Podcast appearances and mentions of john marchica

How are Integrated Delivery Networks (IDNs) shaping the future of healthcare, and what role—if any—does value-based care still play? In this episode, I sit down with John Marchica, CEO of Darwin Research Group, to discuss how IDNs are transforming patient care. We also examine the ongoing challenges of value-based care and why it continues to miss the mark on enhancing patient experiences, improving population health, and managing costs.

Jeff Wells, MD, CEO & Co-Founder, Marathon HealthJeff Wells, MD, is the CEO and co-founder of Marathon, a modern health company that partners with employers, benefit consultants and unions to deliver a health care experience that focuses on driving real behavior change, resulting in better employee health and financial savings. Marathon Health's model consists of onsite health centers, Network health centers and virtual advanced primary care. Wells, who earned his MD in internal medicine from Indiana University, was president and co-founder of OurHealth, which merged with Marathon Health in January 2020. He is the former director of Indiana's Office of Medicaid Policy and Planning.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Ruth Krystopolski is President of Ayin Health Solutions at Providence Health Systems. In her role as President, Ruth leads the development of population health capabilities across Providence's ministries and extends them externally to reach additional communities.Ruth joined Ayin in November 2021 after serving as the Senior Vice President of Population Health at Atrium Health, where she was responsible for the development and implementation of value-based care models across the organization. Ruth also led the system-level Care Management, Employer Solutions and other Value-Based Programs and provided oversight of the Poison Control Center in Charlotte, NC.Ruth holds an undergraduate degree in Health Policy and Administration from Pennsylvania State University and a Master of Business Administration in Finance from the University of Pittsburgh.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Heitham Hassoun, MD, Vice President & Medical Director, Cedars-Sinai InternationalDr. Heitham Hassoun is the Vice President & Medical Director for Cedars-Sinai International in Los Angeles, California. He previously served as Global Medical Director for Johns Hopkins Medicine and was an Associate Professor in the Department of Surgery at The Johns Hopkins University School of Medicine.Dr. Hassoun has a wealth of experience in international patient services, global collaborations and health system development. He was instrumental in the creation of Johns Hopkins Aramco Healthcare, a joint venture between Saudi Aramco and Johns Hopkins Medicine, as well as a number of other institutional management and affiliation agreements throughout the Middle East and Asia. Currently, he aims to expand the global footprint of Cedars-Sinai.Dr. Hassoun maintains a clinical practice in vascular & endovascular surgery and he continues to educate and research in a variety of topics related to global collaborative healthcare and academic medicine. He completed his fellowship training in vascular and endovascular surgery at Northwestern University in Chicago and earned his medical degree at Baylor College of Medicine in Houston.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Rob Allen, FACHE, President and Chief Executive Officer, Intermountain HealthcareRob Allen, FACHE, was named as the new president and chief executive officer of Intermountain Healthcare and began serving in that role on December 1, 2022. Previously, Rob served as the organization's senior vice president and chief operating officer. In addition to Rob's 25-plus years of executive leadership at Intermountain, he has also held CEO roles at hospitals and health systems in Wyoming, New Jersey, and Massachusetts.A fellow of the American College of Healthcare Executives, Rob has served on many foundation, chamber, and service boards. Rob earned a Master of Business Administration degree from Utah State University and a Bachelor of Science degree in operations management from Brigham Young University. His passion for healthcare began during his childhood as he was raised on a farm in Star Valley, Wyoming, where his mother served as a nurse and later as administrator at Star Valley Hospital. He and his wife, Becky, have three children and four grandchildren.Intermountain Healthcare is headquartered in Utah with locations in eight states and additional operations across the western U.S. Intermountain is a nonprofit system of 33 hospitals, 385 clinics, 60,000 employees, medical groups with some 3,900 employed physicians and advanced care providers, a health plans division called SelectHealth with more than one million members, and other health services. With its mission of “Helping people live the healthiest lives possible,” Intermountain is committed to improving community health and is widely recognized as a leader in transforming healthcare by using evidence-based best practices to consistently deliver high-quality outcomes at sustainable costs.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

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

In his role as Strive Health's Vice President of Strategy & Development, Jackson Brasher draws on more than 15 years of experience to lead Strive Health's system team in their company mission to transform kidney care.Before joining the leadership team at Strive, Jackson held corporate strategy and business development roles at The Advisory Board Company, Trilliant Health, and Cardinal Health –  working with hospitals, health systems, and provider practices across the country on various innovation and growth initiatives. Jackson holds a B.A. from the University of Virginia and an M.B.A. from Duke. A Nashville native, Jackson enjoys spending time with his wife, daughter and the family's playful black lab. Outside of the office, he can be found on the lake, at a concert, or planning his next big trip. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

David Stewart, MD; Head, Division of Medical Oncology, University of Ottawa; Author, A Short Primer on Why Cancer Still SucksDr. Stewart received his MD degree from Queen's University, Kingston, followed by training in internal medicine at McGill University and in medical oncology in the Department of Developmental Therapeutics at the UT MD Anderson Cancer Center. He first moved from MD Anderson to the University of Ottawa in 1980, and served as Chief of Medical Oncology at the Ottawa Civic Hospital from 1989 to 1999. He returned to the Department of Thoracic/Head and Neck Medical Oncology at MD Anderson Cancer Center from 2003 to 2011 where he served as Chief of the Section of Experimental Therapeutics (2003-2005), Chair Ad Interim (2005), Deputy Chair (2006-2009), and Director of Translational Research (2009-2011). He was also the Principle Investigator of MD Anderson' phase II N01 contract with the National Cancer Institute, and was the clinical leader of a number of other federally-funded translational research projects. In 2011, Dr. Stewart returned to Ottawa from the University of Texas MD Anderson Cancer Center (Houston, TX) in 2011 to assume the position of Head of the Division of Medical Oncology at The Ottawa Hospital and the University of Ottawa. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Adam Wilson founded BioPharmGuy in 2008 after gaining engineering and government experience in biotech. Professional stops prior to BioPharmGuy include Biopure (Cambridge, MA), FDA (Detroit, MI) & Henry Ford Hospital (Detroit, MI). His formal educational background consists of a Chemical Engineering Bachelors ('02) and Pharmaceutical Engineering Masters ('06) both from the University of Michigan. BioPharmGuy currently operates out of West Lafayette, IN. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Chris is the Chief Executive Officer (CEO) of Landmark Health. Chris joined Landmark in 2017 as Vice President and General Manager responsible for launching the New England market. Most recently, Chris has served as Landmark's Head of Corporate Development responsible for the company's growth strategy, strategic partnerships, mergers and acquisitions, and public policy. In this position, Chris played an integral role in spearheading Landmark's merger with Optum and leading the company's integration into Optum's Home and Community platform.Prior to Landmark, Chris was a Principal at Innosight, a healthcare focused growth strategy consultancy and Co-founder of Predilytics, a healthcare analytics business. Chris holds a Bachelor of Arts in economics from Harvard College. He also received his M.B.A. from Harvard Business School. Chris resides in Newton, Massachusetts with his wife and three young children. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

John Gorman is the founder and Chairman of Nightingale Partners, the first Opportunity Zone fund to invest in social determinants of health interventions with health insurers, states, and provider organizations. He also founded and is the former Executive Chairman of Gorman Health Group. John's work focuses on Medicare, Medicaid, and Affordable Care Act strategy, governance, and turnaround of distressed health plans. Prior to founding his firm, John served as Assistant to the Director of Health Care Financing Administration's (HCFA, now CMS) Office of Managed Care, where he provided day-to-day management and served as the external liaison for the Medicare and Medicaid managed care programs.John's career in Washington began as Press Secretary and Staff Director for U.S. Representative John Conyers, Jr. (D-MI), then Chairman of the Government Operations Committee. John serves on the Board of Directors of Henry Ford Health System's Health Alliance Plan in his birthplace of Detroit, MI, and serves as a Senior Advisor to Premier, Inc., the hospital purchasing cooperative, on Medicare Advantage and Medicaid matters. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Jason Gorevic is chief executive officer and a member of Teladoc Health's board of directors. Since taking the reins in 2009, he has led Teladoc Health to its position today as the world leader in virtual care, achieving significant growth in revenue, membership, and telehealth utilization. Under his leadership the company has established a proven track record of successfully shaping the market and driving healthcare transformation by executing on the strategic vision, delivering award-winning innovation, and effectively integrating each corporate acquisition. Nationally recognized as a thought leader and trailblazer in the virtual delivery of healthcare, Mr. Gorevic is fueled by a passion for improving healthcare outcomes and providing universal access to care. His extensive career in healthcare began at Oxford Health, and he has also held executive leadership roles at WellPoint, Inc. (now Anthem, Inc.) and Empire BlueCross BlueShield.He holds a Bachelor of Arts in International Relations from the University of Pennsylvania. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University. John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Tzvia Bader, CEO and Co-Founder of TrialJectory is a savvy and experienced entrepreneur, with decades of experience in business development, product marketing, and strategy. Prior to co-founding TrialJectory, Tzvia headed the global business unit at Amdocs where she was responsible for building a new product growth strategy, as well as for global sales and marketing. Tzvia has held different business development and marketing positions in several tech companies, both B2B and B2C. She holds a Master of Science  degree from the University of Nottingham, in Nottingham, UK. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Michelle Troseth and Tracy Christopherson are co-founders of MissingLogic®. They help healthcare organizations and healthcare leaders combat burnout through the power of a framework driven approach founded on Polarity Intelligence™. The core of their work is leading healthcare organizations through transformational change that results in the best place to give and receive care, and for leaders to live their best lives both personally and professionally.Michelle and Tracy have been interprofessional leaders, friends and colleagues for over 30 years. They are co-hosts of a top healthcare leadership podcast, Healthcare's MissingLogic. Michelle and Tracy have a combined experience of more than 60 years working as consultants and coaches for healthcare organizations across North America supporting healthcare leaders as they strive to create healthy, healing work cultures. They frequently speak at national and international leadership conferences on the topics of managing healthcare polarities, achieving work life balance and living a resilient life.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.

Linda Hand brings 35 years of experience to her role as CEO of Prealize Health, with an emphasis in organizational leadership, product development, solutions delivery and go-to-market strategies across a diverse portfolio of industries. Before joining Prealize, Linda led the Clinical Trial Optimization Solutions division at IQVIA, where she was responsible for creating and delivering a suite of innovative clinical technology products, fueled by predictive analytics and machine learning algorithms, to drug development organizations worldwide.Linda is a past President and CEO of the San Francisco-based DecisionView, the leading provider of clinical trial enrollment optimization solutions. She also ran product development and delivery at a number of leading software companies, including DigitalThink, Hyperion, Arbor Software and Sybase.Linda holds a BA in Computer Science from the University of California, Berkeley, and completed the Haas School of Business Executive Program.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

Robin Shah is the Founder and CEO of Thyme Care, an oncology care management solution providing high-touch, tech-enabled cancer care navigation. Thyme Care was founded with the mission to radically improve the journey for every person diagnosed with cancer.  At the heart of it all is the belief that providing patients with access to the right team at the right time will lead to better quality, outcomes, costs, and ultimately patient experience. Before launching Thyme Care, Robin was a founding member of OneOncology, where he served as the Chief Development and Marketing Officer. Robin's passion for building a stronger future for community oncology then brought him to Flatiron Health, a leading healthcare technology company. There, Robin served as Vice President of Provider Marketing and Strategy. Robin also helped manage a comprehensive community cancer center in his hometown, Gettysburg, PA. Robin earned his bachelor's degree in biomedical engineering from George Washington University and holds an M.B.A from the Carey Business School at Johns Hopkins University.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group. He is leading ongoing, in-depth research initiatives on integrated health systems, accountable care organizations, and value-based care models. He is a faculty associate in the W.P. Carey School of Business and the graduate College of Health Solutions at Arizona State University.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is an active member of the American College of Healthcare Executives and is pursuing certification as a Fellow.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz. with a satellite office in Princeton, N.J.

In this healthcare podcast, I'm speaking with Eric Bricker, MD, about how so many entities in healthcare are getting up in other people's business and swimming in other people's traditional lanes. Consider last week's show with Katy Talento, for example. She mentions employers who are not only doing their own direct contracting (ie, cutting out the traditional carriers and negotiating directly with provider organizations) but also employee benefit consultants who are working on setting up their own hospital—an employer-owned hospital. That was episode 350, and while this hospital idea is a little future oriented, right now today, across the country, we have employers and also unions who are owning their own primary care clinics, which I discussed at some length with Mark Blum from America's Agenda (EP248).   In this episode with Dr. Bricker, we start from the beginning. We kick off the conversation talking about the payer, PBM, and hospital system horizontal consolidation that has transpired over the past decades (that's plural). Horizontal consolidation is pretty much the easiest way to decimate all competition in your own swim lane so that you can charge more and not worry so much about patient/customer/member experience because the patients/customers/members have no better alternative. They effectively have nowhere, or few other places at best, to go if they leave you. So, what's the impact of horizontal consolidation? We get into this in the podcast, but subsequent to this recording, there was a study that came out in JAMA: “The Dysfunctional Health Benefits Market and Implications for US Employers and Employees.” This was by David Scheinker, PhD; Arnold Milstein, MD; and Kevin Schulman, MD. This study showed that commercial insurance costs have gone up 4x the rate of other benchmark goods and services. Bottom line, “It is assumed that insurers compete intensely to improve the value received by employers and employees by negotiating to keep prices down and advocating for employers and employees.” Ha ha … NOT.   With peak horizontal consolidation, there is little meaningful competition—so ixnay on that premise. By the way, if anyone knows any of those authors that I just cited in that study, hit me up. I'd love to get one of them on the show. But let's spend a moment, shall we, on the human impact of all this extreme consolidation. The impact is your sister, your neighbor, your son, your friend. So many feel so much pressure financially in our country today because of healthcare costs. Even families earning significantly more than median household income are forgoing care because of costs. Again, this was in a recent paper. (The authors are Alyce S. Adams, Raymond Kluender, Neale Mahoney, Jinglin Wang, Francis Wong, and Wesley Yin.)   But the direct observable financial toxicity resulting from high healthcare patient costs is really only the tip of the iceberg here. As Dave Chase from Health Rosetta has said a million times already, high healthcare costs have a multitude of effects on employers, big and small. One big one is, if healthcare costs more, then there's less money for salaries. Dave, citing lots of evidence, has long attributed wage stagnation in this country to accelerating healthcare costs, which became even more rampant during periods of industry consolidation. Dave Chase leads Health Rosetta, by the way. Here's another human toxicity: Listen to episode 337 with Oliva Webb on the impact on her life as a result of the undeniably and unquestionably common non-excellent treatment by the PBMs and SPPs that she has to deal with. Because, as Dr. Bricker also says, no competition means basically not a whole lot of concern about patient experience. Why should a for-profit business spend money to improve something when there's nothing really to be gained for them financially to do so? I mean, the best a patient can do most of the time is hop from the frying pan into the fire. That's what happens when there's no competition or no real competition. Also consider the burned-out clinicians who have to get stuck in the middle of this nobody-really-cares-at-the-monopoly customer service paperwork quagmire.  By the way, here's a sidebar that might come as a surprise to some people, but please take this in the spirit with which it's intended. All of us innovators and lifelong learners, we want to update our beliefs when the facts show us an updated conclusion. So, I have learned that all of this consolidation was going on long before the ACA (Affordable Care Act). My point here is to please look into this well-documented trend line before reflexively tweeting that the ACA drove consolidation. Dr. Bricker and others like Dr. Mai Pham have told me that, in their opinion, low interest rates, cheap debt, and a desire to eliminate competition are wildly powerful drivers of consolidation. Anyway, about nine minutes into the interview with Dr. Bricker, if you're one of the ones who knows all you care to know about horizontal consolidation, we get into vertical integration, vertical consolidation—and this is where things get interesting. And when I say interesting, I mean it in a “we live in interesting times” kind of way. The vertical consolidation conversation segues into whose swim lane that the digital health and other innovators or, dare I say, disrupters are diving into and whose lunch they are aiming to eat. Dr. Bricker probably needs no introduction. He is the force behind AHealthcareZ, which you can find online, on Twitter, YouTube, and LinkedIn. He has worked as a clinician, in healthcare finance, and currently serves as a chief medical officer. If that weren't enough, he's also been an entrepreneur—a very successful entrepreneur, I might add. He started one of the first healthcare navigation firms called Compass Professional Health Services. Compass had something like 2000 employer clients serving about 1.8 million people when it was purchased in, I believe, 2018.   You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn.  Eric Bricker, MD, is an internal medicine physician and former cofounder and chief medical officer of Compass Professional Health Services. Compass is a healthcare navigation service that grew to 2000+ clients, including T-Mobile, Southwest Airlines, and Chili's/Maggiano's restaurants. Compass was acquired by Alight Solutions in July 2018. Alight is a 10,000-person employee benefits and HR outsourcing company that separated from Aon in 2017. Dr. Bricker has since started AHealthcareZ.com, with 170+ healthcare finance videos with approximately 90,000 views per month across all platforms. He is also the author of Healthcare Money Campfire Stories.  06:30 What is this “megatrend” happening in healthcare right now? 07:52 How has consolidation changed the healthcare landscape? 10:22 What is vertical integration within healthcare? 11:48 Why doesn't inorganic growth benefit patients? 13:33 “What is best for the patient does not necessarily make the most money.” 14:43 “It's not that it's above the law … it is just intentionally obscured.” 18:58 “Healthcare is glacial. It is slow.” 23:23 “The largest source of healthcare costs is hospitals.” 25:48 EP330 with John Marchica.29:17 “What have the historical priorities been of the administrators of those hospitals?” 29:32 “Every hospital CFO knows that they need sick people.” 30:18 EP343 with David Carmouche.30:59 “The payment change has to come first.” 32:17 “The money wins.” 34:12 “You've got to put the financial incentives in place … to make people actually behave the way that they should.” You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn. @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth What is this “megatrend” happening in healthcare right now? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth How has consolidation changed the healthcare landscape? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth What is vertical integration within healthcare? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth Why doesn't inorganic growth benefit patients? @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “What is best for the patient does not necessarily make the most money.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “It's not that it's above the law … it is just intentionally obscured.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “Healthcare is glacial. It is slow.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The largest source of healthcare costs is hospitals.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “What have the historical priorities been of the administrators of those hospitals?” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “Every hospital CFO knows that they need sick people.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The payment change has to come first.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “The money wins.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth “You've got to put the financial incentives in place … to make people actually behave the way that they should.” @DrEricB discusses #healthcare's changing landscape on our #healthcarepodcast. #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! 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), 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  

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

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

This episode is a little bit of a thought experiment, so hang with me as I bumble my way through it and then hit me up with your comments. The plan is to do another episode in the future where some of you with thoughts share your version of your own thought experiment. Here's the topic: The ultimate impact of telehealth—in 20 minutes or less. In my version of this thought experiment, I want to do something a little bit different (maybe) than everybody who seems to be putting up a poll on Twitter right now. I want to look at telehealth as a leading indicator, not as a trend. The goal here is not to inform you of things that you don't already know because I am entirely confident that much of what I'm gonna say right now the majority of you are already eminently familiar with—probably more familiar with than I am, frankly. So, the goal here is to put this information into a context that maybe is new—at least I hope it's new. The goal of that is to hopefully inspire some of you to take action, right now, with all haste. This whole telehealth thing started in the middle of one of the many conversations I've had lately about what will be the future of telehealth. You have probably had similar chats about the future of telehealth and know what I am going to say. They all seem to devolve into someone ticking off all of the states who have extended temporary telehealth measures and the 1000 telehealth bills pending in state legislatures that might mandate public and private payers cover it. Anyway, in the middle of one of these “let's all study this updated spreadsheet” exercises, I started to wonder if we were missing the bigger takeaway. So, let me tick through a few background points which are all pillars in my “what's the ultimate impact of telehealth” contemplation and the realization that telehealth in and of itself has no impact. What has impact is who is using it and whether their goals are reactionarily (if that's a word) short term and/or shortsighted, or if there's anything that approximates a strategic long game in that mix. For more information, go to aventriahealth.com.   Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. 02:30 Should provider organizations be getting rid of telehealth? 02:40 EP330 with John Marchica. 04:36 EP349 with Lisa Trumble. 05:07 Should telehealth be viewed as a threat? 05:40 “Virtual is a ‘head in the bed at the hospital' demand destroyer.” 06:45 “‘Virtual' is the scapegoat.” 07:42 Patients/Consumers: Is in person really better? 10:42 EP338 with Nikki King; EP347 with Ian Tong, MD; EP320 with Christian Milaster; and EP302 with Blake McKinney, MD. 11:06 How one VP of finance justifies a facility fee for a telehealth visit. 11:54 Do patients actually act like consumers in the digital age? 12:12 Why are virtual-first entities steering patients to clinically integrated networks? 13:08 How is telehealth changing healthcare costs? 14:21 “It adds up to telehealth being inexorable. It's a done deal. It's not a trend.” 15:17 “If telehealth is a leading indicator, anybody in the care delivery business who isn't … trying to figure out how to make telehealth work in their core business is gonna find themselves … in a very problematic position.” 16:50 “When will tele-whatever become an existential problem for laggard traditional provider organizations?” For more information, go to aventriahealth.com. Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Should provider organizations be getting rid of telehealth? Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Should telehealth be viewed as a threat? Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Virtual is a ‘head in the bed at the hospital' demand destroyer.” Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “‘Virtual' is the scapegoat.” Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Patients/Consumers: Is in person really better? Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Do patients actually act like consumers in the digital age? Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why are virtual-first entities steering patients to clinically integrated networks? Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth How is telehealth changing healthcare costs? Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It adds up to telehealth being inexorable. It's a done deal. It's not a trend.” Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If telehealth is a leading indicator, anybody in the care delivery business who isn't … trying to figure out how to make telehealth work in their core business is gonna find themselves … in a very problematic position.” Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When will tele-whatever become an existential problem for laggard traditional provider organizations?” Our host, Stacey Richter, discusses the impact of #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye  

Believe me, filling in for the uncontested master of podcasts, Stacey Richter, is just a tad unnerving! My name is Dr. Steve Schutzer. I'm an orthopedic surgeon specializing in joint replacement surgery, and I think it's fair to say that I'm more comfortable, in my own lane, doing complex surgery than doing this introduction to our encore podcast 294 entitled “Building a Center of Excellence: A Playbook for Physician Entrepreneurs,” which aired originally in October 2020. But when Stacey graciously offered me the honor of doing so, I said to myself (sic: Steve, suck it up) what an opportunity to share with the devoted listeners of this show my humble perspectives on the prominent position COEs (also known as Centers of Excellence) are playing in this rapidly accelerating, evolving, and exciting healthcare landscape. So, there's an ancient Chinese proverb that goes like this: “When the wind of change blows, some build walls, and others build windmills”—or in this case, Centers of Excellence! And the winds of change in healthcare are blowing, maybe even reaching gale force. In the year since episode 294 aired, there's been unambiguous upsurge of activity, in part fueled by the pandemic, that has collectively and finally moved the healthcare value agenda across the chasm, over the inflection point—and there's no turning back. Unaccountable fee for service as the predominant payment model for healthcare services is, well, shall we say, on its last legs—being replaced by reimbursement models that are aligned with the clinical and financial outcome of the services actually delivered to our patients. For COEs, that's characteristically in the form of predictable bundled payments and fully warrantied episodes of care. Question: Where do COEs fit in this new landscape? Answer: COEs are the common pathway for all healthcare purchasers (whether they're self-funded employers, advanced primary care groups, Medicare Advantage—all of them) to steer agnostically to high-quality specialists focused on a defined set of healthcare services and who are willing to assume total cost of care for their product. And the favorable impact of COEs on the ROI for purchasers has now moved beyond the realm of theory to indisputable. Take, for example, the recent report by the RAND Corporation published earlier this year in Health Affairs: A study of over 2300 patients who had either total joint, spine, or bariatric surgery done under the Carrum Health program at one of their COEs. Carrum Health is a value-based national COE platform that connects self-insured employers with top providers under standardized bundled payment arrangements. And now in full disclosure, I serve as medical advisor for the company; and our program, the Connecticut Joint Replacement Institute in Hartford, Connecticut, is actually a Carrum COE. But in this independent RAND analysis of two years of medical claims data, the savings per procedure when the surgery was done at a Carrum COE was over $16,000 per procedure. Readmission rates were reduced 80% on average. Out-of-pocket cost to the patient? Zero. And an astonishing 30% of patients who were in the queue awaiting surgery ultimately were treated nonoperatively! Peter Hayes is president and CEO of the Healthcare Purchaser Alliance of Maine and a frequent guest on this podcast. His organization has been under contract with Carrum for approximately two years and recently reported an ROI of 58% and plan savings approaching $1 million. And these data also closely reflect that reported in the Harvard Business Review two years ago by Ruth Coleman and colleagues from their experience with Walmart COEs. Finally, you know, I heard Stacey say of COEs in one of her podcasts, “This is not something you can do on a Tuesday.” Agree. Prescient advice. As you will hear once again in just a moment, this takes work. But physician leaders and entrepreneurs, take heed. Although you won't be able to stand this up on a Tuesday, there's no reason why you can't begin next Monday. You can contact Dr. Schutzer at steve.schutzer@gmail.com and learn more at the Novel Healthcare Solutions website.   Steven F. Schutzer, MD, graduated with honors from Union College and the University of Virginia School of Medicine. Following a surgical internship at the University of Rochester, he served as lieutenant in the Medical Corps of the United States Navy. After his tour of duty, Dr. Schutzer did his general surgical training at the University of Rochester and then completed his orthopedic residency at the University of Connecticut. He was then a fellow in adult hip and reconstructive surgery at the Massachusetts General Hospital, after which he entered practice in Hartford, Connecticut. Dr. Schutzer is a founding member and medical director of the Connecticut Joint Replacement Institute (CJRI), a Center of Excellence at Saint Francis Hospital in Hartford, where he served as medical director between 2007 and 2021. He is currently the physician executive for the orthopedic service line at Trinity Health of New England. He is on the staff of Saint Francis Hospital and a member of Advanced Orthopedics New England. In 2014, Dr. Schutzer and two colleagues, Ms. Steph Kelly and Ms. Maureen Geary, launched a consulting company, Novel Healthcare Solutions, whose mission is to establish effective and trusting business relationships between physicians and hospital partners—and then create orthopedic Centers of Excellence. Dr. Schutzer is also vice president and co-founder of Upswing Health, a health technology start-up whose charge is to help 10 million lives alleviate suffering from musculoskeletal pain by the end of 2023. 04:52 Why would competitive physician groups gang together? 09:02 “Even if you never … bundle, going through the implementation process … will yield incredible unrecognized value.” 10:19 “It demands an end-to-end care redesign process.” 11:40 “The value of a COE is really unquestionable.” 11:48 “For every dollar saved [in a COE], two-thirds was in the quality side, and one-third was in the price point.” 14:38 Slide deck discussing the definition of a COE and its seven building blocks.15:06 “I'm talking about business relationships between the physicians … these are the most fundamental [relationships].” 16:24 “It is all about trust.” 16:49 What is the most central issue as to why a COE does well or fails? 17:26 “It's not just data. It has to be actionable data because physicians naturally don't trust data.” 22:55 “Employers are definitely taking note to patient-reported outcomes.” 23:38 What is the seventh element that is necessary for a COE, and what is fundamental to that element? 24:28 Where will fee-for-service doctors be in 2 to 3 years? 25:46 “The only way that we can accrue the value that we deserve is through these types of relationships.” 26:12 “The supreme motivator is opportunity.” 28:03 How do physicians and providers begin a transformation of the marketplace they're in? 28:38 “What they need from us is product. They need products to disrupt the status quo.” 31:27 “The problem is that there are vendors who are working at the margin.” You can contact Dr. Schutzer at steve.schutzer@gmail.com and learn more at the Novel Healthcare Solutions website.   @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech Why would competitive physician groups gang together? @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “It demands an end-to-end care redesign process.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “The value of a COE is really unquestionable.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “It's not just data. It has to be actionable data because physicians naturally don't trust data.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “Employers are definitely taking note to patient-reported outcomes.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech Where will fee-for-service doctors be in 2 to 3 years? @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech How do physicians and providers begin a transformation of the marketplace they're in? @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech Recent past interviews: Click a guest's name for their latest RHV episode! Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried

This interview with Lisa Trumble is mostly about clinically integrated networks (CINs)—what they are, how they work, how data get shared. Furthermore, we talk about hybrid CINs, meaning, for example, a virtual front door that might lead to in-person care. After that, we talk about the potential impact of direct contracting, which Lisa says could significantly change the healthcare marketplace. The hybrid talk, by the way, is toward the middle of the show; and we talk about direct contracting—that's near the end if you're short on time and you want to skip around. But before we go there, let's just level set a little bit, shall we, on the topics of accountability and integration as general constructs. Specifically, what's the impact, or lack thereof at times, when the provider is not accountable for patient results? I'm talking here about fee for service, in general, where the provider is not accountable for patient results. Like, if we're talking about a fee-for-service world and what it incents, it goes like this: Transaction happens. Somebody sends a bill. The end. I mean, in a fee-for-service world, the patient encounter may be the highest- or the lowest-value patient-doctor transaction in the history of humankind; but either way, the payment is the same. So, the incentive is to figure out how to encounter lots of patients and/or upcode wildly, I guess. The incentive is not to coordinate care or teach a patient how to take advantage of a telehealth offering to mitigate some social determinant of health or spend 10 minutes doing some education or shared decision making or establishing rapport and being culturally sensitive. Any docs who are doing that stuff are doing it on their own time in an FFS world. Here's the good news and the bad news—and I don't often hear it spelled out this bluntly, so I'll do the honors: If anyone wants to get paid to create patient health, they have to be accountable for the outcomes created—upside and downside. Frankly, when an organization is super worried about the downside, that could be—not in all cases, but it certainly could be—a clue that maybe their approach is a little bit more transactional and/or inefficient than perhaps they would like to admit. There's been much talk over the years about the importance of giving patients so-called “skin in the game,” but what might work out better is to mandate that providers have so-called skin in the game. Providers have to be accountable so good providers can reap rewards and bad ones don't. The episode with Sunita Desai (EP334) is all about how providers have proven to actually be better “consumers” than “consumers,” so there could be a constellation of rationales here.   Now, if you're accountable for care, you must actually create outcomes, as just discussed. And to actually create outcomes, there must be integration. Integration is necessary. Care coordination is necessary both with internal and external other providers and entities. There are very, very few cases where a chronic condition can be appreciably improved by a random assortment of 7- to 15-minute patient encounters. Managing chronic conditions requires a longitudinal journey that weaves together most often more than one doctor, also nurses and a PA and a speech pathologist and a nutritionist and a Certified Diabetes Educator and maybe a physical therapist or two. Considering that 85% of healthcare spend in this country has to do with chronic conditions also ... yeah, integration is really required. And, yeah, how many decades later, we're still talking about interoperability. Here's a tidbit I found kinda apropos: Female doctors make $2 million less, apparently, over a 40-year career than their male counterparts. That's per research in Health Affairs, recently reported in the New York Times. More men become surgeons, and women have been shown to spend more time with their patients, leading to fewer services that can be billed for.   What's the actionable takeaway there, I wonder? In this healthcare podcast, I have the honor and pleasure of speaking with Lisa Trumble. Lisa is president and CEO of a CIN, a clinically integrated network, called the Southern New England Healthcare Organization, or SoNE. SoNE was formed in January 2020 to integrate three ACOs [accountable care organizations] in two states. The CIN manages a population of over 200,000 patients—about $1.5 billion in total costs of care. Previously, she worked at Cambridge Health Alliance building their pop health and value-based structure to the point where about 60% of their business was in some form of risk or alternative payment models. There is one disclaimer that I would just ask you to keep in mind when listening to any conversation about value-based care—and there are lots of them going on right now—but I just want to tuck this in here because I'd be remiss not to mention it at some point. Dr. Mai Pham (EP325) has put this better than I ever would. She said recently, “After a decade of value-based payment contract negotiations in both public and private sectors, I would like to point out that [health systems] can talk a good value game, but if their ... organizations push for ever-higher unit prices, the word value is meaningless. I've seen trends in unit prices for a given health system outstrip the legitimate savings it produces by reducing volume, which was the plan all along.” Dr. Pham is currently writing a piece about this exact topic that's going to appear in AJMC soon, so definitely look out for that.   You can learn more at sonehealthcare.com.   Lisa M. Trumble, MBA, president and CEO of SoNE HEALTH, has had a career showcased by successes in generating strong clinical and financial operating results for healthcare organizations. She has 30+ years' experience at integrated delivery systems and physician organizations. Prior to joining SoNE HEALTH, Lisa served as senior vice president of accountable care at Cambridge Health Alliance (CHA); the scope of her responsibility included systemwide duties for accountable care and population health management, incorporating payer contracting, financial medical economics, regulatory compliance, and administrative and clinical programming. Under her leadership, the organization realized significant improvements in clinical and financial outcomes. Lisa joined CHA from Berkshire Health Systems, where she served as vice president of physician services and executive director of the Berkshire Health Systems Physicians Organization. She was instrumental in transforming physician operation, restructuring provider employment agreements and provider compensation plans, and enhancing patient satisfaction. Prior to Berkshire Health Systems, she served as the vice president of finance and operations at the Cambridge Health Alliance Physician Organization, where she achieved similar outcomes. Previously, Lisa was administrative director for anesthesia and surgery services lines at North Shore Medical Center and chief financial officer of North Shore's Physicians Organization, a subsidiary of North Shore Medical Center. Additionally, she held positions in operations and finance at Commonwealth Health Management Service and Independent Physicians Association. Lisa holds a bachelor's degree in business administration from North Adams State College and a master's degree in business administration and healthcare finance from Western New England University. 06:20 Why do accountability and integration go hand in hand? 08:56 “Aggregation just for the point of aggregation doesn't necessarily produce better outcomes.” 09:18 What questions should we be asking when considering aggregation? 09:45 Does aggregation equal integration? 11:42 What exactly is a clinically integrated network? 12:26 What is the intention of a clinically integrated network? 13:22 Are all CINs ACOs? Are all ACOs CINs? 17:22 What entities make up a clinically integrated network? 19:26 “We want providers that are able to generate the outcomes that we're expecting.” 20:44 “There is a lot of work that goes into data integration.” 23:14 What is a hybrid CIN model? 25:22 Encore! EP206 with Ashok Subramanian.26:53 “Everyone is sitting around the table proactively.”—Stacey 29:37 What kind of structure could move the Medicare market quickly? You can learn more at sonehealthcare.com.   Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN Why do accountability and integration go hand in hand? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN “Aggregation just for the point of aggregation doesn't necessarily produce better outcomes.” Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN What questions should we be asking when considering aggregation? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN Does aggregation equal integration? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN What exactly is a clinically integrated network? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN What is the intention of a clinically integrated network? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN Are all CINs ACOs? Are all ACOs CINs? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN What entities make up a clinically integrated network? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN “We want providers that are able to generate the outcomes that we're expecting.” Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN “There is a lot of work that goes into data integration.” Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN What is a hybrid CIN model? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN “Everyone is sitting around the table proactively.” Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN What kind of structure could move the Medicare market quickly? Lisa Trumble discusses #ClinicallyIntegratedNetworks on our #healthcare #podcast. #healthcarepodcast #digitalhealth #CIN Recent past interviews: Click a guest's name for their latest RHV episode! Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera

The discussion to follow is probably a 400-level class in payviders. If I just said the word payvider and you're scratching your head wondering where you may have heard that term before, this show is probably not the best place for you to start. I'd go back and get some context by listening first to the episodes with Steve Blumberg from GuideWell (EP304) and/or the one with John Moore from Chilmark (EP172); and for a really retrospective lookback, check out the one episode with Dr. Kris Smith from Northwell (EP127) from back when they were still trying to become an insurance carrier. It's like a time capsule into their ambitions.   OK, if you're still with me, in this episode I'm looking forward to digging into payviders with Jeb Dunkelberger, who is the CEO of Sutter Health | Aetna. Sutter Health | Aetna is the payvider joint venture between, you guessed it, Sutter Health and Aetna. Not only is Jeb one who would obviously know a whole lot about payviders and how they operate given his role, but he's also super articulate and thoughtful in terms of the potential impacts that this type of entity can have on patients and the surrounding healthcare ecosystem. I started to get really curious about payviders and what they're up to because the term keeps coming up in conversations, number one. And the more it came up, the more it started to become really obvious that payvider is one of those terms that everybody tosses around and may or may not define it the same way. Jeb refers to a payvider as an entity that delivers care but also writes insurance products and takes risk for them—not just taking capitated payments or doing direct contracting. While it's the employer who actually takes the risk, this is the definition of payvider that we explore in this healthcare podcast. Two kinds of interesting points that Jeb makes, which I'll just underscore here: One is “demand destruction.” I like the idea of the term because it brings a really obvious point into stark focus. Bottom line, taking on risk or value-based programs is easier if you are a smaller percentage of the healthcare spend. The bigger a percentage of the healthcare spend that gets cha-chinged into your cash register, the more you destroy your own demand by creating value-based programs that minimize downstream costs. Those downstream costs are your revenue, after all. Value-based care is all about demand destruction at its core. In the last question of this interview (so, this is the second thing I'm underscoring here), I ask Jeb if he thinks payviders will ultimately lower healthcare costs; and he comes back with a reframe of my question. He says if we take costs out of the system, will hospitals close? And if the hospitals close, then people get laid off. Fair point, since in many places the health system is one of the biggest employers in town if not the biggest—and also a political tour de force. So, there's more nuances here; but you'll have to either get to or skip to almost the end of the episode to hear them. Jeb Dunkelberger began his career as a health economist and consultant. He became the CEO of Sutter Health | Aetna to focus on alternative reimbursement models and value-based care. Jeb also wrote a book called Rich & Dying. You can learn more at sutterhealthaetna.com.   You can also connect with Jeb on LinkedIn and follow him on Twitter.   Jeb Dunkelberger, MSc, MHCI, currently serves as CEO of Sutter Health | Aetna (SH|A), a commercial insurance plan serving Northern California. The health plan aims to combine the value of retail, provider, and payer via its partnerships with CVS, Sutter Health, and Aetna. Prior to SH|A, Jeb led growth for two bay-area healthcare start-ups: Cricket Health and Notable Health. Jeb has also held executive roles at Highmark, McKesson, and EY. Jeb holds healthcare-related degrees from Virginia Tech, The London School of Economics, Cornell University, and University of Pennsylvania. 03:58 What all does Sutter Health | Aetna entail? 04:31 What does it mean to be a “performance network”? 04:48 What does it mean to be a payvider? 06:35 How common are payviders? 07:31 “We are writing direct risk.” 09:21 How does the fully insured product work? 12:30 “You want to hold their feet to the fire, from a value-based perspective.” 12:42 What's the incentive for providers to partner with payers? 15:25 “It's just math. It's the amount of lives times the amount of utilization multiplied by your unit costs.” 20:58 “You have to have a day of reckoning, and that only comes from financial incentives creating that gateway out.” 24:55 How do we think about reform and taking money out of the healthcare system? 26:58 “We also have to talk about repurposing the workforce.” 27:27 “We need to upskill our workforce.” 30:14 “Can a health system survive as the largest employer, year over year, if they give unit cost concessions, year over year? … The answer is no.” You can learn more at sutterhealthaetna.com.   You can also connect with Jeb on LinkedIn and follow him on Twitter.   @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth What all does Sutter Health | Aetna entail? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth What does it mean to be a “performance network”? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth What does it mean to be a payvider? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth How common are payviders? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We are writing direct risk.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth How does the fully insured product work? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You want to hold their feet to the fire, from a value-based perspective.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's the incentive for providers to partner with payers? @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's just math. It's the amount of lives times the amount of utilization multiplied by your unit costs.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You have to have a day of reckoning, and that only comes from financial incentives creating that gateway out.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We also have to talk about repurposing the workforce.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We need to upskill our workforce.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Can a health system survive as the largest employer, year over year, if they give unit cost concessions, year over year? … The answer is no.” @Jeb_Dunk discusses #payviders on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham

I attended the STAT Summit last week and heard the heart-wrenching story told by Charles Johnson, who is the founder of 4Kira4Moms, which is a group dedicated to improving maternal health equity. Charles's family is African American. After a planned C-section, his otherwise-healthy wife died an avoidable death because 10 hours after the clinical team was alerted that she had internal bleeding—10 hours later—they got around to wheeling her into surgery. At that point, she had three liters of blood in her abdomen. She bled out and died, leaving her newborn infant motherless. This all went down at a large, incredibly well-respected integrated delivery network. One of the biggest issues in healthcare today … well, there are many issues, so maybe I should start again. One of the biggest issues in healthcare that is going to be discussed on this podcast today is how to engage those patients or members or employees or consumers who might need our healthcare industry to work better on their behalf. This is especially a problem (a well-known problem) when we consider those patients who our healthcare system in so many ways does not serve well: many minority patients, Black people, other people of color, the LGBTQ community, people who do not speak English as their first language. These patient cohorts emerge on the other side of our healthcare industry sporting patient outcomes that are even worse than our usual not-so-great average patient outcomes.   In this healthcare podcast, we're gonna talk about a new coalition formed by Walmart and six other employers, plus Included Health, which is the combined entity of Grand Rounds and Doctor On Demand. (They merged recently.) So, there was a coalition that was formed. It's called the Black Community Innovation Coalition, and in short, it's a new virtual-care program aimed at combating health disparities among African American workers. I wanted to learn more about this coalition, so in this episode I'm speaking with Ian Tong, MD, about the aforementioned Black Community Innovation Coalition—the how and also the intent. Dr. Tong is the chief medical officer over at Included Health and also a clinical assistant professor and adjunct faculty in the medical school at Stanford. One reason I was so intrigued is that the Black Community Innovation Coalition leverages ERGs (employee resource groups) in a way I thought was different. If you're unfamiliar, ERGs or, as I said, employee resource groups, used to be called employee affinity groups. Many big companies have them. These ERGs bring together groups with shared identities, shared experiences, shared interests. What I thought was worth contemplating if you're interested in improving health equity, health outcomes … through these existing ERG organizations, it might be possible to pull the healthcare system and these patients closer together to create healthcare benefits and care delivery models that are designed with them in mind. So, what I think might be actionable to others relative to this coalition and its methodology is the best practice of building the engagement mechanism into the design of the initiative. So often it's an afterthought if you think about it. We build the thing, and then we wonder how to “market” it—like the “marketing” is this separate and sequential function. It's not. And marketing is also probably a limiting misnomer. This is especially true, though, when contemplating minority populations for a whole bunch of reasons that we get into in this conversation. So that's number one: Build the engagement mechanism into the program design. But here's number two: Consider the engagement mechanism relative to existing channels of engagement, re: ERGs or otherwise. Other links on the show include: Rebecca Etz, PhD (EP295) talking about some best ways to measure primary care quality. The Harvard Implicit Bias Test You can learn more by checking out the Implicit Bias Test, the CDC REACH site, and includedhealth.com.  Ian Tong, MD, is chief medical officer at Included Health (formerly Doctor On Demand and Grand Rounds Health). In this role, Ian leads all clinical care delivery, including clinical products and service lines, clinical quality, and practice performance of the clinical staff. Prior to Doctor On Demand, Ian held leadership roles including chief resident of Stanford Internal Medicine and co-medical director of the Arbor Free Clinic. He also founded and was medical director of The Health Resource Initiative for Veterans Everywhere (THRIVE), honored with the Award for Outstanding Achievement in Service to Homeless Veterans in 2008 by the US Secretary of Veterans Affairs. A national collegiate champion in rugby at the University of California at Berkeley, Ian was named to the All-American Team in 1994. He graduated from Berkeley with a bachelor's degree in English, then earned his medical degree from The University of Chicago Pritzker School of Medicine. He completed residency and chief residency at Stanford Hospital and Clinics and is currently a clinical assistant professor (affiliated) at Stanford University Medical School. He is board certified in internal medicine. Ian has dedicated his career to improving equity in, and access to, high-quality care. He lives in the San Francisco Bay area. 04:33 What is the Black Community Innovation Coalition? 05:06 Who are the partners behind the Black Community Innovation Coalition? 06:23 How is the Black Community Innovation Coalition focusing on patients? 08:05 “If you take a one-size-fits-all approach to your employees, that is not going to be adequate or complete.” 08:56 How the Black Community Innovation Coalition is incorporating engagement into its core foundation. 13:18 “There's a great deal of hesitancy around engaging care, and there's a high level of avoidance.” 15:26 EP338 with Nikki King, DHA.16:34 “The technology is not making that experience worse. It's a bad experience, and it's broken already.” 23:27 “I feel very strongly that everyone should probably have a virtual primary care clinician.” 27:20 EP295 with Rebecca Etz, PhD.28:15 “We really want to pay attention to that encounter being the best encounter possible because that … might be the only chance you get to engage that patient.” 29:00 Why is virtual care important for self-insured employers? 32:08 “We cannot afford to have low-value encounters.” You can learn more by checking out the Implicit Bias Test, the CDC REACH site, and includedhealth.com.  @Driantong discusses the Black Community Innovation Coalition on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth What is the Black Community Innovation Coalition? @Driantong discusses community health initiatives on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth Who are the partners behind the Black Community Innovation Coalition? @Driantong discusses community health initiatives on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth How is the Black Community Innovation Coalition focusing on patients? @Driantong discusses on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth “If you take a one-size-fits-all approach to your employees, that is not going to be adequate or complete.” @Driantong discusses the Black Community Innovation Coalition on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth “The technology is not making that experience worse. It's a bad experience, and it's broken already.” @Driantong discusses the Black Community Innovation Coalition on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth “I feel very strongly that everyone should probably have a virtual primary care clinician.” @Driantong discusses the Black Community Innovation Coalition on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth “We really want to pay attention to that encounter being the best encounter possible because that … might be the only chance you get to engage that patient.” @Driantong discusses the Black Community Innovation Coalition on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth Why is virtual care important for self-insured employers? @Driantong discusses the Black Community Innovation Coalition on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth “We cannot afford to have low-value encounters.” @Driantong discusses the Black Community Innovation Coalition on our #healthcarepodcast. #healthcare #podcast #healthcareinitiatives #pophealth Recent past interviews: Click a guest's name for their latest RHV episode! Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy

Over the holiday season here, we're running some of our favorite episodes from years past. This one is with Mike Schneider, who actually has taken another role since this show was recorded. Other than that, the information that Mike shares during this episode from 2020 is all good. So, let's do this thing. Disclaimer before we get started here: This show is probably a 300-level class in pharmaceutical/PBM relations. If you are tuning in for the first time and you aren't pretty familiar with the role of PBMs, I would go back and listen to, say, episode 241 with Vinay Patel or episode 166 with Tim Thomas from Crystal Clear Rx. OK, now that that's out of the way, if you're still with me, this episode is like a ride on a roller coaster. I talk with Mike Schneider. And we get into, you know, kinda deeply, the what and the why behind the “Big Three” traditional PBMs deciding that now might be a fantastic time to set up GPOs. PBMs are pharmacy benefit managers—there's three huge ones. GPO stands for group purchasing organization. Traditionally, these GPOs have purchased drugs and supplies for hospitals and other providers at, according to their marketing materials, volume discounts. So, the unfolding story here, in a nutshell, is that ESI (Express Scripts) set up a GPO called Ascent in Switzerland. Optum has had an Ireland operation going in full swing for a while. And now we have CVS Caremark setting up a GPO called Zinc. These GPOs are not like normal GPOs working with hospitals, but instead, these GPOs are the entity which is now going to negotiate with pharma companies. In the past, it was the PBM that was negotiating with the pharma company to get rebates. Now it's this GPO entity. “But wait,” you may say. “Wasn't there an executive order the other day requiring PBMs to, for example, pass through all of the rebates that they're collecting to patients?” Indeed, there was. And that rule doesn't say anything about GPOs having to do the same, especially GPOs in, let's just say, Switzerland. It's a tangled web we weave. You can learn more by connecting with Mike on LinkedIn.  Mike Schneider is an experienced healthcare executive with over 20 years of experience in the pharmaceutical manufacturer, pharmacy benefit manager, and payer side of healthcare. He previously spent 9 years at CVS Caremark, where he was a director of industry relations with responsibility for trade strategy development, rebate negotiations, and contract execution for CVS Caremark's own Medicare Part D plans and that of its clients. He held a similar position at Universal American (UA) before it was acquired by CVS Health, where he also negotiated UA's commercial business. Mike has held various sales and market access roles with pharmaceutical manufacturers with increasing responsibility. Before entering healthcare, Mike began his career as a researcher at the Procter & Gamble Company in Cincinnati, where he worked on hair care product formulation development focusing on the key markets of China and Japan, and then moved on to work in drug development. Mike holds a BS degree from the University of Illinois and an MBA from the University of Akron. 02:48 What does a GPO add to a PBM? 05:23 Rebates vs driving more revenue. 10:39 PBMs vs safe harbors. 12:25 The net impact on the commercial side. 14:07 PBMs vs pharmaceutical manufacturers. 14:54 How the “Big Three” PBMs compete with each other, and how employers would choose between them. 15:56 What the net-net is here. 18:06 How PBMs are shifting their models. 20:42 How GPOs may be making things even less transparent. 21:31 “The PBM world as a whole is not very transparent.” 25:00 “One of the biggest beneficiaries of this whole rebate [system] is the government.” 25:46 “The question is, ‘Who's paying those costs?'” 26:02 EP216 with Chris Sloan.27:00 A better way to move money from Pharma to employers and plan sponsors. 28:04 “Put your money where your mouth is.” You can learn more by connecting with Mike on LinkedIn.  Check out our newest #healthcarepodcast with Mike Schneider as he discusses #PBMs and #GPOs. #healthcare #podcast #digitalhealth #healthcarefinance #pharma What does a GPO add to a PBM? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma Rebates vs driving more revenue. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs safe harbors. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma What is the net impact on the commercial side? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs pharmaceutical manufacturers. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How do the “Big Three” PBMs compete with each other? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How do #employers choose between the “Big Three” PBMs? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma What's the net-net here? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How are PBMs shifting their revenue models? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How are GPOs making things even less transparent? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “The PBM world as a whole is not very transparent.” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “One of the biggest beneficiaries of this whole rebate [system] is the government.” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “The question is, ‘Who's paying those costs?'” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma A better way to move money from Pharma to employers and plan sponsors. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “Put your money where your mouth is.” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma Recent past interviews: Click a guest's name for their latest RHV episode! Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis

In this healthcare podcast, I speak with Peter Hayes, who is president and CEO at the Healthcare Purchaser Alliance of Maine and a national presence in healthcare strategy, innovation, and a frequent keynote speaker. One thing, among many, that Peter said during our conversation struck me. He said it will take a village to fix what ails the healthcare industry in this country. There are too many interdependencies. This point obviously resonates around these parts because it's the rationale for the Relentless Health Value podcast. We started this show on the recognition that if you want to achieve anything in healthcare, you cannot do it without collaboration/cooperation/grudging acquiescence of other stakeholders in the patient journey or the payment journey. And when I say, “You can't do anything,” I mean you can't sell anything, you can't improve patient care, and, most relevant to this particular episode, you can't contain prices. If we're talking about health systems (for example, hospitals and the like), they are not going to curtail their price hikes or improve the value of care delivered or safety or infection control really unless patients and employers and CMS and others demand that they do—and unless employers and others do some of the five things that Peter Hayes mentions at the end of our conversation. Spoiler alert there. For context to this discussion, let's check in with some of the biggest, most powerful health systems in this country. If I limit this comment to the “nonprofit” ones—and I say “nonprofit” with air quotes because what does that mean exactly?—look, I know there are many health system execs that listen to this show, but there's some inalienable facts here. And let's talk about them with the intent of fixing them because nothing is going to get fixed that isn't talked about. It's not my nature to mince words, so I won't. Many hospitals are, by almost every account, pretty darn inefficient. And they don't do cost accounting, but then they'll scream and claim to be losing money when paid the exact same prices for certain services that other hospitals can get paid and make a fair profit. Crappy workflows cost money. Talk to anybody who has watched even the trailer to a Six Sigma course. Another thing that costs money is when all the burned-out doctors quit and you have to recruit new ones, but that's a topic for a different day. Listen the EP323 with Arshad Rahim, MD.  But there's also inefficiencies in how many health systems purchase supplies. (Listen to EP281 with Rob Austin for more on that.) Further, paying the C-suite millions of dollars but maybe underpaying or understaffing nurses has consequences. There's complaints about Medicare payer mixes, but then somehow there's enough spare shekel to put a waterfall in the lobby. Nonprofit hospitals also don't pay any taxes, keep in mind, which is a huge financial windfall, especially when they provide vanishingly small amounts of charity care compared to revenue. See the top 10 health system hall of shame in this category here.   Here's another point to ponder: Amongst the hundreds, thousands, of requests I get from PR firms pitching guests to come on this show, there are plenty from what appears to be a pretty large cottage industry that I had never heard of before. I'll call it the real estate for nonprofit hospitals cottage industry. From what I can gather by the promo copy, this involves buying up medical office buildings, not paying any real estate taxes, and then leasing out the space. I should have one of these guys come on the show just to shine some light on whatever this apparently pretty common shenanigan is. As Vikas Saini, MD, from the Lown Institute has said, “No margin, no mission” can become an excuse for all kinds of questionable behavior. So bottom line, we have employers, employees, taxpayers, cash-pay patients whose federal and/or state and/or local taxes are going to support these nonprofit hospitals—but then there's this double tax. Because they claim to be losing money on Medicare patients, they justify cost shifting some pretty big bucks onto the commercially insured patients, who are then paying, on average, some wildly inflated prices for healthcare services. This might be considered a double tax if you think about it: tax dollars going to the IRS directly and then after-tax dollars buying that knee replacement for $125,000 that should cost $25,000. Consider that a $100,000 double tax. But why should a hospital with a motive to maximize margins quit it with their questionable and secretive billing practices if employers just pay whatever the bill is no fuss no muss? Short answer: They won't. So, it's going to be up to someone else in the village to make it untenable to continue. It's going to be up to another party to slow that roll. In this conversation, Peter Hayes talks about the RAND Hospital Price Transparency Study.  One last thing that may or may not be relevant here, but I can't resist a good sidebar. New catchphrase I have been hearing lately: the “deconstruction of hospitals.” Have you heard it, too? In fact, I was listening to Zeev Neuwirth's podcast recently that featured Raphael Rakowski. Raphael said that the average fixed cost of any given brick-and-mortar hospital is 65% of revenue. So, just having the building, the physical plant, and paying for all the things you need to pay for to run that physical plant is really high. I heard Jason Wells say in a HealthIMPACT forum the other day that it costs a million dollars to build a bed in California due to all the regulatory requirements. Add to that something Christin Deacon highlighted the other day on LinkedIn about how operating rooms are empty 30% of the time.   So, it makes me wonder whether some of the issues that hospitals have when they claim that they are losing money on Medicaid or Medicare is because their fixed costs are out of whack. This potentially disproportionate situation, however, is one reason why hospitals really have to watch it for hospitals at home or virtual offerings. After all, this is exactly how Amazon ate everybody's lunch. Erase 65% of your costs, or even 50% of your costs, and that cost-plus profit threshold becomes a weapon of mass destruction. At the end of this podcast—the very end, so if you're in a rush, jump to 28 minutes or something [32:45]—Peter gives five ideas for employers to limit the ability for hospitals to take advantage. If you're a hospital exec that's listening, I would urge you to please help your local employers do these things. Let's all get on the same team here to improve the health of our communities with pricing and business models that are reasonable and fair. Don't be like the hospital that Katy Talento is going to talk about in an upcoming episode who won't do direct contracting with employers because the coding is kind of a hassle. Seriously now. You can learn more at purchaseralliance.org. Peter Hayes is president and CEO of the Healthcare Purchaser Alliance of Maine and formerly a principal of Healthcare Solutions and director of associate health and wellness at Hannaford Supermarkets. He has been in innovative, strategic benefit design for the past 20+ years. During the past several years, Hannaford has received numerous national awards in recognition of the company's commitment to working collaboratively with healthcare providers and vendors in delivering health benefits that are focused on value (high-quality efficient care). Hannaford Supermarkets has been successful in this arena by focusing on innovative solutions for patient advocacy, chronic disease management, and health promotion programs. Hannaford was recognized by receiving the National Business Group on Health Platinum Award for the health promotion and wellness programs three years in a row. These programs, along with healthcare delivery strategies, contributed to a flat trend line over five years. Peter has also been involved in healthcare reform leadership roles on both the national and regional levels with organizations like the Center for Health Innovation, Care Focused Purchasing, and Leapfrog. He's also cofounder of the Maine Health Management Coalition (now Healthcare Purchaser Alliance of Maine) and has been appointed by two different Maine Governors to serve on Health Care Reform Commissions to recommend public policies to improve the access and affordability of healthcare for Maine citizens. 07:51 Who are the commercial payers? 08:48 Are hospitals actually losing money on Medicare and Medicaid? 11:26 Is cost inversely connected to quality when it comes to hospital care? 13:46 “A lot of hospitals don't do cost accounting.” 13:59 If hospitals don't know their costs, how does Medicare know their costs? 15:52 “In the hospital financial world … they start the budget upside down.” 18:48 “There's plenty of accountability to spread around for where we are.” 20:30 Do employers have any options in the current health system situation? 21:39 “If this market's going to change, purchasers have to step up and start demanding more accountability, more transparency.” 26:21 How is the new transparency legislation impacting plan sponsors and employers? 29:41 EP342 with Christin Deacon.32:38 “I think the whole dialogue around how we pay for hospital services is going to really change.” 32:45 What is Peter's advice to employers? You can learn more at purchaseralliance.org.   @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth Who are the commercial payers? @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are hospitals actually losing money on Medicare and Medicaid? @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is cost inversely connected to quality when it comes to hospital care? @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “A lot of hospitals don't do cost accounting.” @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth If hospitals don't know their costs, how does Medicare know their costs? @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “In the hospital financial world … they start the budget upside down.” @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “There's plenty of accountability to spread around for where we are.” @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth Do employers have any options in the current health system situation? @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If this market's going to change, purchasers have to step up and start demanding more accountability, more transparency.” @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth How is the new transparency legislation impacting plan sponsors and employers? @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think the whole dialogue around how we pay for hospital services is going to really change.” @pefhayes of @HPAofMaine discusses #healthsystempricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim

At the beginning of 2021, my guest in this healthcare podcast, Paul Simms, had come up with a set of predictions for 2021. Some came true; some didn't. But I was fascinated by a bunch of things, one of them being Paul's sort of implicit and explicit assessment of the context of these predictions. Right now, Pharma is in a weird moment: It's a confluence of technology, consumer expectations, changes in care delivery accelerated by the pandemic, policy at the state and federal level, and the financial realities of where we're at today. So, if you meet patients or providers or payers where they were last year or the year before that, you're gonna potentially be pretty far off the mark. There's also the financial realities which Pharma kind of exacerbated for themselves when some, many, spent the past however many years making their numbers by raising prices on existing drugs and developing drugs for mostly rare diseases but then, at the same time, not innovating antibiotics or for other diseases that impact so many lives. I mean, no comments on these strategies, but is it safe to then assume that an environment that allows for this sort of thing will continue indefinitely? Not only from an “Is this really the most patient-centric thing we can do?” standpoint, especially when you consider how many patients are being left behind as a result of both the narrow focus and also the price points—upwards of 40% of Americans have said they've abandoned meds due to cost, after all—but potentially also from a business continuity standpoint. Right now could be a decent time to start getting creative and experiment with new models and new ways to reach and engage. My guest in this episode, Paul Simms, is the former chairman of eyeforpharma, which ran the largest events in the pharmaceutical space for a number of years. His new company, Impatient Health, helps a very conservative industry find ways to deliver and provide patient value. During our conversation, Paul made a bunch of thought-provoking points; but one of them I keyed onto was a counterpoint to the ye old pharmaceutical conventional wisdom that high drug prices are needed for innovation. He said that actually all the money sloshing around could inhibit R&D innovation. Here's the thinking: If you can make a ton of money not being super innovative, then why be innovative? If you can make a ton of money not really improving OS (overall survival) in a meaningful way and not really helping a whole lot of patients, then why bother doing anything else, especially if the “anything else” might require risk or new business models that are going to take time and determination? During our chat, the work of Clay Christensen comes up more than once. Just to remind you, Clay Christensen is the one who coined the term disrupters. He wrote The Innovator's Dilemma back in the 1990s. Keep in mind that the main point of that whole book is that if you're a big incumbent, it's pretty easy to cruise along thinking everything is great until you get kneecapped by a competitor who takes advantage of a new business model or consumer preference or technology or law—all of which are coming out of the woodwork right now. Paul Simms has put it this way: When the habitat changes, evolution happens and entities that are able to adapt will thrive. I've also heard it put this way: It's not IQ or even EQ that matters most when change is afoot. It's AQ—the ability to adapt. You can learn more by connecting with Paul on LinkedIn. Paul Simms is known as the “pharma provocateur” for his efforts to realize the unfulfilled potential of the life sciences industry. His journey started in 2003 with eyeforpharma, an organization which he quickly grew into the pharmaceutical industry's most influential and largest event organizer, acquired by Reuters in 2019. He has since set up a think tank and consultancy called Impatient Health. Paul counts the industry's CEOs and innovators amongst his friends and is a regular speaker, host, author, and commentator.   05:04 “We're at that catalyst point where we could go one way or the other.” 05:39 How can the analogy of Web 1.0 vs Web 2.0 be applied to the future of healthcare business models? 07:06 “People need to improve their awareness at the very least as to a new generation of companies coming forward.” 08:31 “What now is the new business model that can exist in that world?” 09:07 Is there a stage pre-agility that will allow pharma companies to pivot to future markets? 12:08 What are the new ways to think about things in the future of healthcare business? 14:09 “The mind boggles at what is possible but is not yet being achieved.” 16:11 Why could prices falling actually spark more innovation? 16:49 EP300 with Bruce Rector, MD.21:36 “It's these companies that have this data-driven consumer relationship that I think are very interesting.” 25:16 “I just think that it's a mindset change first.” 25:38 “I'm not here to be right or wrong. I'm just here to enable the conversation.” 25:56 “What I find is that companies make significant efforts and that they don't quite gain the same traction as quickly as they might like to.” 26:20 “It seems to be this great impatience that companies can turn around these non-medicine initiatives more quickly.” 29:42 “It seems to me that the pharmaceutical industry's reaction to the pandemic has been, ‘We need to double down.'” You can learn more by connecting with Paul on LinkedIn. @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “We're at that catalyst point where we could go one way or the other.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “People need to improve their awareness at the very least as to a new generation of companies coming forward.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “What now is the new business model that can exist in that world?” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth Is there a stage pre-agility that will allow pharma companies to pivot to future markets? @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth What are the new ways to think about things in the future of healthcare business? @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “The mind boggles at what is possible but is not yet being achieved.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth Why could prices falling actually spark more innovation? @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “It's these companies that have this data-driven consumer relationship that I think are very interesting.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “I just think that it's a mindset change first.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “I'm not here to be right or wrong. I'm just here to enable the conversation.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “What I find is that companies make significant efforts and that they don't quite gain the same traction as quickly as they might like to.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “It seems to be this great impatience that companies can turn around these non-medicine initiatives more quickly.” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth “It seems to me that the pharmaceutical industry's reaction to the pandemic has been, ‘We need to double down.'” @xpablo of @HealthImpatient discusses the future of #pharma in our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharmahealth Recent past interviews: Click a guest's name for their latest RHV episode! Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson

I was on LinkedIn, and someone was saying, “Oh, there's no real money in generic drugs. It's not a huge issue if patients are paying 10 bucks instead of 93 cents for something. It's not like anyone is getting rich off of that, and it's not like patient impact here is super meaningful.” This is a pretty common refrain, actually; and from a conventional wisdom perspective, I get it, especially for those living comfortable middle- or upper-middle-class lives where an extra $9.07 for a prescription isn't a huge deal—except there are big-time issues with the generic supply chain that are worth billions and billions of dollars and that have a major impact on patient health. So, let's discuss. I started casting my eye over to what was going on on the generic drug front mainly because of the huge lawsuits in the news lately that were either filed and/or settled. Generic drug manufacturers are and have been the defendants in these lawsuits, accused of price collusion amongst other things. These lawsuits aren't fighting over chump change either, unless you consider hundreds and hundreds of millions of dollars as chump change, that is. The number of zeros on the table in these lawsuits may strike you, as they did me, as a factor of interest. I mean, we're talking about generic drugs here. The cost of goods on these drugs—there was a WHO study on this—and the cost of goods to manufacture a small molecule generic is, a lot of times, pennies. Further, there's no innovation undertaken by generic manufacturers in their manufacture of generic meds. Just so no one gets confused here, the rationale branded pharma manufacturers tout for high-cost branded (ie, new) drugs is that branded pharma manufacturers have to spot the R&D (research and development) dollars to come up with the new therapies and they take a lot of risk therein. Generic manufacturers, on the other hand, are getting a recipe that has been handed down to them. There is no R&D. There is no innovation. So, to restate the situation analysis, we have generic manufacturers spending no money on innovation and enjoying, many times, a low cost of goods. If the price were set using a cost plus methodology, you'd expect the prices paid by payers and patients to be correspondingly low—except they aren't. Depending on what study you look at, somewhere between 29% and 44% of patients who have been prescribed a med say they aren't taking it because it is unaffordable. Considering that 90% of the prescriptions written in this country are for generics, one could logically assume that there's some generics in that mix that are unaffordable due to their high prices.   But there's a compounding factor here: The patient affordability problem has another aspect to it beyond just patients having to pay a portion, or all, of the price of generic meds that may be, let's just say, higher than one might expect them to be given the cost of goods. But here's this other factor: The share of patient out of pocket is weirdly high when it comes to generics. Consider that generics and branded generics account for 19% of invoice-level spending but represent 65% of patient out-of-pocket costs (IQVIA National Prescription Audit, 12/2020). So, that seems out of whack. But keep in mind, as I mentioned earlier, that 90% of prescriptions written in this country are for generics. That's five billion scripts a year. As my guest in this healthcare podcast, Steven Quimby, MD, says, generic medications touch many more lives than new branded drugs. Obviously, GoodRx comes up in the conversation in this episode. If you want to learn more about pharmacy list prices and how GoodRx makes money, listen to the conversation I had with Ge Bai (EP306 and AEE13). Several people actually mentioned on LinkedIn and Twitter that hers was one of the best explanations they had heard on these topics, so I recommend those shows.  The show also with Vinay Patel dives pretty deeply into the “what's the what” between PBMs and pharmacies (EP241) if you're looking for more on that.   Dr. Quimby also mentions how important it could be for providers to know at the point of prescribing what the cost of medications are for a patient and get this information right in their EHR system. Refer to the episode with Carm Huntress (EP284) for more info on that.  My guest, as I said, Steven Quimby, MD, is an author and newly retired physician. His father was a pharmacist with a little drugstore that thrived in the late 1960s and early 1970s, so he literally grew up in the business. Dr. Quimby recently wrote a book called Billions in Your Generic Drugs. In sum, it's a supply chain where not only is nobody watching the henhouse, but everybody within that supply chain has a very, very vested interest to see prices go up. This is kind of a theme in healthcare, but nonetheless. Oh, and one last point to ponder before we get started here: Dr. Quimby mentions at one point that 86% of Americans believe that their health insurance plan always offers the lowest price for a generic and 67% (two-thirds) of people in this country have never heard of GoodRx or other shopping tools. So, yeah … really makes you realize you live in a bubble. You can learn more by reading Dr. Quimby's book Billions in Your Generic Drugs.   You can also reach Dr. Quimby on Twitter and LinkedIn.  Steven Quimby, MD, is a physician who has worked in academic medicine at the Mayo Clinic and in private practice. He has been involved in drug treatment studies, including major pharmaceutical trials, and maintained an active interest in the interface of corporate business, pharmacy, and medicine for over 50 years. Dr. Quimby is concerned escalating prices for generic drugs, which fill 90% of our prescriptions, threaten access to needed medications and patients going without treatment risk worsening of their medical conditions and further costs. Too often controversies over high new drug prices and the funding of new drug development and innovation obscure addressable problems in the generic drug supply and financing chain. 05:54 What are the current lawsuits involved in the generic drug space right now? 06:52 How is price fixing happening in the generic drug space? 07:58 “If I was the major payer for drugs … I'd want to know answers.” 08:06 What's the scale on new and generic drugs? 09:02 What's the problem with using price tools for generic drugs? 10:22 “I think right now, virtually everyone should be checking [those sites vs] their insurance price.” 10:47 Are payers paying too much for generic drugs? 11:53 Who are these generic manufacturers? 12:10 “They're distinctly different corporations than those that we have called Big Pharma.” 13:55 Why is it important to have adequate numbers of manufacturers for generic drugs? 17:03 “We just can't get legitimate acquisition and then sale prices of the actual drugs.” 17:17 “The industry's opaque to all of these things.” 19:39 “The prices that patients are getting at the prescription counter are so high that some studies say a third of them or more are walking away without buying the drug.” 20:02 AEE13 with Ge Bai, PhD, CPA, on the GoodRx model.20:50 EP241 with Vinay Patel.22:05 What and who should be on formulary? 26:24 “If they'd give us the numbers, we could see when it happens.” 28:58 How can we overcome the challenges of these high generic drug costs? 30:38 EP284 with Carm Huntress.30:46 EP334 with Sunita Desai, PhD.  31:26 “How can we judge value when we don't know price?” You can learn more by reading Dr. Quimby's book Billions in Your Generic Drugs.   You can also reach Dr. Quimby on Twitter and LinkedIn.  @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing How is price fixing happening in the generic drug space? @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing “If I was the major payer for drugs … I'd want to know answers.” @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing What's the problem with using price tools for generic drugs? @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing Are payers paying too much for generic drugs? @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing “They're distinctly different corporations than those that we have called Big Pharma.” @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing Why is it important to have adequate numbers of manufacturers for generic drugs? @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing “We just can't get legitimate acquisition and then sale prices of the actual drugs.” @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing “The industry's opaque to all of these things.” @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing “The prices that patients are getting at the prescription counter are so high that some studies say a third of them or more are walking away without buying the drug.” @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing “If they'd give us the numbers, we could see when it happens.” @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing “How can we judge value when we don't know price?” @QuimbyMD discusses #genericdrugpricing on our #healthcarepodcast. #healthcare #podcast #genericdrugs #drugpricing Recent past interviews: Click a guest's name for their latest RHV episode! Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco

Most people who have been in the healthcare industry for a while have heard by now the metaphor about the two canoes. Provider organizations or health systems with some of their payments coming from a fee-for-service (FFS) payment model and some of them coming from value-based arrangements have the challenge of one foot in the FFS canoe and one foot in the value-based canoe. They're probably going through a lot of metaphorical pants is the main takeaway that often comes to mind for me. But wardrobe malfunctions aside, this is a really difficult organizational challenge. That's what I'm talking about in this healthcare podcast with Dr. David Carmouche: how to deal with the operational challenges, the cultural challenges, maybe even (very arguably) the generational challenges here. Top line (very top line), to succeed in value-based care, you gotta have three things aligned: The payment model, the construct of the contract. No kidding, you have to have value-based contracts to succeed in value-based care. The big problem here—which is not to be underestimated—is that there are some areas of the country where it's really tough to find somebody, or enough somebodies, willing to offer a capitated, prospective value-based contract. That would be really frustrating to want to go forward (if you're a provider) in a value-based way but to not have a willing payer partner and/or employer partner to do so. So please step up, payers, policy makers, and employers in those areas of the country. But the construct of the value-based contracts can also not be overlooked. Toward the end of this interview, Dr. Carmouche gets into the different results that were achieved between two patient populations: one served by a Medicare Advantage (MA) plan and one in an MSSP (Medicare Shared Savings Program) model. So, the same provider network, the same environment, same geography, same number of lives, different payment model. Stick around for that part of the conversation. It's pretty eye-opening. The second of the three things to be aligned to be successful in value-based care are physician/administrative incentives and the employment models. Seriously, who is thinking that anyone's gonna succeed managing downstream risk when the physicians making the decisions about downstream services used are bonused by how much downstream costs they can drive and everyone is eating what they kill? If culture eats strategy for breakfast, incentives eat culture for lunch, as they say. Leadership skills. Leaders who are going to succeed in a world moving from FFS to VBC have to be mission driven toward that cause. They have to be strategic enough in their approach to take potential short-term revenue hits in pursuit of the longer-term goal—even the medium-term goal, honestly, if you think about the whole context of what's going on here. Leaders also need the skill and aptitude to pull off the change management and adjustments to the organizational culture that are needed. Staffs and teams really need systematic support. Value-based care is a team sport, and teams require leadership. Here's one example of where not having great leadership trickles down to bad results: If nurses or social workers or, in general, people of color or women in an organization feel demeaned or not valued by a critical mass of those in power—and maybe here I mean physicians or other physicians that they work with—then patient safety scores diminish and quality goes down. There's enough studies on the impact of having and not having psychological safety that it's getting harder to dispute what I just said. And if this environment becomes as toxic as the stories that you read about often enough, that's on the C-suite to fix. If the C-suite has value-based aspirations, that C-suite really might want to reprioritize their to-do lists. So, think about stuff like this because toxic environments make consistently delivering high-value care and satisfied patients difficult at best for many reasons. Here's a timely side note: I heard someone say the other day that in light of the pandemic and the FFS inpatient and outpatient volume fluctuations that plummeted and rose at various points during the pandemic, compounded with Medicare FFS rates that some institutions claim are not profitable or profitable enough … someone said that, given these factors, the best way to de-risk is to take on more risk. That's interesting to think about on a number of levels. In this healthcare podcast, as I mentioned, I'm talking about all this and more with Dr. David Carmouche. Dr. Carmouche was recently the executive vice president of value-based care and network operations at Ochsner, which is a very big integrated delivery network in Louisiana. You heard it here first, folks, but Dr. Carmouche will take on a new role in November 2021. He will oversee Walmart's expanding clinical care offerings and operations, including Walmart Health MeMD and its social determinants of health line of business. Here's a quote from the announcement about Dr. Carmouche's move that I thought was interesting: “Connecting with patients in more places and creating a seamless, personalized patient experience is a crucial component in the new healthcare environment, and a space where Ochsner—as well as retail leaders like Walmart—will continue to invest.” Dr. Carmouche has been on this podcast before (EP316 and AEE15), so if you'd like to hear more from him, go back and listen to those two shows.   Also, if you're looking for another episode that digs into the importance of leadership, listen to the one two weeks ago with Gary Campbell (EP341).   You can learn more by visiting Dr. Carmouche's LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  David Carmouche, MD, views healthcare from three distinct perspectives: as a physician provider, an executive for an insurance company, and as a leader in a health system. Specifically, he built a large, multidisciplinary internal medicine and preventive cardiology practice in Louisiana; served as the chief medical officer for Blue Cross Blue Shield of Louisiana; and has a triad of responsibilities with Ochsner Health, the largest nonprofit academic healthcare system in the Gulf South. He was promoted to serve as executive vice president of value-based care and network operations in addition to his duties as president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network. He is known as an expert in value-based care. He led one of the top 15 performing accountable care organizations in the United States, managing billions in care spend and generating millions in year-over-year shared savings. Dr. Carmouche earned a bachelor's degree from Tulane University and a medical degree from Louisiana State University School of Medicine in New Orleans. He completed his residency in internal medicine at the University of Alabama at Birmingham. 06:31 How do you operationally deal with conflicting FFS and VBC processes? 07:23 “It's pretty clear in Medicare that our strategy in the future … is one of value.” 11:31 “I think a bigger challenge, though, is that in many markets, there are just no opportunities to have experienced value-based care.” 13:18 “How do we engage in collaborative relationships that would allow us to move into value?” 14:01 “No one wants to rush through their day in a series of seven-minute visits.” 15:53 “In a fee-for-service environment … you're forced to bring people into the office to create an encounter who don't necessarily need to be there.” 19:22 “We haven't really changed how we select and train physicians … in the last hundred years.” 20:32 “We, as physicians, were taught to be accountable for outcomes; and we create probably an unnecessary and unfair burden on ourselves.” 21:30 “In the value-based care world, a physician does have to recast themselves as part of a team.” 22:30 “It is an enormous cultural shift … but ultimately, it's one that the facts … mandate.” 26:58 “You have to have a compelling vision and belief that value-based care offers benefits to all of the actors in the healthcare ecosystem.” 27:24 “You have to be able to communicate effectively across sectors.” 27:43 “You have to have courage.” 28:29 What are the leadership skills required to make value-based care work? You can learn more by visiting Dr. Carmouche's LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare How do you operationally deal with conflicting FFS and VBC processes? @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “It's pretty clear in Medicare that our strategy in the future … is one of value.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “I think a bigger challenge, though, is that in many markets, there are just no opportunities to have experienced value-based care.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “How do we engage in collaborative relationships that would allow us to move into value?” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “No one wants to rush through their day in a series of seven-minute visits.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “In a fee-for-service environment … you're forced to bring people into the office to create an encounter who don't necessarily need to be there.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “We haven't really changed how we select and train physicians … in the last hundred years.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “We, as physicians, were taught to be accountable for outcomes; and we create probably an unnecessary and unfair burden on ourselves.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “In the value-based care world, a physician does have to recast themselves as part of a team.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “It is an enormous cultural shift … but ultimately, it's one that the facts … mandate.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “You have to have a compelling vision and belief that value-based care offers benefits to all of the actors in the healthcare ecosystem.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare “You have to be able to communicate effectively across all platforms.” @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare What are the leadership skills required to make value-based care work? @CarmoucheMd discusses #vbc on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare Recent past interviews: Click a guest's name for their latest RHV episode! Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15)

This episode's conversation is about the new Consolidated Appropriations Act (CAA), the fee disclosure part of it, as well as ERISA and the fiduciary responsibility that self-insured employers are responsible to comply with under the law. Don't worry, the first thing my guest in this healthcare podcast, Christin Deacon, does is explain these terms, what they actually mean, and how they can be a tool actually in CEOs' or CFOs' toolboxes to get access to the employer's own claims data, which is a linchpin here that we'll talk about in a sec. But suffice to say here that the ERISA fiduciary responsibility has a few provisions and, in general, self-insured employer health plan administrators kind of tend to off-load worrying about these provisions to their brokers and consultants. The problem with this is that brokers and consultants do not bear the ERISA fiduciary responsibility. They do not bear the responsibility of complying with the CAA either. The employer does. You'd think that, given this, more self-insured employers would dig in hard to do their own due diligence to check whether or not their plan is compliant. But they don't. I asked Parker Edman from Leavitt Partners why, and he said he thought that it's likely a combination of the “old boy's network” and a fear of the massive lift that switching up plan designs or even looking at this might entail. But here's another facet: There's a contingent of plan advisors and carriers who have a very vested interest in self-insured employers not knowing what's going on with their spend. And they actually even have a magic trick that they have developed to beat back inquiries. In this magic trick, HIPAA is the abracadabra. Let me give you an example role-play. Self-insured employer: I need my claims data. Carrier: HIPAA. Self-insured employer: Nooo, not the HIPAA. I stand down. Forget I mentioned it. Here's a pro tip: Actually read HIPAA. Pull it up on your computer. It's easy to find. Spoiler alert: You know what you'll discover? Ninety percent of it is a love note to the carriers themselves that govern the data they must possess and the structure of that data. Ten percent of it is about the privacy of that data, and in that 10%, it specifies clearly that a self-insured employer is a covered entity and, therefore, falls under the umbrella of who can have access to claims data, especially if it is deidentified. Of course, said employer has obligations as to how to treat that data, but yeah, just don't be fooled by the HIPAA when it's wielded like sorcery. The only reason that word has any power is because so many C-suites let it have power. Also now, there's some provisions in the Consolidated Appropriations Act, the CAA (which was passed in 2020), which really ups the ante here. My guest, Christin Deacon, explains all of this and more, including what's up with the CAA, which is good because I could barely remember the name of it throughout the course of this interview. Christin Deacon is a healthcare leader and public-sector entrepreneur. She is a former deputy attorney general, a “recovering attorney” as she calls herself. Earlier this year, 2021, she left her role running the state health and school health benefits plan for about 800,000 New Jersey public employees. Now, she's just transitioned to the private sector where she serves as an executive VP at 4C Health Solutions. You can learn more by emailing Christin at cdeacon@4chealthsolutions.com. You can also connect with her on LinkedIn.   Christin Deacon is a healthcare thought leader who brings with her a wealth of experience in both public and private sector. Driven by her passion to change the healthcare system to truly benefit patients and payers, she focuses on bringing solutions and agency to self-funded and government-sponsored health plans.     04:10 What is ERISA, and what does it stand for? 05:40 What is a fiduciary obligation for an employer? 08:18 “We're now at a point of spending 17.7% of our GDP on healthcare costs.” 09:39 “You absolutely have the keys to … controlling that spend.” 13:35 “You have to own your data.” 15:04 “If you don't have your claims data, how do you know you're paying reasonable fees?” 15:31 “If your carrier is telling you, ‘Oh, HIPAA … you can't look at your data,' you need to pull out that red BS card.” 16:25 How do employers navigate carriers refusing to share claims data? 21:36 “It has only as much teeth as the self-funded employer is … willing to learn about it and … willing to push back.” 22:22 “This is not aspirational; this is an absolute floor.” 24:11 “What does value mean?” 27:41 “Become familiar with HIPAA beyond just the privacy piece.” 29:30 “At the end of the day, it's about people.” 29:38 “If you're not paying reasonable fees, you're using plan assets to enrich others.” 32:21 “The self-insured market … they hold the keys to unlocking value. And they're holding them; they just have to use them.” 34:10 Marshall Allen's new book. You can learn more by emailing Christin at cdeacon@4chealthsolutions.com. You can also connect with her on LinkedIn. @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is ERISA, and what does it stand for? @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is a fiduciary obligation for an employer? @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We're now at a point of spending 17.7% of our GDP on healthcare costs.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You absolutely have the keys to … controlling that spend.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You have to own your data.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you don't have your claims data, how do you know you're paying reasonable fees?” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If your carrier is telling you, ‘Oh, HIPAA … you can't look at your data,' you need to pull out that red BS card.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do employers navigate carriers refusing to share claims data? @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It has only as much teeth as the self-funded employer is … willing to learn about it and … willing to push back.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “This is not aspirational; this is an absolute floor.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “What does value mean?” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Become familiar with HIPAA beyond just the privacy piece.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “At the end of the day, it's about people.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you're not paying reasonable fees, you're using plan assets to enrich others.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The self-insured market … they hold the keys to unlocking value. And they're holding them; they just have to use them.” @deacon_christin of @4CHealth discusses the #CAA and #ERISA for #selfinsured #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster

First, let's talk about reducing administrative waste in the US healthcare system. There was a pretty famous 2019 study by Shrank et al. that estimated about 25% of the $3.6 trillion the US spends on healthcare annually is potentially wasteful. This is each person spending $2500 unnecessarily. Robert Kocher wrote a really interesting article about getting rid of administrative waste and inefficiencies, and he said that it is the “safest form of health care cost savings; virtually no one argues that administrative costs should remain high. Reducing administrative waste should be the highest priority … [because] everyone, including patients and clinicians, would benefit from lower health care costs.” In my mind, “everyone” means payers, policy makers, and also providers who are or want to take some accountability for the total cost of care here. To talk about the possibilities, I have the perfect guest: Gary Campbell, who is the CEO of Johnson Health Center, which is an FQHC, a Federally Qualified Health Center, in Lynchburg, Virginia. Why is the CEO of an FQHC a great person to talk about cutting out administrative waste with? Well, first of all, the patient population is what many would consider challenging at an FQHC. Second, they really have to cut out as much waste as possible because there is zero potential to cost shift. They do not have the option to charge their commercial lives 4x Medicare or whatever and effectively cost shift the impact of inefficiencies. There basically are no commercial lives. You either figure out how to be efficient, or the patient population does not get care. As Gary and I were talking, however, it became clear that when you cut out administrative waste, you wind up actually with the potential to become a great place to work. One reason for this just has to do with the process of cutting out waste, which requires culture and process. And a by-product of a great culture and a great process means a great place to work. You might be thinking, as I was thinking, that this show, which is supposed to be about cutting administrative waste, is going to be all about how to do lean and Six Sigma and pretty much go peak MBA. Spoiler alert: It's not. When I asked Gary how to be operationally efficient, it all ladders up to organizational leadership: leaders who commit to putting patients first, to have core values with the expectation to actually achieve them (for reals—not just in the marketing). Because without effective, accountable, committed leadership, patient first, lowering the cost of care, removing administrative waste … it ain't gonna happen. Leaders should be visible, have a vision, a strategic plan, project plans, and be inspirational. They also need to not be afraid to “move along,” as they say, people who are pulling the team down and holding it back—maybe even if a short-term revenue hit will transpire. Before we get started here, let's talk about FQHCs for a sec just in case you're unfamiliar. Besides the acronym giving me fits of dyslexia—my brain always wants to invert the letters, so I have a Post-it Note here and I'm staring at it so, hopefully, I'll be able to keep this straight—FQHCs (Federally Qualified Health Centers) are usually nonprofits that are oriented to take care of the underserved. Today they serve upwards of 30 million people in the United States, and that's a growing number. There's something like 1500 of them across all 50 states. They're federally funded. They are a safety net really for individuals out there who may not be able to access care anywhere else. There's generally bipartisan support for FQHCs and often a real purpose and passion to really care for people regardless of their ability to pay. They also tend to offer a lot of resources under one roof (eg, medical care, dental care, other things, mental health care), which can add substantially to the operational complexity. Gary Campbell, my guest in this healthcare podcast as I said, is the CEO of an FQHC. Gary has a procurement and operations background, and this background informs how he approaches leadership and care delivery in ways that I find inspirational—and I hope that you do, too. Some of the conversation that we had in this episode reminded me of the interview with Tony DiGioia, MD, in EP332; so if you want to dig further into this topic, go back and listen to that episode. That interview is very specifically about how to create a patient-centric value system, which Dr. DiGioia says should be the new OS for healthcare delivery. During this show, I also mention my conversation with Jerry Durham (EP297), where we talk about streamlining the front desk.  I didn't mention this in the show, but another episode that would be great to go back and listen to if this topic intrigues you is the one with Matt Anderson, MD, MBA, talking about how things get better when the scrubs and the suits collaborate (EP266).   You can learn more at impact2lead.com.  Gary Campbell is the founder and owner of Impact2Lead, LLC, and the CEO of Johnson Health Center (JHC), where he has enjoyed a career centered on leading for-profit/not-for-profit organizations and helping to unleash potential in others along the way. In 2011, he left Bayer and came to JHC; and in 2013, he launched Impact2Lead to provide transformation-consulting services to other firms across the United States. Since joining JHC, the center has enjoyed unprecedented success and growth by transforming the culture using his Impact Leadership model and becoming the first Federally Qualified Health Center to be recognized as an Employer of Choice by Employer of Choice International, Inc. The health center has achieved multiple workplace and community awards since that time and has enjoyed exponential growth during his seven years as the CEO. Gary currently speaks and consults nationally on leadership, workplace strategies, and motivational topics. 05:15 Why is there no opportunity to cost shift in an FQHC? 05:46 What happens when an FQHC is operating inefficiently? 06:12 “Have you workflowed it out? … You can overstaff yourself in a way that your cost per patient goes way up.” 06:37 Why is taking a lean approach not an excuse to cut staff? 08:05 “The nurses are linchpins to everything.” 09:05 How does standardizing care lead to personalization of care? 10:28 “Our clinical teams see that we care.” 10:48 “If you don't have a vision for where you want to be two and three years down the road, you're struggling.” 11:03 “I want everybody to understand, What is their why?” 20:10 “They don't teach leadership in most medical schools.”—Dr. Robert Pearl 21:19 “Get to know these clinicians … sincerely.” 23:11 “From a core values perspective, you can make every single decision … on core values.” 23:35 “We always start with those values. … They're embedded in everything we do.” 24:16 “You have to project plan things out that you want.” 25:09 How does an FQHC or private practices that are patient-oriented attract talent? 30:45 “First and foremost, be visible.” You can learn more at impact2lead.com.  @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is there no opportunity to cost shift in an FQHC? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth What happens when an FQHC is operating inefficiently? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Have you workflowed it out? … You can overstaff yourself in a way that your cost per patient goes way up.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is taking a lean approach not an excuse to cut staff? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The nurses are linchpins to everything.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth How does standardizing care lead to personalization of care? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Our clinical teams see that we care.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I want everybody to understand, What is their why?” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Get to know these clinicians … sincerely.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We always start with those values. … They're embedded in everything we do.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You have to project plan things out that you want.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth How does an FQHC or private practices that are patient-oriented attract talent? @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth “First and foremost, be visible.” @Impact2Lead discusses #administrativewaste and #healthcareemployment on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell

There's a next generation of digital front doors being created that open up to a patient/member experience that folds in payer, provider, and employer data—plus behavioral data the patient themselves generates when they browse through content in there. Because that's what it takes for a so-called personalized experience or patient journey to ensue. This is what I'm talking about in this healthcare podcast with Kristin Begley, PharmD. In an ideal world, you'd have, for example, a member/patient/customer who goes to their doctor and is handed a tablet to fill out an intake form. When they hit submit, they get access to a digital front door that leads to a vast Web portal inhabited by the doctor as well as the patient's payer and their employer. This personalized Web portal then knows this patient has asthma and is nonadherent to their maintenance medication and is using their rescue med a lot, because it's in the payer PBM (pharmacy benefit manager) data. The portal also knows the patient is searching a lot on content like what to do when you have a terrible asthma attack. Further, the portal knows that the patient's current doctor visit, the one where they're filling out the intake form, is about a respiratory chief complaint, because it's in the doctor data and also on that intake form, which, by the way, was immediately uploaded with structured insights available to all parties sharing the portal data. Now, everybody who needs to know knows this patient is at obvious rising risk. What can happen now? Lots of things. Because the portal knows what's included in the patient's benefit plan, there can be a proactive reach-out to get that patient into an available whole longitudinal program before they wind up in the ER. Maybe that's a point solution. Maybe that's a high-quality doctor offering a bundle. Which leads me to the whole value-based care part of this. Front doors are not only for patients to get steered to the best provider—maybe one with a value-based arrangement—but also, in a way, a front door for providers and payers to work together. A portal can be the “hub,” if you will, the shared neutral interoperable space for all the parties who need to share space for their value-based arrangement to work out. In fact, some of these portals are taking on risk themselves. Like, you guys all use our portal for your value-based arrangements, and we'll guarantee this level of performance in those arrangements. Portals sharing risk and taking upside becomes even more relevant when the portal comes with its own network of existing provider users, for example—provider users who want to be paid for value and also with EHR (electronic health record) data and direct access and influence over patient care. It's the old network effect. But besides helping make sure the patient gets the right care at the right time, digital front doors also have the potential to ease patient administrative burden. While there's lots of well-placed attention on affordability, patient administrative burden means delayed or foregone care. That's as per a new study by Michael Anne Kyle, PhD, and Austin Frakt, PhD. Kristin Begley is chief commercial officer at Wildflower Health right now, but she started out as a pharmacist before she defected to the business world. She has spent time in the pharmacy space with big companies and small companies before transitioning into the value-based, risk-based world. She's now at Wildflower leading sales and account management, and she knows a whole lot about digital front doors. You can learn more at wildflowerhealth.com.   Kristin Begley, PharmD, is a proven leader in the healthcare space with 20 years of experience in health information technology and the pharmaceutical supply chain, focusing on innovative solutions and software. She currently serves as the chief commercial officer of Wildflower Health, a modular digital-enablement care company that activates women and their families within the healthcare ecosystem. Wildflower's software, hardware, and humanware amplify and personalize available resources to women, breaking down silos of care between payers and clinicians while fueling the shift from fee-for-service to value-based care. Wildflower supports the whole person by helping clinicians address both clinical and social determinants of health needs and empowering women to confidently navigate and access care for the family.  Kristin is a founding member of All Tru Health, a consulting organization dedicated to improving quality and lowering healthcare costs for Americans, with an emphasis on emerging technology and high-value clinical care. She also served as the chief commercial officer at EmpiRx Health, a pharmacy care manager with a model rooted in payer alignment through at-risk management and concierge service. Prior to that, Kristin was the chief pharmacy officer of Truveris, a healthcare technology company that sheds light on the inner workings of the pharmaceutical supply chain, serving all segments, including consumers. She also led Hewitt's national pharmacy practice, where she managed Rx benefit strategy for Fortune 500 employers. Kristin holds a doctor of pharmacy degree from Samford University. 04:20 What do we mean by “digital front door” in healthcare? 05:27 “In healthcare, the next generation of digital front door is connecting all those stakeholders that try to help patients stay healthier.” 06:20 “What we're trying to migrate to is … walk into any front door.” 07:24 Why is engagement the hardest part? 10:24 “Are they digital providers … or are they healthcare providers?” 12:25 “When we live in a capitalistic healthcare system, we all have a price tag on our head.” 14:01 “How will providers and payers ever be successful in value-based care if we don't have activated, educated, motivated patients?” 16:36 “I don't know how … we succeed in value-based care without having … personalized content for everyone.” 18:24 “What does a consumer want?” 26:52 How does Wildflower Health achieve their value-based care network effect? 29:54 What do stakeholders want relative to value-based care? You can learn more at wildflowerhealth.com.   Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare What do we mean by “digital front door” in healthcare? Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare “In healthcare, the next generation of digital front door is connecting all those stakeholders that try to help patients stay healthier.” Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare “What we're trying to migrate to is … walk into any front door.” Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare Why is engagement the hardest part? Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare “Are they digital providers … or are they healthcare providers?” Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare “When we live in a capitalistic healthcare system, we all have a price tag on our head.” Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare “How will providers and payers ever be successful in value-based care if we don't have activated, educated, motivated patients?” Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare “I don't know how … we succeed in value-based care without having … personalized content for everyone.” Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare “What does a consumer want?” Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare What do stakeholders want relative to value-based care? Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare Recent past interviews: Click a guest's name for their latest RHV episode! David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard  

Reference-based pricing, the way that most employee benefit consultants use the term anyway, refers to a methodology used by employers to pay providers for services. Usually we're talking within a fee-for-service (FFS) environment here. The way it typically works ... there are different flavors, but how it typically works is this: Reference-based pricing (RBP) means that an employer starts with some reference-based price. Many times, it's the Medicare rate. Medicare will pay X dollars for something. The employer—and when I say employer, I mean the vendor/company the employer is using to run this whole thing mainly—but the employer will decide that they're willing to pay some percent over the Medicare rate to providers who render that service to the employee. Maybe it's 10% over the Medicare rate or 20% to 50% as David Contorno talks about in this healthcare podcast. One of the biggest pushbacks against RBP schemes has been that it results in balance bills for employees, meaning that an employee goes to the hospital, the employer decides to pay some RBP amount for that service to the hospital, but the hospital hasn't necessarily agreed to accept that amount. There's no contract in place. So, the hospital decides to bill whatever their chargemaster rate is—which, as we all know, is redonkulous—and the employee gets a giant out-of-network balance bill. For the most part, this doesn't have to happen if you do it right; and David Contorno discusses all of this and more on this An Expert Explains. You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn.   David Contorno is founder of E Powered Benefits. As a native of New York, David began his career in the insurance industry at the age of 14 and has since become a leading expert in the realm of employee benefits over the last 22 years. David was Benefits Selling magazine's 2015 Broker of the Year, and in March 2016, Forbes deemed him “one of America's most innovative benefits leaders.” More recently, he received the 2017 Leadership Award at ASCEND, the annual conference of The Association for Insurance Leadership, which recognizes those whose leadership in support of improving the value and performance of employee benefits has significantly advanced the industry. David is a member of the board of directors for both the Charlotte Association of Health Underwriters and HealthReach Community Clinic. He served on the NC Insurance Commissioners Life and Health Agent Advisory Committee, as well as participated in the Technical Advisory Group that helped with the market reforms required under the Affordable Care Act in North Carolina. He is a longtime member of the Lake Norman and South Iredell Chambers of Commerce as well as the National, North Carolina, New York, and Long Island Associations of Health Underwriters. David contributes to numerous publications, including Forbes, Benefits Selling magazine, Business Leader magazine, and Insurance Thought Leadership. David is committed to giving back to his community and actively participates in the membership drive for the United Way, assisting the local chapter of Habitat for Humanity, and supporting The Dove House Child Advocacy Center. When he is not working, he enjoys boating and traveling. 01:37 What does good reference-based pricing look like? 01:57 What is the pricing methodology that 97% of healthcare is using? 04:25 How has E Powered Benefits minimized the noise around reference-based pricing? 04:55 “You're getting what we view as balance bills all the time.” 06:47 “What very few people really recognize is that hospitals have multiple revenue streams.” 07:36 “Which is the highest price? The answer is, commercial.” You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn.   @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast What does good reference-based pricing look like? @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast What is the pricing methodology that 97% of healthcare is using? @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast How has E Powered Benefits minimized the noise around reference-based pricing? @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast “You're getting what we view as balance bills all the time.” @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast “What very few people really recognize is that hospitals have multiple revenue streams.” @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast “Which is the highest price? The answer is, commercial.” @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa  

Let's just start here: As a general construct, insurance carriers have every incentive for health insurance premiums to go up every year. If you're an employer, that is a material fact. Is it counterintuitive? Maybe. Except if you're an employer and your premiums are going up year after year, it begs the question why, every single year, the already-extravagant amount you pay continues to go up way more than the inflation rate. You'd think that if your broker and your plan administrator were so great at their fiduciary responsibility over your self-insured plan that this wouldn't be happening. Oh right, whosever PPO network you're using, they don't have any fiduciary responsibility over your self-insured plan. You do, all you CFOs and CEOs and benefit professionals out there. Wait, I misspoke. Plan administrators do have fiduciary responsibility—to their shareholders. The CEO of CVS/Aetna made $36 million in 2019. He's clearly very good at that job. The rest of them are, too. I'm not singling anyone out here. And also, this podcast is not investment advice. In short, as previously stated, most major insurance carriers and the brokers they pay commissions to have every incentive for your premiums to go up every single year. That's where we're at, folks. It's an open secret, yet so many are just getting so wildly taken advantage of by carriers and brokers whom they have really put their trust in. If you work for a self-insured employer, tell your CFO/CEO to listen to this show. Or if you are a CEO/CFO or a benefits professional in charge of healthcare benefits, welcome. I hope this information is helpful. My guest in this healthcare podcast, David Contorno, has been in the benefits industry longer than he hasn't been in the benefits industry. I think he started working in a benefits brokerage when he was 17 or something. Currently, he's the founder of E Powered Benefits. In this episode, we talk about the keys for self-insured employers that lead to better health for their employees at something like 20% or more lower costs. Here's some of the imperatives for employers that David digs into in this episode: Advanced primary care—really valuing primary care providers who do not work for hospital systems and, therefore, are not subjected to the ball and chain of perverse incentives that David talks about at some length. Getting cost and quality data so you can make prospective choices and not get hit in the back of the head with an after-the-fact “gotcha” in the form of an overpriced bill that you are now obligated to pay. Let me bring up all the articles lately in the New York Times and elsewhere … people paying hundreds of thousands of dollars for something that should cost a fraction of that. Most of them have “good” insurance (keep that in mind) from their employer. Also keep in mind that most of these stories that hit the news are the ones where some poor employee got stuck with a bill—not the metric ton of other examples where the self-insured employer was on the hook. If you're an employer, you can get ahead of these “gotcha” moments. It's textbook risk mitigation if nothing else. Create benefit designs to help employees find and incent them to use the highest-quality providers charging a fair price. Listen to EP334 with Sunita Desai for more on the topic of incenting consumerism. Know how your broker gets paid. If someone is paying your broker a commission and it isn't you, then your broker makes more money when your premiums and rates go up. They are a sales rep getting paid to make someone else money off of you. Get a handle on your pharmacy spend. David gets into some nuances here which are super interesting. You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn.   David Contorno is founder of E Powered Benefits. As a native of New York, David began his career in the insurance industry at the age of 14 and has since become a leading expert in the realm of employee benefits over the last 22 years. David was Benefits Selling magazine's 2015 Broker of the Year, and in March 2016, Forbes deemed him “one of America's most innovative benefits leaders.” More recently, he received the 2017 Leadership Award at ASCEND, the annual conference of The Association for Insurance Leadership, which recognizes those whose leadership in support of improving the value and performance of employee benefits has significantly advanced the industry. David is a member of the board of directors for both the Charlotte Association of Health Underwriters and HealthReach Community Clinic. He served on the NC Insurance Commissioners Life and Health Agent Advisory Committee, as well as participated in the Technical Advisory Group that helped with the market reforms required under the Affordable Care Act in North Carolina. He is a longtime member of the Lake Norman and South Iredell Chambers of Commerce as well as the National, North Carolina, New York, and Long Island Associations of Health Underwriters. David contributes to numerous publications, including Forbes, Benefits Selling magazine, Business Leader magazine, and Insurance Thought Leadership. David is committed to giving back to his community and actively participates in the membership drive for the United Way, assisting the local chapter of Habitat for Humanity, and supporting The Dove House Child Advocacy Center. When he is not working, he enjoys boating and traveling. 04:20 How do you ensure better care for patients? 05:10 “What's required to correct those things is not really a massive degree of intellect or even innovation.” 05:38 What's the road map for self-insured employers who want to take control of their healthcare costs? 10:06 “Higher costs equal more profit and more revenue.” 14:03 “The problem with devalued primary care is … that most people pass over the primary care provider and go right to the specialist.” 19:41 “Every employer should have every broker sign a compensation disclosure form.” 20:06 “If you think there's perverse incentives on the medical side … it gets even worse on the pharmacy side.” 21:01 What changes do employers find when they follow the road map to taking control of their healthcare costs? 21:44 “It's not uncommon for us to reduce total healthcare spend for an employer by between 20% and 40% at the end of the first year.” 22:09 “I can't change [the] outcome without changing the path you walked to get there.” 22:41 “Going self-funded is where the journey starts, not where it ends.” 24:47 “If most employers truly understood how badly these carriers and health systems are taking advantage of them … [it's almost like] Stockholm syndrome.” 27:09 “The only legitimate fear that employers should have is, How do they message these changes … to the employees?” 29:21 “This has to happen, and if it doesn't happen, the system's going to break and … be picked up by entities that are, I think, only going to make the situation worse.” You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn.   @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits How do you ensure better care for patients? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “What's required to correct those things is not really a massive degree of intellect or even innovation.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits What's the road map for self-insured employers who want to take control of their healthcare costs? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “Higher costs equal more profit and more revenue.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “The problem with devalued primary care is … that most people pass over the primary care provider and go right to the specialist.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “Every employer should have every broker sign a compensation disclosure form.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “If you think there's perverse incentives on the medical side … it gets even worse on the pharmacy side.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits What changes do employers find when they follow the road map to taking control of their healthcare costs? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “It's not uncommon for us to reduce total healthcare spend for an employer by between 20% and 40% at the end of the first year.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “I can't change [the] outcome without changing the path you walked to get there.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “Going self-funded is where the journey starts, not where it ends.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “If most employers truly understood how badly these carriers and health systems are taking advantage of them … [it's almost like] Stockholm syndrome.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “The only legitimate fear that employers should have is, How do they message these changes … to the employees?” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits “This has to happen, and if it doesn't happen, the system's going to break and … be picked up by entities that are, I think, only going to make the situation worse.” @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits Recent past interviews: Click a guest's name for their latest RHV episode! Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316)

My overarching thought throughout a lot of this interview was that improving rural health will take everyone remembering to not let perfect be the enemy of the good. If I live in rural America, there's no subspecialists. Forget about even seeing a garden-variety kind of specialist. I might have to drive hours to even get to a PCP. There are NPs (nurse practitioners) in a lot of these remote communities, but everybody's fighting over whether to let them practice independently, even in places where there's zero PCPs for hundreds of miles, effectively leaving everyone in the vicinity with basically zero access to any care. Or here's another issue: Maternal mortality in this country is not only heartbreaking—a mother dying in what should be a precious moment—it's also embarrassing as an industrialized nation to be so far in last place. I don't know this for a fact, really, but women who have to drive literally hours to see a provider during their pregnancy or—God forbid!—they go into labor unexpectedly … is that a factor in our horrific maternal mortality rates? Consider that in Canada, which has, by the way, substantially better maternal mortality rates than the USA, PCPs and NPs deliver babies in low-risk pregnancies even in areas that have access to ob-gyns, unlike a lot of rural America. When do we start wondering if we're letting perfect be the enemy of the good? When do we start considering if no access to care is worse than some access, even if the “some” access is not with, perhaps, the ideal type of provider? These are not questions with easy answers, so we need data. We need to think in shades of gray—not in binary terms where good and bad have static definitions unaltered by wildly different circumstances. That said, one way to potentially make many parties happy might be to do something like the Nuka system has done for Native Americans in rural Alaska. Listen to EP312 for more info on that. It's pretty cool.   But let's just back up a sec with a little situation analysis: The thing with rural hospitals closing—and they are surely running in the red and closing—is the very pernicious cycle that develops. A hospital closing is kind of a bellwether for a community caught in a downward spiral in ways I did not realize until my conversation with Nikki King in this healthcare podcast. The main industry shuts its doors—maybe coal, or I grew up in a steel town when they were “closing all the factories down.” That was a Billy Joel quote there, and I spent a few years as a kid in the very same Allentown that song is about. Community trauma is no joke. Oh, and also, now there's no commercial lives. So, say the hospital in that town isn't prepared for this new payer mix reality and it closes. Then maybe a few hundred doctors and nurses move away, along with their spending habits, so other jobs go away. Then the more affluent senior citizens don't move back to their hometown to retire because who wants to live in a town with no hospital? Also, young families who have a choice might choose to go elsewhere. Former population centers start to disperse, and now there's not even a population big enough to support a hospital even if one would decide to go there. And when that hospital goes, so does its maternity department—and likely, even OB/GYN practices. Forget about a laborist.   You then will have local PCPs leave town because, right, a PCP connected to a hospital can make twice as much as an indie. Reference the huge number of PCPs in this country who are employed by a health system. Most of these employed PCPs will not work in rural communities where their employer health system has no facilities to refer to. There's no jobs there for an employed physician. Obviously, no specialists can stay in business in this environment either. Things go from bad to worse: Child abuse rises, and multigenerational diseases of despair start to set in. And there's no healthcare to treat these diseases or prevent them. Things go from bad to worse to even more worse. In this healthcare podcast, I am honored and thrilled to talk with Nikki King, DHA, who offers up three community-centric ideas around solving the crisis of access that people in rural communities face. In short, these ideas include: Freestanding ERs (ERs that have the financial discipline to not take advantage of the communities they claim to serve, that is) Telehealth that recognizes broadband issues, which is possible Expanding nurse practitioner rights and maybe even the scope of PCP practices to, for example, include maternity care for low-risk pregnancies in areas that have zero or very minimal access to healthcare otherwise Here's the shorter-than-short version: Perfect can't be the enemy of the good when we're talking about some of these communities that have no healthcare options. Nikki King grew up in Kentucky in the coalfields of central Appalachia. She managed a behavioral health and addictions unit at a critical access hospital and also worked in biostatistics. She is on the board of directors of the Indiana Rural Health Association and has developed policies as a member of the National Rural Health Association, among a whole list of other achievements. Nikki is innovative and compassionate, and she understands the culture of those she serves. She talks about a few things that she worked on during the pandemic that are truly inspirational. You can learn more by emailing Nikki at king.nikki2014@gmail.com. You can also connect with her on LinkedIn and follow her on Twitter.   Nikki King, MHSA, DHA, was born and raised in the coalfields of Southeastern Kentucky. Prior to working in the healthcare industry, she worked for the Center of Business and Economic Research studying models of sustainability in rural communities with a single economic engine. She has been working at Margaret Mary Health since 2015, occupying roles in clinical statistics, as well as currently managing the behavioral health and addiction services department. In addition to her role at Margaret Mary, Nikki completed her DHA at the Medical University of South Carolina and her MHSA from Xavier University. She currently serves on the Indiana Rural Health Association's Board of Directors, the American Hospital Association's Opioid Stewardship Advisory Group, and the National Rural Health Association's Policy Congress and Government Action Committee, and as the Board Chair of Rural Health Leadership Radio Board of Directors. 05:57 How dire is the rural hospital situation right now? 06:18 How could freestanding ERs be a potential solution for rural hospitals? 08:21 What are other potential rural health access solutions? 09:25 Why is broadband a roadblock to telehealth as a solution for rural health access? 14:06 The “hot potato” of nurse practitioners in the healthcare world. 15:05 “The number of residencies for physicians each year is not increasing, but the population … is increasing.” 19:06 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care. 20:41 What's the issue with maternity care in rural America? 22:53 “As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse.” 26:50 How is mental health care affected in rural communities? 27:23 “Rural communities are trying very hard to hang on to what they have.” 28:49 “When you look at the one market plan that's available in a rural community, you probably can't afford it.” 30:39 What's the single biggest challenge to moving to a model that incentivizes keeping people healthy? 31:33 “The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare.” You can learn more by emailing Nikki at king.nikki2014@gmail.com. You can also connect with her on LinkedIn and follow her on Twitter.   @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth How dire is the rural hospital situation right now? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth How could freestanding ERs be a potential solution for rural hospitals? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth What are other potential rural health access solutions? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth Why is broadband a roadblock to telehealth as a solution for rural health access? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth The “hot potato” of nurse practitioners in the healthcare world. @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth “The number of residencies for physicians each year is not increasing, but the population … is increasing.” @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth What's the issue with maternity care in rural America? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth “As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse.” @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth How is mental health care affected in rural communities? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth “Rural communities are trying very hard to hang on to what they have.” @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth “When you look at the one market plan that's available in a rural community, you probably can't afford it.” @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth What's the single biggest challenge to moving to a model that incentivizes keeping people healthy? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth “The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare.” @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth Recent past interviews: Click a guest's name for their latest RHV episode! Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews

Here's the cold hard truth: The whole specialty pharmacy operational model is not built to serve patients, a fact that becomes crystal clear when you're a patient. Instead, the specialty pharmacy model is, rather, pretty blatantly dedicated to the power struggle for revenue and captive patient populations. It's war between providers and the whole PBM/insurer/specialty pharmacy vertical consolidations. Employers and pharma manufacturers are, of course, on the battlefield as well. The patient, meanwhile, gets to be more the product than the customer if you think about. It's probably more similar than anyone would like to admit to the way that Facebook or Twitter users are the product, not the customer. This analog is not entirely parallel, but there's unsettling similarities if you think about it. What is a drug that qualifies to be a specialty pharmacy drug? Usually, these drugs are complicated to store, dispense, to use, and/or they're expensive—generally, really expensive. Lots of zeros, completely unaffordable to pay cash for them as an individual. No one is using a GoodRx card and not using their insurance to pay for these puppies. They can cost as much as a house. Biologics, for example, usually considered specialty drugs—lots of cancer and immunology therapies, injectable medications, IV/infused medications—all these are usually considered specialty drugs. There's no one definition of a specialty drug. It's more that someone somewhere decided to not run the drug through your traditional retail pharmacy for any number of reasons. The problem with the current status quo, wherein the patient gets tossed around while everybody fights over them, is that some basic needs are not being met—like if a patient asks the person administering the drug maybe even a pretty simple question about the drug or its side effects. It's way more likely than it should be that the nurse or whomever doesn't know the answer. Not knocking nurses here at all but definitely knocking a system that allows that to happen. I mean, really now. We're injecting a six-figure therapy in someone's arm that will impact their body in a myriad of maybe frightening ways, some of which are a problem and some of which are not. Said another way, there's a really good financial and clinical use case for making sure that we're patient-centric at a specialty pharmacy point of service—if you care about the patient and cost efficiency, that is. But I guess therein lies the root cause of the trouble. In this healthcare podcast, I'm talking with Olivia Webb about what it would take and be like to create a “patient-first specialty pharmacy,” as she has coined the term—a specialty pharmacy dedicated to patients not only having a half-decent experience but also one that might actually create better patient outcomes. Olivia Webb is author of the Acute Condition newsletter. I would certainly recommend subscribing. Coming up, we're doing a few more shows on this topic wherein we cover the whole brown bagging, white bagging, clear bagging extravaganza. Also, hospitals opening up their own PBMs, which is a fascinating wrinkle. One last thing: If you're following the whole PBM/insurer/specialty pharmacy vertical integration skullduggery, keep an eye on a bunch of lawsuits against these combined entities (three examples here, here, and here) alleging that they are doing some not super upright and honest things with their massive market power. (Say it isn't so!) You can learn more at acutecondition.com. Olivia Webb, PharmD, is a healthcare strategist and writer. She publishes the weekly healthcare newsletter Acute Condition, in addition to writing freelance pieces. She also works as a senior communications manager at the specialty care start-up Thirty Madison. In the past, Olivia has worked on healthcare policy and hospital consulting at Economic Liberties, Massachusetts General Hospital, and Advisory Board Company.   04:11 Why did Olivia start thinking about a patient-centric specialty pharmacy? 05:33 “There's really no layer on top of it to make it look nice.” 06:23 “You're kind of dealing with this vertical stack that doesn't really deal with patients frequently.” 06:35 Is the specialty model more patient friendly or less? 07:08 What would a patient-centric specialty pharmacy look like? 07:58 “There's a lot of fragmentation; there's a lot of friction.” 08:11 What's unique to specialty pharmacy prescriptions? 10:38 Why can infusion centers be a high-drama place? 12:15 What's “the question” around specialty pharmacy? 12:42 Who has the vested interest in ensuring patients take their medications correctly in specialty pharmacy? 14:39 “It's really just a unique area of healthcare where the people that I think of as the good guys and the bad guys completely flips.” 16:05 Why might the time be ripe for disruption in the specialty pharmacy area? 19:56 “There's no one with a clear incentive to cap the prices.” 20:09 What are the barriers in specialty pharmacy? 20:31 “The patient just isn't at the center, the financial incentive, in any direction.” 29:22 “I think people who are designing these things need to see how patients are actually doing it.” 29:50 “I think there's a lot of money here; I think this market is going to only increase in size.” 30:10 “I think you need scale.” 30:20 AEE15 with David Carmouche, MD, of Ochsner. You can learn more at acutecondition.com.   @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why did Olivia start thinking about a patient-centric specialty pharmacy? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “There's really no layer on top of it to make it look nice.” @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You're kind of dealing with this vertical stack that doesn't really deal with patients frequently.” @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is the specialty model more patient friendly or less? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What would a patient-centric specialty pharmacy look like? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “There's a lot of fragmentation; there's a lot of friction.” @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's unique to specialty pharmacy prescriptions? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why can infusion centers be a high-drama place? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's “the question” around specialty pharmacy? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why might the time be ripe for disruption in the specialty pharmacy area? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's really just a unique area of healthcare where the people that I think of as the good guys and the bad guys completely flips.” @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The patient just isn't at the center, the financial incentive, in any direction.” @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think people who are designing these things need to see how patients are actually doing it.” @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think there's a lot of money here; I think this market is going to only increase in size.” @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14)

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

Here's a hot take for you. I just learned what a hot take was last week, so, of course, I needed to get me one on the quick. The thing with hot takes, from what I understand, is that they are open for discussion. What I'm talking about today is something I've been thinking about for a while, and I would be interested in your thoughts, since probably some finesse is needed here. I want to talk about the imperative of collaborating with organizations across the care continuum, even the ones you may have a problem with. Let us begin by discussing why collaboration is so vital if the intention is to improve patient care, quality, and lower costs. The story really begins with fragmentation. Turns out, the US ranks last among 10 other countries in a recent study on healthcare systems. One of the reasons why is the fragmentation of professionals and patients and siloed health information. This is from a Commonwealth Fund study. In fact, according to an AJMC article I found the other day—or do a Google search for any number of others—fragmentation is associated with increased costs of care, a higher chance of having a departure from clinical best practice, higher rates of preventable hospitalizations … Even among patients with the same chronic condition, lower quality happened and costs were higher in patients who received more fragmented care. So, nothing for nothing, but it's kinda self-evident that to fix American healthcare, we need to fix fragmentation. But to fix fragmentation, stakeholders along the care continuum have to—God forbid!—collaborate and work with each other. For more information, go to aventriahealth.com.   When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specializes in helping pharmaceutical, employer, pharmacy, and health system clients improve patient outcomes by creating and leveraging collaborations with other health care organizations. For more than 20 years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders and, most of all, the patient.   00:12 What's Stacey's hot take on collaboration in healthcare? 00:43 Why is collaboration so vital, and how does fragmentation play into that? 01:38 “To fix American healthcare, we need to fix fragmentation.” 03:23 “Nobody gets to be holier than thou.” 04:38 What is the bottom line on collaboration in healthcare? 05:20 What's the difference between collaboration and collusion? 05:35 “More is not usually better.” For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth Why is collaboration so vital, and how does fragmentation play into that? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth “To fix American healthcare, we need to fix fragmentation.” Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth “Nobody gets to be holier than thou.” Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth What is the bottom line on collaboration in healthcare? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth What's the difference between collaboration and collusion? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth “More is not usually better.” Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry

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

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

Let's discuss price transparency, which isn't an end unto itself obviously. The great hope of price transparency (or at least one of them) is that it furthers consumerism, which is also not an end unto itself. Obviously. The great hope of consumerism is that it effectively forces the health care industry to straighten up and fly right. Before I dig into this, let me make one critically important point for context. Enabling consumers to find low-cost providers is not the only goal of price transparency. Employers should be hiring companies to do cost analytics and bring them back insights which should, along with quality indicators, be part of network selection or direct contracting or bundle considerations. Add to that something I heard Katy Talento say the other day. She said something along the lines of: Anyone sitting around whiteboarding cockamamie reasons to keep their prices secret ... how is that not corrupt? You're trying to conceal the prices that your patients will ultimately be responsible to pay, as per, by the way, the financial document that every provider I've ever seen makes patients sign on the way in. You, patient, are ultimately responsible for the bill here. Don't be thinking otherwise. What did I hear the other day, which is a great message for patients everywhere? If you can't see who's holding the bag, check your hands. It might be you. But let's get down to the business of this particular podcast here. As I tend to contemplate many complicated things, I like to play a kind of simplified version of moneyball, otherwise known as sabermetrics, if you are as big a geek as I am. You start at the end state, and you work backwards. If the goal of price transparency ultimately is to drive the usage to better, lower-priced providers, then people/patients have to be shopping. OK … for patients to shop, there has to be shopping tools. For shopping tools to exist, there has to be price transparency. If you look at this flow in reverse, that's the progression needed to realize the goal of disrupting the health care system and causing competition and health care providers and others to get themselves subjected to free market forces to up their game and lower their prices. Going through this again in a bullet point list, here are the seven steps to get from price transparency to the impact of consumerism to create health care quality overall improvements and for costs to go down: Price transparency Shopping tools People shopping People taking the information gleaned from the shopping tools and putting it to use Higher-quality, lower-priced providers get more business. Lower-quality, higher-priced providers get stomped on by the market. Health care quality overall improves, and costs go down. It's funny because we talk about concepts like the impact of consumerism all the time, but I don't think I've ever seen anybody literally write out the mechanics of that progression. And this is an incredibly valuable exercise (I think anyway) because, as we all know so well, to actually achieve anything, we have to be willing to check out how it's going, to learn some lessons, and then evolve our approach accordingly. The short version of the “how's it going,” based on available research, is that most people—your average civilians, I mean—do not really use shopping tools when they are made available. Good news is, if there's advertising and other outreach efforts, then this number of users goes up. So then the next question becomes, what are people then doing with the information? Are they heading to lower-cost providers? Bad news is, sadly, no. They do not tend to do so. Let me just interject right here. There's going to be two different reactions to what I just said. One reaction is going to be anger. I just kicked somebody's sacred cow, and they're all “Earmuffs!” right now. Another reaction is the more productive one, and frankly, it's the only reaction for anyone who is truly committed to transforming health care. That reaction is, “Huh … so then how do we incrementally improve? What are the barriers to this mechanism of action, so to speak, and how are we going to then address those barriers to get the results that we're looking for here?” This is what the conversation with Sunita Desai, PhD, is about in this health care podcast. Sunita Desai is a health economist and assistant professor in the Department of Population Health at the NYU Grossman School of Medicine. She and her colleagues have done extensive research into everything that we discuss in this episode. We talk in depth about the barriers that consumers face when trying to make price information actionable, and you gotta know what the problem is if you're going to solve for it. IRL, if we want consumerism to work, we must overcome its challenges. It would be nice if we didn't need to, but we do. One last thing, and this is going to be a recommendation: I really enjoyed Adam Grant's latest book, which is called Think Again. He talks, for an entire book basically, about how most of us are accustomed to defining ourselves in terms of our beliefs, our ideas, and our ideologies. He says that this becomes a serious issue when our opinions become so sacred that our totalitarian ego leaps in to silence any counterarguments, squash contrary evidence, and close the door on learning, effectively.  You can learn more at Sunita's NYU Web site or by emailing Sunita at sunita.desai@nyu.edu. Sunita Desai, PhD, is a health economist. Her research investigates how policies and incentives shape health care provider behavior and organizational structure. She also examines the role of information and price transparency in consumer decision-making in health care. Her work has been published in leading journals, including JAMA and Health Affairs, and has been covered by media outlets such as the New York Times and Washington Post. She is an assistant professor in the Department of Population Health at NYU Grossman School of Medicine, with secondary appointments in the Department of Economics at NYU Stern and the Department of Health Policy at NYU Wagner. From 2015 to 2017, Sunita was a Seidman Fellow in Health Policy and Economics at the Department of Health Care Policy at Harvard Medical School. Sunita received her PhD in health care management and economics from The Wharton School of the University of Pennsylvania in 2015 and her bachelor's degree in economics from the University of Pennsylvania. 06:23 Why is everyone so interested in price transparency right now? 07:30 How does price transparency enable consumerism? 08:05 What are the two aspects to consumerism in order to enable it in health care? 11:01 Does access to price transparency tools lower costs and spending? 15:19 Why is there such low utilization of price transparency tools? 16:13 What's the first barrier to using price transparency tools? 17:10 Why bypassing the physician at the point of care limits the use of price transparency tools. 17:53 EP284 with Carm Huntress.23:20 EP308 with Mark Fendrick, MD.23:31 How does reducing spending with high-deductible health plans negatively affect high-value health care? 25:23 “There is not a strong correlation between prices of providers and quality.” 28:48 How does a reduction in physician choices undermine price transparency? 29:30 “We owe that information to patients … it's useful for patients to know what out-of-pocket costs they should expect.” You can learn more at Sunita's NYU Web site or by emailing Sunita at sunita.desai@nyu.edu. @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth Why is everyone so interested in price transparency right now? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth How does price transparency enable consumerism? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth What are the two aspects to consumerism in order to enable it in health care? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth Does access to price transparency tools lower costs and spending? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth Why is there such low utilization of price transparency tools? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth What's the first barrier to using price transparency tools? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth Why bypassing the physician at the point of care limits the use of price transparency tools. @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth How does reducing spending with high-deductible health plans negatively affect high-value health care? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth “There is not a strong correlation between prices of providers and quality.” @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth How does a reduction in physician choices undermine price transparency? @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth “We owe that information to patients … it's useful for patients to know what out-of-pocket costs they should expect.” @sunitamd of @nyugrossman discusses #transparency in #healthcare on our #healthcarepodcast. #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312), Ge Bai, Sumit Nagpal

Recently I was talking to someone, a civilian not in health care, and I mentioned something about how patients don't always get a treatment plan (a care plan) based on the best evidence or sometimes even any evidence. Here's how I explained it to him—what this looks like in the real world: Let's say two patients, patient 1 and patient 2, with the exact same clinical needs and zip code … both these two patients see the exact same doctor. The only difference between these two patients is that they're two different colors. And let's add a third patient into this mix: say, ME. Let's say I have the exact same profile and zip code as those first two patients. I see a different clinician in the same exact practice, though. In all these circumstances, evidence is evidence, right? There should be one care plan that all three of us get when we show up at that same care setting. Until the evidence changes, that is, right? But the reality is that it's just as likely that those other two patients and I, we all get various shades of different care plans. The civilian I was having the original conversation with about evidence-based medicine and this care planning? He literally recoiled in surprise. He was shocked. He said he thought medicine was more science than that. I'm going to take that anecdote as a data point to suggest that there is a disconnect between what patients think is going on and what is actually going on relative to how care plans tend to happen in health care. Alex Akers from Health Catalyst in episode 176 and Clint Phillips from Medici in episode 201 get into this in detail. You can listen to full episodes and learn more about this week's guests at relentlesshealthvalue.com.  Jeffrey Hogan is the northeast regional manager for Rogers Benefit Group, a national benefits marketing and consulting firm. Jeff has been with Rogers Benefit Group for 30 years. Additionally, Jeff operates a consulting firm, Upside Health Advisors, where he provides expert witness services on health care–related litigation, is a consultant to payers and large provider groups for product development and launch, and is a resource to employers desirous of implementing strategies to manage their health spend. Jeff is focused on health care payment reform, health policy, care coordination, value-based health care, health care quality, and precision medicine. Jeff regularly appears on national forums focused on moving to value-based health care and is actively working to promote health care–related transparency measures in the market. He serves as the group's liaison to the National Alliance of Healthcare Purchaser Coalitions. Jeff is the regional leader for The Leapfrog Group. He is also one of the coordinators of Connecticut's Moving to Value Alliance. Darrell Moon founded Orriant in 1996 to change the dynamics of health care and give employers some control over the ever-increasing costs of the health care benefits they offer their employees. Darrell believed that engaging individuals in the management of their own health was a key that had to be inserted back into the economic equation of health care. Darrell received both his bachelor's degree in finance and his master's degree in healthcare administration from Brigham Young University. As the CEO, COO, or CFO, Darrell managed medical and psychiatric hospitals throughout the country for over 10 years prior to creating Orriant. He also has more than a decade of experience managing insurance and managed care products. Darrell is a Forbes leadership contributor. Grace E. Terrell, MD, MMM, is CEO of Eventus WholeHealth, a company focused on integrated value-based behavioral medicine and primary care in the long-term care space. She is a national thought leader in health care innovation and delivery system reform and a serial entrepreneur in population health outcomes driven through patient care model design, clinical and information integration, and value-based payment models. She is the former CEO of Cornerstone Health Care, one of the first medical groups to make the “move to value” by lowering the cost of care and improving its quality for the sickest, most vulnerable patients; the founding CEO of CHESS, a population health management company; and the former CEO of Envision Genomics, a company focused on the integration of precision medicine technology into population health frameworks for patients with rare and undiagnosed diseases. Dr. Terrell currently serves on the US Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee and the board of the AMGA (American Medical Group Association), is a founding member of the Oliver Wyman Health Innovation Center, and is the coauthor of Value-Based Healthcare and Payment Models. Rich Klasco, MD, FACEP, has focused throughout his career on rendering evidence-based medicine operational—that is, making the right thing the easy thing to do. He has pursued this goal in academia, in industry, in policy, and in the press. In addition to publishing extensively in both peer-reviewed journals such as JAMA and lay publications such as The New York Times, Dr. Klasco has taught at leading academic medical centers, including Harvard, Stanford, Mayo, and the University of California, San Francisco; served on the executive committee of Brigham and Women's Hospital Center for Patient Safety Research and Practice; testified before the United States Congress on evidence-based practices; and won CMS (Centers for Medicare & Medicaid Services) approval for an officially designated compendium of evidence-based oncologic drug information. Dr. Klasco previously served as chief medical officer and editor-in-chief for the Thomson Reuters group of health care companies, where he had editorial responsibility for companies including Micromedex, the Physicians' Desk Reference (PDR), and the United States Pharmacopoeia (USP) Drug Information. For the past 15 years, Dr. Klasco has served as chief medical officer for Motive Medical Intelligence, where he provides clinical leadership for the development and deployment of solutions that quantitative assess physician performance for payers, providers, and patients, and integrate scientific knowledge into workflow systems where it can be accessed and applied in real-time. Dr. Klasco received his medical degree from Harvard Medical School. He completed his internship and residency in internal medicine at Brigham and Women's Hospital, and he completed his residency in emergency medicine at the Denver Health Residency in Emergency Medicine, where he served as chief resident. Nicole Bradberry is the founder and chief of growth and innovation officer for MIND 24-7. MIND 24-7 runs mental health crisis centers with a focus on immediate access, quality care, and the understanding that mental health and substance abuse drive significant health cost. She is also the founder of ValueH Network, which aggregates high-performing value-based care network providers in order to enable the best performance in new innovate contracts. In addition, she is currently the chief executive officer and chairman of the board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for accountable care organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value health care space. Nicole spent 16 years leading operations and information technology programs for UnitedHealth Group and Cigna HealthCare. While there, she served as business lead for the technology transformation of the country's largest dental and vision services company, led the national deployment of health care quality and affordability programs, and was responsible for the successful integration of many major health plans. Nicole holds a bachelor's degree in statistics from the University of Florida. She has been recognized for her personal and professional achievements many times, recently as the nation's Outstanding Midmarket IT Leader of the Year and one of the Business Journal's “Women of Influence.” She is often found on the speaker faculty for health care conferences focused on ACOs, population health, and value-based care. She is passionate about changing health care and enabling physicians to provide high-quality, cost-effective, and consumer-focused care. Kelly A. Conroy is director of Pinnacle Healthcare Consulting and brings more than 30 years of health care finance, management, and leadership experience with significant experience in value-based care. As a leader in the field, she'd contributed through multiple start-up health care companies with a leading-edge focus on advancements in care delivery and alignment. Kelly started the first Medicare ACO in the country, which delivered nearly $40 million in savings in its first year and has gone on to manage some of the most profitable ACOs in the country. She is now sought after as a senior advisor and consultant, having developed a reputation as one of the most experienced and effective ACO professionals in the country. As a true catalyst driving the shift in health care culture toward physician leadership, her understanding and strategic vision are unmatched, along with her comprehension of the latest government-proposed valued-based agreements. From starting health care organizations to serving in multiple senior executive leadership roles, Kelly is a seasoned executive with a career record of negotiating and increasing revenues through new product offerings while optimizing efficiency and productivity in the medical field. 02:10 Jeff Hogan (EP309) talks about the consequences of when there's a disconnect between what the patient thinks is happening and what is actually happening in a care plan.03:48 EP315 with Bob Matthews. 03:58 Merrill Goozner's perspective on successful population health.04:55 Why did Darrell Moon (EP305) give up being a hospital administrator because of care plans? 08:02 “It's a myth that population medicine … and precision medicine are incompatible or opposites.”—Dr. Grace Terrell (EP319) 11:28 Dr. Rich Klasco (EP321) explains “noncognitive” medicine and why it bogs physicians down.14:45 What is at the core of appropriateness for care? 16:33 “You start to bring that data to the physician, and it really does open their eyes.”—Nicole Bradberry (EP324) 16:51 Nicole Bradberry and Kelly Conroy (EP324) discuss how to really change the way physicians work. You can listen to full episodes and learn more about this week's guests at relentlesshealthvalue.com.  Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the consequences when there's a disconnect between what the patient thinks is happening, and what is actually happening in a care plan? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth Why did Darrell Moon give up being a hospital administrator because of care plans? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “It's a myth that population medicine … and precision medicine are incompatible or opposites.” Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth What is “noncognitive” medicine, and why does it bog physicians down? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth What is at the core of appropriateness for care? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth “You start to bring that data to the physician, and it really does open their eyes.” Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth How do you really change the way physicians work? Jeff Hogan, Darrell Moon, @gracet22, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy discuss #careplans in our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312), Ge Bai, Sumit Nagpal, Dr Vikas Saini and Shannon Brownlee

In this health care podcast, I'm interviewing John Marchica, who is the CEO at Darwin Research Group. Starting last year in the middle of the worst of the COVID pandemic, Darwin Research Group conducted a study about what was going on at health systems or integrated delivery networks (IDNs), and they've updated it every quarter since then. The goal was to try to stay on top of the effects of COVID-19 on care management and the business of care delivery. I loved having this opportunity to quiz John about what health systems are saying about how they are doing and what they are doing, both strategically and reactively, coming out of the pandemic and in response to the pandemic. Now this is a half-hour conversation about an extensive research report, so we're kind of aggregating all of the health systems in one big bucket. Said another way, we're obviously not going to play the deep cuts here. No worries—the insights that John lays out are fascinating and give an insider's look into what's going on at these really powerful institutions. By the way, when I say powerful institutions, I just was looking at some stats the other day. Something like 50% of all prescriptions these days run through IDNs (that was in 2020). And also in 2020, aggregate IDN market size was $1 trillion. And by 2027, their anticipated combined revenues may exceed $2 trillion. That's double. (I know, that was some quick math by me. You're welcome.) We'll see, though, what the recent Executive Order yields—the one to look into the market power that some of these consolidated IDNs wield. Regardless of who you are, it is tough to deny the mountain of evidence showing that IDN health system consolidation considerably jacks up prices that patients, employers, and taxpayers pay in any geography where consolidated IDNs, otherwise known as monopolies, have destroyed all competition. Probably the most striking takeaway I had from this conversation was how much there is to read between the lines. At the end of the day, IDNs are, and are run, like businesses; and regardless of whether they have a nonprofit on the door or not, that is still true. Before I get into this, let me just clearly say that my heart goes out to the frontline workers—doctors, nurses, everybody else—and all they have done and continue to do for us, and I mean that with three underlines. While I really admire and support some of the rural and urban truly safety net hospitals who are trying to cobble together positive net revenue against all odds, I am far less sympathetic to some of the huge institutions who will engineer an “it's good for patients, honestly” cover story for any and all endeavors which all seem to have one thing in common: their profitability. Like, nobody mentioned 340B revenue opportunities or how much money there is in specialty pharmacy when explaining the rationale for standing up specialty pharmacies within some health systems' walls. Maybe it goes without saying. Here's my conversation with John Marchica, CEO of Darwin Research Group and host of the Health Care Rounds podcast, by the way. You should check that out. You can learn more at darwinresearch.com or by emailing John at jm@darwinresearch.com. You can also listen to the podcast Health Care Rounds wherever you listen to podcasts. John Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He's a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and MA in public policy from the University of Chicago, and completed his PhD coursework at The Dartmouth Institute. He is a faculty associate in the WP Carey School of Business and the College of Health Solutions at Arizona State University and is an active member of the American College of Healthcare Executives. 03:50 What were John's top three health system findings during COVID? 05:24 What is priority for integrated delivery network health systems right now? 08:57 Why do health systems have a renewed focus in primary care? 10:07 How did infusion centers manage throughout the pandemic? 13:58 “It's not just in cancer, people not getting screened and being diagnosed; it's in other areas as well.” 14:17 Which of these telemedicine changes are permanent? 19:39 “A visit is a visit … so why would you reimburse at a lower rate?” 19:57 “Telemedicine … is, by its nature, more efficient … and they should be able to figure out how to make money.” 27:17 What are health system plans that own their specialty pharmacy groups doing right now? 29:57 What does Darwin Research Group focus on? You can learn more at darwinresearch.com or by emailing John at jm@darwinresearch.com. You can also listen to the podcast Health Care Rounds wherever you listen to podcasts. @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What were John's top three health system findings during COVID? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What is priority for integrated delivery network health systems right now? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions Why do health systems have a renewed focus in primary care? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions How did infusion centers manage throughout the pandemic? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “It's not just in cancer, people not getting screened and being diagnosed; it's in other areas as well.” @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions Which of these telemedicine changes are permanent? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “A visit is a visit … so why would you reimburse at a lower rate?” @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “Telemedicine … is, by its nature, more efficient … and they should be able to figure out how to make money.” @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What are health system plans that own their specialty pharmacy groups doing right now? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions

Dr. John Shufeldt founded NextCare Inc. in 1993 and served as the CEO and Chairman of the Board until 2010. He now serves as the business manager and one of the founding partners of Empower Emergency Physicians and continues to practice emergency medicine at St. Joseph's Hospital and Medical Center. Dr. Shufeldt also founded MeMD, LLC, a platform used by more than 300 medical and mental health providers in 50 states to virtually treat patients on-demand and in the comfort of their home or place of work. Dr. Shufeldt has authored 11 books on leadership, self-improvement, business, entrepreneurism, urgent care management and urgent care medicine.Dr. Shufeldt received his BA from Drake University and his MD from the University of Health Sciences, The Chicago Medical School. He completed his Emergency Medicine Residency at Christ Hospital and Medical Center where he spent his final year as Chief Resident. Dr. Shufeldt received his MBA and his Juris Doctorate from Arizona State University. His certifications include Fellow, American Board of Emergency Medicine, College of Legal Medicine and American College of Emergency Physicians and completed a certificate program in Artificial Intelligence at MIT's Sloan School of Management. Dr. Shufeldt also completed his Six Sigma Black Belt from the Fulton School of Engineering at Arizona State University.  John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He's a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

 Josh Komenda is co-founder, CEO and president of healthcare logistics leader, Veyo, a full service NEMT broker using technology to better manage NEMT benefits for Medicaid and Medicare programs, state governments, and Managed Care Organizations.While focusing on the technology platform, Josh and his team recognized the need for Non-emergency Medical Transportation (NEMT) in the industry and created Veyo. Combined with the healthcare logistics and transportation division of Total Transit, Veyo is a full-service transportation brokerage designed specifically to provide access to healthcare for people who need assistance getting to and from medical appointments. Veyo's new tech-enabled healthcare approach has the most powerful network in NEMT and continues to deliver higher levels of reliability, quality, and transparency to customers, partners, and members.Josh received his degree in Computer Engineering from the University of Waterloo and his graduate degree in Business from the Marshall School of Business at University of Southern California.John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He's a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin's client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group and former president of The Mid-Atlantic Permanente Medical Group. In these roles was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the west and east coasts. Named one of Modern Healthcare’s 50 most influential physician leaders, Pearl is an advocate for the power of integrated, prepaid, technologically advanced and physician-led healthcare delivery.He serves as a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business, where he teaches courses on strategy and leadership, and lectures on information technology and health care policy.He is the author of “Mistreated: Why We think We’re Getting Good Healthcare—And Why We’re Usually Wrong,” a Washington Post bestseller that offers a roadmap for transforming American healthcare. His most recent book, Uncaring: How the Culture of Medicine Kills Doctors and Patients was published May 2021.  John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

A podcast by Stewart Gandolf, CEO, Healthcare Success and John Marchica, Founder and CEO, Darwin Research Group. The topic is: 6 Key Healthcare Trends Emerging from the Pandemic.

Spencer Hutchins is the CEO and co-founder of Concert Health, America’s leading behavioral health medical group with a turnkey solution designed for primary care and women’s health physicians. Concert Health’s exceptional team of clinicians deliver Collaborative Care Management, an evidenced-based model proven to treat anxiety, depression, and other behavioral health conditions.  Prior to Concert, Spencer co-founded Reflexion Health, where he served as CEO for three years. Spencer also previously served as Senior Director at West Health, where he helped source and support investments in innovative companies such as Humedica, Change Healthcare, and goBalto. Spencer has also served as a member of the founding healthcare team at the Federal Communications Commission during the Obama administration.  Spencer received an MBA from Yale School of Management and BA from Colby College.   John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Dr. Emanuel has over 26 years of research and development, marketing and management experience in biotechnology projects, including development of drug delivery systems and immunology. His extensive expertise includes immunotherapy, vaccines, immunodiagnostics, systemic and local drug-delivery, and medical devices. Dr. Emanuel has a number of approved patents in the field of drug delivery and diagnostics. Dr. Emanuel is a co-founder of PolyPid and served as its CEO during the company’s first three years. He received his Ph.D. from the Faculty of Medicine at the Hebrew University of Jerusalem. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Christopher Robertson joined the Boston University law school faculty in 2020 as a tenured professor and an N. Neal Pike Scholar in health and disability law. Prior to that, he served as associate dean for research and innovation and professor of law at the University of Arizona. He is also a principal at Hugo Analytics, a firm that  provides scientific services to litigators. In 2019, Harvard University Press published his book, Exposed: Why Our Health Insurance Is Incomplete and What Can Be Done About It. Chris has also co-edited three books, Nudging Health: Behavioral Economics and Health Law (2016,) Blinding as a Solution to Bias: Strengthening Biomedical Science, Forensic Science, and Law (2016), and Innovation and Protection: The Future of Medical Device Regulation (2021). Chris graduated magna cum laude from Harvard Law School and earned a doctorate degree at Washington University in St. Louis. He has taught at Harvard Law School, NYU Law, and the London School of Economics. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Karthik Ganesh is the CEO of EmpiRx Health, the industry’s only value-based PBM, with a clinically focused, technology-enabled approach to bending the Rx cost curve. Prior to EmpiRx Health, Karthik was the founding operations leader of CareAllies. He is a senior health care executive with a solid track record of comprehensively scaling, transforming, and maximizing value at tech-enabled health service companies while driving dramatic before-and-after results across all facets of the organization. Karthik is recognized as a thought leader on health care, leadership, and resilience. He is a published author and has been featured in leading industry journals. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Dr. Thomas Young is a board-certified family physician with more than 35 years of medical experience. He is recognized as an innovator and thought leader in the fields of consumer-directed health care and population health care management. Dr. Young is the founder and chief medical officer of nView Health, an innovative software company that helps providers better identify, treat, and monitor patients with behavioral health conditions. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Dr. Hale is the chief medical officer at VirtuSense Technologies, a health care company that uses proprietary technology and artificial intelligence to reduce adverse events within hospitals, skilled nursing facilities, and senior living communities. He previously was the senior vice president for care solutions at Navvis Healthcare, after a 37-year career at Mercy Health, where he was the leader and clinical architect of the world’s first virtual care center. As the executive medical director of Mercy Virtual, Dr. Hale led the development of new ways to effectively and efficiently deliver health care to Mercy communities. Prior to his current position, Dr. Hale maintained a general internal medicine practice for 23 years. He was a founder of Mercy Medical Group and served as its first president for 15 years.  Dr. Hale holds a Ph.D. in pharmacology from Saint Louis University. He received his medical degree from the University of Missouri-Columbia Medical School, subsequently completing his internal medicine internship and residency at Mercy Hospital St. Louis leading to board certification in 1983. In 2011, he earned a master’s degree in medical informatics from Northwestern University. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Sean Brusky, health care entrepreneur, executive advisor, strategist, and former head of health care delivery innovation at Genentech/RocheSean’s career has developed around a central theme: How can we innovate to help Pharma become true partners in value-based care? Over the course of 15 years in various leadership roles with Genentech/Roche, Sean has lived experience attempting to solve the problems at the core of this challenge, directly engaging key market stakeholders from the seat of one of the world’s largest integrated health care companies, focused on both innovative new medicines and novel diagnostics, and real-world data solutions. Sean has built and led teams responsible for brand-focused marketing and sales, managed care marketing, channel contracting and engagement, integrated health system engagement, government and commercial payer engagement and, most recently, digital health partnerships and novel approaches to health care delivery. He spearheaded Genentech’s efforts to execute value-based pricing models in collaboration with health systems and group practices. He has directly initiated and executed more than 20 novel commercial and medical partnerships in the personalized medicine, digital health, and value-based contracting space.  This unique blend of business development, commercial, managed care, medical affairs, and strategy experience has contributed to Sean’s unique perspective on what is broken about the current pharmaceutical pricing, purchasing, and partnership model and how we can fix it. John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives. About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.

Paul VerHoeve is CEO and a board member for Mission Healthcare. With more than 20 years of health care leadership experience, he has been recognized as a driver of healthy workplace culture. Prior to his involvement with Mission Healthcare, Paul was president of the west region with Louisville, Ky.-based Kindred Healthcare, one of the largest post-acute care systems in the country. Before joining Kindred Healthcare, he served in several leadership positions with Gentiva Health Services (now part of Kindred Healthcare), Haven Healthcare, and VITAS Healthcare.  John Marchica, CEO, Darwin Research GroupJohn Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade.John did his undergraduate work in economics at Knox College, has an MBA and M.A. in public policy from the University of Chicago, and completed his Ph.D. coursework at The Dartmouth Institute. He is a faculty associate in the W.P. Carey School of Business and the College of Health Solutions at Arizona State University, and is an active member of the American College of Healthcare Executives.About Darwin Research GroupDarwin Research Group Inc. provides advanced market intelligence and in-depth customer insights to health care executives, with a strategic focus on health care delivery systems and the global shift toward value-based care. Darwin’s client list includes forward-thinking biopharmaceutical and medical device companies, as well as health care providers, private equity, and venture capital firms. The company was founded in 2010 as Darwin Advisory Partners, LLC and is headquartered in Scottsdale, Ariz., with a satellite office in Princeton, N.J.