Podcasts about direct contracting

In Episode 472, Stacey Richter speaks with Dr. Eric Bricker about the impactful strategies hospital systems use to maximize revenue from high-cost patients. They explore the financial complexities and contracting tactics that enable hospitals to profit significantly from a small percentage of high-cost claimants. Key points include the negotiation of provider stop-loss contract provisions, strategic adjustment of charge masters, and the intentional steerage of patients to high-revenue service lines. This episode highlights the intricacies of hospital finance and the hidden mechanisms that drive healthcare costs for self-insured employers and other plan sponsors. We could have 0.5% to 1% of total plan members costing upwards of 40% of total plan dollars. And I bring this up just to highlight the magnitude of the money here. In that show from last week, we take the issue of high-cost claimants from the standpoint of the plan sponsor. Today, however, we're gonna be looking at this from the standpoint of the hospital system. If we were to come up with a motto for the show today with Dr. Eric Bricker, it's that all costs are somebody else's revenue. And when it's revenue and profit of the magnitude that we're talking about with many high-cost claimants, it starts to be less of an accidental “Oh, wow! How did that CABG patient wind up in our clinic? What are the odds?” and more of a “Whoever is not steering patients is letting someone else with a big profit incentive lock down that steerage in deeply embedded ways.”  === LINKS ===

**Struggling with Low Foot Traffic? Boost Your Pharmacy Profits with Dr. Lisa Faast Expert Tips! In this video, Dr. Lisa Faast shares strategies to help your pharmacy thrive. Whether it's breaking free from the broken rebate system or building new revenue streams, these tips will help you take control of your profits.** **Show Notes:** 1. **PBM Optimization and Pharmacy Profitability** [0:00] 2. **Challenges with Primary Wholesalers and Buying Groups ** [3:20] 3. **Contracting and Direct Contracting ** [7:01] 4. **Optimizing Over-the-Counter (OTC) Sales** [8:54] 5. **Community Engagement and Special Deliveries** [17:22] Websites Mentioned: https://diversifyrx.com/weekly-awesomeness-newsletter/ https://www.drlisafaast.com/ ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be Apart of the Pharmacy Podcast Network**

In this episode of Impact Healthcare, host Lester Morales sits down with Daniel McCauley, founder of Mac Consulting Group, to discuss how his personal experiences have shaped his passion for transforming healthcare benefits.

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

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

In this last ever episode of the Race to Value podcast, we are leaving you with inspiration for a more optimistic future in the value transformation of our country.  Sadly, this will be our last show, but we are ending it on such an incredible high point!  This week's interview brings a message of hope, compassion, and human connection balanced with the business success of value-based care within a national leading health system.= Albert Einstein once said that “Only a life lived for others is a life worthwhile” and no one better captures that spirit of servant leadership than our guest this week. Philip Eaves is the President and CEO of Ascension Seton ACO | Ascension Seton Health Alliance and the Vice President of Population Health at Ascension Texas, and he is a leader in the value movement that you should know about. In this interview we focus on change management, leadership, and the human side of healthcare economics. Overseeing the value-based care strategy and operations for one of the largest clinically integrated networks in Texas, Philip is leading the ACO to outstanding success…and transforming the lives of people along the way. Bookmarks: 01:30    The human side of healthcare economics – compassion is the currency; empathy is the language. 02:00    Introduction to Philip Eaves, President and CEO, Ascension Seton ACO and VP of Population Health, Ascension Texas 02:30    Ascension Seton ACO is the largest clinically integrated network in Texas with 3,600 providers with 300K value-based lives. 04:45    “Only a life lived for others is a life worthwhile” -- Albert Einstein 05:30    Philip shares how a humble, faith-based upbringing fueled his ambition, work ethic, and compassion as a healthcare leader. 07:30    “Healthcare is about serving others.” 08:30    Occupational medicine as a stepping stone to value-based care. 09:45    Team-based care that enables providers so they can build meaningful patient relationships. 11:00    $24M in MSSP Shared Savings for 23,000 Medicare beneficiaries to achieve a top 7% performance ranking of all ACOs in the country (#32 out of #482). 12:45    Valuable partnerships with independent practices (e.g. Austin Regional Clinic, Capital Medical Clinic). 13:00    “Physician engagement is the overall key to ACO success.” 14:00    The impact of Annual Wellness Visits (AWVs) in practice transformation. 15:00    HCC recapture for documentation accuracy as an area of educational focus. 15:45    Centralized versus Embedded Care Management. 16:30    Analytical insights to drive high risk CM interventions. 17:15    Quality campaigns to close care gaps and improve population health outcomes. 18:00    Refining a Post-Acute Care network for optimal transitional care. 18:30    An after hours program as an effective ED diversion strategy. 20:00    Change management to improve team culture and reinvent the business model for VBC. 22:00    Phillip shares his experience leading an inflection point for the ACO business. 23:30    Applying the principles of the Kübler Ross Change Curve in organizational change. 24:30    Inspiration from John Kotter (“Leading Change”) – Leadership versus Management. 25:00    Recognizing the need for change in shifting a new strategic direction. 26:00    Communicating the vision and creating short-term wins. 26:45    New initiatives: a new ACO for early adopters, Medicare Advantage risk, and Direct-to-Employer partnerships. 28:00    Financial toxicity as a driver of Direct Contracting between employers and providers in value-based care. 30:00    Employer frustration with rising medical spend and the lack of solutions from their brokers. 30:45    Designing an ACO value proposition based on employer pain points. 31:00    Leveraging network adequacy and CIN care infrastructure for commercially insured populations. 32:45    PBM transparency to reduce extreme spending on pharmacy drugs. 34:00    Forging a new partnership with Signify/CVS to suppor...

We've turned to our Facebook community, The Frugal Physicians, and your emails to bring you a unique segment. Dr. Disha is answering a few of your questions about managing finances, making smart investments, and seeking out alternative income streams in the world of healthcare. A significant portion of today's episode is dedicated to real estate investment. Dr. Disha shares her personal journey, inspired by the principles in "Rich Dad, Poor Dad," and discusses the tangible benefits of real estate, including tax advantages, inheritability, and the potential for high returns. She provides practical advice on getting started, managing risks, and understanding the nuances of different types of real estate investments, from long-term rentals to short-term vacation properties.  Looking for something specific? Here you go: 00:00:11 - Introduction and Apology for Delay 00:00:33 - Welcome to Finding Financial Freedom Podcast 00:01:00 - Community Questions on Finance in Healthcare 00:02:06 - Passive Income for Physicians 00:04:13 - Creating Intellectual Property for Passive Income 00:04:55 - Exploring Side Gigs for Doctors 00:06:00 - Monetizing Blogs and Podcasts 00:07:17 - Affiliate Marketing Explained 00:08:02 - Direct Contracting and Content Creation 00:08:55 - Multiple Income Streams and Wealth Building 00:09:53 - Real Estate Investment for Financial Security 00:11:07 - Benefits and Strategies of Real Estate Investing 00:13:45 - Tax Benefits of Real Estate Investing 00:15:58 - High Risk and Reward of Real Estate 00:17:02 - Real Estate Investment Types 00:18:26 - Real Estate as a Tangible Asset 00:19:56 - Short-Term Rental Investing and Tax Benefits 00:23:28 - Addressing Investment Losses and Tax Implications 00:28:57 - Subscription Model in Healthcare Business 00:34:17 - Physician Groups for DIY Enthusiasts 00:38:06 - Closing Remarks and Contact Information This episode is sponsored by  Eckard Enterprises – is an asset management company that focuses on providing families access to diverse, alternative investments. If you enjoyed the show, find and follow Dr. Disha everywhere else: Twitter Website Facebook The Frugal Physicians Facebook Group YouTube  ----------- Please note: The content shared on the podcast is for informational purposes only and should not be considered individualized financial advice. It is essential to consult with professionals such as accountants, financial advisors, or attorneys to receive personalized guidance based on your specific needs.

This is episode 103, “Why Medicare for All Is Better Than Direct Contracting.”  Do not miss this episode as host Joe Sparks explains why Medicare for All is better than direct contracting.

Christopher Habig, the CEO and co-founder of Freedom Health Works, hosts Healthcare Americana. On this episode, Jay Kempton, the President and CEO of the Kempton Group and one of the founders of the Free Market Medical Association, is a guest. Together, they discuss the upcoming 2023 Free Market Medical Association Annual Conference, which is an event that brings together people in the healthcare industry who are fed up with the status quo and have a desire to change it. They also talk about the Kempton Group, which is in the business of helping people navigate the complex, opaque, and wasteful health insurance industry. The conversation emphasizes the importance of putting patients first and restoring trust in American healthcare.0:00:00"Exploring the Free Market Medical Association with Jay Kempton of the Kempton Group"0:02:16Conversation with Jay Kempton of the Kempton Group on Self-Insurance and Managed Care0:04:31Conversation on Taking Ownership of Self-Funded Health Plans0:07:59Heading: Explaining the Benefits of Self-Insured Healthcare to Employees0:09:52Conversation with Jay Kempton, President and CEO of Kempton Group, on Quality and Cost in Healthcare0:15:33Exploring the Benefits of Direct Contracting with Jay Kempton, President and CEO of Kempton Group0:17:27Conversation with Jay Adkins, Founder of the Free Market Medical Association0:19:43FMA's Plans for 2023 and 2024: A Conversation with Jay Wolfson, Executive Director of the Free Market Medical Association0:21:49Interview with Jay Kempton, President & CEO of Kempton Group and Co-Founder of the Free Market Medical AssociationFollow Healthcare Americana:TwitterInstagramLinkedInMore on Freedom HealthworksMore on Jay KemptonSubscribe at https://healthcareamericana.com/episodes/

Dawn Carter, Director of Product Strategy of Centauri Health Solutions joined Sean to discuss Risk Adjustment Audits and the ins and outs of these often times annoying administrative requirements if you participate with an MA Plan... This was such an interesting discussion and we believe you will think so too! Links to articles from the show: Article 1: Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,' Part 1: The Risk-Score Game - https://www.healthaffairs.org/do/10.1377/forefront.20210927.6239/full/ Article 2: Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,' Part 2: Building On The ACO Model - https://www.healthaffairs.org/do/10.1377/forefront.20210928.795755/full/ Article 3: Halvorsen/Crane rebuttals: https://www.healthaffairs.org/do/10.1377/forefront.20220106.907235and https://www.healthaffairs.org/do/10.1377/forefront.20220203.915914/ Article 4: Gilfillan and Berwick rebuttal to Halvorsen and Crane: The Emperor Still Has No Clothes: A Response To Halvorson And Crane - https://www.healthaffairs.org/do/10.1377/forefront.20220602.413644 Article 5: Kang/Duncan/Hunh response: Making The Right Diagnosis: A Response To Berwick And Gilfillan - https://www.healthaffairs.org/do/10.1377/forefront.20220706.909897/ About Dawn Carter: Her career in healthcare spans 28 years, which most recently includes extensive experience in developing revenue integrity and quality software solutions, with a focus on encounter management, risk adjustment, and social determinants of health solutions for Medicare Advantage, Medicaid and Commercial health plans, as well as providing risk adjustment strategic advisory services for these markets. Prior to that, her experience spans all domains of health care including health plan and provider systems administration, finance, compliance and healthcare applications development inclusive of EDI and X12 and HL7 development. Her experience also includes multiple teaching engagements in medical administration, billing and coding. Dawn holds a Bachelor's degree in Business Administration, and she holds the American Association of Professional Coders CPC (Certified Professional Coder), CRC (Certified Risk Adjustment Coder), and CPMA (Certified Professional Medical Auditor) credentials. She is also a Certified Scrum Product Owner (CSPO). Dawn is a passionate and prolific industry speaker, author, blogger and subject matter expert in claims, EDI management, and risk adjustment.

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  

**In this Episode of the Becoming a Badass Pharmacy Owner Podcast; Dr. Lisa Faast with Whitney Brace talk about direct contracting** **Show Notes:** 1. **Whitney Brace Introduction** [1:29] 2. **How We Started with Direct Contracting** [2:04] 3. **Brand and Generic Effective Rates** [5:04] 4. **Leaving PSAO** [6:44] 5. **Termination Tips** [10:11] 6. **The Difference We Get** [11:41] 7. **Advice For Fellow Pharmacy Owners** [14:34] ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be Apart of the Pharmacy Podcast Network** Learn more about your ad choices. Visit megaphone.fm/adchoices

Primary Care in the United States is flawed, especially for our most complex patients in the Medicare program.  We have built this incredibly expensive primary care model around a fee-for-service system that is incredibly fragmented and uncoordinated.  There is now a need for a new model – one that yields a much better experience for patients and physicians.  We now stand at the threshold a great dawning. An era is ending, and we are at the core of creation in reimagining a more idealized, value-based model for primary care – one that untaps a massive reservoir of healing capacity. This vision for “A New Primary Care Model” will transform community health for our most clinically complex and vulnerable populations.  And it all starts with payment model innovation which, in turn, spawns care delivery innovation. Although we are in early days of full-risk Medicare Advantage and global capitation models in Medicare, there are leading indicators that show promise for the future of health. What exactly does a reimagined primary care model look like and how can it scale?  Look no further than agilon health – a company that partners with independent primary care practices that are leaders in their markets and helps them transition to value-based care success in the Medicare program. On the Race to Value this week, we are joined by Steve Sell, the Chief Executive Officer and a member of the board at agilon health.  Steve leads agilon health as an experienced, mission-based CEO known for transforming organizations through partnerships, product innovations and talented, collaborative teams. With over 25 years of experience in value-based care in the health plan environment, Steve Sell is building a new model of primary care for the future. Under Steve's leadership and guidance, agilon health is transforming health care delivery through a technology enabled, full risk value-based care model that places the primary-care physician as the quarterback of patient care. And they are doing this at scale, in geographies that have operated in a fee-for-service environment. If you are want to know more about how we can transform primary care at scale, this week's podcast episode is a must-listen! Episode Bookmarks: 01:30 Introduction to Steve Sell and agilon health 04:00 agilon's growth to over 250k Medicare Advantage members and over 90k attributed Direct Contracting beneficiaries 06:30 “Primary Care in this country is really flawed. It's been built around a FFS system that is incredibly fragmented and uncoordinated.” 07:00 The vision for “A New Primary Care Model” to transform community health that is empowered by payment model and care delivery innovation 08:00 Steve discusses the rapid growth of agilon health since its founding in 2016 (1% of all PCPs in the country, 23 communities in 12 states) and how PCP trust is built over time 09:00 Partnering with physicians to support scale and alignment in markets that have been historically dominated by FFS 09:45 “We believe that full-risk, value-based care is the best way to organize an entire community. PCPs can then move to the top of the overall delivery of care.” 10:15 The Speed of Transformation -- agilon's intensive 12-month implementation period 10:45 Win/Win/Win (Patients, Doctors, Communities) – transformed health outcomes, satisfied primary care providers, high industry-leading Net Promoter Scores 12:00 The consumer-centric innovation opportunity in fully-delegated, capitated Medicare Advantage plans 13:30 How changing demographics and an aging population fuels Medicare Advantage Growth 14:00 The economic challenges of a shifting payer mix in primary care, i.e. less concentration of commercial business when a population ages 14:45 “The reform of payment models are the key to starts the process of transformation in primary care practices.” 15:00 The early days of full-risk MA and global capitation models in Medicare as an indicator for future...

Locumstory contributor and emergency medicine locums Dr. Rip Patel shares when he thinks it's best to work with an agency and when direct contracting is the better choice. Dr. Rip Patel is a long-time locum tenens doc and Locumstory partner, read more of his thoughts on the Locumstory blog.

The Centers for Medicare & Medicaid Services (CMS) earlier this year rebranded an aspect of the Medicare program that used to be called Direct Contracting. The newly named ACO REACH stands for “Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health.”

Produced by KSQD90.7FM (Action Requested: Flood the White House switchboard to urge President Biden to stop DCE/REACH today! Call 202-456-1111 from 11:00am-3:00pm EST. A script may be found at www.nationalsinglepayer.com and click on the call-in script link.) “Be Bold America!” Sunday, May 22, 2022 at 5:00pm (PDT) When Willie Sutton was asked why he robbed banks, he responded, “because that's where the money is.” During the final days of the Trump Administration, officials at the Center for Medicare and Medicaid Innovation (CMMI) launched a dangerous and insidious pilot program known as Medicare Direct Contracting. (This program was recently rebranded as REACH by the Biden Administration.) Left unchecked, Direct Contracting and REACH would allow profit-hungry middlemen to “manage” the care of up to 30 million traditional Medicare beneficiaries. These middlemen, some of whom have received a huge influx of money from private equity, have every incentive to frustrate patients and deny medically necessary care! Unless we stop REACH, this program could spell the end of Medicare as a public, nonprofit, social insurance program. “Medicare was designed as a lifeline for America's seniors and those with disabilities, NOT a playground for Wall Street investors.”– Dr. Susan Rogers, President, PNHP Interview Guest: Dr. Ana Malinow spent decades working as a pediatrician with immigrant, refugee and underserved children in Ohio, Texas, Pennsylvania and California. She is past president of Physicians for a National Health Program, co-founder of Health Care for All Texas, and lead organizer for the National Single Payer. She has authored opinion pieces on how national single payer will improve patient care and bring us closer to social justice. She has been a speaker on healthcare reform and featured on national and international television and radio. She recently retired as Professor of Pediatrics from the University of California in San Francisco.

Lots of talk about direct contracting going on these days. Many of you will be familiar with the term, but in short, direct contracting means when a self-insured employer directly contracts with a provider organization with no payer in the middle of that arrangement. And when I say “employer,” I mean the employer and all their peeps—their TPAs, repricers, other vendors, and consultants. Most of this talk, though, seems to come from the point of view of the employer. It's super easy to quantify what's in it for employers. US healthcare costs get blamed for all kinds of things: companies who have lost big global contracts because all of those fringe benefits cost way too much around here. If we're looking around for a why on that point, let me refer you to last week's episode (EP366) with Dr. Kevin Schulman entitled “An In-Depth Dissection of Our Dysfunctional Healthcare Benefits Market.” Or the show with Dr. Wayne Jenkins (EP358) about how premium and deductible financial toxicity negatively impacts plan members. Never forget that financial toxicity is clinical toxicity.   So, like a knight riding in on a white horse, direct contracting with a provider organization has some interesting potential. Most obviously, when an employer contracts directly with a provider organization, they cut out the middleman. They put the direct in direct contracting. Considering the multi-billions of dollars that some of these middle people are raking in every quarter in profits and/or “margins,” cutting out the middle people could have a financial upside as big as those billions in profit. If those billions get passed on to patients in the form of lower co-pays/coinsurance or premiums, there could be some big benefits to direct contracting for pretty much all involved … except the middle people, of course. My guest in this healthcare podcast, Doug Hetherington, says that it's not uncommon to see on the low end a 10% reduction in costs to maybe up to 50% reduction in costs. It's amazing what can be accomplished when everybody starts working together for the good of the local community and patient and is held accountable for more than just revenue maximization. But there's also quality and patient outcomes upsides to these cost reductions. Here's a few we can speculate about: For example, if the middle people add layers of bureaucracy and administrative burden that make it really hard and/or upsettingly inefficient for anyone trying to serve their patients' needs to actually serve their patients' needs, then yeah, direct contracting can make getting the right care to patients faster and easier. That matters to burned-out clinicians. Also, here's another potential point to ponder: benefit designs. Listen to the show with Dr. Mark Fendrick (EP308) on this, but most benefit designs offered by middle people are really, as they call them, blunt instruments. High-value care costs as much (or more) as low-value care. Deductibles don't care if you need your diabetic foot ulcers checked urgently or you might get your foot amputated. It's a known fact that health outcomes plummet in January when, all of a sudden, cancer meds or whatever essential lifesaving medical innovation cost as much as a patient's deductible. So, patients abandon care—and outcomes go down.   When an employer direct contracts with a provider, in its most sophisticated form—which my guest, Doug Hetherington, calls a “full-pay open contract”—the employer and the provider work together to construct a benefit design that helps patients get the best outcomes. Or here's another benefit, for the whole community, not just the employer: The whole community keeps the money local. Many of these middle people are big national companies. As Dave Chase and others have said often, when these Fortune whatever companies arrive on the scene, lots of money exits stage left out of the community. If local employers contract with local providers, the money stays local. So, all that I have said has been said before. What I wanted to dig into in this episode is the why and the how from the provider organization standpoint. I got curious about this after my conversation with Katy Talento (EP350). She talks about a major barrier for self-insured employers who want to work with local hospitals is that the local hospitals couldn't, frankly, get out of their own way. Maybe they couldn't see the benefit for themselves that made the juice worth the squeeze? That's what I talk about in this episode with Doug Hetherington: what's in it for providers and what a provider organization interested in direct contracting needs to actually pull it off.  Doug Hetherington is CEO of Health2Business, and he has done and continues to do pioneering work with community hospitals in eastern Idaho and elsewhere. Health2Business helps facilitate direct contracting between hospitals and local employers. You can learn more at health2business.com and connect with Doug on LinkedIn.  You can also learn how to engage in direct contracts from Doug's presentation, “Beyond the Direct Contract.”    Doug Hetherington is a health plan visionary, innovator, and program architect who believes providers are the key to sustainable and meaningful healthcare in our communities. Midway through his 20-year tenure as a benefit advisor, Doug began innovating around self-funding, captives, reference-based pricing (RBP), and population management in search of viable solutions that gave his employer clients control over cost and plan design. His creativity and tenacity for change drove his development of several first-of-their-kind innovations, including RB EmCap, a national access captive program for RBP employers. Doug founded Health2Business (H2B) in 2019 after successful proof of concept that better healthcare results when employers, providers, and health systems work together at the local level through direct contracts. Tackling one aspect of our broken healthcare system, H2B solves for how we access and pay for care. While establishing scalable direct contracts with some of the largest flagship health systems in the country, Doug realized that in order to truly decapitalize healthcare, direct contracts need to be transparent, open, and free for employers of all sizes to access. By establishing H2B's independent, agnostic, and collaborative direct contract administrative platform infrastructure, Doug has created an entirely new vendor class known as direct contract administration. An optimist by nature, Doug truly believes that the more we work together, the faster we can restore value to our healthcare system and create a sustainable mutual benefit for provider, employer, and employee/member stakeholders. 05:38 Why are health systems interested in direct contracting? 09:43 EP308 with Mark Fendrick, MD.10:06 What are the essentials for direct contracting between a health system and an employer or payer? 11:16 What are the three categories of open direct contracting agreements? 12:44 EP350 with Katy Talento.12:59 EP363 with David Scheinker, PhD.14:43 What direction do we need to be moving to solve the cost problems in healthcare? 18:10 “What does a value-based model begin to look like?” 20:31 What is one of the inherent benefits of a direct contracting environment? 21:01 What data should we actually be capturing? 25:01 “Sometimes you really begin to wonder, why is there such a high level of misalignment?” 25:16 How much can an employer save, on average, with a direct contract? 26:33 What are healthcare costs going up by per year? 26:50 “We pay for these insurance plans … and yet what you're paying for that and how they're assessing the risk is not … in line with the actual cost of care.” 30:20 “I would say that … consolidation … is one of the reasons why we're … seeing more movement towards direct contracting.” You can learn more at health2business.com and connect with Doug on LinkedIn.  You can also learn how to engage in direct contracts from Doug's presentation, “Beyond the Direct Contract.” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why are health systems interested in direct contracting? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the essentials for direct contracting between a health system and an employer or payer? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the three categories of open direct contracting agreements? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What direction do we need to be moving to solve the cost problems in healthcare? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “What does a value-based model begin to look like?” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is one of the inherent benefits of a direct contracting environment? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What data should we actually be capturing? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Sometimes you really begin to wonder, why is there such a high level of misalignment?” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth How much can an employer save, on average, with a direct contract? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are healthcare costs going up by per year? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We pay for these insurance plans … and yet what you're paying for that and how they're assessing the risk is not … in line with the actual cost of care.” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I would say that … consolidation … is one of the reasons why we're … seeing more movement towards direct contracting.” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! 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, Dr Steven Quimby, Dr David Carmouche (EP343)  

The recent dust-up over Direct Contracting and its ultimate rebranding as the ACO REACH model may have led some to believe that our path forward is unclear. That couldn't be further from the truth. On this episode, we talk with François de Brantes, Senior Vice President of Episodes of Care at Signify Health, about where we are on the pathway to escaping the tyranny of Fee-For-Service healthcare. It's tyranny because it prevents us from delivering care the way we want to and need to. Advanced Alternative Payment Models like ACO Reach allow organizations to separate payment from delivery, stop focusing their efforts on top-line revenue, and begin to operate like typical P & L driven companies. The promise, of course, is that this will change the way healthcare is delivered in the U.S., improve outcomes and lower costs. We discuss: - Has utilization and payment returned to pre-pandemic norms? - Why are commercial carriers lagging behind Medicare and Medicaid in launching Advanced Alternative Payment Models? - Will the shift to value and consumer-centric delivery methods like telemedicine diminish uncompensated care? - Is it possible to be proactive and patient-centric in Fee-for-service? - Are provider systems ready for AAPMs? - Can employers band together to create enough demand for AAPMs in the under-65 commercial market? - What were the arguments against the Direct Contracting Model? - Did they have merit? - What changes were made to Direct Contracting as part of the rebrand to ACO Reach? - How does this dust-up over Direct Contracting confirm we are on a bi-partisan, unwavering march toward value and never going back? - Why did Signify Health acquire Caravan Health?   For full show notes and links: https://thehcbiz.com/189-escaping-the-tyranny-of-fee-for-service-healthcare-francois-de-brantes/

Brian (@chiglinsky) is joined by Aledade's Policy Dream Team: Sean Cavanaugh (@dc_cavanaugh), Chief Policy and Chief Commercial Officer, Travis Broome (@Travis_Broome), Senior Vice President for Policy and Economics, and Casey Korba (@casey_korba), Director of Policy, as they share an overview of Healthcare Value Week and CMS' changes to Direct Contracting, now known as ACO Reach.

Join Health Affairs Insider.Late last month, the Centers for Medicare & Medicaid Services (CMS) announced its redesign of its Global and Professional Direct Contracting Model to its now-branded Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model. The agency stated the redesign is meant to advance health equity and was in response to stakeholder feedback and participant experience.On today's episode of Health Affairs This Week, Harvard Medical School's Michael Chernew joins Health Affairs Forefront Editor Chris Fleming to talk about the new CMS model for ACOs, and where Medicare Advantage could improve.Related Links: Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model (CMS) The Case For ACOs: Why Payment Reform Remains Necessary (Health Affairs Forefront) Podcast: Michael Chernew Makes The Case for Payment Reform (Health Affairs This Week) Medicare Advantage, Direct Contracting, And The Medicare 'Money Machine,' Part 2: Building On The ACO Model (Health Affairs Forefront) Subscribe: RSS | Apple Podcasts | Spotify | Castro | Stitcher | Deezer | Overcast

Chief Operating Officer of Hint Health, Mark Nolan, discussed direct contracting in healthcare among his organization with Managing Editor of Managed Healthcare Executive, Peter Wehrwein, in this week's episode of Tuning In to the C-Suite podcast.

Joining us on the podcast this week is Dr. Clive Fields, the Co-Founder and Chief Medical Officer for VillageMD. Dr. Fields is a leader of high influence in the value economy, having been named to Modern Healthcare's lists of the 50 Most Influential Clinical Executives and the 100 Most Influential People in Healthcare.  His company, VillageMD, is a leading, national provider of value-based primary care services that partners with physicians to deliver high-quality clinical care and better patient outcomes, while reducing total cost of care. In the years since Dr. Fields co-founded the company, VillageMD has grown to 15 markets and is responsible for more than 1.6 million patients. In 2021, VillageMD received a $5.2 billion investment from Walgreens Boots Alliance, which is looking to expand its healthcare offerings with VillageMD as a partner. This significant multi-billion investment will accelerate the opening of at least 600 Village Medical at Walgreens primary care practices in more than 30 U.S. markets by 2025 and 1,000 by 2027, with more than half of those practices in medically underserved communities. The Race to Value is honored to have Dr. Fields share his perspective on the opportunity for consumer-centric care delivery in our country.  We discussed important issues such as health equity, digital transformation, integrated pharmacy, home-based care delivery, multipayer contracting, health policy, and employer healthcare costs. Don't miss out on this important interview so you can learn what it takes to succeed for the future of value-based care! Episode Bookmarks: 01:40 Introduction to Dr. Clive Fields and VillageMD 05:00 The intersection between value-based care delivery and consumerism 07:00 “Value-based health care success requires affability, availability and ability.” 08:40 Using a team-based, proactive, risk-stratified approach to care to deliver the best outcomes 09:00 Are we using the term “value” incorrectly in the industry? 10:00 VillageMD's recently announced partnership with Walgreens and how it will provide scalability 12:00 How outcomes-based reimbursement can improve health equity in underserved communities 13:00 The transformative impact of the value movement on primary care 16:00 The acceleration of virtual care and the role it plays in a consumer-centric care delivery 18:00 What will virtual care look like in the post-pandemic era? 18:45 How the economics of global capitation drives improved health outcomes 20:00 The role that pharmacy integration plays in value-based care 21:45 Dr. Fields discusses how pharmacists should be utilized in the ambulatory care setting 23:00 Lessons learned from pharmacy integration and how that informed VillageMD's collaboration with Walgreens 24:20 How pharmacist intervention can improve both provider and consumer experience by switching to formulary-equivalent drugs 26:45 Referencing recent McKinsey & Company study that projects up to $265B in facility care shifting to the home setting by 2025 27:45 Village Medical at Home – a leading example of home-based care delivery 28:40 “The lack of home-based care is partly related to the hubris of physicians.” 29:30 Dr. Fields reflects on how office-based care contributes to a misinterpretation of social barriers 31:45 Care in the home as the safest and most comfortable option 34:00 How VillageMD has cares for all patient populations (not just particular high-risk segments) 36:20 “We built a model that actually expands doctors' panels – not limiting them to a certain product or payer.” 37:45 Managing risk across different populations with segregation by SDOH and risk determination (not payer status) 39:30 Referencing Dr. Fields' most recent Op-Ed in Modern Healthcare addressing the criticisms of the Direct Contracting model 40:30 Dr. Fields provides commentary on the hyper-politicized debate related to public-private partnerships in the Medica...

Last week, Medicare announced the next phase of its plan to transform traditional Medicare. Critics argue that the planned transformation of the fee-for-service program will amount to a dramatic expansion of privatization. And, if you are enrolled in traditional Medicare, or expect that you will be in the future know this: no matter if you want it or not, Medicare plans to enroll you in this new model by the end of this decade, as early as next year in some cases. Millions of retirees have opted out of traditional Medicare over the past two decades. Instead, they have joined Medicare Advantage, which is a privatized, managed-care version of the program. But the choice between those two options might not be in their hands much longer.Medicare has been quietly testing a new model for traditional fee-for-service Medicare. Medicare enters into contracts with healthcare provider groups that receive a flat annual payment to provide care for enrollees in the traditional program. Up until this point, Medicare called the health care contractors involved in this experiment “Direct Contracting Entities,” but starting next year they will be known as Accountable Care Organizations, or ACOs.The concept of ACOs is not new - many health care experts say they have the potential to improve health care by incenting healthcare providers to work together as teams. But this particular version of ACOs is drawing criticism from some health policy experts, who view it as unwarranted - and unwise - further privatization of Medicare.The new model launching next year is called ACO REACH. The word REACH is an acronym, standing for Realizing Equity, Access, and Community Health. Medicare is pitching the program as a way to advance health equity for underserved communities. And that’s a very laudable goal. But ACO Reach providers actually will have much in common with Medicare Advantage, Like Advantage plans - which usually are HMOs or PPO plans - ACO Reach plans will create networks of preferred healthcare providers, and they can retain as profit the portion of the annual per-patient payments that are not spent on healthcare.A big worry here is the rush of private equity firms and other investment groups into the business, which points to even more privatization of Medicare than we’ve seen already. And here’s something important to know if you are enrolled in traditional Medicare, or expect that you will be in the future. Medicare plans to enroll everyone who uses traditional Medicare in an ACO by 2030. And starting next year, if you live in an area where a REACH ACO operates, you can be assigned to one without your consent.This week on the podcast: Joining me on the program this week to talk about the REACH ACO model is Dr. Ed Weisbart. Ed is a family medicine practitioner. And he chairs the Missouri chapter of Physicians for a National Health Program, a national group of 21,000 physicians and other health professionals who support single-payer national health insurance. PNHP has taken a leading role in opposing Medicare’s ACO plans.I’ve been really surprised that this topic hasn’t surfaced much in general media yet, considering its importance to millions of seniors. After Medicare announced its plans for ACOs last week, it seemed like a good idea to turn up the volume a bit. Click the player icon at the top of this post to listen to the podcast. The podcast also can be found on Apple Podcasts and Stitcher.Further reading on Medicare ACOsA quiet experiment is testing further privatization of Medicare Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,’ Part 1: The Risk-Score Game.Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,’ Part 2: Building On The ACO ModelBiden Pursues Trump Plan That Creates Big Profits by Denying Health CareTrump-era Medicare program under increased scrutinyPhysicians for a National Health Program - page of resources on ACO Reach.What I’m readingIRS releases long-awaited Secure Act RMD regulations . . . Medicare’s finances and the saga of the Alzheimer’s drug Aduhelm . . . The pandemic pummeled long-term care – it may not recover quickly. Subscribe at retirementrevised.substack.com

The team from Meet Up talks all things Direct Contracting. Sign up for our weekly Medicare newsletter.  

Brian X held my feet to the fire: he insisted that I take a more lengthy, serious look at this newly concocted managed care monster. I could not fulfill his request to predict the future of the DCE pilot program because my crystal ball is just not that powerful. However, I share his fear of this Medicare bastardization. Contact me at: DBJ@MLMMailbag.com (Most severe critic: A+)   Inspired by "MEDICARE FOR THE LAZY MAN; Simplest & Easiest Guide Ever! (2021)" on Amazon.com. Return to leave a short customer review & help future readers. Official website: https://www.MedicareForTheLazyMan.com

Mortality lower during five-year period among adults who supplemented with calcium plus vitamin D   Thirumalai Mission Hospital (India), February 16 2022.    A study published in the  Indian Journal of Endocrinology and Metabolism found a decrease in fractures and mortality during a 5-year average follow-up period among individuals who regularly supplemented with calcium and vitamin D. The study involved participants in a community-based osteoporosis detection program that included women aged 50 and older who had been postmenopausal for five years and men over the age of 55.  Osteoporosis and osteopenia were detected among 2,882 participants, who were subsequently advised to consume 500 mg calcium and 250 IU of vitamin D3 per day. These participants were additionally offered annual injections of 600,000 IU vitamin D3. The current analysis was limited to 2,113 participants among this group who were not treated with prescription drug therapy for severe osteoporosis and who were followed for at least two years. Among those who supplemented regularly, the risks of experiencing a fracture or death were respectively 73% and 47% lower during the 5-year average follow-up compared to those who failed to adhere to the regimen.   (NEXT)   Black walnuts found to suppress appetite and oxidative degradation of lipids   University of Georgia, February 3, 2022   Researchers have found that adding black walnuts (Juglans nigra) to your breakfast not only helps you feel fuller, but also protects your cells from oxidative damage. In their report, which was published in the journal Nutrition Research, the team explored the benefits of using black walnuts as a butter substitute. In their report, the team noted that most studies on the health benefits of walnuts use English walnuts, which have a different nutritional profile than black walnuts. While walnuts are nutrient-dense, they argued that black walnuts have more protein than the more popular English walnuts. Black walnuts, they proposed, can improve satiety and even regulate postprandial increases in lipid peroxidation better than English walnuts. A total of 30 healthy adults participated in the randomized, double-blind control crossover study. At each testing visit, the participants were asked to eat a breakfast meal that had either butter (which served as the control) or a butter substitute (black walnut or English walnut). After three testing visits, the team noted that participants who ate black walnuts reported feeling fuller than those who had English walnut and butter. In addition, they had greater suppression of lipid peroxidation after eating. “Substituting butter in a breakfast meal with [black walnuts] or [English walnuts] increased fullness; however, the [black walnut] meal was superior for suppressing overall appetite while also lowering postprandial lipid peroxidation,” the team wrote in their report.   (NEXT)   Human brain doesn't slow down until after 60   Heidelberg University's Institute of Psychology, February 17, 2022   You used to be able to make snap judgments in your 20s, but now it feels like you take a lot longer to react to questions, decisions and challenges put before you. Don't fret, it's not that you're losing brain power. Your response time does tend to slow down as you age, but a new study argues that's not because your brain's processing speed is deteriorating. Your brain remains as nimble as ever until you hit your 60s, according to a report published Feb. 17 in the journal Nature Human Behaviour. "Our research now shows that this slowing is not due to a reduction in cognitive processing speed," von Krause said. "Until older adulthood, the speed of information processing in the task we studied barely changes."   (NEXT)   Study shows exercise can help older adults retain their memories   We all know exercise is good for us, but that still leaves plenty of questions. How much exercise? Who benefits the most? And when in our lives? New research led by University of Pittsburgh psychologists found that it seems like exercising about three times a week for at least four months is how much you need to reap the benefits in episodic memory." Episodic memory is the kind that deals with events that happened to you in the past. It's also one of the first to decline with age. "I usually like to talk about the first time you got behind the wheel of a car," said Aghjayan. "So you might remember where you were, how old you were, who was in the passenger seat explaining things to you, that feeling of excitement." Seeking clarity in the muddy waters of the scientific literature, the team pored over 1,279 studies, eventually narrowing them down to just 36 that met specific criteria. The researchers found that pooling together those 36 studies was enough to show that for older adults, exercise can indeed benefit their memory.   (NEXT)   Prevention Against Gallstones - Eat More Foods With Vitamin E   University of Kiel (Germany), February 16, 2022   More than 90 percent of the population does not meet their recommended daily allowance of vitamin E. Researchers in Germany led by the University of Kiel found that subjects with gallstone disease had lower blood levels of vitamin E than those who did not have gallstones. Vitamin E does everything from ease exercise soreness, treating menstrual pain, preventing cancer and playing a central role in neurological and cardiovascular function. Adequate levels of vitamin E, an essential micronutrient, are especially critical for the very young. The scientists also found that those with gallstone disease also had a lower alpha-tocopherol/cholesterol ratio than healthy individuals. A similar association was found with gamma-tocopherol levels. However, with the gamma form, the results were not statistically significant.   (OTHER NEWS)   How Medicare is quietly being privatized   By Abdul El-Sayed, M.D. Detroit Metro Times, February 9, 2022   Healthcare is big business — literally one of the most lucrative corporate endeavors in the country, accounting for one-fifth of our total economy. And the way that the business of healthcare interferes with actually providing Americans with appropriate, accessible, and affordable healthcare has been a frequent subject of my writing in these pages. From hospital consolidation to drug pricing, rising premiums to healthcare inequities, the fact that our healthcare system is designed to maximize profit for a few large corporations is the root, if not all, of the problem. The fattest slice of that very, very large pie is healthcare for seniors — the Americans who most often need care. American seniors are insured through Medicare, a government health insurance program that's supposed to offer them affordable, comprehensive healthcare. But as this is the American healthcare system we're talking about, the knives are constantly out for Medicare — looking for just another bite. Late last year, I wrote about the Medicare (dis)Advantage program, a frontal assault on Medicare, which cajoles beneficiaries into selecting privately managed Medicare plans. The private health insurance corporations that administer these plans get to keep the money they don't spend on healthcare as profit, putting $27 billion of taxpayer moneyinto the pockets of health insurance corporations in 2018 alone. As bad as Medicare Advantage is, a new plan hatched under the Trump administration — and being allowed to proceed under the Biden administration — is even worse. But unlike Medicare Advantage, most seniors haven't even heard about it. It's called Direct Contracting. Designed by the Trump administration, it's a sop to the health insurance corporations and private equity firms that have been such a persistent force in Republican healthcare circles. They agree on a simple goal: privatize everything. Instead of cajoling seniors to hand over their Medicare dollars, large corporations, called Direct Contracting Entities, target doctors. When a doctor signs up, all of the Medicare beneficiaries they see are signed up too — without their knowledge or consent. The Direct Contracting Entity acts as a middleman between the physician and Medicare — and like Medicare Advantage, they profit off of the Medicare dollars that aren't spent on beneficiaries. In exchange for signing up, the doctors earn a kickback from the Direct Contracting Entity. But Direct Contracting isn't a matter of law; Congress never voted on this. It's just a pilot program designed by the Trump administration … that the Biden administration is now carrying forward. They could kill Direct Contracting in its tracks if they wanted to! The fact that it's not should be extremely worrying to seniors, consumer rights advocates, and anyone who pays taxes to the U.S. government. The irony here is that President Biden ran on a public option — which doesn't look to be coming anytime soon. Instead of that promise, his administration is allowing a backdoor private buyout of Medicare.

Allison Brennan is the Senior Vice President of Government Affairs for the National Association of ACOs (NAACOS) in Washington, D.C. where she helps develop and advocate for policies to benefit ACOs. In this special bonus episode, she provides an extensive update on health policy and directly addresses the critics of the Global and Professional Direct Contracting (GPDC) Model.  This episode was recorded and released on February 16, 2022 in order to address the alarming concerns related to the potential cancellation of the Direct Contracting program. Check out this episode for the latest health policy updates and to learn more about this controversial GPDC issue in the value-based care movement! Episode Bookmarks: 01:30 Introduction to Allison Brennan, NAACOS Senior Vice President of Government Affairs 03:00 Controversary and panic around the rumored cancellation of the Global and Professional Direct Contracting model (or GPDC) model! 05:30 The history of the ACO program as the premier payment model in the shift to value-based care 07:00 The recent trend of flat or declining growth of ACOs 08:00 Allison provides her perspective on the value movement as it relates to the growth of ACOs and other APMs 09:30 Recent changes in ACO policy and the importance of not defining “risk” as the same as “value” 11:00 The integration of health equity in all CMMI payment models and the need for upfront funding 13:00 Allison discusses the need to support providers (e.g. data, tools, education) in order to address SDOH and equity requirements of APMs 17:00 Prior success with the ACO Investment Model (AIM) and other provider investment programs to support APM adoption 18:30 Benchmarking methodology and the importance of focusing on inequities 20:00 An outline of value-based care legislative priorities contained within the “Value In Health Care Act of 2021” 22:30 Incentives for MSSP ACOs adoption and the extension of the 5% Advanced APM bonus as a top priority for NAACOS 29:00 Allison reflects on her work with the current Administration and the continued leadership needed 32:00 Allison explains the challenge with the “Rural Glitch” and the importance of fixing the MSSP Benchmarking Methodology 37:00 An overview of the Global and Professional Direct Contracting (GPDC) model 39:00 Allison explains NAACOS' support of the Direct Contracting model and the differences between the three DC options (Global, Professional, and Geographic) 42:00 Recent criticisms of GPDC and the need for the model to be more “provider focused” 43:00 Approaches to capitation models and benchmarking for DCEs 45:30 The deeply partisan arguments against the Direct Contracting program and rumors of its pending cancellation (e.g. Physicians for a National Health Program, Senator Warren) 49:30 Allison provides a real-time, in-depth perspective on the recent GPDC controversy 54:00 “Cancelling the program would shatter the confidence of the provider community in the shift to value” and why outright cancellation of GPDC is unlikely 57:00 Parting thoughts from Allison on the state of the value movement (Is health policy heading in the right direction and moving fast enough in this Race to Value?)

Co-host Brian (@chiglinsky) is joined by Dr. Farzad Mostashari (@Farzad_MD), CEO and co-founder of Aledade, and Dr. Richard Gilfillan, former Deputy Administrator of the Centers for Medicare and Medicaid Services and Director of the Center for Medicare and Medicaid Innovation from 2010 to 2013, for a special episode of The ACO Show. They discuss the future of Medicare and Dr. Gilfillan's recent co-authored, two-part piece in Health Affairs, “Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine'.”   

In this healthcare podcast, I'm talking about direct contracting IRL (in real life) with Katy Talento. This is a conversation that's more about the reality of direct contracting than the theory of direct contracting, and this was not an accident. So much of healthcare transformation is really easy to say and much harder to actually do. So … direct contracting. In the context we discuss in this episode, generally direct contracting means when an employer or their benefits consultant, more likely, hooks up with a provider organization, lots of times a hospital or a health system. Moving forward here, I'm just gonna say employer when I sort of really mean the employer and their TPA and their repricer, the constellation of consultants and other vendors that are working with the employer. So, just for simplicity, the employer says to the provider organization, “Hey, let's cut out the middleman here” (middleman likely being some insurance carrier). “I will just pay you directly, and it will be a win-win because no one is sucking out up to 15% to 20% right out of the middle, and also I'll steer my employees/patients/members your direction, which is great for us as a self-insured plan because money saved and also because I've done some quality analytics and I think you're relatively good at delivering care … so I'm happy to help my members find you.” The employer will, in general broad strokes, pay the provider organization some percentage over the Medicare rate for procedures or codes or bundles. By the way, the dollar amount over Medicare for the bundles or procedures or codes can vary depending on factors like what service line it is because, unlike RBP (reference-based pricing), direct contracting is a negotiation. It's a two-way deal. RBP, a lot of times, is the payer/employer deciding what they're gonna pay and then paying it—without sitting around a table with the provider figuring all this out together. So, if only from this one dimension, direct contracting is something that you'd think that hospitals/health systems/providers would be kind of into and up for. One thing that I didn't really understand before this conversation is that, if we're talking about an employer direct contracting with, say, a hospital, the list of direct-contracted procedures or codes or bundles might include pretty much all of the services that the hospital can perform; but, in general, the employer is only going to steer members there or make it financially attractive to go to the hospital for, for example, emergency or unavoidable procedures. Why? Because no employer wants patients going to the hospital for things that they could get a whole lot cheaper in an outpatient setting with no less quality. So, unless a hospital is willing to compete on price with other care settings, then an employer is not going to steer their members there. If you're a hospital, you might take this as a con. But, on the other hand, consider that if there's a few hospitals in the area, the general direction will be to go to the one with the direct contract. Furthermore, if a plan is gonna steer members, they're gonna steer them whether they have a direct contract with you or not. Katy makes one point early and often throughout this conversation. From a hospital perspective, doing a direct contract is and should be pretty easy. From an employer perspective, too, there should not be a lot of disruption or friction for employees. There doesn't need to be. Done right, it should be a win-win for the employer, provider, and, most of all, the patient who doesn't get stuck with high bills, balance bills, and lower-quality care than might be available to them through their benefits. Katy goes through the steps to create a direct contract and the challenges she has faced along the way. We also get into the wonderful world of payviders, so you could consider this an extension to the episode with Jeb Dunkelberger (EP348) from last month. My guest today, Katy Talento, started out as an infectious disease epidemiologist (which I did not realize). She ended up doing public health policy. She's worked on Capitol Hill for various senators and, in the last administration, as health policy lead. Katy is the CEO of AllBetter Health and works with the Health Rosetta organization. She is a benefits advisor for employers who are looking to create better health plans that reduce costs dramatically while, at the same time, improving benefits. I mean, you can only do that in healthcare, right?—where there's basically no relationship between price and quality. You can learn more at allbetter.health or contact Katy directly at katy@allbetter.health. Katy Talento is an infectious disease epidemiologist, a veteran health policy advisor, and healthcare consultant. She is CEO of AllBetter Health, an insurgent benefits advisory firm building innovative health plans for employers that are free of misaligned financial incentives. Katy served as the health policy lead in the White House on the Domestic Policy Council where her portfolio included public health issues such as eliminating domestic HIV/AIDS, ending secret healthcare prices, lowering prescription drug prices, expanding health IT interoperability, combating the opioids and other drug addiction crisis, and promoting bioethics in the life sciences. Katy has appeared on or been published in a number of media outlets, including CNN, Sky News, Newsmax, The New York Times, The Hill, The Morning Consult, RealClearPolitics, and others. Prior to her White House appointment, Katy served five U.S. Senators over a 15-year period, including as top health advisor and manager of legislative staff and oversight investigators. She also worked in the private sector helping multinational energy companies protect their global workforce from infectious diseases and on the research faculty at Georgetown University Medical School. Katy served as the director of speechwriting for the Republican National Committee and has written a number of published opinion pieces, Web copy, and video scripts. She spent two years as a Catholic nun and has worked with the poorest of the poor from East Africa to industrial Russia and inner-city America. Katy received a master of science degree in infectious disease epidemiology from the Harvard School of Public Health and an undergraduate degree in sociology from the University of Virginia. 05:21 Why are employers direct contracting? 06:37 “When you directly contract … you don't have to chase patients.” 07:43 Why the growing 501(r) movement is making direct contracting more enticing. 10:16 “They're going to be giving better rates, whether they want to or not.” 11:46 “I think it's the future hospitals want, too.” 12:58 What is the primary driver of increased healthcare costs? 14:56 “The fixed costs that the hospitals … have may not be so fixed.” 15:08 “A hospital should not be a freestanding profit center. … The hospital is a failure of healthcare. It alone should not be profitable.” 15:35 “We have the system we have, but why do we have to live with it? We don't have to.” 17:15 What's step 1 of direct contracting? 24:12 What's the TPA's role in direct contracting? 25:21 What's the repricer's role in direct contracting? 33:28 “I think the thing that makes all this work is having a benefits advisor that knows how to do all this.” You can learn more at allbetter.health or contact Katy directly at katy@allbetter.health. @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth Why are employers direct contracting? @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth “When you directly contract … you don't have to chase patients.” @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth Why the growing 501(r) movement is making direct contracting more enticing. @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth “They're going to be giving better rates, whether they want to or not.” @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth “I think it's the future hospitals want, too.” @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth What is the primary driver of increased healthcare costs? @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth “The fixed costs that the hospitals … have may not be so fixed.” @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth “A hospital should not be a freestanding profit center. … The hospital is a failure of healthcare. It alone should not be profitable.” @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth “We have the system we have, but why do we have to live with it? We don't have to.” @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth What's step 1 of direct contracting? @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth What's the TPA's role in direct contracting? @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth What's the repricer's role in direct contracting? @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth “I think the thing that makes all this work is having a benefits advisor that knows how to do all this.” @KatyTalento discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #hospitals #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly

The Tom Ficklin Show: Direct Contracting Entities by WNHH Community Radio

Independent investigative journalism, broadcasting, troublemaking and muckraking with Brad Friedman of BradBlog.com

Independent investigative journalism, broadcasting, troublemaking and muckraking with Brad Friedman of BradBlog.com

Tomorrow is the end of open enrollment for Medicare. The means that before midnight Tuesday night, Dec 7, you can change what type of Medicare plan you're enrolled in. I already knew and was warning my listeners about the realities surrounding Medicare Advantage, and we'll get into that again today. But this article was about the government's newest scam to privatize Medicare and turn it over to big moneyed interests. (Read the article at https://www.commondreams.org/news/2021/11/30/congress-asleep-switch-biden-continues-trump-era-ploy-privatize-medicare.) This new "experiment" was launched in the final months of the Trump administration, and should have ended as they exited. But it didn't. Instead, the Biden administration is continuing this policy that would neither save money nor provide better care, but could fully hand traditional Medicare over to Wall Street investors and other profit-seekers, resulting in higher costs for patients and lower-quality care. Diane Archer is president of Just Care USA, and was quoted in the article I liked to above. She joined me on today's show to explain how the Direct Contracting plan continues the march toward privatization of Medicare...

Entrepreneurs solve problems for customers. There are few problems bigger than the horribly perverse medical care system under which patients suffer in the US. The system has evolved over time, with the stimulus of bad decisions, bad actors, and bad incentives. Entrepreneurship can solve the system problem with specific actions at the component level, each of which are practical and do-able, and can interact to create a new outcome at the system level. Murray Sabrin has studied both the system and the component solutions, and he joins the Economics For Business podcast to enumerate his proposed actions. Key Takeaways and Actionable Insights Healthcare is a consumer good, and a consumer responsibility. Medical care is a provider proposition. Consumer sovereignty is a cornerstone concept in Austrian economic theory. Consumers determine what is produced as a result of their buying or not buying. Does this principle apply in healthcare? To answer requires us to differentiate between healthcare and medical care. Healthcare is an individual choice and a personal responsibility: we do everything we can to maintain a healthy lifestyle of eating and drinking, exercise and sound physical and mental health practices. In the internet age, there is plenty of knowledge available to help us in our decision-making. Medical care is what we turn to when sound healthcare proves to be insufficient to keep us off medication and out of hospital. How do consumers realize value from medical care providers? To do so is very challenging due to (among other barriers) price fixing, price opacity, price inflation, monopolistic and duopolistic market structures, the misuse of insurance, bureaucratic management, perverse incentives, government intervention, and barriers to entrepreneurial entry. Are there potential solutions in the face of this systemic dysfunction? Yes: solutions that come from the best countervailing source — entrepreneurship. Entrepreneurial Solution #1: Direct Primary Care — Restoring the doctor-patient relationship. Murray Sabrin recalled the $5 doctor visit of the past, characterized by a personal relationship with no bureaucracy or insurance forms. Entrepreneurs are now re-establishing that relationship via Direct Primary Care. DPC is retainer fee-based access to unlimited doctor visits, including office-based testing and additional services, with no insurance forms. DPC doctors have fewer patients in their practice and can consequently provide more time and attention. Stronger relationships are built, which is the essence of entrepreneurial value-generation. Entrepreneurial Solution #2: Transparent versus distorted pricing. Pricing is one of the most important bulwarks of free markets. In medical care, pricing is opaque to the point of invisibility, distorted, and inflated. It is unresponsive to the normal choice-based supply-demand mechanisms, and not indicative of value. Some entrepreneurs are acting to change these pricing conditions via what is termed fee-for-service: transparent pricing for specific services. An often-cited example is Surgery Center of Oklahoma, where specific prices for specific surgical services are openly posted on their website. Other members of the Free Market Medical Association provide similar price transparency. One of the results is revelatory price comparison: Murray told the story of a DPC practice patient who identified a 75% price reduction at Surgery Center of Oklahoma compared to a local South Florida hospital. Entrepreneurial Solution # 3: One stop shopping at local non-profit clinics. Murray described the launch and success of several non-profit local and regional clinics, including one for which he was the founding trustee. These are philanthropically established and funded local clinics with volunteer staff, providing a range of services. Equipment and pharmaceuticals may be fully or partially donated by the manufacturing companies. The combination of direct primary care doctors and specialists can make these clinics one-stop shopping solutions for patients seeking quality medical care. With a little philanthropic assistance, they could eliminate the need for Medicaid. Entrepreneurial Solution #4: Direct Contracting. Insurance companies purposefully inflate medical care prices to fund their business model. Murray told the story of a large (4-500 employees) company that contracted directly with a service that brought a vehicle with an MRI machine to the employers location, and charged $400 per MRI to the employees. The same vehicle was utilized by a nearby hospital that charged $6,000 for the same MRI. Direct contracting saved $5400 per unit cost, or 90%. Direct contracting has the potential to significantly reduce costs in the Medical Care system, while opening access and increasing convenience. Entrepreneurial Solution #5: The 3-tier household medical care budget system. Murray has a well-constructed and eminently practical household medical care budget system. There's a version for families with at least on member in employment and an alternative for those on Medicare today. There are three elements: Direct Primary Care for a monthly fee, covering unlimited office visits and routine tests.A Health Savings Account to cover costs of specialists, prescription drugs, medical equipment, major tests and brief hospitalizations.Catastrophic insurance coverage for major operations and hospitalizations and long term care. Greater detail is provided in Murray's book, Universal Medical Care From Conception To End Of Life. Download our corresponding PDF, which features an adapted table from Murray's book: Mises.org/E4B_137_PDF In a system of personal responsibility, we would all manage our household medical care budgets with these kinds of tools. Entrepreneurial Solution #6: Voluntarism And Mutualism. Voluntarism has a long tradition in America. Mutual aid societies were prevalent before the New Deal. Ethnic, religious and trade groups joined together for mutual support. The Federal Government co-opted these functions and now people look to Washington DC to solve their problems. But young people today are more interested in voluntarism and non-political social activism. 30 years ago in the Wall Street Journal, Peter Drucker argued for the non-profit sector to replace the welfare state. Creative and innovative people find ways to surmount institutionally-erected barriers in all phases of life, and medical care is certainly one of those. There's a liberating and energizing sense of acting as the custodian of one's own life and helping others who need it. It's the entrepreneurial ethic. Entrepreneurial Solution #7: Distributed Knowledge. There is so much available knowledge today about healthy life habits and about the symptoms and characteristics of various medical conditions, and about options for treatment. We as individuals are free to explore, and responsible for gathering our own store of knowledge. The outcome of the research may not be definitive, and we may find ourselves making a choice between alternatives. But doctors and hospital administrators make choices too, and they are not infallible. It may be possible for an individual to gather more knowledge about their own specific condition from the internet than any single doctor can know, simply as a consequence of concentrated effort. Each of us can take responsibility for our own life. Summing up: Murray Sabrin's prescription: Eliminate employer-based insurance.Make a single exception for the case in which the employer pays the direct primary care fee for the patient.The resultant employer savings are deposited in employees' health savings accounts.Employees determine their best medical care options.Phase out Medicare and Medicaid.Let young people create super health savings accounts so that they don't need Medicare in the future.Hospitals price at realistic market pricing, not insurance-inflated prices.All prices are transparent.Get the government out of medical care — it's none of their business.Free up resources from the medical-pharmaceutical-insurance complex and redirect them to savings, investment and philanthropy. Additional Resources Read Murray's book, Universal Medical Care from Conception to End of Life: The Case for A Single-Payer System: Mises.org/E4B_137_Book It's self-published and all proceeds go to charity and non-profits. "Individual Single-Payer Alternative For Employer-Based Insurance" (PDF): Mises.org/E4B_137_PDF Surgery Center Of Oklahoma: surgerycenterok.com Forward: goforward.com Direct Primary Care Coalition: dpcare.org Volunteers in America: vimamerica.org

Entrepreneurs solve problems for customers. There are few problems bigger than the horribly perverse medical care system under which patients suffer in the US. The system has evolved over time, with the stimulus of bad decisions, bad actors, and bad incentives. Entrepreneurship can solve the system problem with specific actions at the component level, each of which are practical and do-able, and can interact to create a new outcome at the system level. Murray Sabrin has studied both the system and the component solutions, and he joins the Economics For Business podcast to enumerate his proposed actions. Key Takeaways and Actionable Insights Healthcare is a consumer good, and a consumer responsibility. Medical care is a provider proposition. Consumer sovereignty is a cornerstone concept in Austrian economic theory. Consumers determine what is produced as a result of their buying or not buying. Does this principle apply in healthcare? To answer requires us to differentiate between healthcare and medical care. Healthcare is an individual choice and a personal responsibility: we do everything we can to maintain a healthy lifestyle of eating and drinking, exercise and sound physical and mental health practices. In the internet age, there is plenty of knowledge available to help us in our decision-making. Medical care is what we turn to when sound healthcare proves to be insufficient to keep us off medication and out of hospital. How do consumers realize value from medical care providers? To do so is very challenging due to (among other barriers) price fixing, price opacity, price inflation, monopolistic and duopolistic market structures, the misuse of insurance, bureaucratic management, perverse incentives, government intervention, and barriers to entrepreneurial entry. Are there potential solutions in the face of this systemic dysfunction? Yes: solutions that come from the best countervailing source — entrepreneurship. Entrepreneurial Solution #1: Direct Primary Care — Restoring the doctor-patient relationship. Murray Sabrin recalled the $5 doctor visit of the past, characterized by a personal relationship with no bureaucracy or insurance forms. Entrepreneurs are now re-establishing that relationship via Direct Primary Care. DPC is retainer fee-based access to unlimited doctor visits, including office-based testing and additional services, with no insurance forms. DPC doctors have fewer patients in their practice and can consequently provide more time and attention. Stronger relationships are built, which is the essence of entrepreneurial value-generation. Entrepreneurial Solution #2: Transparent versus distorted pricing. Pricing is one of the most important bulwarks of free markets. In medical care, pricing is opaque to the point of invisibility, distorted, and inflated. It is unresponsive to the normal choice-based supply-demand mechanisms, and not indicative of value. Some entrepreneurs are acting to change these pricing conditions via what is termed fee-for-service: transparent pricing for specific services. An often-cited example is Surgery Center of Oklahoma, where specific prices for specific surgical services are openly posted on their website. Other members of the Free Market Medical Association provide similar price transparency. One of the results is revelatory price comparison: Murray told the story of a DPC practice patient who identified a 75% price reduction at Surgery Center of Oklahoma compared to a local South Florida hospital. Entrepreneurial Solution # 3: One stop shopping at local non-profit clinics. Murray described the launch and success of several non-profit local and regional clinics, including one for which he was the founding trustee. These are philanthropically established and funded local clinics with volunteer staff, providing a range of services. Equipment and pharmaceuticals may be fully or partially donated by the manufacturing companies. The combination of direct primary care doctors and specialists can make these clinics one-stop shopping solutions for patients seeking quality medical care. With a little philanthropic assistance, they could eliminate the need for Medicaid. Entrepreneurial Solution #4: Direct Contracting. Insurance companies purposefully inflate medical care prices to fund their business model. Murray told the story of a large (4-500 employees) company that contracted directly with a service that brought a vehicle with an MRI machine to the employers location, and charged $400 per MRI to the employees. The same vehicle was utilized by a nearby hospital that charged $6,000 for the same MRI. Direct contracting saved $5400 per unit cost, or 90%. Direct contracting has the potential to significantly reduce costs in the Medical Care system, while opening access and increasing convenience. Entrepreneurial Solution #5: The 3-tier household medical care budget system. Murray has a well-constructed and eminently practical household medical care budget system. There's a version for families with at least on member in employment and an alternative for those on Medicare today. There are three elements: Direct Primary Care for a monthly fee, covering unlimited office visits and routine tests.A Health Savings Account to cover costs of specialists, prescription drugs, medical equipment, major tests and brief hospitalizations.Catastrophic insurance coverage for major operations and hospitalizations and long term care. Greater detail is provided in Murray's book, Universal Medical Care From Conception To End Of Life. Download our corresponding PDF, which features an adapted table from Murray's book: Mises.org/E4B_137_PDF In a system of personal responsibility, we would all manage our household medical care budgets with these kinds of tools. Entrepreneurial Solution #6: Voluntarism And Mutualism. Voluntarism has a long tradition in America. Mutual aid societies were prevalent before the New Deal. Ethnic, religious and trade groups joined together for mutual support. The Federal Government co-opted these functions and now people look to Washington DC to solve their problems. But young people today are more interested in voluntarism and non-political social activism. 30 years ago in the Wall Street Journal, Peter Drucker argued for the non-profit sector to replace the welfare state. Creative and innovative people find ways to surmount institutionally-erected barriers in all phases of life, and medical care is certainly one of those. There's a liberating and energizing sense of acting as the custodian of one's own life and helping others who need it. It's the entrepreneurial ethic. Entrepreneurial Solution #7: Distributed Knowledge. There is so much available knowledge today about healthy life habits and about the symptoms and characteristics of various medical conditions, and about options for treatment. We as individuals are free to explore, and responsible for gathering our own store of knowledge. The outcome of the research may not be definitive, and we may find ourselves making a choice between alternatives. But doctors and hospital administrators make choices too, and they are not infallible. It may be possible for an individual to gather more knowledge about their own specific condition from the internet than any single doctor can know, simply as a consequence of concentrated effort. Each of us can take responsibility for our own life. Summing up: Murray Sabrin's prescription: Eliminate employer-based insurance.Make a single exception for the case in which the employer pays the direct primary care fee for the patient.The resultant employer savings are deposited in employees' health savings accounts.Employees determine their best medical care options.Phase out Medicare and Medicaid.Let young people create super health savings accounts so that they don't need Medicare in the future.Hospitals price at realistic market pricing, not insurance-inflated prices.All prices are transparent.Get the government out of medical care — it's none of their business.Free up resources from the medical-pharmaceutical-insurance complex and redirect them to savings, investment and philanthropy. Additional Resources Read Murray's book, Universal Medical Care from Conception to End of Life: The Case for A Single-Payer System: Mises.org/E4B_137_Book It's self-published and all proceeds go to charity and non-profits. "Individual Single-Payer Alternative For Employer-Based Insurance" (PDF): Mises.org/E4B_137_PDF Surgery Center Of Oklahoma: surgerycenterok.com Forward: goforward.com Direct Primary Care Coalition: dpcare.org Volunteers in America: vimamerica.org

Entrepreneurs solve problems for customers. There are few problems bigger than the horribly perverse medical care system under which patients suffer in the US. The system has evolved over time, with the stimulus of bad decisions, bad actors, and bad incentives. Entrepreneurship can solve the system problem with specific actions at the component level, each of which are practical and do-able, and can interact to create a new outcome at the system level. Murray Sabrin has studied both the system and the component solutions, and he joins the Economics For Business podcast to enumerate his proposed actions. Key Takeaways and Actionable Insights Healthcare is a consumer good, and a consumer responsibility. Medical care is a provider proposition. Consumer sovereignty is a cornerstone concept in Austrian economic theory. Consumers determine what is produced as a result of their buying or not buying. Does this principle apply in healthcare? To answer requires us to differentiate between healthcare and medical care. Healthcare is an individual choice and a personal responsibility: we do everything we can to maintain a healthy lifestyle of eating and drinking, exercise and sound physical and mental health practices. In the internet age, there is plenty of knowledge available to help us in our decision-making. Medical care is what we turn to when sound healthcare proves to be insufficient to keep us off medication and out of hospital. How do consumers realize value from medical care providers? To do so is very challenging due to (among other barriers) price fixing, price opacity, price inflation, monopolistic and duopolistic market structures, the misuse of insurance, bureaucratic management, perverse incentives, government intervention, and barriers to entrepreneurial entry. Are there potential solutions in the face of this systemic dysfunction? Yes: solutions that come from the best countervailing source — entrepreneurship. Entrepreneurial Solution #1: Direct Primary Care — Restoring the doctor-patient relationship. Murray Sabrin recalled the $5 doctor visit of the past, characterized by a personal relationship with no bureaucracy or insurance forms. Entrepreneurs are now re-establishing that relationship via Direct Primary Care. DPC is retainer fee-based access to unlimited doctor visits, including office-based testing and additional services, with no insurance forms. DPC doctors have fewer patients in their practice and can consequently provide more time and attention. Stronger relationships are built, which is the essence of entrepreneurial value-generation. Entrepreneurial Solution #2: Transparent versus distorted pricing. Pricing is one of the most important bulwarks of free markets. In medical care, pricing is opaque to the point of invisibility, distorted, and inflated. It is unresponsive to the normal choice-based supply-demand mechanisms, and not indicative of value. Some entrepreneurs are acting to change these pricing conditions via what is termed fee-for-service: transparent pricing for specific services. An often-cited example is Surgery Center of Oklahoma, where specific prices for specific surgical services are openly posted on their website. Other members of the Free Market Medical Association provide similar price transparency. One of the results is revelatory price comparison: Murray told the story of a DPC practice patient who identified a 75% price reduction at Surgery Center of Oklahoma compared to a local South Florida hospital. Entrepreneurial Solution # 3: One stop shopping at local non-profit clinics. Murray described the launch and success of several non-profit local and regional clinics, including one for which he was the founding trustee. These are philanthropically established and funded local clinics with volunteer staff, providing a range of services. Equipment and pharmaceuticals may be fully or partially donated by the manufacturing companies. The combination of direct primary care doctors and specialists can make these clinics one-stop shopping solutions for patients seeking quality medical care. With a little philanthropic assistance, they could eliminate the need for Medicaid. Entrepreneurial Solution #4: Direct Contracting. Insurance companies purposefully inflate medical care prices to fund their business model. Murray told the story of a large (4-500 employees) company that contracted directly with a service that brought a vehicle with an MRI machine to the employers location, and charged $400 per MRI to the employees. The same vehicle was utilized by a nearby hospital that charged $6,000 for the same MRI. Direct contracting saved $5400 per unit cost, or 90%. Direct contracting has the potential to significantly reduce costs in the Medical Care system, while opening access and increasing convenience. Entrepreneurial Solution #5: The 3-tier household medical care budget system. Murray has a well-constructed and eminently practical household medical care budget system. There's a version for families with at least on member in employment and an alternative for those on Medicare today. There are three elements: Direct Primary Care for a monthly fee, covering unlimited office visits and routine tests.A Health Savings Account to cover costs of specialists, prescription drugs, medical equipment, major tests and brief hospitalizations.Catastrophic insurance coverage for major operations and hospitalizations and long term care. Greater detail is provided in Murray's book, Universal Medical Care From Conception To End Of Life. Download our corresponding PDF, which features an adapted table from Murray's book: Mises.org/E4B_137_PDF In a system of personal responsibility, we would all manage our household medical care budgets with these kinds of tools. Entrepreneurial Solution #6: Voluntarism And Mutualism. Voluntarism has a long tradition in America. Mutual aid societies were prevalent before the New Deal. Ethnic, religious and trade groups joined together for mutual support. The Federal Government co-opted these functions and now people look to Washington DC to solve their problems. But young people today are more interested in voluntarism and non-political social activism. 30 years ago in the Wall Street Journal, Peter Drucker argued for the non-profit sector to replace the welfare state. Creative and innovative people find ways to surmount institutionally-erected barriers in all phases of life, and medical care is certainly one of those. There's a liberating and energizing sense of acting as the custodian of one's own life and helping others who need it. It's the entrepreneurial ethic. Entrepreneurial Solution #7: Distributed Knowledge. There is so much available knowledge today about healthy life habits and about the symptoms and characteristics of various medical conditions, and about options for treatment. We as individuals are free to explore, and responsible for gathering our own store of knowledge. The outcome of the research may not be definitive, and we may find ourselves making a choice between alternatives. But doctors and hospital administrators make choices too, and they are not infallible. It may be possible for an individual to gather more knowledge about their own specific condition from the internet than any single doctor can know, simply as a consequence of concentrated effort. Each of us can take responsibility for our own life. Summing up: Murray Sabrin's prescription: Eliminate employer-based insurance.Make a single exception for the case in which the employer pays the direct primary care fee for the patient.The resultant employer savings are deposited in employees' health savings accounts.Employees determine their best medical care options.Phase out Medicare and Medicaid.Let young people create super health savings accounts so that they don't need Medicare in the future.Hospitals price at realistic market pricing, not insurance-inflated prices.All prices are transparent.Get the government out of medical care — it's none of their business.Free up resources from the medical-pharmaceutical-insurance complex and redirect them to savings, investment and philanthropy. Additional Resources Read Murray's book, Universal Medical Care from Conception to End of Life: The Case for A Single-Payer System: Mises.org/E4B_137_Book It's self-published and all proceeds go to charity and non-profits. "Individual Single-Payer Alternative For Employer-Based Insurance" (PDF): Mises.org/E4B_137_PDF Surgery Center Of Oklahoma: surgerycenterok.com Forward: goforward.com Direct Primary Care Coalition: dpcare.org Volunteers in America: vimamerica.org

Congresswoman Katie Porter (D-CA) discusses Direct Contracting Entity (DCE). This Trump-era policy is an ingenious way to kill Medicare. It is one of many policies we must get revoked. David Lipschutz, JD – Associate Director of the Center for Medicare Advocacy talks about the dangers of Medicaid Advantage. He makes it clear that changes must be made to Medicare to prevent Medicare Advantage from taking whole with its false claims as they use the deficiencies in Medicare. (PNHP) And here is a funny one courtesy of Recount via MSNBC. These are people, anti-vxxers and anti-maskers who are shouting at their boards. It is hard to believe that t --- If you like what we do please do the following! Most Independent Media outlets continue to struggle to raise the funds they need to operate much like the smaller outlets like Politics Done Right SUBSCRIBE to our YouTube Channel here. LIKE our Facebook Page here. Share our blogs, podcasts, and videos. Get our books here. Become a YouTube PDR Posse Member here. Become a Politics Done Right Subscriber via Patreon here. Become a Politics Done Right Subscriber via Facebook here. Consider providing a contribution here. Please consider supporting our GoFundMe equipment fund here. --- Support this podcast: https://anchor.fm/politicsdoneright/support

  A lot has happened since we last met with Dr. Keith Smith from the Surgery Center of Oklahoma back in 2018. Back then, we talked about how he brought the radical notion of full price transparency to the surgery space in 2009 all without taking any government payers. We also spoke about how the system was rigged to enrich the hospital systems, insurance carriers, and PBMs (what's new right?). So what's happened since then and how has the center done with the pandemic? Is the Surgery Center of Oklahoma Thriving or Just Surviving? Not surprisingly, Dr. Smith says that the center is doing just fine and has increased its market share from other states. Additionally, the international community from Canada is now being allowed to come back into the US for their surgeries which are more backed up than ever. His surgery center is a great alternative for an increasingly backlogged health system that is strained under the COVID crush of patients. Can Other Surgery Centers Dabble in Direct Contracting? One interesting aspect to Dr. Smith and his crusade for more transparency and market forces within medicine is the development of using clearinghouses for arranging surgery. The clearinghouse is used as a quick means for posting prices anonymously and then linking the agreeable surgery center and potential payers who are either patients or employers.. This is a great way to ease into direct contracting for a lot of surgery centers that are still dealing with commercial and government contracts. What is the Future for the Free Market Medical Association? Dr. Smith says the FMMA has grown significantly over the past few years as more and more facilitators, physicians, surgical centers, and administrators gather to learn how to harness the market to increase their book of business. Now that the pandemic has caused a lot of disruption in the market people are really starting to look for fresh solutions to survive and the FMMA feels like it has just what they need. Anyone can sign up and their next conference in in April 2022. Dr. Keith Smith is the co-founder of the Surgery Center of Oklahoma which has 100% price transparency which opened its doors in 1997. He also founded the Free Market Medical Association which works to promote the free market in all health care transactions. show notes Episode 145: Today's show Surgery Center of Oklahoma: Dr. Smith's 100% price transparent surgery center in Oklahoma City, OK. Free Market Medical Alliance: The organization that Dr. Smith helped co-found to encourage using the free market in more US health care transactions. @SurgeryCenterOK: Twitter for the Surgery Center of Oklahoma LinkedIn for Keith Smith, MD Atlas Billing Company: The company that helps link employers with surgery centers without posting all their prices openly to allow some direct contracting. Episode 012: Dr. Keith Smith on a fully transparent pricing system for surgery. Deputy: Today's sponsor who helps you with your employee scheduling and so much more. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  When I began this podcast in the Spring of 2018, there were a lot of things I felt needed to be said about the US Health Care system. Foremost among them was the problems with the third party payment system (using both commercial and government insurance to make most of the payments for services). Also, the system was becoming more and more consolidated and the power of those extracting that wealth continued to expand. It was a pretty depressing outlook for patients and doctors. However, most things aren't so black and white. While the regulatory capture of medicine is certainly a concern and no friend for docs and patients, there is a new movement that has sprung up in response to it. As my guest Ron Barshop says, it is leaderless, decentralized, and growing exponentially despite the powers that be. he loosely calls it direct contracting which is a way of bypassing the usual middlemen and gatekeepers in health care. It includes direct primary care (which we've discussed many times on the show here, here, here, and here) but is so much more. How big is the Direct Contracting Movement? Ron Barshop, host of the Primary Care Cures podcast, describes the direct contracting movement broadly. It involves millions of patients who are employees at small, medium, and large corporations. He estimates that direct contracting for health services comprises maybe 10% of the US population or about 30 million. But it is hard to get an exact count because it depends on your definition of direct contracting. Sometimes, just negotiating with a separate pharmacy benefits manager (PBM) or laboratory is what is done by a company. Some, however, have gone all in and are putting their employees in direct primary care offices or virtual services and contracting separately for nearly every contact their employees have in the health care environment. What is Direct Contracting for Health Services? The best way to describe direct contracting for health services is by looking at the financial transaction. If it is between the employer and the facility or person providing the care then is is direct contracting. If you are using a middleman or intermediary like an insurance company to make the payment, then it is probably not direct contracting. This isn't always the cleanest definition but it is a good starting point. Right now, large employers are finding millions of dollars in savings by directly negotiating with hospitals, surgery centers, imaging centers, laboratories, pharmacies, and primary care physicians. They self fund their health care needs for employees and usually save money and provide better services because of the incredible amount of waste spent on administrators within the typical health plan. How does Direct contracting Save Health Care? Simply put, by direct contracting and eliminating a lot of the middle men who provide no value (but plenty of expense) to health care billions or maybe even trillions of dollars can be reinvested into employees pockets. Also, by pushing for an improved model of primary care and urgent care, direct contracting has the potential to keep people healthier too. It is truly a triple win of lower costs, happier providers of care (not dealing with refusals to pay by third parties), and improved health. The beauty of this movement is that it does not reside within any particular political ideology or camp and does not really require any legislation to occur. It is happening organically and is a quiet revolution that most still don't see. Ron Barshop is the host of the Primary Care Cures podcast. He has been on a personal detective hunt on how to fix the US health care system and discovered that it is fixing itself through direct contracting. show notes Episode 144: Today's show Primary Care Cures: Ron Barshop's excellent podcast where he interviews disruptors, innovators, and thought leaders in the transforming health care in America. LinkedIn for Ron Barshop Episode 002: Dr. Amat on why she chose to become a direct primary care doctor Episode 067: Dr. Josh Umbehr on DPC Episode 049: Dr. Keith Smith and fully transparent pricing for surgery centers. Episode 037: Rheumatologist, Dr. Ellen McKnight, describes her venture into direct contracting as a specialist Episode 093: Zach Zeller of Scriptco talks about his direct warehouse membership pricing for generic pharmaceuticals. @FIPhysician: Twitter for Dr. Graham Deputy: Today's sponsor who helps you with your employee scheduling and so much more. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

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

There is an immediate opportunity for value-minded medical practices and health systems in joining a Direct Contracting Entity (DCE) that is already established.  Many of these DCEs (typically existing health care delivery organizations or newly-organized physician aggregators) are now seeking formal partnerships with providers in their area. These partnerships may facilitate an entry point for organizations who have not participated in prior CMMI models or those organizations more advanced in risk who wish to increase their value profile in a model that emphasizes beneficiary engagement and improved patient outcomes. If you have been approached to join a DCE, the ACLC wants to support you in the consideration of this opportunity. To that end, we are pleased to share this bonus episode, with our guest Dr. Tom Davis. Dr. Davis is an expert in value-based care, a family physician, angel investor, founder of 6 companies, consultant, and speaker. In this episode, he helps simplify the decision process for the independent physician who wants to know whether they should consider participating in the GPDC model. Independent physicians now is an important time to consider your participation in value – whether you join the GPDC model or do something different, this episode will accelerate your move to value! In addition to listening to this episode, make sure to read our blog post with additional details: https://www.accountablecarelc.org/publications/global-and-professional-direct-contracting-starter-checklist-prepare-dce-partnerships Episode Bookmarks: 03:00 What are Direct Contracting Entities (DCEs) and how did they come about? 04:15 What types of DCEs are currently recognized by CMS and should I consider joining one? 06:45 What are the potential benefits to medical practices that are considering joining a DCE? 12:00 How is Value-Based Care innovation better addressed by DCEs than other payment models? 13:15 Is there a competitive disadvantage to not participating in a DCE? 14:30 How should an organization evaluate a prospective DCE suitor when approached to join one? 17:30 Why is joining a DCE such a rare and historic opportunity? 18:30 Parting comments and contact information for Dr. Tom Davis

Back by popular demand! We know that the Direct Contracting program continues to change and adapt, including a new abbreviation: GDPC. We brought back our VillageMD expert on the Direct Contracting program, Lucy Sola, to walk us through these changes. This is helpful information for any provider or healthcare group who is thinking about participating in this new CMS program.Thank you to all of our loyal listeners, or as we call them, Smarties! If you enjoy the podcast, we want your help in spreading the word! Share this episode with your friends and colleagues. We are now available on Apple, Spotify, or wherever you get your podcast. Our references and other show notes are on our website: https://vmdworkingsmarter.com/conversations/

This week's episode features a conversation with T.J. Morrison, President at Benefit Design Specialists. Direct contracting offers competitively priced bundles to patients and quick payments to providers. They carve out a niche away from networks while, at the same time, avoiding direct competition with them. Direct contracting uses data-based baseline pricing to set the most competitive rates for otherwise cost-inflated procedures. You can find show notes and more information by clicking here: https://bit.ly/3wLLSOX

In this week's episode Senior Editor Peter Wehrwein chats with Founder and Executive Chairwoman of Caravan Health Lynn Barr. The two discussed the relationship of payers and ACOs and the approach toward the direct contracting model.

The difference between average people and achieving people is their perception of and response to failure.  “Failing Forward” was a concept defined by John C. Maxwell several years ago, and that axiomatic truth could not be more readily apparent than in value-based care.  Transforming healthcare to lower costs and improve patient outcomes is tough work. PERIOD.  It requires many years of experimentation and “trial and error” innovation. The suffering index in the value movement can be immense, but the returns – in both financial success and personal/professional fulfillment – make it a purposeful endeavor. Dr. Jesse James, the Chief Medical Officer for CHESS Health Solutions, is a leader in the value movement who believes in Failing Forward as a key to success in value-based care.  In his role, he oversees quality and clinical services for a population health management company that supports more than 3,000 providers and 150,000 patients. Dr. James joins us this week to show us that as leaders in value, “We must be willing to fail forward. “It's our scar tissue that makes us stronger.”  Tune in this week to learn from one of the best!  In this episode, Dr. James provides leadership and business insights that are profoundly helpful for physicians, executives, and entrepreneurs looking to win this Race to Value. Episode Bookmarks: 04:20 Dr. James' “defining moment” when he found his calling to practice medicine 06:00 The decision to begin a medical career at the bedside and then working at the system-level to transform healthcare 07:30 Dr. James' early work in clinical quality and the influence and mentorship of Dr. Cary Sennett (“The Godfather of Quality Measurement”) 08:45 The permission to fail bestowed by a mentor has been a constant reminder to “Be Humble” in the practice of medical leadership 11:00 The legendary basketball coach John Wooden on how "Failure is not fatal, but failure to change might be." 12:25 “As a leader, you have be willing to fail forward. It's our scar tissue that makes us stronger.” 12:45 The story of how CHESS was borne out of an innovative medical practice that embraced value before the payment environment would support it 14:30 Lessons learned from hardships in the Value Journey (transitioning from FFS to P4P to Gainshare to Full Downside Risk) 15:30 “You have to remove the stigma around failure. These are opportunities to learn and grow.” 15:40 The story of Sir William Osler and how the ideal physician should be equally to call out failures as much as successes 16:50 The influence of the Institute of Medicine report “To Err is Human” on the culture of safety in the practice of medicine 17:00 The need for a new culture change in medicine to learn from mistakes and failed experiments to advance population health and VBC 19:00 Medicare payment model innovation and how CHESS isgetting as close to premium dollar as possible by taking downside risk with MA and commercial insurers 20:00 CMS experimentation with global capitation and why providers should be thinking about the Direct Contracting model 23:30 The use of “innovation cells” to effectively disseminate learnings within partner organizations 25:00 Addressing transportation as a social determinant of health in rural areas 26:00 Partnering with Wake Forest Baptist Health to deploy a “hospital at home” model 27:15 Creating wrap-around services in the technology and clinical domains to meet with needs of clients with varying degrees of maturity 29:30 Dr. James describes the value-based care landscape in North Carolina and the impact of the Atrium Health--Wake Forest Baptist Health merger 33:10 Developing a leading Medical Management program with service hubs in Care Management, Pharmacy, Quality, and Risk Adjustment 33:40 Data Analytics and Predictive Modeling and how CHESS partnered with Wake Forest to develop a frailty index 34:35 Implementing a high utilizer conference to re...

In this episode of Start Your Day with Avalere, Chris Johnson of Landmark Health joins us to discuss his organization’s experience as an early participant in CMMI’s Direct Contracting payment model.

Even though Direct Contracting has been around for decades, employers are finding creative ways to tailor their employees' health care needs. On this episode of Side Affects, we have invited our partner at M3 Insurance, Vice-President of Employee Benefits Sales, Ryan Barbieri, to present how Direct Contracting has adapted beyond the single provider relationship for employers. Kenzie McEvily and guest host Anne Marie Singleton ask Ryan to dig deeper into Direct Contracting and share how those employers willing to tackle the non-traditional methods of health care could reap benefits beyond the ROI. Find out if you have what it takes as an employer to put direct contracting into motion for a long-term solution.

This week's episode features a conversation with Doug Geinzer, Founder and President at High Performance Providers. Bundled plans provide cost benefits to providers while also connecting patients to quality healthcare. Direct contracting gives patients lower costs which are transparent upfront and provides options for destination medicine too. For an even more attractive offer, patients also get safety guarantees in high performance networks with proven reliability. You can find show notes and more information by clicking here: https://bit.ly/3sS5sq3

By Michael Tetreault, Editor-In-Chief Today our special guest is Michael Kopko, CEO or Pearl Health (www.PearlHealth.com). This is the first interview inside our new 3-Part Series with Michael. Our topic today: "Physician Leadership and Introduction to Direct Contracting (DCE) by CMS" Questions We Will Answer: 1. What is Direct Contracting from CMS? 2. Why should physicians consider it? Why should they be concerned? 3. What makes this different from other programs offered by CMS? Michael is the co-founder and CEO of Pearl Health, focused on empowering physicians and providers to lead our healthcare system to better and more human outcomes. He served as an early employee and Vice President at Oscar Health Insurance running their largest P&L (+$3 billion) and building their network contracting and early sale systems. Prior to Oscar, Michael worked for Bridgewater Associates as a manager in the company's Research, Client Service, and Recruiting departments. While at Bridgewater, he was responsible for 60 investors, managers, and staff reporting to the CEO of the company. In 2009 he successfully sold DormAid, a college service company, which he launched and ran while he was a student at Harvard and Columbia Business School. He is the recipient of Columbia's Feldberg Fellowship, a full tuition merit scholarship in honor of former Dean Feldberg. His mentor of over 15 years is George David, Chairman of Raytheon Technologies. He enjoys reading, exercising, meditation, and meeting interesting people. He is a graduate of Columbia Business School and Harvard College. ---- Michael Kopko Chief Executive Officer Pearl Health 212-333-3303 Schedule a Time to Meet with Michael Directly, visit: https://calendly.com/michael-kopko-1

Direct Contracting is a new model from the Center for Medicare & Medicaid Innovation (CMMI, or the CMS Innovation Center) aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS). At a minimum, it's an opportunity for providers to change the way they care for Medicare FFS patients. And if the Geographic Direct Contracting Model is launched (it's currently under review by CMS), it will be a sea change in the 10 targeted “Geo” regions. Either way, it's worth paying attention to. We covered the Direct Contracting model and options at length in Episode 156 with Gail Zahtz. You should start there if Direct Contracting is new to you. During that conversation, Zahtz identified plenty of areas where the model could benefit doctors and their patients. However, she identified several grey areas that make it difficult for physicians to engage with potential DCEs as the application deadline rapidly approaches (April 1, 2021). The timeline and lack of clarity make it difficult for a physician to evaluate the model and make a sound decision on how, or if to participate. So, that's our goal of this discussion.  I talk with Dr. Krishnan Narasimhan, an academic family medicine physician and an Associate Professor in the Department of Community and Family Medicine at Howard University, about what Direct Contracting means to physicians.   What opportunities does Direct Contracting create for physicians? What opportunities does Direct Contracting create for their patients? How does Direct Contracting compare to other value-based payment programs? How might Direct Contracting lead to deeper physician-payer alignment? How does Direct Contracting enable physicians to truly address the Social Determinants of Health (SDOH)? What questions should a physician ask a DCE to determine if they are a fit? What should physicians' do right now to determine if Direct Contracting is worth pursuing? How can busy physicians fit this in with all their existing priorities during a pandemic?   Dr. Krishnan Narasimhan Krishnan Narasimhan M.D., is an academic family physician who has a proven record of driving health system and policy change. Dr. Narasimhan has led grassroots coalitions to move the political and policy debate on health reform, expand access, and to increase primary care infrastructure. He has spoken at the U.S. Capitol, at universities, and with numerous stakeholders on health reform, health disparities, and physician workforce. He serves on the Boards of Doctors for America and the District of Columbia Academy of Family Physicians. Dr. Narasimhan has a decade of experience in undergraduate and graduate medical education with a focus on curricular design, mentorship, and integrated care models. He has a record of consistently increasing primary care workforce capacity. His research on the Economic Impact of Family Physicians has been utilized extensively by the American Academy of Family Physicians. Currently he serves as Associate Professor at Howard University, Director of the Family Medicine Clerkship, as Residency faculty, and takes care of underserved populations. His training includes an M.D. from Jefferson Medical College, residency at University of Connecticut, Primary Care Health Policy Fellowship at Georgetown University, and a Certificate of Health Policy at the Georgetown Public Policy Institute. Dr. Narasimhan is also an advisor to WiseCare, a startup applying to become a Direct Contracting Entity (DCE).  LinkedIn: https://www.linkedin.com/in/krishnanmd/   Links and Resources   Doctors for America - Doctors for America mobilizes doctors and medical students to be leaders in putting patients over politics on the pressing issues of the day to improve the health of our patients, communities, and nation. District of Columbia Academy of Family Physicians: The District of Columbia Academy of Family Physicians (DCAFP) is a state chapter of the American Academy of Family Physicians. A membership organization for DC Family Physicians, the Academy advocates for Family Physicians and our patients, and conducts continuing medical education for Family Physicians. Episode 156: Direct Contracting: It's Coming Fast and Will Have a Big Impact on Medicare-fee-for-service w/ Gail Zahtz – you'll find additional Direct Contracting resources there. WiseCare     The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

CMS Direct Contracting is coming fast, is very nuanced, and full of grey. In a nutshell, 50% of Medicare patients are in Medicare Advantage (i.e., value-based care) and 50% are still Medicare fee-for-service (FFS). Direct Contracting is CMS' bold play to quickly move many of the remaining Medicare fee-for-service (FFS) patients into value-based care. If you're a doctor who takes care of Medicare fee-for-service (FFS) patients, then it is going to affect you whether you're paying attention or not. That's doubly true if you're in one of the 10 “Geo” model regions (Atlanta, Dallas, Houston, Los Angeles, Miami, Orlando, Philadelphia, Phoenix, San Diego, Tampa). In those regions, 100% of non-Medicare Advantage beneficiaries will have to align with one of three to seven awarded Direct Contracting Entities (DCE). DCE applications are due April 1, 2021 and all beneficiaries will be re-aligned under this fully capitated plan beginning January 1, 2022. Ya… that fast.   “There will no longer be any fee for service for all of Medicare and all of dual eligibles, which is Medicaid and Medicare eligible, in up to 10 regions of our country starting the first of next year.” Gail Zahtz, Founder and CEO, WiseCare   Today we're talking with Gail Zahtz, Founder and Chief Executive Officer at WiseCare, a startup applying to become a Direct Contracting Entity (DCE).  Gail helps us to understand the urgency of the situation and walks us through the nuance of the model. And while she acknowledges the hurdles for providers and the risks CMS' rapid timeline imposes, she also embraces the opportunity that Direct Contracting represents. As a cancer survivor, Gail understands firsthand the difficulty of navigating our healthcare system and she believes Direct Contracting offers a pathway to really make a difference in how care is delivered. It makes new services and care models possible, and it allows doctors to care for patients in the way they dreamed of when they got into medicine.   Direct Contracting / Direct Contracting Entity (DCE) Topics Covered   What is Direct Contracting and how does it differ from MSSP and Next Gen ACO models? What are the timelines? What are the different types of Direct Contracting Models? How are beneficiaries aligned to DCEs? Do patients have a choice in any of this? How will patients' benefits and/or costs change? What will happen to doctors who ignore this and let the pieces fall where they may? How do doctors interact with DCEs? How does payment flow through the DCEs? How can doctors find the DCEs in their area who they might partner with? How should providers evaluate DCEs to determine if they are right for their patients and their business? How does quality measurement work in Direct Contracting? Will there be any changes to the model under the Biden Administration?   There's a lot here, and still a lot of open questions on Direct Contracting. We're going to do our best to unravel this for you in the coming weeks. Drop me a note at don@thehcbiz.com and let me know what questions you'd like us to cover.   Gail Zahtz Founder and Chief Executive Officer, WiseCare Inc. Gail Zahtz has spent her career focusing on the intersection of evidence-based healthcare and user-centric design to honor and empower the doctor-patient relationship. An entrepreneur since the 1990s when she took a health-in-the-workplace property to $100M valuation, she has served as an adviser to healthcare start-up funders, a thought leader and advisor to industry on designing for health outcomes, a consultant to health innovation startups, and the architect of value-base healthcare delivery for NY's largest post-acute healthcare system. She has won numerous awards for her work at the intersection of health and design, including: Top 100 in Health Info Technology, Top 100 International Influencers in Health, and Top 50 Most Influential Health Leaders. As a survivor of late-stage cancer and domestic violence, Gail is dedicated to sharing her story of how to survive and thrive in the most challenging of circumstance to show young women everywhere a way forward.   Twitter: https://twitter.com/GailZahtz LinkedIn: https://www.linkedin.com/in/gailzahtz/ About WiseCare   WiseCare is an Integrated Healthcare Collaboration Company, enabling doctors to deliver true wrap-around care to Medicare patients by leveraging the new value-based care models. WiseCare makes thriving within the new capitated models seamless for physician practices and alternate-level-of-care facilities. A partner, not just a payor, we offer the ready-made collaborations and working partnerships across the healthcare continuum that will be the key to success. And we're expert in helping physicians keep, grow, and better care for their Medicare populations in this fast-changing environment. We lessen administrative burdens, improve financial stability, provide the data physicians need to make strategic care decisions, and deliver benefit enhancements that pay off for patient and caregiver, physician, and the practice. And our CareCoaches support patients and care plans between office visits, providing: condition and wellness education, targeted referrals to medical and social providers, and resolution of issues that stand between your patients and better outcomes. That's what we call Healthcare Made Well. To learn more about how WiseCare can partner with you, email us at info@wisecare.health. Web: https://www.wisecare.health/ LinkedIn: https://www.linkedin.com/company/wisecare-health/   Links and Resources   Notice of DCEs Participating in the Implementation Period of the Direct Contracting Model, Global and Professional Options This is dated, and only covers the Global and Professional options, but is worth a look if you're trying to figure out what's happening in your area. CMS Announcement: Geographic Direct Contracting Model (“Geo”) CMS Direct Contracting Model Options Industry Voices—CMMI chief: Direct Contracting Geographic Model a win for all stakeholders ACOs press for halt to Geographic Direct Contracting model due to complexity concerns ACOs Fear Direct Contracting Options Stray Too Far From Providers     The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

ACOs are increasingly moving into two-sided risk options with MSSP BASIC E and ENHANCED. The Direct Contracting model (with both Professional and Global options) introduces new opportunities and flexibilities that are not included in other CMMI models or through the MSSP. Prospective participants must act now to evaluate their model options in preparation for the 2022 performance year, with both MSSP and DC application cycles quickly approaching. CMS will soon reopen the MSSP for the 2022 performance year, and the application period for DC's second and final cohort is also expected to open around in Spring 2021, according to CMMI's latest timeline.  Now is the time for organizations to evaluate options and make decisions.  To aid in that analysis and decision-making, the ACLC and Lumeris partnered together to develop an intelligence brief (coming soon) that is also the focus of this podcast episode. The brief is designed to help provider organizations who are ready to take on significant levels of downside risk to judiciously evaluate the available options, consider the general opportunities and risk associated with the models, compare the methodological differences between MSSP BASIC Level E and MSSP ENHANCED with DC Professional and DC Global, and assess organizational fit. We share detailed comparisons across 7 key areas:   Participant Eligibility  Beneficiary Attribution  Financial Benchmarking  Quality Performance  Payment Models  Financial Settlement   Additional Benefits  Our guest this week is Rick Goddard, Senior Director of Market Strategy at Lumeris. Rick is a subject matter expert on value-based payment models and primarily serves as an enterprise strategist. Prior to joining Lumeris, Rick served as the Director of Clinical Innovation at Advocate Physician Partners / Advocate Health Care where led the Clinical Innovation Team. His in-depth operational and consulting experience makes him the perfect guest to help organizations considering their next step on this race to value!  (Information coming from CMS is ongoing and any opinions are not necessarily those of Lumeris, the Accountable Care Learning Collaborative, or our research associate Leavitt Partners.) Access the transcript for this episode here. Glossary of Acronyms: MSSP – Medicare Shared Savings Program ACO – a contracted entity in the MSSP DC – Direct Contracting (new CMMI payment model) DCE – a contracted entity in the DC model APM – Alternative Payment Model MA – Medicare Advantage CMS – Centers for Medicare and Medicaid Services CMMI – Center for Medicare and Medicaid Innovation TIN – Tax ID# (ACO participants in the MSSP are contracted by TIN) NPI – National Provider ID # (DCE participants are contracted by the individual NPI)   Episode Bookmarks: 4:50 Rick Goddard explains his personal connection with mental health and how that informs his “Why” 6:00 Finding balance and lessons learned from training for the Ironman World Championship 7:00 “What excites me is that value is starting to get momentum in the environment, and that thaws out providers and forces them into the game.” 8:50 The accomplishments of the MSSP (growth, building a bridge to risk, and $2B in savings to date) 11:30 The early years of the Pioneer and MSSP ACO programs and what we learned as an industry 12:30 “The upside-only ACO opportunity didn't have the teeth, nor did the program offer effective levers for us to succeed in managing the total cost of care.” 12:40 MSSP Challenges (e.g. beneficiary complaints and CCLF opt-outs, delays in data sharing, “black box” reconciliation) 14:00 “There weren't enough managed care-like designs to assist MSSPs to progress in risk.” 14:40 CMS offering incentives for ACOs to accept risk (e.g. SNF 3-day rule, Telehealth waivers, an availability to work with a prospective attribution model) 15:00 “Up until the Next Generation ACO,

We welcome Travis Broome (@travis_broome) back on the ACO show, as well as our new co-host, Brian Chiglinsky (@bchiglinsky). They discuss the newest Medicare total cost of care model- Direct Contracting and what practices thinking about venturing into value-based care should consider.

This episode features guest Aneesh Chopra, the first Chief Technology Officer of the United States and more currently, the co-founder and president of CareJourney. Hosts Gary Austin and Ken Kleinberg sit down with Aneesh to discuss smarter choices the industry can make to move more quickly towards value based care, specifically direct contracting and third party apps.Aneesh first gives some background on his company CareJourney. He explains that CareJourney is, in many ways, the private sector implementation of his passion of serving in government around open data, open APIs and payment reform. His primary mission is to make sure we use all these open resources to help patients, through the organizations they trust, make smarter decisions throughout the healthcare delivery system.Gary asks Aneesh to overview direct contracting as well as what's to win here for providers. Aneesh says direct contracting is ripping the band-aid off the move to value-based care. Direct contracting is Medicare Advantage-like, but without the insurance company and without the consumer changing their actual insurance benefits. They retain all their Medicare benefits, but they have their capitated dollar. They can bring their resources to a primary care group and integrated delivery network to help them better manage their care without taking away any of their rights to see any doctor they wish. This model is a leapfrog from training wheels to full downside capitated risk. Aneesh explains that remote patient monitoring could be a category. CMS explicitly invites applicants who have proposals who can reduce the cost burden and improve quality for high needs patients, especially those who have historically fragmented care. The model allows for these entrants to drive the process and bring along a physician network that may help administer some of the services. Aneesh thinks it is traditional doctors and networks applying from Medicare Shared Savings to direct contracting.Gary asks Ken how interoperability plays into these arrangements. Ken says risk is about what you know and what you can control. The more you know, the better you can control that risk. Interoperability can bring in all kinds of data about that patient, traditional clinical data, social determinants of health and claims data. We can pull information from many different sources and understand our population in ways we've never been able to before. That gives you the power to control risk and do a better jobGary asks Aneesh what he thinks of the “patient gets everything from everyone, on demand, delivered anywhere model.” Is it good for the marketplace? Aneesh says it's great for the marketplace. It builds the healthcare data sharing infrastructure on a foundation of “must share.” One of the challenges we've had for the last 20 years is that we've built all these data sharing networks and policies that try to square a complicated circle. We are saying we want all of the information flowing where it's needed, but we have to honor the HIPPA minimum data necessary provisions. So, the broader the network, the broader the use cases, the weaker the signal because by definition, someone is on the network to do something that is only entitled to a minimum amount of data. If I have to join a network where I've got to meet the lowest common denominator, I'm not going to get the information I need nor am I going to help make better decisions for people because limited information, limited affect. What we need is a mechanism to right size the information sharing to the legal frameworks under which those information sharing provisions exist. The consumer's right to access health information by being bedrock as a foundational right in HIPPA. Now technically materializing through these two rules is a smarter method of sharing data because no matter what I am entitled to my full medical record and if I choose to share it with my primary care doctor, that's my choice and that's my right. Gary asks Aneesh how to get payers moving along. Aneesh suggests that instead of just working to meet the letter of the rule, payers should ask themselves what they are doing to meet the spirit of the rule and how that benefits the strategic plans of their organizations. His overarching message is shift from defense to offense. How can the investments you're making advance the goals you have? What apps are you putting in the hands of your consumers? Are you working to get those apps connected to every single EHR in your network? Ken agrees with Aneesh on the compliance. He says these organizations often ask themselves what is their bigger fear? Is it financial penalty? Losing some business? Will we do the best by just giving the minimum possible? In the end, what you're really trying to do is meet the business objectives, which is increase your brand and gain loyalty. You do that by providing information in a format that's more usable. That's where a lot of these technologies can play a role. That's where we get into these apps. You have the potential to give people information in a format that's usable to them. Gary moves the conversation to third-party health apps. Aneesh views CommonHealth and Apple Health as infrastructure. He notes there is a hypothetical fear that Google, Amazon, or Apple are going to swoop in and take over healthcare, but he does not believe that is the case. Aneesh says if anything, Google, Microsoft, and Amazon are going to be infrastructure partners to existing players in healthcare or these new direct contracting entities who are managing risk, building clinically integrated networks and engaging patients.Gary asks Ken what he thinks of third-party apps. Ken agrees with Aneesh in that trust starts with primary care physicians. Primary care physicians are likely going to go with apps that work with the EHRs and the portals that they are already familiar with. With regulations coming up, some consumer-type apps may surface that tend to do a better job than what might have been offered to the physician and their EHR vendor. As community pressure builds, the physician may go back to their EHR vendor and ask why they can't support this. That can drive some advance here. Gary asks Aneesh if this is an opportunity for payers to engage their members more deeply. Aneesh explains that high need patients suffer from terrible care fragmentation. It's so obvious that the plan can do a better job here. The decision support to go from fragmentation to coordination is best done by an entity that is trusted by the consumer to do that coordination. You want to trust an app that can be connected to a portal, get the updated feeds and have other context about my healthcare needs. Gary asks Ken for his closing remarks. Ken says this really has been a long journey, measured in decades. He is optimistic that things are getting better. Interoperability in the past decade or two has been like the wild west. Now, he thinks we are aiming with FHIR, projects like Da Vinci and USCDI to be much more practical. That's going to benefit everyone.Aneesh shares in Ken's optimism. We don't have the luxury of waiting decades for this chapter to have success. So, while it does take decades, we must move faster and make smarter decisions to comply with the rules, embrace value-based care and better engage consumers. These things will help accelerate that timeline. Let's do it smarter, together.  

Physician groups are becoming the dominant type of new entrant into the ACO space and have been most successful in achieving savings to date.  Many in our industry think that physician-led ACOs are at a disadvantage in comparison to hospital-led ACOs because they lack the capital and the administrative firepower to spin up a population health infrastructure. RGV ACO, one of the leading Accountable Care Organizations in the country, has proven that physician leadership is actually the key ingredient to success in health value. Located in the southernmost tip of Texas along the US-Mexico border in the Rio Grande Valley, RGV ACO has achieved its success with some of the most insurmountable odds imaginable.  In the Rio Grande Valley, more than a third of families live in poverty. Nearly half of the residents have no health insurance, and obesity, diabetes, and heart disease are widespread. This region, made infamous by Dr. Atul Gawande over a decade ago in the New Yorker article “The Cost Conundrum” was once the most expensive healthcare market in the country.  In response to the problems of its local community, RGV ACO was formed and took the charge to lead a revolution in health value.  Their success story shows that something truly magical can happen when physician leadership, innovation, and aligned incentives converge in a way to solve important problems in our health care system. In this podcast episode, we are speaking with Edwin Estevez, the Chief Executive Officer of RGV ACO.  Edwin is a remarkable leader in our health care industry and will share his journey in health value.  Anyone interested in how leadership can transform the care outcomes in a community should listen to the story of RGV ACO.  We are in a race to make health value work in our country, and RGV ACO is a true success story of how to beat the odds and transform the lives of many.   06:45  Creating a competency-based framework for value-based care 07:40  Implementation of the ACLC Accountable Care Atlas 10:00  The Success of Physician-Led ACOs 13:00  When “something magical happens in value-based care” 15:20  Community engagement with high-risk populations 18:10  Tapping into the altruism inherent in the practice of medicine 19:30  Creating “interdependence” for independent physicians 22:14  Capital requirements for startup ACOs 25:15  Creative thinking and capital support from payers 28:17  Incentivizing for physician leadership and process transformation 32:40  Overcoming the “The Cost Conundrum” by refusing to fail 35:00  Engaging the community in a culturally appropriate way 36:00  Home Health Partnerships 38:42  Addressing Racial Disparities in Care and Health Equity 43:00  Developing a Patient-Centered Diabetes Care Playbook 48:55  Partnering with local grocery stores to improve population health 54:00  Edwin shares his passion for health care and education 58:00  Workforce Development for independent practices within an ACO 1:02    Next-level risk contracts and multi-payer strategies 1:07    Direct Contracting must be “physician-led” to be successful

The latest edition of the Medical Association of Georgia's (MAG) ‘Top Docs Radio' show addresses the direct primary care/direct contracting practice model – and it features Brian E. Hill, M.D., the co-founder, president and CEO of HIPnation.

This podcast is the second in a series on direct contracting by physicians and medical groups. See Direct Contracting By Physicians and Medical Groups for the first post in the series. Before we get too deep into the subject, let's ask an epistemological question: If you saw one dead raccoon, does that mean that all raccoons are dead?

Ebay and Craigslist have disintermediated the classified section in the newspaper, which used to be the largest moneymaker in that business. The newspaper as middleman has been put to bed for the last time. But in healthcare, middlemen abound. Hospital systems are middlemen for their controlled/employed physicians. Insurance companies, and even more so on steroids, IPAs and risk bearing medical groups are the middlemen between, largely, employers and their employees' medical care.

Mike Dendy is CEO and Founder at Advanced Medical Pricing Solutions (AMPS) and a student of the irrational pricing and misaligned incentives that drive today's US healthcare system. We begin our conversation by discussing the widely-held myth of the PPO discount. From there we explore the general pricing methodologies and incentives in healthcare. Once you wrap your head around all of that, the discussion of how often claims are incorrectly priced and what can be done about it will bring us to a conversation around a concept known as “Direct Contracting”. We will also find out why Mike thinks that healthcare is like the OPEC oil cartel. You can find show notes and more information by clicking here: http://bit.ly/2NsOTx5