weirdly common. There's a whole show with Dawn Cornelis (EP285) about this. 32BJ has an engineering team that is creating an app to help members navigate to great doctors with fair prices. All of these things roll into basically three categories: Cutting wasteful spending and finding fraud Making smart benefit decisions Being able to see trends and forecast the future, which is really helpful for financial solvency etc As Cora Opsahl says, “I think we [all can] recognize [that] you [cannot] make smart … decisions and be a fiduciary of [a] fund without having [data].” You can learn more at 32bjhealthfundinsights.org.  Cora Opsahl is the director of the 32BJ Health Fund, a self-funded plan that provides affordable, comprehensive, and innovative health coverage to 200,000 union members and their families. During her time at the Health Fund, Cora has led the implementation of multiple benefit changes: removing NewYork-Presbyterian Hospital System and physicians from the network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and implementing an expanded Centers of Excellence program administered by Mount Sinai Hospital System. These efforts are projected to save over $35 million in 2022. Prior to joining the 32BJ Health Fund, Cora spent 12 years with Express Scripts, a pharmacy benefit manager. During her time there, she held a variety of roles, including Medicare Part D, strategy and acquisitions, operations, and account management. 08:55 How much data does 32BJ Health Fund have, where do they get it, and how do they use it? 10:56 How did 32BJ Health Fund successfully demand their data from 100% of their vendors? 11:45 “We feel it's really important that we own this information ourselves.” 12:08 “It always concerns me—if a vendor doesn't want to give you the information, what are they hiding?” 12:34 “It's not just getting the data; it's then using the data.” 15:44 “Without data, you're really just taking a guess; and guesses are never gonna get you where you need to go.” 17:23 EP285 with Dawn Cornelis.17:42 Is the cost of creating a data analytics team worth the cost savings of those data discoveries? 21:07 “The use of data has really built our knowledge.” 22:55 “It's really important to us that as we make benefit decisions, we're doing it smartly.” 27:34 EP358 with Wayne Jenkins, MD.27:42 How is 32BJ Health Fund making their data knowledge actionable? 30:14 “If we can figure out how to make telehealth accessible … there may be an opportunity for telehealth … to upset some of these … monopoly systems or low-choice options.” 32:25 “It's really easy to think that we can solve this problem through benefit design … but in the end … it's the price.” You can learn more at 32bjhealthfundinsights.org.  @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth How much data does 32BJ Health Fund have, where do they get it, and how do they use it? @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth How did 32BJ Health Fund successfully demand their data from 100% of their vendors? @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We feel it's really important that we own this information ourselves.” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It always concerns me—if a vendor doesn't want to give you the information, what are they hiding?” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's not just getting the data; it's then using the data.” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Without data, you're really just taking a guess; and guesses are never gonna get you where you need to go.” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is the cost of creating a data analytics team worth the cost savings of those data discoveries? @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The use of data has really built our knowledge.” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's really important to us that as we make benefit decisions, we're doing it smartly.” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth How is 32BJ Health Fund making their data knowledge actionable? @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If we can figure out how to make telehealth accessible … there may be an opportunity for telehealth … to upset some of these … monopoly systems or low-choice options.” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's really easy to think that we can solve this problem through benefit design … but in the end … it's the price.” @CoraOpsahl discusses #healthdata on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294)  

In INBW32, I talked about telehealth. In this episode, I'm talking about collaboration between healthcare stakeholders or the lack thereof. My grandfather suffered from heart failure. This was many years ago now. But when I say suffered, I mean it. As many of you know, when heart failure is uncontrolled, it is painful to go through or even watch a loved one go through. There was that one time when I accompanied my grandfather (and my grandma was there, too) on a trip to the emergency room, you know, because he was drowning in his own lung fluid and could barely breathe. And when we arrived, they were going to wheel him into one of the exam rooms. But my grandmother put her foot down. She did not want to go into that one exam room because the TV was broken in there. Yes, the two of them had been in the ER so many times that they were familiar with the pros and cons of the various exam rooms. The end of my grandfather's life was almost unbearable, and I can't even begin to estimate the hundreds of thousands of dollars racked up in ER visits and inpatient stays. He was in the ER once a month at a minimum, and he would come home disoriented and confused. Now, as everybody listening to this show knows, this anecdote is also a data point that is, dare I say, all too common. But to that end, let me just talk about heart failure data for a second. Patients with heart failure generate a third of Medicare spending and 40% of Medicare fee-for-service deaths. They are also responsible for 55% of Medicare readmissions. You'd think that if there were any chronic condition that we'd be looking to improve outcomes on, it'd be this one. So, everybody's on it, right? Oh, wait … heart failure readmissions have actually gone up in recent years.   I just want to point out that in between ER visits and inpatient stays, my grandfather received effectively no education, no PCP or cardiology follow-ups, no community support. He did not get a case manager. He got no coaching. He got 25 pages of tiny, printed instructions just before the door hit him in the butt on his way out to the parking lot. Obvious point here, but to do any of this in-between stuff would have required collaboration between the hospital and others. And it was conspicuous in its absence. Look, this is sad and I'm not telling the story because I think it's unique. If I asked who else has a story like this one where a family member or a loved one got lost in the gaps between their care, I am suspecting that everyone would raise their hands—even those of you who have medical degrees. No matter how much any of us know or care or try to help, stories like my grandfather's are painfully and unequivocally common in this country today. OK, so how to improve care, especially for chronic care patients. At its core, and I am not telling anyone listening something that you probably have not already thought about at great length, but there are two important contributors to patient outcomes. Not the only contributors for absolutely sure, but here are two important ones: Nonfragmented patient journeys that adhere to evidence-based best-practice care. My grandfather and anyone with a chronic condition requires a patient journey that isn't a game of whack-a-mole. Carly Eckert, MD, says this so well in EP361. Steering patients to the best care setting, which is required to get the highest-value best-practice care and also reduce financial toxicity. Short but important sidebar: We know that financial toxicity is clinical toxicity. There was just a study that came out that said in 2030, a leading cause of death will be noncompliance to treatment due to patients abandoning care because it costs too much. Wayne Jenkins, MD, from Centivo (EP358) talks about other implications of financial toxicity for a half-hour. Also, there's another paper that, again, is just more on this point. At this juncture, it is not arguable. Financial toxicity is clinical toxicity. So, we need to get patients, people, customers to the next place that is the highest value for them. Doing either or both of these things—nonfragmenting the patient journey and making sure patients get to the next care setting—it requires collaboration. Let me quote Dr. Steve Klasko, who, until recently, was president and CEO over at Jefferson Health in Philly. He said—and this is an adaptation of an old Steve Jobs mantra—but Steve Klasko said that for hospitals, our old math was inpatient revenue, outpatient revenue, and in-person tuition and funding. The new math is going to be strategic partnerships around this healthcare at any address model. Right? But good collaborations don't just improve patient outcomes. Here's another benefit: They also make happier clinicians or employees. If every outside interaction is a friction point, where employees, clinicians, doctors, nurses are rubbed raw because every interaction becomes a battle, if that's the ecosystem that any given party has created for themselves, patients aren't happy and clinicians aren't happy. And since everything in healthcare spirals around that one relationship, the one between the patient and their clinicians, this could not be more vital. There's that famous Richard Branson quote, which I'll paraphrase: If you want to keep the customers happy, keep the employees happy. How anyone thinks that patients are going to get amazing care when those providing the care are miserable is just the very definition of magical thinking. All right … so, let's get into the hard thing about hard things: why with the lack of collaboration across the industry there are a lot of excuses for why parties cannot collaborate. For example, interoperability, HIPAA, legal, cyber, bureaucracy … Also, people are busy, COVID response, being overworked and burned out is a big deal. And I'm not saying that some of these are not valid, but the elephant in the room is this: In healthcare today, most (if not all) big organizations for sure and a lot of small ones have a business model that is built on revenue maximization. Look, when I'm referring to organizations as revenue maximizers, maybe I'm not talking specifically about specific departments and people working hard in those departments within any given organization. Organizations are not one-celled organisms, after all. But what I am saying is that, as a whole, healthcare organizations—the vast majority and certainly every so-called incumbent payer and health system—when you factor in the actions of the CFO, the actions of the billing department, the group that sets premiums, the one that sets prices, the group that incentivizes brokers, the group that sells to employers, the group that lobbies politicians, the group that writes the contract terms … if you factor in the whole organization, what you get is an organization who acts to maximize outcomes—financial outcomes, that is. As per my normal MO, I'm gonna say the quiet part out loud here. One big reason why parties do not collaborate is because they are thinking they are going to maximize their revenue by info blocking to prevent network leakage, or not sharing data with an employer because then the employer might steer the employee to an infusion center for their chemo, or drugs will get switched from the profitable one to the not profitable one. I just saw another article the other day, entitled “The Many Barriers to Payer-Provider Alignment on Value-based Care.” Two entities vital for a nonfragmented frictionless patient journey cannot figure out how to align incentives, share data, or even figure out what good looks like. Speaking industry-wide here, but if patient outcomes were the top of either the payer or the provider's organizational lists of priorities, I do not think that this would be the case decades later. Listen to the show with Kevin Schulman, MD (EP366); Scott Haas (EP365); or an upcoming one with Autumn Yongchu and Erik Davis coming out in a few weeks that just drives this point home.   So, can you do well by doing good? Yes, you can. I have a degree from a business school, after all; but there is a line that gets crossed when maximizing revenue harms patients. And I'll tell you how you can tell if you're over the line. And again, I'm talking organizations here who have power and control in their local markets. I would say that a lack of collaboration is a symptom. If we all agree that collaboration is essential and some organization is not doing it, maybe it is a sign. It is an actionable bit of information that I hope, if relevant, gets contemplated. For example, back to my grandfather for a sec, it's pretty well known how to reduce heart failure revisits. There are more than a few care models that have definitely been shown to work. Here is one of them, and this was talked about in Dr. William Bestermann's Substacks. There was a nurse in the Carolinas—and I talked about this before—but there was a nurse in the Carolinas who decreased heart failure readmissions markedly by simply calling up heart failure patients and making sure they were doing OK and that they understood how to take care of themselves. She was caring, and she had relationships with these patients. That's all she did.   So, hospital collaborates with a payer case manager or a CBO (community-based organization) or an MSO (management services organization), or maybe the hospital has pop health capabilities internally. I mean, we can manage to transplant important organs in this country, and most healthcare organizations cannot figure out how to work together well enough that a nurse calls up a bunch of patients? Is this some arcane or highly complex thing to do? No, it's not. But most are not doing anything even close to this because revenue maximization is the goal of one or more of the entities who would need to be a party to this, and everything else is just an excuse. If anyone is thinking interoperability right now, I've heard Don Lee say on The #HCBiz Show! often enough that there's lots of evidence at this point that interoperability has been solved from a technical standpoint. It's been solved for years. The problem is a business case problem. No one wants to be interoperable because … revenue maximization All right … aspirationally here, despite all of this, great collaborations happen every single day—collaborations that are bright spots and that definitely improve patient outcomes and reduce financial burdens short-term and long-term. Let me give you some examples: what 32BJ is doing in New York City (upcoming episode with Cora Opsahl talking about the cool things that they are doing with Mount Sinai); CINs (clinically integrated networks), like Lisa Trumble, who talks about SoNE HEALTH in EP349.   There are MSOs that work with ACOs (accountable care organizations) and others. Listen to Shawn Rhodes (EP354); also what Nicole Bradberry and Kelly Conroy are doing in Florida (EP324).   In an upcoming episode, Dave Chase from Health Rosetta: He's got one great story after another about how employers these days are teaming up with provider organizations, pharmacies, and their communities to put a serious dent in costs while raising patient outcomes and satisfaction. Doug Hetherington's episode (EP367) talks about direct contracting with hospitals. Katy Talento (EP350) talks about this also. Steve Schutzer, MD, talks about collaborating with other local orthopedic surgeons to stand up a now nationally recognized center of excellence in Connecticut (EP294). We also have some pharma companies who are developing some pretty great disease-centric resources for providers. Some pharma companies and some internal teams at those companies can actually be fair and good community players. Mike Levitt and the work that he has done on the Accountable Care Learning Collaborative, which is headed up by Dr. Eric Weaver, who has been on the show (EP277); or I'm sure after this show airs, I'm gonna hear about more. Please send them my way.   Now, look … let's get real here. These collaborations may have been initiated with, let's just say, other beneficial side effects; but they all improve care and reduce costs. If I were gonna list some common and appealing side effects that could motivate some prospective collaborators to come to the table, some of the usual suspects are proposing that the collaboration will, for example, improve HCAHPS scores, quality metrics, star ratings; improve predictable spend; reduce shock claims; avenge your common competitor and steal their market share; gang up against a payer or some consolidated health system; improve OR utilization; or improve efficiency in some way. What I would say, though, is that if leveling up patient care happens and costs do not rise as a result, that's the shared priority I'd focus on. If someone gets some beneficial side action, this is kind of the definition of doing well by doing good. All right, so let's talk about the different kinds of collaboration just briefly. I'm gonna say that there's three kinds of collaboration: Collaboration along the patient journey by multiple parties who are all along the patient journey Collaboration by parties who can help inform the patient journey, but they're not necessarily on the patient journey themselves Collaboration by parties who can help navigate the patient journey I am mentioning these three because there's often sort of this insinuation that collaborators should have equal stature in the care journey or have similar roles, that if you're not actually on the clinical journey, then you don't have any responsibility or accountability for the clinical journey and, therefore, are not a worthy collaborator. That is limiting if you are trying to figure out who you might be able to collaborate with to help you. The patient journey is not like a movie showing all the minutes a patient spends in clinic, and then all the gaps in between visits are edited out. Care can be improved at the population level, at the community level. Care can be improved at the disease or the condition level when clinicians get needed insights or information or tools. I mean, frankly, to my mind, it shouldn't be considered a plus when a pharma company or a payer actually does something in the service of improving patient outcomes. It should almost be a requirement that they do. I don't mean by delivering care in any way. And for the record, most prior auth programs are the opposite of collaborative. Payers can collaborate by supplying data, as just one example. Heck, external collaborations are great, but we also could think about collaborating internally, like invite the CFO or maybe the gang rewarding brokers with sales competitions. I don't know. I'd consider ethically dubious: Invite them to come to some meeting where oncology patients are choosing to die rather than bankrupt their families. Communication is the first step to collaboration, after all. That's a place to start. Or life science types: They can supply knowledge and expertise about specific diseases or conditions with the purpose of improving patient outcomes. Informing the patient journey could be a collaboration with some of these amazing patient efficacy organizations or CBOs that are out in the community. Now, I think one barrier to collaboration that we all need to get over is the whole, I call it, stakeholder prejudice thing. Here's what Colton Ortolf wrote on Twitter the other day. He tweeted, “Hospitals are the Lance Armstrong of healthcare. Pissed [off] at all the [crappy] things they do economically, but also grateful for all the lives they save.” If we're gonna eliminate everybody in healthcare who has revenue maximization as their organizational goal, as aforementioned, there is going to be basically no one left standing. As Ge Bai, PhD, CPA, said in EP356, there's no angels and no demons in healthcare. Everybody is both.   If we're talking about stakeholder prejudice, though, I would be remiss not to single out Pharma. When I mentioned them a sec ago, I bet some of your eyebrows went up. Here's my take on it. Consider Pharma's potential role in leveling up disease-/condition-specific outcomes. I mean, there are thousands, millions probably, of diseases and conditions and health problems out there that any given doctor or clinician has to be familiar with. Pharma has huge infrastructures and physicians and smart people who focused on, like, six of them. They know more about those six than anybody else. We pay a ton also for their drugs. It's my view that people along the patient journey should ask for what they want and need relative to the expertise that Pharma possesses. It should be about helping those providing care on the patient journey to level up the standard of care. Frankly, I'd expect collaboration from some of these entities. Ask for it on your own terms, and if all you get back is a sales pitch, you deserve better than that. Find somebody higher up on the food chain to talk to. And also, outcomes-based contracts … yeah, we need to figure out how to operationalize them so that really good drugs that actually produce outcomes like overall survival get paid for and those that do not do not. Point of note must be said: Colluding and conflict of interest is not cost neutral. If someone is getting things bought for them and then thinking, falsely, that it does not impact prescribing, that is not collaboration. Any of these revenue-maximizing hookups are not included in my definition of collaboration. So, in sum, ultimately, what we're talking about here is our legacy. As David Muhlestein, PhD, JD, talks about really well in EP364, we got to ask ourselves, What do we want to leave behind to our children and our grandchildren? Some of this is generational change, for sure. But seriously, talking about today, I mean, who wants to sign their family member up for what my grandfather went through? Right now, across the country, there are heart failure patients going through exactly what he did; and there are other patients with care journeys so dysfunctional that lives are shattered.   Chronic care patients, oncology patients … and this isn't going to change unless we contemplate, first of all, what we can do today—right now. Even little things can matter a lot, but then also to really consider what we want healthcare to look like in 20 or 25 years and then start working back from that vision and collaborating today so that, slowly and surely, we reach a place with better care that is not financially toxic. Check out the 8-Step Collaboration Roadmap for more resources to operationalize a collaboration. For more information, go to aventriahealth.com.   Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. 03:07 How do we improve care, especially for chronic care patients? 03:18 What are two important contributors to patient outcomes? 03:40 EP361 with Carly Eckert, MD. 03:56 “We know that financial toxicity is clinical toxicity.” 04:09 EP358 with Wayne Jenkins, MD. 06:05 Why can't parties across the healthcare industry seem to collaborate? 08:05 EP366 with Kevin Schulman, MD. 08:07 EP365 with Scott Haas. 08:10 Upcoming episode with Autumn Yongchu and Erik Davis. 08:34 “I would say that a lack of collaboration is a symptom.” 10:10 There's lots of evidence that interoperability has been solved. It's been solved for years. 10:37 Upcoming episode with Cora Opsahl. 10:46 EP349 with Lisa Trumble. 10:53 EP354 with Shawn Rhodes. 10:57 EP324 with Nicole Bradberry and Kelly Conroy. 11:04 Upcoming episode with Dave Chase. 11:19 EP367 with Doug Hetherington. 11:25 EP350 with Katy Talento. 11:28 EP294 with Steve Schutzer, MD. 11:50 EP277 with Eric Weaver, DHA, MHA. 13:00 What are the three kinds of collaboration in healthcare? 13:23 Do collaborators need to have equal status in a collaboration? 13:57 “Care can be improved at the population level, at the community level … at the disease or the condition level.” 15:10 How is stakeholder prejudice holding healthcare back? 15:42 EP356 with Ge Bai, PhD, CPA. 16:55 “Outcomes-based contracts … we need to figure out how to operationalize them.” 17:08 “Colluding and conflict of interest is not cost neutral.” 17:30 EP364 with David Muhlestein, PhD, JD.   For more information, go to aventriahealth.com.   Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab How do we improve care, especially for chronic care patients? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab What are two important contributors to patient outcomes? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab “We know that financial toxicity is clinical toxicity.” Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab Why can't parties across the healthcare industry seem to collaborate? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab “I would say that a lack of collaboration is a symptom.” Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab There's lots of evidence that interoperability has been solved. It's been solved for years. Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab What are the three kinds of collaboration in healthcare? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab Do collaborators need to have equal status in a collaboration? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab “Care can be improved at the population level, at the community level … at the disease or the condition level.” Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab How is stakeholder prejudice holding healthcare back? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab “Outcomes-based contracts … we need to figure out how to operationalize them.” Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab “Colluding and conflict of interest is not cost neutral.” Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab Recent past interviews: Click a guest's name for their latest RHV episode! Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms  

This week, I'm joined by Dave Chase: the creator and co-founder of Health Rosetta. He and his company are well known for their work to fix the U.S. healthcare system – but today's podcast reveals a more personal side of his life. We talk about being a father that helps his kids grow into confident […] The post Unlocking the Potential in Others with Dave Chase first appeared on Ryan James Miller.