Podcast appearances and mentions of katy talento

Katy Talento, Executive Director of the Alliance for Health Care Sharing Ministries, talks to Shaun about the Democrat pushback on RFK Jr.'s efforts to Make America Healthy Again, the damage of Obamacare subsidies, and the importance of also fighting the demand side of addiction.See omnystudio.com/listener for privacy information.

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Watch Randy Robison from LIFE Today Live To support this ministry financially, visit: https://www.lightsource.com/donate/872/29

Join Richard Harris and Katy Talento as they discuss the truth behind America's health crisis. Learn how the FDA and Pharma industries are failing Americans and why our diets are contributing to an ongoing health epidemic.   Join us in person at the Truth & Liberty Banquet: https://www.truthandliberty.net/award  Subscribe to our newsletter: https://www.truthandliberty.net/subscribe   Get "Hope For The Future" here: https://info.truthandliberty.net/hope   Donate here: https://www.truthandliberty.net/donate   Original Air Date 01-31-25

President Trump isn't wasting any time, and America is already experiencing a massive shift! Pastor Aubrey Shines breaks down Trump's game-changing executive orders and what they mean for faith and freedom. Former White House health advisor Katy Talento reveals how Trump and RFK Jr. are taking on healthcare corruption. Duncan McGregor, host of The Kilted Christian, exposes the battle over suppressed energy tech. And Heidi Crosky uncovers Virginia's shocking crackdown on pet owners and farmers. Buckle up—this one's packed with truth you won't hear anywhere else! [1:50] Trump's First Weeks Back in Office Pastor Aubrey Shines, founder of Glory to Glory Ministries and host of America Shines, joins Shemane to break down Trump's first executive actions, from saving women's sports to securing the border and cutting ties with the WHO. He also weighs in on Trump's efforts to end birthright citizenship, the impact of woke ideology on corporate America, and what Christians should be doing to stand strong against gender ideology. [14:01] Healthcare Reform Under Trump & RFK Jr. Katy Talento, executive director at the Alliance of Health Care Sharing Ministries and former White House health advisor, reveals what's next for healthcare under the new administration. She dives into Biden's biggest failures, RFK Jr.'s fight for medical freedom, and what Americans can expect in the battle against Big Pharma, food toxins, and government overreach. [24:40] Tesla Tech & The Global Energy Crisis Duncan McGregor, host of The Kilted Christian podcast, breaks down the long-suppressed potential of Nikola Tesla's energy technology and what could be coming next. He and Shemane discuss how free energy could have changed the world, the elites' desperate attempts to keep it buried, and the deep corruption in global energy markets. Duncan also explores the Z Battalion's mysterious role in Ukraine and its possible ties to JFK Jr. [36:30] Radical Animal Rights Agendas in Virginia Animal rights advocate Heidi Crosky exposes how Virginia's Attorney General, in partnership with PETA, is waging a war on pet owners and farmers. She shares shocking stories of government-backed raids, unjust charges against families, and the deeper agenda behind these attacks. Could this be part of a nationwide push to end private animal ownership? Resources: Aubrey Shines - Glory to Glory MinistriesWebsite: glorytoglory.org Katy Talento - Health Care Sharing Ministries Website: ahcsm.org Instagram: @KatyTalento   Duncan McGregor - The Kilted Christian Podcast: Watch The Kilted Christian on Rumble Listen on Podbean Heidi Crosky - Animal Rights & Farming Advocate Website: GoFundMe.com  Search: Help Animal Owners Fight For Their Animals   Sponsors   Get clean healthy water with SentryH2O Use the promo code: “HEALTHY10”   Get true American made products at  switchtoamericawithshemane.com   Protect yourself with EMP Shield  Use the promo code “SHEMANE”    Activate stem cells & reset your body's clock  at lifewave.com/shemane Please send product inquiries to: shemane.lifewave@gmail.com   Watch Faith & Freedom every Sunday,  10am est on America'sVoice.News   Organic natural products to help your family thrive with  Rowe Casa Organics & use promo code “FAITH”   Purchase “My Pillow” at  mypillow.com or call 800-933-6972 Use promo code “FAITH”   Use promo code “FAITH” to receive  20% off your first order at Field of Greens   Join Shemane's new programs Fit & Fabulous Start Pack Faith Fuel: 21 Day Devotion    Check out Shemane's books:  Purchase Shemane's New Book: ‘Abundantly Well' Shemane's new #1 Bestseller ‘Killer House' "4 Minutes to Happy" Kill It and Grill It Cookbook   Connect with Shemane: Send your questions, suggestions,  & funny pet videos to shemane.chat@gmail.com    Share your hunting photos & questions to shemane.chat@gmail.com    Watch Killer House Documentary: KillerHouse.org Get Wildly Well at shemanenugent.rocks Shemane's Social Media: Facebook: @shemane.nugent Instagram: @shemanenugent Youtube: /shemane Truth Social @Shemane

Katy Talento, Executive Director, Alliance of Health Care Sharing Ministries (The Alliance, ahcsm.org). Former top health advisor at the White House Domestic Policy Council. Will the Senate confirm Robert F Kennedy Jr.?

President Trump isn't wasting any time, and America is already experiencing a massive shift! Pastor Aubrey Shines breaks down Trump's game-changing executive orders and what they mean for faith and freedom. Former White House health advisor Katy Talento reveals how Trump and RFK Jr. are taking on healthcare corruption. Duncan McGregor, host of The Kilted Christian, exposes the battle over suppressed energy tech. And Heidi Crosky uncovers Virginia's shocking crackdown on pet owners and farmers. Buckle up—this one's packed with truth you won't hear anywhere else! [1:50] Trump's First Weeks Back in Office Pastor Aubrey Shines, founder of Glory to Glory Ministries and host of America Shines, joins Shemane to break down Trump's first executive actions, from saving women's sports to securing the border and cutting ties with the WHO. He also weighs in on Trump's efforts to end birthright citizenship, the impact of woke ideology on corporate America, and what Christians should be doing to stand strong against gender ideology. [14:01] Healthcare Reform Under Trump & RFK Jr. Katy Talento, executive director at the Alliance of Health Care Sharing Ministries and former White House health advisor, reveals what's next for healthcare under the new administration. She dives into Biden's biggest failures, RFK Jr.'s fight for medical freedom, and what Americans can expect in the battle against Big Pharma, food toxins, and government overreach. [24:40] Tesla Tech & The Global Energy Crisis Duncan McGregor, host of The Kilted Christian podcast, breaks down the long-suppressed potential of Nikola Tesla's energy technology and what could be coming next. He and Shemane discuss how free energy could have changed the world, the elites' desperate attempts to keep it buried, and the deep corruption in global energy markets. Duncan also explores the Z Battalion's mysterious role in Ukraine and its possible ties to JFK Jr. [36:30] Radical Animal Rights Agendas in Virginia Animal rights advocate Heidi Crosky exposes how Virginia's Attorney General, in partnership with PETA, is waging a war on pet owners and farmers. She shares shocking stories of government-backed raids, unjust charges against families, and the deeper agenda behind these attacks. Could this be part of a nationwide push to end private animal ownership? Resources: Aubrey Shines - Glory to Glory MinistriesWebsite: glorytoglory.org Katy Talento - Health Care Sharing Ministries Website: ahcsm.org Instagram: @KatyTalento   Duncan McGregor - The Kilted Christian Podcast: Watch The Kilted Christian on Rumble Listen on Podbean Heidi Crosky - Animal Rights & Farming Advocate Website: GoFundMe.com  Search: Help Animal Owners Fight For Their Animals   Sponsors   Get clean healthy water with SentryH2O Use the promo code: “HEALTHY10”   Get true American made products at  switchtoamericawithshemane.com   Protect yourself with EMP Shield  Use the promo code “SHEMANE”    Activate stem cells & reset your body's clock  at lifewave.com/shemane Please send product inquiries to: shemane.lifewave@gmail.com   Watch Faith & Freedom every Sunday,  10am est on America'sVoice.News   Organic natural products to help your family thrive with  Rowe Casa Organics & use promo code “FAITH”   Purchase “My Pillow” at  mypillow.com or call 800-933-6972 Use promo code “FAITH”   Use promo code “FAITH” to receive  20% off your first order at Field of Greens   Join Shemane's new programs Fit & Fabulous Start Pack Faith Fuel: 21 Day Devotion    Check out Shemane's books:  Purchase Shemane's New Book: ‘Abundantly Well' Shemane's new #1 Bestseller ‘Killer House' "4 Minutes to Happy" Kill It and Grill It Cookbook   Connect with Shemane: Send your questions, suggestions,  & funny pet videos to shemane.chat@gmail.com    Share your hunting photos & questions to shemane.chat@gmail.com    Watch Killer House Documentary: KillerHouse.org Get Wildly Well at shemanenugent.rocks Shemane's Social Media: Facebook: @shemane.nugent Instagram: @shemanenugent Youtube: /shemane Truth Social @Shemane

Katy Talento, Executive Director of Alliance of Health Care Sharing Ministries, discusses with Shaun that America has the saddest, most over-medicated population in history - and how President Trump and RFK, Jr. will help make us healthy again.See omnystudio.com/listener for privacy information.

Biden hands out pardons like Oprah hands out cars! PLUS, Katy Talento, Executive Director of Alliance of Health Care Sharing Ministries, discusses with Shaun that America has the saddest, most over-medicated population in history - and how President Trump and RFK, Jr. will help make us healthy again. And Shaun talks to Tom DiLorenzo, President of the Mises Institute, about President Trump's incoming economic plan.See omnystudio.com/listener for privacy information.

Katy Talento is Executive Director of the Alliance of Health Care Sharing Ministries and a Trump Administration health policy advisor. In this exclusive Schilling Show Unleashed Podcast interview, Talento discusses the scourge of Abortion on America, how true Covid disinformation warped children, and the dangerous food additives in the American diet.

Katy Talento, the executive director of the Alliance of Health Care Sharing Ministries, talks to Kelly Wright about the battle Americans fight to get good health care. The six-trillion-dollar industry is forcing many into medical debt, which is a common reason for personal bankruptcy. Then Melissa Ortiz, the founder of Capability Consulting, joins the show to discuss the Americans with Disabilities Act and its importance in integrating people with disabilities into American life. Watch America's Hope with Kelly Wright. ⭕️Watch in-depth videos based on Truth & Tradition at Epoch TV

Katy Talento, Executive Director of the Alliance of Health Care Sharing Ministries, joins us to explain why religious employers should be against the HOPE with Fertility Services Act. She also explains the dangers of IVF, the BIG Fertility component, and other helpful insights Christians need to know.

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

Kamala Harris is a hornswoggler!! PLUS, Shaun talks to Katy Talento, Executive Director of the Alliance of Health Care Sharing Ministries, about the historic record breaking rise in health care and how the Alliance of Health Care Sharing Ministries circumvents it.   And The Heritage Foundation's EJ Antoni talks to Shaun about the quietly revised jobs numbers and the growth of the welfare state.See omnystudio.com/listener for privacy information.

Shaun talks to Katy Talento, Executive Director of the Alliance of Health Care Sharing Ministries, about the historic record breaking rise in health care and how the Alliance of Health Care Sharing Ministries circumvents it.See omnystudio.com/listener for privacy information.

WW3 is heating up! Putin meets with Vietnam. PLUS, Shaun takes on Big Fertility with Katy Talento, Executive Director of Alliance of Health Care Sharing Ministries, pointing out that IVF is putting adult's needs before children's rights.   And Bryan Riley, Director of National Taxpayers Union Free Trade Initiative, talks to Shaun about the who really pays tariffs and if tariffs could replace the income tax.See omnystudio.com/listener for privacy information.

Shaun takes on Big Fertility with Katy Talento, Executive Director of Alliance of Health Care Sharing Ministries, pointing out that IVF is putting adult's needs before children's rights.See omnystudio.com/listener for privacy information.

As critical health care costs rise, many Americans with health insurance are putting off medical treatment.  What is an affordable option that also embraces biblical values and community? Katy Talento, a veteran policy advisor, epidemiologist, and executive director of the Alliance of Health Care Sharing Ministries, shares about health care sharing as it was in the early Church and how this Acts-based model is being used today. 

In the 2nd hour of the Marc Cox Morning Show: Patrick Mahomes and Andy Reid say Harrison Butker can have his views even if they don't agree with them. Kaitlan Collins ask Sen. Cruz if he will validate the outcome of the election MO Sen. Holly Thompson Rehder joins the Marc Cox Morning Show to discuss how the MO Legislature failed to pass IP Reform and what she feels is the biggest issue facing MO today. In Other News with Ethan: Apple drops their 100 greatest Albums of all time, Train founding Bassist passes, Graceland not for sale...yet Coming Up: Jim Talent and Katy Talento

Katy Talento, Executive Director at Alliance of Health Care Sharing Ministries, joins Marc & Kim to talk about Health Care Sharing Ministries bringing a suit in CO  to defend member ministries and members to exercise religious liberty in the state.

In the 3rd hour of the Marc Cox Morning Show: Nikki Haley says she will vote for Trump Former US Senator Jim Talent makes his weekly appearance to discuss Nikki Haley saying she's going to vote for Trump, as well as Biden forgiving student loans. Katy Talento, Executive Director at Alliance of Health Care Sharing Ministries, joins Marc & Kim to talk about Health Care Sharing Ministries bringing a suit in CO  to defend member ministries and members to exercise religious liberty in the state. Kim on a Whim too? Coming Up:  Shannon Bream and Griff Jenkins

GUEST 1 OVERVIEW: Executive Director of the Alliance of Health Care Sharing Ministries Katy Talento is a veteran policy advisor, health care reformer, epidemiologist and thought leader. As the former top health advisor at the White House Domestic Policy Council, Katy spearheaded transformative policies to protect religious liberty in health care, end secret health care prices across the United States, end predatory medical collections practices, lower prescription drug prices, guarantee health records access and interoperability for patients and their care teams, combat the opioid addiction crisis and eliminate domestic HIV/AIDS. She first developed her take-no-prisoners approach to waste and corruption as an oversight investigator and legislative director on Capitol Hill, born of love and duty toward the hardworking American taxpayers. 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 such as malaria, dengue and the largest community-based HIV/AIDS service organization in the US. On the faculty at Georgetown University Medical School, Katy managed the Washington site of a multi-site NIH-funded pulmonology study. GUEST 2 OVERVIEW: Dr. William Makis provides in-depth intelligence on Covid-19, sudden deaths, mRNA vaccines, vaccine injuries, new pandemics, and more at makismd.substack.com. He is an expert in Radiology, Oncology and Immunology and ran one of the largest Targeted Radionuclide Therapy Cancer Clinics in North America and diagnosed over 10,000 cancer patients with state-of-the-art diagnostics such as PET/CT. He is a Board Member of The Wellness Company Canada (twc.health) as the Chief of Nuclear Medicine and Oncology. And he is the author of 100+ peer-reviewed medical publications.

OJ is dead and Shaun maintains that he is INNOCENT! PLUS, Katy Talento, Executive Director of Alliance of Health Care Sharing Ministries, tells Shaun the cost of health care has quadrupled and it's about to get worse. And Scott Walter, president of Capital Research and author of Arabella: The Dark Money Network of Leftist Billionaires Secretly Transforming America, talks about the billionaires (some you've never heard of!) funding Arabella Advisors and what their 'dark money' is used for. See omnystudio.com/listener for privacy information.

GUEST OVERVIEW: Executive Director of the Alliance of Health Care Sharing Ministries Katy Talento is a veteran policy advisor, health care reformer, epidemiologist and thought leader. As the former top health advisor at the White House Domestic Policy Council, Katy spearheaded transformative policies to protect religious liberty in health care, end secret health care prices across the United States, end predatory medical collections practices, lower prescription drug prices, guarantee health records access and interoperability for patients and their care teams, combat the opioid addiction crisis and eliminate domestic HIV/AIDS. She first developed her take-no-prisoners approach to waste and corruption as an oversight investigator and legislative director on Capitol Hill, born of love and duty toward the hardworking American taxpayers. 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 such as malaria, dengue and the largest community-based HIV/AIDS service organization in the US. On the faculty at Georgetown University Medical School, Katy managed the Washington site of a multi-site NIH-funded pulmonology study.

The Court will hear oral arguments that day in U.S. Food and Drug Administration v. Alliance for Hippocratic Medicine. GUEST 1 OVERVIEW: Former White House health official Katy Talento to speak against FDA betrayal of women at U.S. Supreme Court rally on March 26.  GUEST 2 OVERVIEW: Rodney Scott served as the 24th Chief of the United States Border Patrol. During his three-decade career in the Border Patrol, under both Republican and Democrat administrations, Scott earned the respect and admiration of agents, colleagues and partners alike while working to successfully enforce our nation's laws and secure our borders.

No doubt about it...for many, the "Affordable Health Care Act" was anything but affordable. One alternative option to consider is a sharing ministry, like Medishare or Samaritan Ministries. Those are but two of the brands represented in The Alliance of Healthcare Sharing Ministries. Former White House employee and Executive Director Katy Talento returns to explain the benefits and value in such sharing ministries.

For so many in our health care fields, from nurses to administrators to public officials, health care is not simply a job, or a problem to be solved, but a life mission. Providing and enhancing the best care possible to those in need is the mission of the Alliance of Health Care Sharing Ministries. Their executive director, Katy Talento, joins the show.

Critical health care costs are rising! What are your affordable options that embrace biblical values and Christian community?  Learn from Katy Talento, veteran policy advisor, epidemiologist, and executive director of the Alliance of Health Care Sharing Ministries, about your health care options.

On this week's interview Paul discusses the New Mexico Insurance Commissioner's efforts to kill Christian Health Sharing plans in New Mexico. Katy Talento is a health care expert and Executive Director of the Alliance of Health Care Sharing Ministries. We discuss how the plans work and why they became so popular in the wake of ObamaCare. We also discuss why the Insurance Commissioner would come after these plans. Paul and his family once were part of one prominent health sharing plan. He describes his experience. 

Our ships are being bombed by terrorists and the mainstream media only cares about coo-coo E Jean Carroll! PLUS, Katy Talento, Executive Director of the Alliance Health Care Sharing Ministries, warns what is coming next with the return of mask mandates. And Gun Owners of America's Luis Valdes applauds Illinoisians for telling JB to FU with the massive non-compliace rate of registering assault weapons.See omnystudio.com/listener for privacy information.

On this episode, we're joined by Katy Talento, an epidemiologist, a health benefits consultant, and a veteran health policy advisor, most recently at The White House as the lead health advisor to President Donald Trump on the Domestic Policy Council. Katy joins us to discuss healthcare in the United States and, more importantly, Healthcare Sharing. See omnystudio.com/listener for privacy information.

On this episode, we're joined by Katy Talento, an epidemiologist, a health benefits consultant, and a veteran health policy advisor, most recently at The White House as the lead health advisor to President Donald Trump on the Domestic Policy Council. Katy joins us to discuss healthcare in the United States and, more importantly, Healthcare Sharing. See omnystudio.com/listener for privacy information.

On this week's TechTalk, Dr. Jay and Brad had the pleasure of interviewing Katy Talento, a licensed health benefits consultant, veteran health care reformer, epidemiologist and thought leader. Based in northern Virginia, Katy Talento is the Chief Executive Officer of AllBetter Health, a benefits advisory firm helping employers navigate the health plan marketplace and implement innovative solutions that reduce costs and improve patient experience. Katy quarterbacks AllBetter's nationwide, custom-curated partnerships of advisors, actuaries, member services teams and analytics gurus to deliver on the AllBetter client promise: significant savings, more generous benefits, and happier employees. As the top health advisor at the White House Domestic Policy Council to President Donald Trump, Katy spearheaded transformative policies to end secret health care prices across the United States, end predatory medical collections practices, lower prescription drug prices, guarantee health records access and interoperability for patients and their care teams, combat the opioid addiction crisis and eliminate domestic HIV/AIDS. She first developed her take-no-prisoners approach to waste and corruption as an oversight investigator and legislative director on Capitol Hill, born of love and duty toward the hardworking American taxpayers. Katy has traveled the world, holding U.S. foreign aid programs accountable for results, as well as protecting the workforce of multinational energy companies from infectious disease threats. On the faculty of Georgetown University Medical School, Katy managed the school's participation in a multi-site NIH study. She founded a mentorship program for junior high girls in inner city DC and even served two years as a Catholic nun! Katy earned her graduate degree in Epidemiology from Harvard School of Public Health and an undergraduate degree from the University of Virginia.

A continuation of reporting on the Pray, Vote, Stand Summit, organized by the Family Research Council (FRC). This episode features excerpts of speeches from Republican presidential candidates. Also, we hear messages from Dr. Ben Carson, former Housing and Urban Development secretary; Mark Robinson, lieutenant governor of North Carolina; and noted author Os Guinness. Plus, Kelly interviews Katy Talento about the impact the rising cost of health care is having on families. And Alex McFarland discusses his outreach to help young Americans find purpose in today's culture.  ⭕️Watch in-depth videos based on Truth & Tradition at Epoch TV

CPS has a bigger budget, but will it produce any better results? Probably not! PLUS, Katy Talento, executive director of Alliance of Health Care Sharing Ministries, points to mainstream media's advertising being controlled by the pharma swamp that is preventing patients of getting the best health care coverage. And Wayne Black, founder of Wayne Black and Associates, tells Shaun there is no excuse for a lack of security at your child's school and he put together a guide for parents to ensure their schools are safe from lunatics gunmen. School Insecurity: A Comprehensive Guide for Parents and Educators on School Security, Protecting Your Children and Fostering a Safe Learning Environment.See omnystudio.com/listener for privacy information.

Are you a decision maker at your business? If you're a CEO, CFO, the head of HR, or perhaps the owner of a small, medium or large business then you owe it to yourself to check out this fairly simple solution to save over 50% on your health care spend. Health insurance is usually one of the biggest overhead expenses after salaries for any company and it affects the bottom line of nearly every business. Imagine what your company could do if it paid out less than 50% in its health care spend - while also maintaining a similar if not improved plan for employees. Before you scoff and say that there is no way you can provide your employees high quality care at less than half the cost, just remember that only about 25% of every dollar spent in health care actually goes to caring for patients. There's plenty of room to cut. Why Health Insurance Is So Expensive?The reasons for expensive insurance is obviously a complicated question. However, it's simplest to think of it in just a few ways - especially when we look for ways to bypass the rotten system to save real money for our business. The insurance companies make money by paying out a lot in claims. This seems illogical at first glance but makes a lot of sense once you realize that the insurance companies are only allowed to use 15-20% of the total they pay out in claims towards profit and overhead. Therefore, the more in claims payouts, the higher amount they can profit. Pharmacy benefit managers (PBMs) hang onto the rebates. Instead of passing on the volume discounts (or rebates) onto the employers and employees they keep that percentage of charges. Just like the insurance companies, the more that is paid out in charges the greater revenue they get to keep leading to ever increasing pharmaceutical prices. Insurance brokers primarily make their money through commissions from the insurance companies. This incentive leads them to find only solutions for your company that involve large insurers. The only way you can actually save money is to bypass the traditional means of creating a health plan which most brokers are not aligned to do. Building a Better Health Plan?What becomes readily obvious as far as solutions go is that you must create your own self-funded health plan and find transparent PBMs and rational contracting to pay for services. Very few companies are prepared to do this which is why you need to find insurance brokers and third party administrators who can set it up for you. There are plenty around, you just need to seek them out. I've had two on in the past whom I reference in the show. Of course, they are hardly an exhaustive list of players in the field but they would be a good start for anyone investigating these solutions for their business: Katy Talento of All Better Health and David Contorno of Epowered Benefits.   show notesEpisode 176: Today's show Episode 111: Katy Talento tells us how she saves businesses money. Episode 150: David Contorno explains his business model. Episode 043: How PBMs jack up drug prices. All Better Health: Katy Talento's business where she helps others create their own health care plans. E Powered Benefits: David Contorno's business helping others create health care solutions. We Are Libertarians: The Paradocs is a proud partner and member of this outstanding podcast network. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Learn more about your ad choices. Visit megaphone.fm/adchoices

Cocaine in the West Wing! Wonder who brought that in.....PLUS, Katy Talento, Executive Director of Alliance Health Care Sharing Ministries, tells Shaun the left is trying to perpetuate racism when it comes to health care - but your health doesn't care about your race! And Aaron Withe, CEO of Freedom Foundation, is taking on the government unions with his new book Freedom is the Foundation: How We are Defeating Progressive Tyranny by Taking on the Government Unions.See omnystudio.com/listener for privacy information.

Famed actor and veterans' advocate Gary Sinise comes on to preview his foundations memorial day activities. Next, syndicated columnist Cal Thomas joins us with his new book "A Watchman in the Night." Then, CEO at AllBetter Katy Talento explains the current war on babies being waged by pharmaceutical companies and the government. Finally we take your calls in open phones across America. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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

They want to arrest the Pentagon document leaker when they should be arresting Joe Biden! Former Texas Congresswoman Mayra Flores joins Shaun and tells about her time spent in Congress, what she learned, and how she is still fighting for the rights of her people in Texas. PLUS, Director of Alliance Health Care Sharing Ministries, Katy Talento, tells Shaun how Robert Kennedy Jr.'s presidential run will affect health care choices for Americans.See omnystudio.com/listener for privacy information.

In this episode of Conversations That Matter, The New American magazine's senior editor Alex Newman talks with Katy Talento, executive director of the Alliance of Health Care Sharing Ministries and former top health advisor at the White House Domestic Policy Council. Alex and Katy discuss how to fight back against the monstrous government healthcare/corporate healthcare/insurance system, including ... The post Katy Talento: We Can Fight Corporate Healthcare appeared first on The New American.

Today, on the Truth & Liberty Live Call-In Show, join host Alex McFarland with guest Katy Talento as they discuss fixing our corrupt healthcare system, as well as the events that are shaping our culture while taking your questions! Tune in Monday-Friday at 3:30 pm MT (5:30 ET) and call (719) 619-2341 and get the answers you need to live in truth and freedom!

The whole world of healthcare changed dramatically in 2009 with the introduction of the Affordable Care Act, also known as Obamacare. Katy Talento was an advisor to President Trump, complete with an office in the White House. Now, she serves this alliance which includes all the big known sharing ministries like Medishare, Samaritan Ministries, and others. Katy discusses a recent article she penned that deals with several urgent manners, including the need to ensure price transparency by hospitals and providers.

On "EWTN News Nightly" tonight: While President Joe Biden continues his trip to Mexico City, the US Department of Justice launched a review of classified documents found at his former institute in Washington DC. Founder and President of the Internet Accountability Project, Mike Davis, joins to share his reaction to the discovery of the classified documents at the Penn-Biden Center. Meanwhile, House Republicans passed their first test of the new Congress - adopting a rules package. It lays out operating rules for the next 2 years. And the FDA changed existing laws last week. Retail pharmacies that agree to certain rules can now distribute the abortion drug Mifepristone to women who have a prescription from their doctors. CEO and President of 40 Days for Life, Shawn Carney, joins to share his reaction to this move by the FDA. Bloomberg Law purchased 33 baby food products in stores and online and mailed them to a laboratory to be tested for results. All but one contained at least 2 of 3 heavy metals: lead, arsenic and cadmium. Executive Director of the Alliance of Health Care Sharing Ministries, Katy Talento, joins to tell us about the FDA's response to the Bloomberg study. Finally this evening, Pope Francis met with Italy's Prime Minister Giorgia Meloni at the Vatican. Senior Rome Correspondent for Catholic News Agency, Hannah Brockhaus, joins to tell us more about this meeting and what topics were discussed. Don't miss out on the latest news and analysis from a Catholic perspective. Get EWTN News Nightly delivered to your email: https://ewtn.com/enn

Maniac Monday! The White House is filled with them! Katy Talento, Executive Director of Alliance Health Care Sharing Ministries, tells Shaun that more people are going bankrupt from medical bills now than ever before and nonprofit hospitals are the biggest perpetrators. PLUS, EJ Antoni says this Christmas is going to be the most expensive Christmas we will see in our lifetime!See omnystudio.com/listener for privacy information.

Shaun is tired of living under this ponzi scheme of a government! Filmmaker Phelim McAleer doesn't know what is worse - the Biden crime family or the media that covered it up. He tells Shaun about his new movie "My Son Hunter" that exposes Hunter's crimes and how Joe Biden is tied up in them. PLUS, Katy Talento, CEO of All Better Health, tells Shaun of the abuses of big pharma and how you can fight back.See omnystudio.com/listener for privacy information.

Dr. Patrick Byrne is a true American Patriot and the embodiment of the American Dream. He is the Founder and former CEO of Overstock.com. We discuss the raids, freedom, and protecting your vote with www.americaproject.com Joe Hoft, Certified Public Accountant and a former International Auditor will publish a second volume of his book The Steal, which provides a unique, in-depth forensic analysis of the abnormalities of the 2020 election. Katy Talento, Executive Director, Alliance of Health Care Sharing Ministries (The Alliance, ahcsm.org LEGAL ANALYST/AUTHOR: John D. O'Connor, is author of the new book, The Mysteries of Watergate: What Really Happened and Postgate: How the Washington Post Betrayed Deep Throat, Covered Up Watergate, and Began Today's Partisan Advocacy Journalism and host of The Mysteries of Watergate Podcast. He is hear to discuss the #TrumpRaid --- Support this podcast: https://anchor.fm/the-buff-show/support

John Stemberger is a longtime attorney in Orlando, and president of the Florida Family Policy Council. John is active in Florida politics, working closely with Tallahassee to promote pro-life and pro-family issues. John brings news of a 13 city pastor's tour, educating Florida pastors on urgent issues. Also today, another visit from Katy Talento from the Alliance of Health Care Sharing Ministries, and finally a talk with Karen England, who is part of the big film out by USPIE entitled "Truth and Lies in American Education."

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

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

In this healthcare podcast, I am speaking with Cora Opsahl, who directs the 32BJ Health Fund. This is the second conversation I'm having with Cora (last one was EP372), but these two conversations are not really linear—so listen in whatever order you want to.   Important to know about Cora's background, in previous roles, she has worked deep in the inner sanctums of the healthcare industry. So, she came to 32BJ armed with a BS meter that's finely tuned, which is, as I said last week, an unfortunately essential skill for anyone trying to help patients and members relying on them to successfully navigate the healthcare industry. Here's a pivotal fact: 56% of total spend at the 32BJ Health Fund goes to hospitals. So, from a “making the juice worth the squeeze” perspective, focusing on hospital prices can have a lot of impact. This is doubly true because of the seriously huge price variations for the same exact types of services at different hospitals, even in the same local market. Because the 32BJ Health Fund demands and gets all of its own data, it can actually run reports and see the impact and nuances of hospital spend very clearly—unlike, frankly, the majority of employers and unions who have zero clue this is all going on behind their backs because they think some other party is actually the fiduciary and not them, which is false, of course. So, let's just linger on this really high hospital prices that are various across a market for one moment. Here's a Tweet from Rik Renard: “The price of CABG [coronary artery bypass graft] varies more than 10-fold across US hospitals (ranging from $44,824 to $448,038). There was no evidence to suggest that hospitals that charge higher prices provide a better quality of care.”   WHAT?! An employer could pay $44,000, or it could pay $448,000. Seriously? This is why we can't have nice raises—because some employer spent $400,000 not on raises but on overpriced hospital services. Ugh … so frustrating. When employers, almost willfully at this juncture, turn a blind eye to all of this because they think it might be disruptive, meanwhile they're worrying about employee retention and trying to figure out how to give raises. Okay, well, here's a suggestion: Get your healthcare house in order and then you'll have enough money for raises, but that aside … In the New York City market, 32BJ used all of the data that we talked about in the last episode (EP372). They used all of that data to deduce, quite crisply, that NewYork-Presbyterian is really, really expensive—even in comparison to other expensive health systems in the New York metro area.   Furthermore, the Fund realized that it could not be sustainable without tackling the challenge of hospital prices. As Cora Opsahl says, “You can't reduce spend by benefit design alone.” Which reminded me of that famous quote by Uwe Reinhardt, “It's the prices, stupid.” Which, of course, reminded me of what David Contorno has said a million times, “You can't pay less for healthcare unless you pay less for healthcare.” I can't overemphasize these points and their impact on employers and workers. It's really hard to be competitive in the global marketplace when shelling out an extra $400,000 here and an extra whatever tens of thousand dollars there for fringe benefits that do not actually add any value from the workers' standpoint and/or confer any additional health. This is just blatantly throwing money away. So, there's gonna be a few health system peeps listening here who will reflexively mutter under their breath a sentence including the terminology “razor-thin operating margin.” It must be an AHA talking point because I talk to a lot of health system people from all over the country, and “razor-thin operating margin” is invariably the term that gets used. But let's just dig into that marketing-speak for a moment. While there are some hospitals who assuredly suffered under COVID (or were suffering even before COVID and definitely after), mostly these are rural ones—but let's not talk about them for a moment. Let's talk about the large, consolidated health systems who got billions in COVID relief. Are you kidding me with their razor-thin operating margin crocodile tears? Check out “New Study—Hospitals Hike Charges by Up to 18 Times Cost.”   Here's a few bullet points from that study: Hospital charges play a major role in mounting healthcare costs, with health expenditures closing in on one-fifth of the gross domestic product (GDP). Hospital profits/margins have mushroomed by 411% since 1999 to a record $88 billion in 2017. The rise in charges coincides with growing hospital mergers and acquisitions by large systems. (This is brutally apparent at this juncture.) The result is increased market consolidation, which leads to, again, higher profits and increased charges, not savings for patients as hospital systems often claim. Listen to the show with Kevin Schulman, MD (EP366). It explains a lot about how these “razor-thin operating margins” and the “oh no, we're losing money on Medicare, so we must cost shift” manifest if you actually follow the dollar. As Dr. Schulman says, it's not A; it's not B. I mean, it's not like payers aren't taking their own piece of the action. You just got to look at their stock valuations to see all that going on. We have a dysfunctional health benefits market and a lot of rational actors in that market doing what you'd expect rational economic actors to do.   So anyway, 32BJ sees in their own data that all this is going on with hospitals, and they aim to stop covering a super expensive hospital in their local market, which is just making bad even worse. It was a whole thing to do this, and in this episode, Cora Opsahl relays the dramatic tale. You can learn more at 32bjhealthfundinsights.org.   Cora Opsahl is the director of the 32BJ Health Fund, a self-funded plan that provides affordable, comprehensive, and innovative health coverage to 200,000 union members and their families. During her time at the Health Fund, Cora has led the implementation of multiple benefit changes: removing NewYork-Presbyterian Hospital System and physicians from the network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and implementing an expanded Centers of Excellence program administered by Mount Sinai Hospital System. These efforts are projected to save over $35 million in 2022. Prior to joining the 32BJ Health Fund, Cora spent 12 years with Express Scripts, a pharmacy benefit manager. During her time there, she held a variety of roles, including Medicare Part D, strategy and acquisitions, operations, and account management. 07:02 What motivated the decision for 32BJ to cut NewYork-Presbyterian out of their network? 09:14 How did 32BJ compare their spending at each hospital in their network? 13:01 “We cannot be sustainable as a health fund … without really tackling the challenge of hospital prices.” 13:38 “It is one of the challenges as a self-funded plan that, even having this data, there's not a lot we can do with it.” 16:10 What is 32BJ Health Fund's maternity program? 19:34 What is the HEAL Act, and why did 32BJ Health Fund support it? 21:39 “For us, we just don't feel it's right that anyone gets to dictate our benefit.” 22:43 EP368 with Ashleigh Gunter.23:34 Why did 32BJ Health Fund reprice their claims using Medicare rates? 24:58 “It really goes to show you how high the commercial prices are in comparison to Medicare.” 25:52 EP366 with Kevin Schulman, MD.   You can learn more at 32bjhealthfundinsights.org.  @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth What motivated the decision for 32BJ to cut NewYork-Presbyterian out of their network? @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth How did 32BJ compare their spending at each hospital in their network? @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We cannot be sustainable as a health fund … without really tackling the challenge of hospital prices.” @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It is one of the challenges as a self-funded plan that, even having this data, there's not a lot we can do with it.” @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is 32BJ Health Fund's maternity program? @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the HEAL Act, and why did 32BJ Health Fund support it? @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “For us, we just don't feel it's right that anyone gets to dictate our benefit.” @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why did 32BJ Health Fund reprice their claims using Medicare rates? @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It really goes to show you how high the commercial prices are in comparison to Medicare.” @CoraOpsahl discusses managing #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32)

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

I wanted to remind everyone about this show from last year because it's becoming increasingly relevant. We have this weird thing going on where everybody seems to be talking about physician incentives and payments and financial implications but so often disregards patient incentives and payments and financial implications. Consider that we're at a place in the time-space continuum where it is inarguable that financial toxicity has become clinical toxicity. Patients are increasingly in huge numbers abandoning care, splitting pills, doing all kinds of things to save money that are clinically toxic. And these are patients with “good insurance” that we are talking about here. So, here's a role play: Provider organization is actually paying doctors for outcomes. In wanders a patient with a huge deductible. Doc says, “Wow, Patient … so important that you take your insulin or med as directed or get a follow-up on that scary colonoscopy finding.” Patient says, “Sorry, Doc. Can't afford it.” And the doc gets dinged because the patient outcomes are avoidably poor. That's what this show with Dr. Mark Fendrick digs into: aligning patient incentives (aka benefit designs etc) with value-based payments on the provider side. And with that, here's your encore: And here I thought I knew a lot about value-based care. In this healthcare podcast, I am speaking with Mark Fendrick, MD, who is the director over at the University of Michigan Center for Value-Based Insurance Design. This conversation is for those of you who already know pretty much about value-based care concepts. If you do not, I'd go back and listen to, say, Encore! EP206, with Ashok Subramanian, before this one.   Dr. Fendrick talks in this healthcare podcast about what it takes for value-based care to happen in the real world. No kidding, it's about making sure that reimbursement is aligned with good things (no great surprise there). But two light bulb moments I had in this conversation with Dr. Fendrick: At the beginning of the year, how many doctors and nurses, inspired to do the right thing, have told their patients with diabetes, say, to go get an eye exam to check for diabetic retinopathy? No one would disagree that this is definitely a good idea. Diabetic retinopathy causes blindness. But here's the reality of that conversation. Doc says, “Go get an eye exam.” And patient says, “I can't. My deductible is huge, and I can't afford it.” So, the patient doesn't get the follow-up care and winds up in the hospital or blind. And the doctor gets dinged on his or her quality scores. Suboptimal outcomes all around, I'd say. This also happens on the pharmacy side of the equation, but I think a lot of us are a little bit more familiar with that scenario—like type 1 diabetics who can't afford to pick up their insulin because of a Medicare Part D or commercial deductible that they haven't met yet. I just never really connected the dots back to the provider getting black marks because their patient has a benefit design that's not aligned with the quality measures. In a majority of benefit designs, consumer price sharing is based not on the value of the service but on how expensive the service just happens to be. Wow! So, we're trying to get our plan members to be consumers and use the power of their wallets to make good healthcare choices. And what we're really doing is driving them toward cheap things or no care and discouraging them from indulging—and I say that sarcastically—in expensive things. But the expensive things might be the high-value care, and the relatively cheap things might be crap that's fully unnecessary or harmful and, over a whole population, adds up to a lot of zeros. Healthcare is not like a consumer market where the expensive things are usually a better version of the cheap things. For all you economists out there, you don't want the demand curve to be elastic when what's cheap and what's expensive has no correlation to quality or necessity. Nobody should be super flabbergasted when a $35 cure-all supplement peddled on YouTube makes some random influencer a millionaire. That's how supply and demand works. Much to ponder in this episode. You can learn more at vbidcenter.org. There's also a great newsletter you can sign up for there.   A. Mark Fendrick, MD, is a professor of internal medicine in the School of Medicine and a professor of health management and policy in the School of Public Health at the University of Michigan. Dr. Fendrick received a bachelor's degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School. He completed his residency in internal medicine at the University of Pennsylvania, where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Fendrick conceptualized and coined the term Value-Based Insurance Design (V-BID) and currently directs the V-BID Center at the University of Michigan (vbidcenter.org), the leading advocate for development, implementation, and evaluation of innovative health benefit plans. His research focuses on how clinician payment and consumer engagement initiatives impact access to care, quality of care, and healthcare costs. Dr. Fendrick has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design. His perspective and understanding of clinical and economic issues have fostered collaborations with numerous government agencies, health plans, professional societies, and healthcare companies.   Dr. Fendrick is an elected member of the National Academy of Medicine (formerly IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the US Senate Committee on Health, Education, Labor and Pensions; the US House of Representatives Ways and Means Subcommittee on Health; and the US Senate Committee on Armed Services Subcommittee on Personnel. 05:00 Is back surgery high-value care? 05:51 If care is patient to patient, how is high-value care decided upon? 06:40 “Flintstones delivery: We have to move from the sledgehammer to the scalpel.” 11:14 “Almost all of the services that we recommend to reduce cost sharing … do not save money.” 12:30 “I didn't go to medical school to learn how to save people money.” 17:03 “When a patient and their clinician agree … the patient should be able to get that [service] easily, and the clinician should be paid generously.” 18:01 “When patients and providers are aligned, they do much better.” 19:59 What services are deemed high value, and what services should be pre-deductible? 21:50 “Are primary care visits high value? … The answer is, it depends.” 25:55 What are V-BID's core pillars to address value-based care? 28:04 How does Dr. Fendrick's method of value-based care and reimbursement actually enable better consumerism? 29:51 What do providers think about changing reimbursement on low-value and high-value care? 30:58 “We have incentives that are run amok.” 32:12 EP176 with Dr. Robert Pearl. 32:49 “It's all about incentives.” 33:43 “You do have the funding; you just have to have the courage.” You can learn more at vbidcenter.org. There's also a great newsletter you can sign up for there. Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth If care is patient to patient, how is high-value care decided upon? Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Flintstones delivery: We have to move from the sledgehammer to the scalpel.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Almost all of the services that we recommend to reduce cost sharing … do not save money.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “I didn't go to medical school to learn how to save people money.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “When patients and providers are aligned, they do much better.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Are primary care visits high value? … The answer is, it depends.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “We have incentives that are run amok.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “You do have the funding; you just have to have the courage.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble  

Katy Talento, Executive Director of the Alliance of Health Care Sharing Ministries, details the features of the new independent accreditation board. More information on http://www.AHCSM.org See omnystudio.com/listener for privacy information.

So, this is a 400-level episode in specialty pharmacy options for plan sponsors, meaning here are your prerequisites: You gotta know what buy and bill is, and you gotta know what pharmacy bagging is, meaning white bagging, for example. If you do not, I would listen to Encore! EP282 with Aaron Mitchell, MD, MPH, where we go deep on buy and bill. And then listen to EP369 for the skinny on pharmacy bagging. If you already know what buy and bill is and you already know what white bagging is, then not only do you know more than 98% of the people in the healthcare industry, but also, you're going to get as much out of this conversation with Erik Davis and Autumn Yongchu as I did.   Last week's show was also with Erik Davis and Autumn Yongchu. Last week, we talked about how some hospitals and cancer centers are managing to ring up up to six times the cost of an expensive-already injected or infused drug through buy and bill. This is why pharmacy bagging became a thing, if we want to talk about this in historical perspective. It's a direct market response to buy and bill. Hospital systems start making egregious amounts of money marking up drugs that already cost hundreds of thousands of dollars, and their markups are hundreds of thousands of dollars on top of that. Hospital starts making a fortune off of drug markups. Plan sponsors need an alternative, and … enter pharmacy bagging (ie, carving out specialty pharmacy drugs to a PBM [pharmacy benefit manager]). In this show, we compare the potential benefits and problematic loopholes and/or patient concerns for plan sponsors who are trying to figure out whether to carve out specialty pharmacy benefits to a PBM or grin and bear it with the buy and bill. Or, as another option, whether to steer patients to specific infusion centers or specific provider organizations that might have more favorable contract terms for the plan sponsor. Or, hooking up with a home infusion company, again, who is willing to negotiate terms that might be far better for said plan sponsor than just letting some hospital have their way with employees and the health plan. As another alternative, of course, plan sponsors could consider medical travel, which some certainly are. My biggest takeaway from this whole conversation and from the episodes that we have had in this, dare I call it, series about pharmacy benefits, starting with the show with Scott Haas (EP365) where we talked about PBM contracts, moving to the show with Dr. Aaron Mitchell (Encore! EP282) where we talked about buy and bill, then going to the show with Keith Hartman (EP369) where we talked about pharmacy bagging, then last week's show how hospitals manage to buy and bill at 6x the price of these expensive pharmaceuticals … my takeaway from this whole specialty drug extravaganza is that specialty drug procurement is very different than retail drug procurement. Retail drugs, you worry about them en masse at scale almost at the population level. Specialty drugs? You can have one patient on a specialty drug, and that one patient costs as much as the entire rest of the member population combined. So, managing specialty drugs and their administration becomes almost a case-by-case operation. What drug is it? Where is the patient? What options are available? It's possible to save hundreds of thousands of dollars on that one patient, for that one patient's care, and get better patient outcomes by getting the right patient on the right drug that is administered in the right setting.   You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis, AAI, CIC, CRM, is senior vice president and principal consultant, managed care and analytics, at USI Insurance Services. He has over 30 years of experience in the insurance and risk management industry. Erik works to create an environment that supports the healthcare risk management goals of an organization while maintaining focus on compliance and financial accountability. He is instrumental in vendor negotiations, data benchmarking, population health strategies, claims analysis, recommendations in plan design, and communication strategies. In this capacity, Erik has been involved with development of rates, payment structures, and recommendations of changes in processes, policies, and procedures. He has a broad understanding of contract analysis, evaluating risk, auditing for correct payment, and structuring of excess loss and pharmacy programs. Erik's experience extends from overall employee benefits consulting to workers' compensation, as well as managed care organizations in Medicaid, Medicare, and commercial contractual risk arrangements. Erik earned his bachelor's degree in economics from Oregon State University. He holds Accredited Advisor in Insurance (AAI), Certified Insurance Counselor (CIC), and Certified Risk Manager (CRM) designations. Autumn Yongchu is a healthcare operational risk consultant at USI Insurance Services. Autumn works with multiple database platforms to examine data for trends and abnormalities. Using investigative querying, medical coding analysis, and report development, she provides resources that help identify cost control opportunities and assists organizations in strategic business decisions regarding the management of healthcare risks. Autumn analyzes and interprets healthcare utilization data, allowing the development of initiatives regarding claim and risk management. This includes identifying fiscal and clinical strategies and providing necessary information to develop, design, and implement management initiatives. Autumn also analyzes trends, assists with insurance underwriting, and adjudicates stop-loss claims. Autumn has an in-depth knowledge of Medicaid and Medicare billing guidelines and payment methodologies. Prior to joining USI, Autumn was a claims auditor and trainer for a managed care organization which serviced over 100,000 commercial, Medicaid, and Medicare lives. Her responsibilities included contract analysis, claims adjudication, ensuring accurate payment, and identifying and recouping errors. 04:45 Can you actually save money by carving out specialty infused drugs and making them a pharmacy benefit? 06:28 How can plan sponsors use white bagging as leverage to reduce costs from markups? 06:47 Does white bagging save money compared to buy and bill? 07:42 “You also need to understand that with some of these drugs, you're dealing with very vulnerable people.”—Erik 08:41 EP369 with Keith Hartman, RPh. 11:10 “When your insurance carrier is married to your PBM, it doesn't matter where the money goes.”—Autumn 11:33 EP365 with Scott Haas. 12:00 “You need to have a collective understanding of every variable … when you're making those … decisions.”—Erik 14:53 How can comparison shopping save plan sponsors money when it comes to specialty infusion costs? 16:51 How can comparison shopping be a vicious circle in the wrong setting for plan sponsors? 18:43 “That's part of the problem: It's not just the plan sponsor not being educated enough; it's also the consultant … that they believe is supposed to be that isn't.”—Erik 19:03 How has transparency been used by healthcare systems to keep buyers' eyes off the ball? 26:55 “It is very case by case, but it comes down to your risk appetite.”—Autumn 28:19 “It's something that you have to, as a plan sponsor, really continue to monitor throughout the plan year.”—Autumn 28:38 “The more you know, the better equipped you're gonna be.”—Autumn 29:27 What can employers who are feeling aggressive do? 31:19 “The dollars circle, whether people realize it or not.”—Autumn You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma Can you actually save money by carving out specialty infused drugs and making them a pharmacy benefit? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How can plan sponsors use white bagging as leverage to reduce costs from markups? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma Does white bagging save money compared to buy and bill? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “You also need to understand that with some of these drugs, you're dealing with very vulnerable people.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “When your insurance carrier is married to your PBM, it doesn't matter where the money goes.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “You need to have a collective understanding of every variable … when you're making those … decisions.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How can comparison shopping save plan sponsors money when it comes to specialty infusion costs? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How can comparison shopping be a vicious circle in the wrong setting for plan sponsors? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “That's part of the problem: It's not just the plan sponsor not being educated enough; it's also the consultant … that they believe is supposed to be that isn't.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How has transparency been used by healthcare systems to keep buyers' eyes off the ball? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “It is very case by case, but it comes down to your risk appetite.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “It's something that you have to, as a plan sponsor, really continue to monitor throughout the plan year.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “The more you know, the better equipped you're gonna be.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma What can employers who are feeling aggressive do? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “The dollars circle, whether people realize it or not.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma   Recent past interviews: Click a guest's name for their latest RHV episode! Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger  

I have been on a mission to figure out why some health systems, particularly in the oncology space but not limited to the oncology space, could manage to mark up the price of infused specialty pharmacy drugs up to 6x. Some employers and patients are paying six times the cost of a specialty pharmacy drug in markup for some already incredibly expensive specialty pharmacy drug at some oncology centers. Read more about this in a study by Roy Xiao, MD, and colleagues. Let's not forget now or ever that financial toxicity is clinical toxicity. This 6x is exactly how financial toxicity is operationalized. Many patients are charged a coinsurance percentage based on their cost of care, after all; and like 20% of 6x is a huge number, it is a huge bankrupting bill for some patients—maybe many patients. That, plus their premiums go up because, of course, their employers are picking up the remaining 80% of that 600% markup. Families are already, on average, paying I think it's $22,000 in premium; and the trend line on that premium growth continues to go up steeply in the 2022-23 projections that I have seen. Bottom line: This 6x is not a victimless modus operandi is my point. But what I wanted to know is how they do it, these health systems. Charging 6x the cost of a super expensive specialty pharmacy drug in markup would seem to require some skill, right? And any time I see a Pandora's box, I have a terrible habit of trying to get in there. Autumn Yongchu and Erik Davis to the rescue. Today's show digs into how some health systems and hospitals stack the odds that no one will notice their 6x markups and just pay the bills. Here's the short version of the playbook, but you'll need to listen to the show for a more robust explanation. First off, keep in mind that while Medicare Part B tells hospitals to charge ASP (average sales price) + 6% (ish) when they buy and bill Medicare patients, there is no such guidance for commercial patients. Commercial insurers negotiate a fee off chargemaster rates, and as we all know, those chargemaster prices are, in general, based on absolutely nothing and are, in general, sky-high. So that's the first thing. The second thing gets into coding. Let me give you the general idea here, but we talk about this in some depth in the conversation to come. As you likely know, hospitals get paid by sending bills with codes on them—procedure codes, for example. We the hospital did this procedure, and our charge for this procedure is $4000—so, here you go. Code followed by dollar amount is shown on somebody's bill or explanation of benefits document. These procedure codes are standardized across the industry for the most part. It's not like every health system and/or payer is making up their own. This standardized set of procedure codes is called the Healthcare Common Procedure Coding System, affectionally known as HCPCS. So, if someone starts talking about a HCPCS code, all it means is that the code comes out of that standard set of codes. Now, J-codes are one kind of code in this common procedure coding system. They are procedure codes that start with a “J.” These J-codes are for procedures involving (usually) specialty pharmacy drugs. A J-code identifies the specialty pharmacy drug that was used in the procedure. So, you'd think it'd be pretty easy to audit a hospital bill, right? You look at the J-code on the bill; you find the ASP, the average sales price, or whatever of the drug; and then you get out your trusty calculator and you do the math on what the markup is. And okay, maybe this works sometimes … but the problem is that so very, very often, the hospital doesn't put the actual drug's J-code on the bill. There's this miscellaneous J-code that doesn't specify the drug used, which is a quite common tactic, it seems. (I learned that in this episode.) Hospital just sticks “Miscellaneous chemotherapy” on a bill with a price after it, and nobody knows what drug was used. Or the hospital will send a bill that just includes revenue codes. I think about revenue codes as the name of the section of the bill. It's like on a menu: There's that section, that headline, that says “Seafood” with a whole list of seafood dishes underneath it. In this example, the Seafood header is like the revenue code; and the J-codes are the actual dishes. Some bills come from the hospital, and all they have on them are the revenue code. There was some seafood. We're not gonna tell you what dish or how much seafood, but yeah, seafood. The only thing we know about seafood is that there was some and it was very pricy. Here's a great example of a bill with some explanations.   The main point here is that how health systems get away, in large part, with charging a whole lot for specialty pharmacy drugs is that their bills roll up charges into these very opaque codes that include lots and lots of stuff that is not broken out. When I interviewed Marshall Allen (EP328) and we talked about his book Never Pay the First Bill, he said step one in getting an accurate and fair bill is to ask for the line item charges—and now that is totally making sense to me and also why this is so vital. Just be aware, if you ask for these breakouts, you will likely get a huge box of hard copies. Check out this photo of a literally three-foot pile of printouts that one patient-turned-artist exhibited at an art show recently that I saw. If you don't have the stamina to sort through all of those pages and pages and pages, you could be subject to 6x or more in markups or billing errors which are all too common and all too expensive. Hospital charges are a huge chunk of any employer's healthcare spend, after all—over half of it in some cases. These are not small potatoes that we're talking about. These are bills that bankrupt patients and make premiums go so high that patients cannot afford to get care.   In this healthcare podcast, as mentioned earlier, we have two guests—Erik Davis and Autumn Yongchu—both from USI Managed Care Consulting and both having spent decades deep in the inner workings of the healthcare industry. And the topic of today's show required that depth of knowledge, for sure. You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis, AAI, CIC, CRM, is senior vice president and principal consultant, managed care and analytics, at USI Insurance Services. He has over 30 years of experience in the insurance and risk management industry. Erik works to create an environment that supports the healthcare risk management goals of an organization while maintaining focus on compliance and financial accountability. He is instrumental in vendor negotiations, data benchmarking, population health strategies, claims analysis, recommendations in plan design, and communication strategies. In this capacity, Erik has been involved with development of rates, payment structures, and recommendations of changes in processes, policies, and procedures. He has a broad understanding of contract analysis, evaluating risk, auditing for correct payment, and structuring of excess loss and pharmacy programs. Erik's experience extends from overall employee benefits consulting to workers' compensation, as well as managed care organizations in Medicaid, Medicare, and commercial contractual risk arrangements. Erik earned his bachelor's degree in economics from Oregon State University. He holds Accredited Advisor in Insurance (AAI), Certified Insurance Counselor (CIC), and Certified Risk Manager (CRM) designations. Autumn Yongchu is a healthcare operational risk consultant at USI Insurance Services. Autumn works with multiple database platforms to examine data for trends and abnormalities. Using investigative querying, medical coding analysis, and report development, she provides resources that help identify cost control opportunities and assists organizations in strategic business decisions regarding the management of healthcare risks. Autumn analyzes and interprets healthcare utilization data, allowing the development of initiatives regarding claim and risk management. This includes identifying fiscal and clinical strategies and providing necessary information to develop, design, and implement management initiatives. Autumn also analyzes trends, assists with insurance underwriting, and adjudicates stop-loss claims. Autumn has an in-depth knowledge of Medicaid and Medicare billing guidelines and payment methodologies. Prior to joining USI, Autumn was a claims auditor and trainer for a managed care organization which serviced over 100,000 commercial, Medicaid, and Medicare lives. Her responsibilities included contract analysis, claims adjudication, ensuring accurate payment, and identifying and recouping errors. 07:33 How do hospitals maximize inpatient bills? 08:05 How can hospitals upcode on specialty pharmacy products? 09:44 “It's really not uncommon to be overbilled and overcharged.”—Autumn 11:11 Why do marked up bill charges actually affect the price commercial payers pay? 12:49 “If your payer's not double-checking … how do you know that fraud's happening?”—Autumn 12:52 “If the payer doesn't have the detail to validate what that drug actually is, then are they really checking?”—Autumn 13:33 Why is it so hard to verify what you're actually paying for on a hospital bill? 16:28 How do hospitals maximize profit with outpatients? 17:12 “Really it comes down to contracts and how [the] contracts are written.”—Autumn 21:54 “There are … silos within healthcare, and none of them actually talk to each other.”—Autumn 24:56 “There are these rules out there, but there are also big loopholes out there.”—Autumn 26:13 How can hospitals maximize payments for Medicare patients on drugs that have been out for a while? 29:30 “We just have a tendency to assume … that Medicare has a rate for everything, and Medicare doesn't.”—Autumn 30:32: EP369 with Keith Hartman, RPh.   You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How do hospitals maximize inpatient bills? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How can hospitals upcode on specialty pharmacy products? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “It's really not uncommon to be overbilled and overcharged.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems Why do marked up bill charges actually affect the price commercial payers pay? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “If your payer's not double-checking … how do you know that fraud's happening?” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “If the payer doesn't have the detail to validate what that drug actually is, then are they really checking?” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems Why is it so hard to verify what you're actually paying for on a hospital bill? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How do hospitals maximize profit with outpatients? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “Really it comes down to contracts and how [the] contracts are written.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “There are … silos within healthcare, and none of them actually talk to each other.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “There are these rules out there, but there are also big loopholes out there.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How can hospitals maximize payments for Medicare patients on drugs that have been out for a while? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “We just have a tendency to assume … that Medicare has a rate for everything, and Medicare doesn't.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems   Recent past interviews: Click a guest's name for their latest RHV episode! Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong    

Last week's show was an encore episode with Dr. Aaron Mitchell (Encore! EP282), and we talked about buy and bill. To continue our exploration of specialty pharmacy intrigue, let's talk about so-called “bagging.” I wanted to get an overview of all of the different kinds of specialty pharmacy bagging. Bagging is a big deal. If you have anything to do with trying to control pharmacy costs or the clinical outcomes of specialty pharmacy patients, you too are going to want to understand what's going on here with bagging. I was thrilled to have a chance to chat with Keith Hartman, who is my guest in this healthcare podcast. He is the CEO of ContinuumRx. He's a pharmacist by education and has been in the pharmacy space for over 25 years now, touching just about every aspect of pharmacy from retail operations to long-term care and now, most recently, home infusion. This makes him an ideal person to chat with about this topic. And FYI, it was not easy to find someone to do so to clearly see the actions and reactions going on here because that's what this is all about: actions and reactions—how any self-respecting market distortion is going to cause a cascade of equal and opposite market distortions. So, let's cruise through the whole infused/injected specialty pharmacy historical play-by-play, shall we? It's like a “Who's on First?” routine—except very, very not funny. So, here we go. This is, of course, the semi-reductive abridged version; but let's do this thing. Once upon a time, the bagging story starts in ye olden days, meaning more than ten years ago, before specialty pharmacy drugs really became the massive profit centers for any party who can manage to get their fingers in the specialty pharmacy cookie jar. In these ancient and halcyon times, brown bagging was kind of a modus operandi. Don't forget, we're talking about infused or injectable drugs here, especially ones that need to be infused or injected in the provider's office. So, brown bagging means and meant when a specialty pharmacy drug is shipped directly to a patient, or a patient goes and picks up the specialty pharmacy drug at the pharmacy. Doc takes out prescription pad (this is in ye olden days, remember) and writes out the Rx. Patient picks up the drug from the pharmacy, which may be handed to them in a brown bag. Get it? But then they take that “brown bag,” as it were, to their doctor's office. The doctor takes the drug out of the brown bag and infuses or injects it. I say doctor's office because many times, in the olden days, that's where this went down. And this brown bagging had some issues, for sure; but specialty pharmacy drugs really weren't all that big of a thing either dollar-wise or frequency-wise. At some point in our story here, pharma manufacturers start seeing just exactly how much money the market will bear for specialty pharmacy drugs, and the prices of these specialty drugs go through the roof. At the same time, for a bunch of reasons I actually discussed with Dr. Bruce Rector (EP300), a whole bunch of these specialty pharmacy drugs start hitting the market all at once. So, these drugs have skyrocketing prices—and there's lots of them.   At that point, some (certainly not all, but enough) CFOs at provider organizations were like—wowza, epiphany, light bulb moment—there's a lot of money that can be made here because buy and bill. In buy and bill, which I talked about last week with Dr. Aaron Mitchell, provider organizations get reimbursed the cost of the drug plus some percentage when they administer it—meaning the more expensive the drug, the more money a provider can make because a percentage of a bigger number is, of course, a bigger number. Add to that a party-sized container of other provider shenanigans to maximize revenue on specialty pharmacy patients—and that revenue got bigger every single year. A recent report just came out that, on average, for oncology drugs, some providers are making six times the cost of the drug. Six times the cost of a drug that can cost lots of zeros! Just wow—6x! That's real money. This is winning the lottery every single time a patient needing a specialty drug shows up on your doorstep.   Continuing the tale here, this buy and bill health system extreme greed hits employers in their pocketbooks. And, of course, plan sponsors start desperately seeking relief. Who rides up on a white horse? PBMs (pharmacy benefit managers), of course. PBMs say that they will negotiate with drug companies and buy the drugs on behalf of the plan sponsors for much cheaper. Then they will ship the drugs purchased to the provider organizations. Thus, the plan sponsor only needs to pay providers to administer the drug, not that and some crazy markup on the drug itself. Ladies and gentlemen, white bagging has entered the building. White bagging is when the drug is not shipped directly to the patient à la brown bagging. It is when the drug is shipped to the provider. But wait … there's more to the story than a grand PBM gesture of goodwill. They see how much money the employers are used to paying providers for these drugs and realize that the PBM only needs to come in with a price that's less than that, at least at the beginning. So, over the years, weird stuff starts happening with rebates on the specialty drugs. Listen to the show with Scott Haas (EP365) for more on that. But bottom line, white bagging becomes not exactly a mecca of cost savings. PBMs are, as we all know, not known for their ability to moderate their profitability, after all. At this point in our story, let's just pause to say that provider organizations are very, very, very not happy with this whole white bagging intervention. Not only did a piece of the provider's specialty pharmacy cash cow get snatched by the PBMs, but there are also clinical issues with white bagging that we talk about on the show today. And some of these issues are not BS. Do not get me wrong. They are very real, and I do not want to minimize them. And so, provider organizations start to stand up their own hospital specialty pharmacies because then at least they can get some of the white bagging cha-ching. See what I mean? Plan sponsor, health plan mandates that the drug be filled in a pharmacy, hospital owns the pharmacy or part of the pharmacy … and now they have so-called clear bagging. Clear bagging is when one organization owns the pharmacy and the provider who will administer the drug. Clear bagging solves some of the clinical issues with white bagging, and the hospital also gets to take a cut. I'd be remiss not to mention here that some hospitals have worked very hard on their clear-bagging programs and definitely have tried to improve the quality of service here. You're going to have to listen to the show to hear about gold bagging and also the latest developments in this whole war employers and patients and taxpayers are fighting with PBMs and hospitals who are fighting with each other over who gets the money. Also, the continuing trend of brown bagging, especially as “in the patient's home” gets tagged on the end of lots of care delivery like “in bed” gets tagged on the end of lots of fortune cookies. Next week's show will dig into how exactly some providers are managing to get the up to 6x the cost of specialty pharmacy drugs when Medicare Part B at least says that they're only supposed to get ASP [average sales price] + 6% (ish). I just could not figure out how they were managing to get 6x just given that Medicare Part B rule, but yeah, they are—and we'll learn about that next week. You can learn more at continuumrx.com.   Keith P. Hartman, RPh, is chief executive officer of ContinuumRx and an experienced operating entrepreneur and pharmacy business owner spanning two decades. Keith founded and grew a chain of retail pharmacies, a compounding pharmacy, and two specialty pharmacies along with a long-term care pharmacy. All were built and grown under the guise of operational excellence and produced great results. Some were sold, while others he still owns and provides limited strategic guidance as a member of the board of directors. Keith graduated from the University of the Sciences with a degree in pharmacy. Today he is still involved mentoring future pharmacists and pharmacy owners. 08:09 What kinds of patients and/or drugs is the concept of bagging relevant to? 08:53 What is brown bagging, and what are the issues with it? 10:28 What is white bagging, and how is it different from brown bagging? 11:30 Who are the key players in pharma bagging? 12:25 Why does a PBM want a specialty drug to go through them? 12:49 From the physician's perspective, why is buy and bill ideal? 16:46 How does white bagging impact patient clinical care? 22:12 Encore! EP216 with Chris Sloan. 23:05 What are the two main reasons patients might not continue their therapy? 23:29 “We've got to leave some authority with our prescribers to be able to make a clinical decision of what's best for that … patient.” 24:41 What is clear bagging? 26:51 How does a hospital specialty pharmacy get in network with a PBM? 28:57 What is gold bagging? 30:11 “Outlook really needs to be what's best for the patient.” 32:10 EP337 with Olivia Webb.   You can learn more at continuumrx.com.   Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma What kinds of patients and/or drugs is the concept of bagging relevant to? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma What is brown bagging, and what are the issues with it? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma What is white bagging, and how is it different from brown bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma Who are the key players in pharma bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma Why does a PBM want a specialty drug to go through them? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma From the physician's perspective, why is buy and bill ideal? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma How does white bagging impact patient clinical care? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma What are the two main reasons patients might not continue their therapy? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma “We've got to leave some authority with our prescribers to be able to make a clinical decision of what's best for that … patient.” Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma What is clear bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma How does a hospital specialty pharmacy get in network with a PBM? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma What is gold bagging? Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma “Outlook really needs to be what's best for the patient.” Keith Hartman of @continuumrx1 discusses #specialtypharmabagging on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider  

After that recent episode with Scott Haas (EP365), where we talked about the real deal with PBM contracting, I kicked into high gear trying to untangle this whole apocalyptic honky-tonk we call benefits for prescription drugs. Notice I did not say prescription drug benefits because that would imply that pharmaceuticals are only charged for under the umbrella of pharmacy benefits. Ha ha, that would be just too easy. No, some pharma drugs are charged as part of patients' medical benefits. An amazing primer for what that looks like in the real world follows.   Just pointing out that any self-respecting healthcare market distortion deserves another, and if anything qualifies as a market distortion, it's buy and bill—what I talk about with Dr. Mitchell in this healthcare podcast. In the following weeks, we'll chat about how the market has responded to this buy and bill market distortion that we talk about in this episode. So, next week, we're gonna get into all the different kinds of bagging: the so-called brown bagging, the white bagging, the clear bagging … and what is this newfangled gold bagging? Spoiler alert there. Tune in next week. And here's another spoiler alert: While in this show today we chat about how provider organizations tend to make somewhere between 4.5% and 20% additional over drug costs, there was a recent study claiming that 4.5% to 20% is chump change. Some provider organizations are, in fact, making four times to six times the cost of the drug—a very expensive drug, mind you (lots of zeros here)—in profit. In the show in two weeks, I'm speaking with April Yongchu and Erik Davis from USI about exactly and specifically how provider organizations can manage to perform this “let's make hundreds of thousands of dollars today” magic trick. So, with that, here's your encore. In the April [2020] issue of Value-Based Cancer Care (that's a journal), there's an article talking about a keynote presentation and a study highlighting a big problem for patients with cancer: toxicity. It's a fact that some chemo agents are pretty toxic, but in this healthcare podcast I am talking about financial toxicity. The financial burden of cancer care has a seriously negative influence on patients' quality of life. This keynote speaker quoted in the Value-Based Cancer Care article implored his fellow oncologists: “Think twice before ordering costly interventions that may have little impact on the clinical course,” he said. This might be difficult for a number of reasons, and one of them is that oncology centers make money, a whole lot of money, sometimes the most money, from infusing cancer medications. It's this little payment paradigm called “buy and bill.” The cancer center buys the meds and then gets paid an additional fee to infuse the drug. This fee is a percentage of the drug cost. You've probably heard a lot lately about the skyrocketing costs of some of these cancer agents. Realize that if you're an oncology center, the higher the drug costs, the higher your revenue. Now consider the patient suffering under the weight of increased cost sharing and employers and taxpayers who are funding this strange payment model. In this healthcare podcast, I dig into this so-called “buy and bill” payment model with Aaron Mitchell, MD, MPH. Dr. Mitchell is an oncologist and health services researcher over at Memorial Sloan Kettering. You can learn more at drugpricinglab.org. You can also connect with Dr. Mitchell on Twitter at @TheWonkologist.   Aaron Mitchell, MD, MPH, is a practicing medical oncologist and health services researcher. He is an assistant attending at Memorial Sloan Kettering Cancer Center in the department of epidemiology and biostatistics. His research focuses on understanding how the financial incentives in the healthcare system affect physician practice patterns and care delivery to cancer patients. He cares for patients with prostate and bladder cancer.   04:34 Following the drug and following the dollar. 04:56 The “buy and bill” system. 05:43 The perverse and problematic incentives of the system. 08:38 “It creates the incentive for us to gravitate toward the more expensive drug.” 08:42 The hesitancy to address the financial toxicity of drugs for patients. 09:53 Why the only person losing in this situation is the patient. 10:51 The financial impact from the patient perspective. 13:57 Are patients realizing this impact? 14:42 Solving the problem of oncology drug choice. 16:45 Reimbursement reform. 18:24 Capitated systems and incrementalist impacts to reimbursement reform, and what these look like. 23:30 Are we at a tipping point? 23:51 “The current system … works too well for too many people.” 25:01 Who isn't well served by the current system. 25:32 Who has to lead the charge for change. 28:28 Large oncology providers vs small oncology providers in the buy and bill system.   You can learn more at drugpricinglab.org. You can also connect with Dr. Mitchell on Twitter at @TheWonkologist.   Check out our #healthcarepodcast with @TheWonkologist of @sloan_kettering as he discusses #oncology #drugpricing and #reimbursement. #healthcare #podcast #digitalhealth Following the drug and following the dollar. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth The “buy and bill” system. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth The perverse and problematic incentives of the system. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth “It creates the incentive for us to gravitate toward the more expensive drug.” @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Why is there hesitancy to address the financial toxicity of drug pricing for patients? @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Why the patient is the only one that loses. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth What's the financial impact from the patient perspective? @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Are patients realizing this financial impact? @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Solving the problem of oncology drug choice. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth What should reimbursement reform look like? @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth “The current system … works too well for too many people.” @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Who has to lead the charge for change? @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Large oncology providers vs small oncology providers in the buy and bill system. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes  

Shaun remembers all those that have given their lives for our freedoms today as we continue to fight back against the Democratic scum trying to take them away. PLUS, Gary Rabine tells Shaun why it's Rabine-time in Illinois and Katy Talento, executive director of The Alliance, gives Shaun an alternative to health insurance. See omnystudio.com/listener for privacy information.

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

Katy Talento was tapped by President Trump as a health care advisor in the White House. She now leads the Alliance of Health Care Sharing Ministries (think MediShare and Samaritan Ministries), which has become a very popular healthcare alternative for America's citizens. Judeen Parkes hails from Jamaica, but has spent the last over twenty years in Florida. She is a student in college, and one who loves to volunteer for her church and other ministries.

People are averse to change. It's a thing. It's a thing that affects even those of us who consider ourselves highly educated and/or very smart. Nobody likes disruption or, even worse, the prospect of disruption and the uncertainty that goes along with that. Nobody likes to feel like the rug just got pulled out from under them or that they've lost control of something, especially something important like their health benefits or how they care for patients. Changes to health insurance and healthcare, from any angle, are fraught with stress. A big reason for this is because health and healthcare are filled with so-called “one-way-door” types of decisions and decision points. If I cannot get the care I need today, or if the care I want to provide today to a patient does not go as desired, I feel like the door is one-way: Once I make a decision, I cannot go back. I can't click “undo” on that and go back through the door and arrive at yesterday. Health decisions, therefore, have a very “you got one shot at this” kind of feel. And it's that, right there, that just upped the ante considerably in the stress department for employees and then also for any clinician who is working with patients. It's life or death, and this is why making changes either to the insurance side or the care side of the equation feels like they will be so disruptive. It's a big reason why some self-insured employers or even fully insured employers won't mess with the status quo benefit designs or switch up their EBC (employee benefit consultant) or their ASO/TPA (Administrative Services Only/Third-Party Administrator), even if everybody in the entire company is currently complaining about the price and complexity of said status quo (it's kind of like the devil that you know) and even if it's possible to offer employees overall better-quality care at lower prices, meaning that everybody in the company could get a raise funded by the sometimes massive savings that could be had. I just heard a union leader the other day, and she said that every worker would have an extra $5000 in their pocket if their healthcare costs were what they should be. So, for many employers, the prospect of disruption is just too much. It's not in the CHRO's (chief human resources officer's) job description to open that Pandora's box. Nobody gets fired for doing what they did last year—I guess, until they do (one straw or another is gonna break the camel's back, after all). But in the meantime, we have this fear-induced festering inertia. Let me just point out one thing: Implicit in everything that I just said is the notion that one day everyone will have their familiar insurance card snugly tucked in their wallet, and then the next day, it will be ripped from their bloody fingers in a violent and unexpected fashion. Or, let's talk about provider organizations now. Say one's trying to move from the world of fee for service to the world of value-based payment structures with downstream risk, or direct contracts with employers. To do this well, let's chat about one aspect of this that health systems seem to struggle with that's been a topic of some conversation lately. There's an article cautioning that “practicing at the top of one's license” and its attendant need for team-based care is a giant fail and/or a money grab, or it could be. And it could be both of these things, don't get me wrong. Team-based care isn't a homogeneous construct. It would be like saying that all movies are bad because Super Baby Geniuses 2 was such a dog.   I mean, team-based care—pretty much like team-based anything—if it's not implemented well, nobody on the team knows what they're supposed to be doing and nobody is accountable. There's no infrastructure supporting it. There was no testing or iteration or discussion about the intent. No one actually on the proposed teams was even consulted about the whole idea. And so, everyone starts to suspect, maybe rightfully or maybe not, that it's all financially driven and a cost-cutting exercise. On the show today, my guest, Ashleigh Gunter, warns about all of these exact things. You switch something up without going through the proper steps and stages, everybody gets very suspicious. And, nothing for nothing, their suspicion could be the least of the leader's problems. The initiative's ensuing failure maybe should be their biggest concern. Which is a shame if something was done in the spirit of better patient care, for example, because there's tons of research on the immense power of well-functioning teams as just continuing this one example. And there's just as much research and well-proven case studies showing that innovative benefit designs can be a 365-degree win when they cut out wasteful spending and navigate employees and plan members to high-value care. For all of these reasons and more, I wanted to get Ashleigh Gunter, who is an expert in change management, on the show to talk about how to succeed when you want to change something as touchy as healthcare and health insurance. This all really goes back to the show with Matt Anderson, MD, MBA (EP266) and what Robert Pearl, MD, writes about all the time. It's a skill we all need to learn to lead change. Many of us had to learn this the hard way because we see our vision so clearly and we want to make it a reality as fast as possible, but the result of our enthusiasm might be that we skip implementation steps that are really not optional.   As Thomas Edison said (and I love this), “Having a vision for what you want is not enough. Vision without execution is hallucination.” So, to transform anything effectively, we have to put as much effort into the implementation as we do into the strategy. If we don't do that, then sadly, despite all of the best intentions, whatever we're trying to do is not gonna work and it might be labeled disruptive. So, I couldn't be more pleased to have learned a thing or two from Ashleigh Gunter about change management that avoids this disruption label. Ashleigh Gunter is president of Translucent Healthcare Consulting. She also is an expert in change management as aforementioned and how to help align employees and staff so that an organization can move forward together. According to Ashleigh, there's five steps to effective change management that will ensure success: Having great leadership Creating a case for the change Finding champions, engaging people who have to change so that they can contribute and be supportive Overcommunicating Measuring how things are going and also celebrating small triumphs You can learn more at translucenthc.com.  Ashleigh Gunter, president of Translucent Healthcare Consulting, combines her experience, an understanding of organizational culture, and a practical mindset to meet her clients' needs. With over 30 years of management consulting experience, Ashleigh has deep expertise in advising in the dramatically changing healthcare market. Ashleigh specializes in helping her clients drive change within their health plans, resulting in increased employee engagement, improved human resources experience, and reduced cost for both the employer and the employee. She believes in challenging the status quo by creating direct relationships between employers and providers. Ashleigh has been a key contributor to several community-owned health plans in states from Washington to Virginia and has been credited with being key to employee participation and support of the plans. In working for Andersen Consulting/Accenture, Deloitte Consulting, and The Gunter Group, Ashleigh has provided advice and consulting support to Fortune 100 C-suite executives over her career. She has an MBA with a focus in strategic management and organizational change from the University of Texas at Austin and a bachelor's degree in business administration from the University of Denver with a concentration in finance. 07:46 How does change management go wrong in healthcare? 08:27 “Communication [of change] in and of itself isn't change management.” 10:03 What is change management? 11:06 What does great leadership look like in change management? 12:29 “Leadership sets the tone.” 12:38 What makes change management so hard? 13:27 “What's the company reason to make this change happen?” 15:57 What are change champions, and why do you need to create them when changing your benefit plan? 19:18 Why is it important to overcommunicate change? 22:46 Why is it important to measure your successes and communicate those after a change? 24:14 How does change management work on the provider organization side? 28:53 “You want to ensure you are educating the operational folks.” You can learn more at translucenthc.com.  Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast How does change management go wrong in healthcare? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast “Communication [of change] in and of itself isn't change management.” Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast What is change management? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast What does great leadership look like in change management? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast “Leadership sets the tone.” Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast What makes change management so hard? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast “What's the company reason to make this change happen?” Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast What are change champions, and why do you need to create them when changing your benefit plan? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast Why is it important to overcommunicate change? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast Why is it important to measure your successes and communicate those after a change? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast How does change management work on the provider organization side? Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast “You want to ensure you are educating the operational folks.” Ashleigh Gunter of Translucent Healthcare Consulting discusses #benefitdesign and #deliverymodels on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby  

Lots of talk about direct contracting going on these days. Many of you will be familiar with the term, but in short, direct contracting means when a self-insured employer directly contracts with a provider organization with no payer in the middle of that arrangement. And when I say “employer,” I mean the employer and all their peeps—their TPAs, repricers, other vendors, and consultants. Most of this talk, though, seems to come from the point of view of the employer. It's super easy to quantify what's in it for employers. US healthcare costs get blamed for all kinds of things: companies who have lost big global contracts because all of those fringe benefits cost way too much around here. If we're looking around for a why on that point, let me refer you to last week's episode (EP366) with Dr. Kevin Schulman entitled “An In-Depth Dissection of Our Dysfunctional Healthcare Benefits Market.” Or the show with Dr. Wayne Jenkins (EP358) about how premium and deductible financial toxicity negatively impacts plan members. Never forget that financial toxicity is clinical toxicity.   So, like a knight riding in on a white horse, direct contracting with a provider organization has some interesting potential. Most obviously, when an employer contracts directly with a provider organization, they cut out the middleman. They put the direct in direct contracting. Considering the multi-billions of dollars that some of these middle people are raking in every quarter in profits and/or “margins,” cutting out the middle people could have a financial upside as big as those billions in profit. If those billions get passed on to patients in the form of lower co-pays/coinsurance or premiums, there could be some big benefits to direct contracting for pretty much all involved … except the middle people, of course. My guest in this healthcare podcast, Doug Hetherington, says that it's not uncommon to see on the low end a 10% reduction in costs to maybe up to 50% reduction in costs. It's amazing what can be accomplished when everybody starts working together for the good of the local community and patient and is held accountable for more than just revenue maximization. But there's also quality and patient outcomes upsides to these cost reductions. Here's a few we can speculate about: For example, if the middle people add layers of bureaucracy and administrative burden that make it really hard and/or upsettingly inefficient for anyone trying to serve their patients' needs to actually serve their patients' needs, then yeah, direct contracting can make getting the right care to patients faster and easier. That matters to burned-out clinicians. Also, here's another potential point to ponder: benefit designs. Listen to the show with Dr. Mark Fendrick (EP308) on this, but most benefit designs offered by middle people are really, as they call them, blunt instruments. High-value care costs as much (or more) as low-value care. Deductibles don't care if you need your diabetic foot ulcers checked urgently or you might get your foot amputated. It's a known fact that health outcomes plummet in January when, all of a sudden, cancer meds or whatever essential lifesaving medical innovation cost as much as a patient's deductible. So, patients abandon care—and outcomes go down.   When an employer direct contracts with a provider, in its most sophisticated form—which my guest, Doug Hetherington, calls a “full-pay open contract”—the employer and the provider work together to construct a benefit design that helps patients get the best outcomes. Or here's another benefit, for the whole community, not just the employer: The whole community keeps the money local. Many of these middle people are big national companies. As Dave Chase and others have said often, when these Fortune whatever companies arrive on the scene, lots of money exits stage left out of the community. If local employers contract with local providers, the money stays local. So, all that I have said has been said before. What I wanted to dig into in this episode is the why and the how from the provider organization standpoint. I got curious about this after my conversation with Katy Talento (EP350). She talks about a major barrier for self-insured employers who want to work with local hospitals is that the local hospitals couldn't, frankly, get out of their own way. Maybe they couldn't see the benefit for themselves that made the juice worth the squeeze? That's what I talk about in this episode with Doug Hetherington: what's in it for providers and what a provider organization interested in direct contracting needs to actually pull it off.  Doug Hetherington is CEO of Health2Business, and he has done and continues to do pioneering work with community hospitals in eastern Idaho and elsewhere. Health2Business helps facilitate direct contracting between hospitals and local employers. You can learn more at health2business.com and connect with Doug on LinkedIn.  You can also learn how to engage in direct contracts from Doug's presentation, “Beyond the Direct Contract.”    Doug Hetherington is a health plan visionary, innovator, and program architect who believes providers are the key to sustainable and meaningful healthcare in our communities. Midway through his 20-year tenure as a benefit advisor, Doug began innovating around self-funding, captives, reference-based pricing (RBP), and population management in search of viable solutions that gave his employer clients control over cost and plan design. His creativity and tenacity for change drove his development of several first-of-their-kind innovations, including RB EmCap, a national access captive program for RBP employers. Doug founded Health2Business (H2B) in 2019 after successful proof of concept that better healthcare results when employers, providers, and health systems work together at the local level through direct contracts. Tackling one aspect of our broken healthcare system, H2B solves for how we access and pay for care. While establishing scalable direct contracts with some of the largest flagship health systems in the country, Doug realized that in order to truly decapitalize healthcare, direct contracts need to be transparent, open, and free for employers of all sizes to access. By establishing H2B's independent, agnostic, and collaborative direct contract administrative platform infrastructure, Doug has created an entirely new vendor class known as direct contract administration. An optimist by nature, Doug truly believes that the more we work together, the faster we can restore value to our healthcare system and create a sustainable mutual benefit for provider, employer, and employee/member stakeholders. 05:38 Why are health systems interested in direct contracting? 09:43 EP308 with Mark Fendrick, MD.10:06 What are the essentials for direct contracting between a health system and an employer or payer? 11:16 What are the three categories of open direct contracting agreements? 12:44 EP350 with Katy Talento.12:59 EP363 with David Scheinker, PhD.14:43 What direction do we need to be moving to solve the cost problems in healthcare? 18:10 “What does a value-based model begin to look like?” 20:31 What is one of the inherent benefits of a direct contracting environment? 21:01 What data should we actually be capturing? 25:01 “Sometimes you really begin to wonder, why is there such a high level of misalignment?” 25:16 How much can an employer save, on average, with a direct contract? 26:33 What are healthcare costs going up by per year? 26:50 “We pay for these insurance plans … and yet what you're paying for that and how they're assessing the risk is not … in line with the actual cost of care.” 30:20 “I would say that … consolidation … is one of the reasons why we're … seeing more movement towards direct contracting.” You can learn more at health2business.com and connect with Doug on LinkedIn.  You can also learn how to engage in direct contracts from Doug's presentation, “Beyond the Direct Contract.” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why are health systems interested in direct contracting? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the essentials for direct contracting between a health system and an employer or payer? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the three categories of open direct contracting agreements? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What direction do we need to be moving to solve the cost problems in healthcare? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “What does a value-based model begin to look like?” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is one of the inherent benefits of a direct contracting environment? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What data should we actually be capturing? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Sometimes you really begin to wonder, why is there such a high level of misalignment?” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth How much can an employer save, on average, with a direct contract? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are healthcare costs going up by per year? Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “We pay for these insurance plans … and yet what you're paying for that and how they're assessing the risk is not … in line with the actual cost of care.” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I would say that … consolidation … is one of the reasons why we're … seeing more movement towards direct contracting.” Doug Hetherington of @MyH2B discusses #directcontracting on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343)  

Katy Talento is a veteran policy advisor, health care reformer, epidemiologist and thought leader.  A compelling communicator, Katy has served as Director of Speechwriting for the Republican National Committee.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. Talenko now serves as Executive Director of the Alliance of Health Care Sharing Ministries.  The mission of AHCSM is to - Protect the liberty of member ministries to practice their religious convictions in health care.Inform legislators of the important work and benefit of health care sharing ministries.Seek exemptions from mandates requiring our members to purchase health insurance, in that they are already served in this area by the ministries which they participate in.Seek parity with other health care solutions with respect to federal and state tax codesI'm honored to have Katy on "I'm Glad You Said That" as my guest today. Hope you can tune in.Support the show

First of all, this is a 400-level discussion. If you think you already know all about our dysfunctional healthcare benefits market, then this show is for you. Before we begin, I just want to say something. I'm gonna refer back to David Muhlestein's episode (EP364), where he talks about the first step toward healthcare transformation. It is, let's just say, for incumbent health systems and payers, people who work there, to step back and in the harsh light of day really contemplate their business model—see it clearly. If you're listening to this show, then know that I love you; so this is not a condemnation of you or the great things that you are likely doing in your department. I see you as a changemaker. But contemplating your organization as a whole is like the first step of a 10-step program … to admit what friends and family were saying at the intervention. If you're not yet at the—what's it called?—contemplative stage in your journey toward transformation, you could skip ahead to the 23:00 mark approximately for some advice on what people who work at incumbent payers and/or providers can do right now. My one and only intent here is to see change happen. What I see currently are certainly efforts to improve quality at some level. But those responsible for finance, premiums, and the employer sales team are in a different part of the building. I mean, maybe a first step here is, Can you invite those guys and gals to your meetings? OK … so, there was a paper that came out in JAMA entitled “The Dysfunctional Health Benefits Market and Implications for US Employers and Employees.” It was by David Scheinker, PhD; Arnold Milstein, MD; and Kevin Schulman, MD, who is my guest in this healthcare podcast. David Scheinker, by the way, was on the show earlier (EP363), so certainly go back and listen to that.   This paper (the “Dysfunctional Health Benefits Market” paper) showed that commercial insurance costs have gone up 4x the rate of other benchmark goods or services in price. So, 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.” It turns out, though … not so much with that. My guest in this healthcare podcast, as mentioned, is Kevin Schulman, MD, an author on that paper. And he says this much more eloquently than I will, but the skinny is this: Because insurer profits are capped at 15%, that means that the more healthcare costs go up, the more possible profit in absolute terms that a health insurance carrier can make. After all, 15% of a bigger number is … a bigger number. If you look at how Wall Street responds to these bigger numbers all the way around—higher costs translating to higher profits, that whole thing—you will find that Wall Street likes this profit-generating formula … very much. Share prices go up when that 15% goes up. What does Wall Street like less? It likes less restructuring and pushing providers to deliver better care for less cost and then passing those savings on to employers and employees. Even if you increase quality and decrease costs really well and/or profitably as an insurer, share prices do not rise nearly as much as they rise if you phone it in with the “negotiations” with providers. Nonprofits, by the way, get no pass here either. Some of the most expensive hospitals in the country, which are nonprofit, are doing their thing in areas where nonprofit carriers are the big kahunas. Call it margins. Call it profits. Whatever … same thing. Listen to the show with David Muhlestein, PhD, JD (EP364) from two weeks ago. It's all about the business models. And that business model is revenue maximization. Period. End of the sentence.  So, who loses in this equation? Oh, right … patients. And employers. Read anything by Dave Chase for more on how crushing this loss is that patients and employers suffer: middle-class wage stagnation, bankruptcies, financial toxicity that is actually clinical toxicity, skyrocketing premiums way over the cost of inflation, that healthcare costs borne by employers are a driver for offshoring because they make American labor so expensive. A study the other day said that nonadherence due to a patient's inability to pay for treatment will be a leading cause of death in 2030. That's what this all is adding up to.   Because of business models, insurers have become the piggy banks for health systems, as my guest Dr. Kevin Schulman says. This piggy bank is funded with the pennies, nickels, and dimes from you and me, the insured lives, our employers, and taxpayers. So, unless you're a shareholder in one of these carriers and their vertically integrated PBMs, of course, then, I guess, good for you. Or getting political donations from them might also be a net plus for you personally. Where are the activist investors in all of this? Something that Dr. Schulman said in this episode I had never heard before, and—wow!—it explains so much. It's this whole idea of some, not all, but some health systems clamoring about how they have to charge commercial patients more because they are losing so much on their Medicare patients. They have to cost shift to commercial lives. Here's what Dr. Kevin Schulman said about that in my own words: Cost is a construct. Cost is a dynamic fiction. I mean, say I buy a mansion. I put in a Jacuzzi and a tropical flower bed that needs to be misted with water on the half-hour. Then I tell you that my fixed costs are really high and, therefore, my tuna sandwiches are really expensive. I just made them expensive. I made the decision to increase my costs. The interesting backdrop for that is that in competitive marketplaces, or in Maryland, hospitals do just fine (thank you very much) getting paid Medicare rates. They don't have to price shift. But in markets with no competition, where the hospitals decided to build, baby, build, they created these giant brick-and-mortar money pits that, yeah, cost a boatload. And then they complain that they have to price shift to employers and their own patients to pay for it all. One thing that we don't talk about in this episode are non–fee-based brokers and the role that they play in all of this. One recent lawsuit is a pretty perfect example of what I'm saying here.   You can learn more by visiting Dr. Schulman's profile page and connect with him on LinkedIn. Kevin Schulman, MD, is a professor of medicine for the Clinical Excellence Research Center (CERC) at the Stanford University School of Medicine and, by courtesy, professor of operations, information, and technology at Stanford's Graduate School of Business. He is the faculty director of Stanford's new applied master degree program, the master of science in clinical informatics management program. His research focuses on broad, system challenges in the healthcare market, looking for ways to better understand hidden costs throughout the system. He then works to develop innovative solutions to deliver great care at lower cost. 07:13 Why have commercial insurers become price-takers? 10:04 How does a health plan get bigger profits? 10:40 “At the core at this, Wall Street rewards predictable performance; and the predictable performance … is great if healthcare costs go up.” 11:00 What does it mean to have a “dysfunctional equilibrium” in healthcare? 12:05 What's really changed in healthcare in the last 20 years that's caused this increase in healthcare pricing? 12:47 Commercial price versus Medicare: Do hospitals really need to cost shift? 15:51 How is value-based care really going to work? 17:43 “It's not A or B; it's a dysfunctional market.” 17:57 “Little changes in volume or incentives is not going to change the underlying dynamics.” 24:32 “I think it's an open question whether this model is really serving the American public.” 29:25 “It's a really important time for us to think about, how do we create a different trajectory?” You can learn more by visiting Dr. Schulman's profile page and connect with him on LinkedIn. @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket Why have commercial insurers become price-takers? @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket How does a health plan get bigger profits? @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket “At the core at this, Wall Street rewards predictable performance; and predictable performance … is great if healthcare costs go up.” @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket What does it mean to have a “dysfunctional equilibrium” in healthcare? @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket What's really changed in healthcare in the last 20 years that's caused this increase in healthcare pricing? @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket Commercial price versus Medicare: Do hospitals really need to cost shift? @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket How is value-based care really going to work? @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket “It's not A or B; it's a dysfunctional market.” @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket “Little changes in volume or incentives is not going to change the underlying dynamics.” @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket “I think it's an open question whether this model is really serving the American public.” @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket “It's a really important time for us to think about, how do we create a different trajectory?” @kevin_schulman discusses #healthcarebenefits on our #healthcarepodcast. #healthcare #podcast #benefitsmarket   Recent past interviews: Click a guest's name for their latest RHV episode! Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon    

A full display of liberal crazies on at the Correspondents Dinner. Joe Biden's jokes were as bad as the inflation he caused. Trevor Noah had a lot of misses, but he hit a few. We have all the clips you want to see. After watching the recent viral documentary, “Watch The Water,” on the Stew Peters Show, Pastor Michael Petro discovered a connection between Dr. Bryan Ardis' ‘Venom Theory' and biblical prophecy of an end time plague that would mark the second coming of Christ, and bring judgment on the religious system and world.  Here the shocking comparisons. Dr. Vermelle D. Greene, has been a schoolteacher and administrator for more than 45 years. She is author of Please Teach Me Like I'm a Boy! Ten Steps to His Success in School and in Life. Greene is the Executive of the Boys Initiative. Let's hear it for the boys for a change. Katy Talento, Executive Director, Alliance of Health Care Sharing Ministries (The Alliance, ahcsm.org) is here. The Alliance of Health Care Sharing Ministries is an organization to represent the common interests of health care sharing ministries. We discuss all of the options. Support the show (https://www.patreon.com/thebuffshow) --- Support this podcast: https://anchor.fm/the-buff-show/support

One of my mentors often said price is irrelevant. He said he would sell anything for any price as long as he could define the terms of the deal. During this conversation today with Scott Haas about PBMs, that quote was playing in my head like an earworm. I'm henceforth gonna struggle with the term rebate to define dollars that the PBM gets back from Pharma, because, according to my guest in this healthcare podcast Scott Haas, it turns out “rebates” comprise only about 40% of those back-end dollars that some PBMs manage to score from pharma manufacturers. I don't have any insight really into this, but Scott Haas certainly does—and this is the average that he has seen in his work and that we're going to dig into today. But in sum … wow! Let me just repeat that a mere 40 cents on the dollar of the gross amount that PBMs take in “rebates” from Pharma these days winds up going back to plan sponsors, even plan sponsors who are getting “100% of the rebates.” If you didn't understand what I just said, no worries. I'm gonna explain it right now. If you did and you know the why behind all of this also, you could probably skip ahead about five minutes. Here's the backstory on this whole rebate fandango. Let's start with part one of what is a two-part transaction. So, part one: the deal between pharma manufacturers and PBMs. In general, a pharma manufacturer signs a deal with a PBM to give back whatever percentage of their gross sales revenue to the PBM at the end of the year, say. It's along the same lines as a cash-back coupon for the PBM. Why would a pharma company be up for giving cash back like this? Well, to get on a PBM's formulary, giving cash back is like the price of admission. PBMs have a lot of leverage, after all—at least the big ones. They control access to millions and millions of patient lives. So, if Pharma wants their drug to be accessible to those millions and millions of lives, they have to play the cash-back game, otherwise known as the rebate game. They have to agree to give back to the PBM a certain amount of cash on the back end. So, PBM pays Pharma's list price up front—that's the gross amount paid, based on the list price of the drug—and then after all the cash back gets toted up at the end of the year, there'll be a net price. List price or gross price minus the cash back equals net price. It's this net price that's the true kind of final price which the pharma company gets paid per script by said PBM at the end of the day. These days, most everybody pretty much knows that PBMs are getting these so-called rebates—this cash back from pharma companies that I just explained. And it's pretty common knowledge the so-called gross-to-net bubble (the gross-to-net dollar amount) is pretty huge, meaning the rebate or cash-back amount is pretty huge. And many have also noticed that the gross-to-net dollar amounts seem to be growing bigger and bigger every year. I mean, for one insulin manufacturer, consider this: Their list price, their gross price, is $350 per script. And their net price after cash back/rebates was $52 this past year. Wait ... what? After all the cash back to the PBM, the insulin manufacturer got paid 86% less than their list price—$350 went down to $52 per prescription. The PBM vacuumed up 86% of the dough for every script written for this particular brand of insulin.   OK … so, say Pharma gives $100 back to the PBM based on the terms of their deal. Call that part one of this example transaction. Here's part two: the deal between PBMs and health plans or self-insured employers. Health plans and self-insured employers are customers of the PBM. They hire PBMs to manage the pharmacy benefits for their members or employees. So, because everybody knows this whole rebate thing is going on, as part of the contracts that the PBMs put in place with their customers (meaning the health plans or employers), the PBMs tell their customers that they're going to give 100% of the rebates back to the plan/employer. So, you'd think that if the pharma manufacturer paid $100 to the PBM, that the customers of the PBM (the plan sponsors) would get the $100 back then, right? The PBM would pass on 100% of the savings, as it were, if they're saying that they're gonna give 100% of the rebates. I mean, if this is actually true, that $100 in and $100 out, then the PBM is potentially performing a useful service, right? They're lowering drug costs for their customer, the plan sponsors for their members and employees. Except … turns out, not so much. Because what is a rebate, really? A rebate can be anything the PBM defines as a rebate. And it turns out that, on average, as I said before, according to those in the know, something like $60 of that $100 is not a rebate. It's an administration fee. Or a data fee. Or an education fee. A clinical program fee. Some other name that is not rebate. As my guest Scott Haas says, the term rebate is meaningless because it can mean whatever the PBM wants it to mean. It's like inconceivable from The Princess Bride. I do not think that word rebate means what you think it means.   Now it is a tangled web we weave here, and for more on why I say that, listen to the episode with Chris Sloan (Encore! EP216) entitled “How Medicare Part D Plans Became Addicted to Drug Rebates.” There's also a show with Pramod John (EP353) where we dig into, specifically, specialty drugs and rebating and so-called rebate walls.   But net net, all of this probably myopic focus on rebates means that you have to keep an eagle eye out for so-called exclusions in contracts if you are a plan sponsor. So, what are exclusions? This is that whole thing where some cheap generic is excluded from a PBM formulary while some expensive brand for the same condition is on formulary. Why would a cheap generic be excluded from a PBM formulary? Simple. Cheap generics don't have rebates. PBMs lose a lot of money when some high-priced specialty drug, for example, goes generic. They might have made thousands of dollars per script on that high-priced brand by collecting its rebate. Think about that insulin example. The rebate is 86% of the cost of the drug. And everybody wonders why some cheap generic insulin or biosimilar or whatever isn't on formulary. It is not a mystery when you're dealing with for-profit enterprises built around a model of revenue maximization. So, given all this, what's my guest Scott Haas's bottom-line advice in this whole thing? If you're a health plan or employer and you're trying to negotiate a PBM contract where your spend is predictable and your contracted price promises have any meaning whatsoever, Scott Haas's advice is, you have to ensure that the contract defines the actual prices for the drugs in the contract. With absolute numbers. Not percentages off or weird formulas or the empty promise of getting an AWP or a WAC (which means average wholesale price or wholesale acquisition cost) or any of the other various acronyms for some drug pricing schema. All of these are basically shorthand for “this price could change at any moment.” There's a reason in-the-know people say AWP stands for “Ain't what's paid,” meaning ain't what's ultimately going to be paid by plan sponsors. What is necessary in PBM contracts is the final price—that number. Some digits with a dollar sign in front of them and a “per unit” after them. No acronyms and no percentage signs. Whoever gets to define the terms ultimately controls the price. So, get the price up front. As mentioned several times already, I am talking to Scott Haas, who is a senior VP over at USI Insurance Services. He's speaking today from the perspective of a plan sponsor, meaning from the point of view of a health plan, including those health plans managed by and paid for by a self-insured employer and their employees. For more information on PBMs and how drugs get adjudicated, listen to the show with AJ Loiacono (Encore! EP231), which was one of the most popular episodes over here at Relentless Health Value. Somebody on a LinkedIn post the other day commented on how much she appreciated AJ Loiacono's frank assessment of things and how she would love to go to a meeting with more people similarly telling it like it is. That's pretty much what we aim to do at every episode over here at Relentless Health Value, and AJ nails it on that objective for sure in this episode.   One last thing, also on the show: Scott Haas brings up GPOs that the Big Three PBMs have been spinning up to aggregate and maximize all of those rebates that we just talked about. I discuss this exact topic at some length in another incredibly popular episode with Mike Schneider (Encore! EP288).   You can learn more at usi.com or by emailing Scott at scott.haas@usi.com.  Scott Haas has over 38 years of employee benefits experience. His background includes the development and validation of care management programs; prescription benefit management solutions; provider network evaluation, valuation, and negotiation; and underwriting. Scott started and operationalized a third-party administrator (TPA) and a pharmacy benefit manager platform from scratch. He has worked in the arena of alternative funding for most of his career. Scott's primary focus is in the area of alternative delivery and financing of healthcare other than fee for service, along with prescription benefit and healthcare risk management consulting. Scott has held officer-level positions within Blues plans and TPAs as vice president of sales and marketing, vice president of underwriting, and president. Scott has also served as a trustee for both union and non-union health and welfare and pension plans. Scott frequently shares his consulting expertise speaking at national events hosted by organizations such as Health Rosetta, the International Foundation of Employee Benefits, the Health and Welfare Plan Management Conference, the Western Pension and Benefits Conference, and the Self-Insurance Institute of America (SIIA). Scott has authored and coauthored articles on various topics over his career. Scott earned his bachelor's degree in business administration and economics from the University of Nebraska at Kearney. Scott also holds Chartered Life Underwriter (CLU) and Registered Health Underwriter (RHU) designations. 10:29 What's the major flaw with the buyer-seller relationship between plan sponsors and PBMs? 12:04 What are the five things that need to be considered in order to get a fair price from a PBM? 13:16 Why does using average wholesale price cause problems for plan sponsors? 15:05 What does it mean to put the network risk on the PBM? 17:10 What's happening with drugs moving from specialty brand to specialty generic? 19:14 “A generic is a generic; in our world, it's binary.” 23:31 “The term 100% of rebates is really irrelevant.” 23:54 What does it mean to have a minimum guarantee in drug rebates? 26:39 “When you do a line-item assessment … is it producing an optimal result in comparison to competitively achieved … pricing for generics … and for specialty?” 27:52 “Plan sponsors need to grow a backbone.” 28:36 EP342 with Christin Deacon.29:05 Why do you need to understand your consultant's process as a plan sponsor? 29:30 Why do you need to understand formulary exclusions as a plan sponsor? 29:41 Why is it important to create a more equal PBM contract? 30:52 “Rebates inure to the benefit of the plan sponsor; they don't necessarily benefit the consumer.” 31:45 What does Scott do at USI? You can learn more at usi.com or by emailing Scott at scott.haas@usi.com.  Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast What's the major flaw with the buyer-seller relationship between plan sponsors and PBMs? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast What are the five things that need to be considered in order to get a fair price from a PBM? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast Why does using average wholesale price cause problems for plan sponsors? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast What does it mean to put the network risk on the PBM? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast What's happening with drugs moving from specialty brand to specialty generic? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast “A generic is a generic; in our world, it's binary.” Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast “The term 100% of rebates is really irrelevant.” Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast What does it mean to have a minimum guarantee in drug rebates? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast “When you do a line-item assessment … is it producing an optimal result in comparison to competitively achieved … pricing for generics … and for specialty?” Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast “Plan sponsors need to grow a backbone.” Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast Why do you need to understand your consultant's process as a plan sponsor? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast Why do you need to understand formulary exclusions as a plan sponsor? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast Why is it important to create a more equal PBM contract? Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast “Rebates inure to the benefit of the plan sponsor; they don't necessarily benefit the consumer.” Scott Haas of @USIIns discusses #PBMs and #drugrebates on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell  

In this healthcare podcast, we're gonna zoom out and look at the entire healthcare industry. I am very confident that you know a lot about the healthcare industry and its basic stats. It's huge. The healthcare industry is approaching the $4 trillion mark, and it employs more people than any other industry in 47 states. Think about that momentarily. More people work in healthcare than in any other industry in every state except for Wisconsin, Indiana, and Nevada. We could get into (but we won't) how many of the gigantic, consolidated incumbents in the healthcare industry are either for-profits sporting very happy shareholders or investors. Then, of course, we have our “nonprofits”—especially mega-nonprofit health systems—who enjoy some pretty healthy margins while, at the same time, these health systems in general offer up some fairly embarrassing levels of charity care considering the amount of taxes they deprive their communities of. You also are probably eminently familiar with various ways that have been cited to transform the industry. So, the usual suspects here are, of course, changing incentives—offering true value-based care contracts, for example—and then the whole creative destruction angle, wherein upstarts come in with far superior products and services, à la the whole Kodak case study or what happened to Sears and Kmart. Maybe this will happen in healthcare. Other ideas to transform the healthcare industry include employers harnessing the latent power that they have in some markets and then, of course, getting rid of middle people, for sure. Or we could go single payer, of course. That's another suggestion/solution. Today's conversation is a rather holistic look at all of this. I dig into this with David Muhlestein, who is chief research and innovation officer at Health Management Association (HMA). And when I say dig in, I mean dig in. David made some very intriguing points that I had not heard before, actually—and I've heard a lot in my time, so that's saying something. I'm gonna tick off a couple of them, but I don't do them justice. So, you'll need to listen to David explain them and give context. First off, what's the problem with healthcare being a $4 trillion industry in this country—I mean, almost 20% of GDP—and employing more people than any other industry in 47 of our 50 states? There are other big sectors in our economy, after all, that get lots of love. Why is big healthcare “bad” and these other sectors “good” in economic terms when we talk about employment? That's one thing I wanted to know. And David made a point that may be self-evident for some but is worth reiterating in all cases. The government pays for roughly half of healthcare, and from a consumer or just American standpoint, it kind of sucks. I mean, I don't see many Insta selfies of someone rocking their brand-new insurance premium. Dollars going to healthcare or health insurance are not going to consumer goods. And that matters economically as well as retail therapy. For all you econ geeks out there, this industry offers no marginal utility. Here's a second interesting point: Just changing incentives might not be enough. Organizations downstream and upstream need to be on board with the spirit and objective of the incentive change. If they are not, then it's game on for every CFO and their revenue cycle managers to finagle how to find the loophole that enables revenue maximization. Revenue maximization. Period. Revenue. The end. Which brings me to another interesting point: Boards of directors, CEOs, people with fiduciary responsibility … they need to know thyself and consider their actual customer. Spoiler alert: 99% of the time, that actual customer is not patients, no matter what is printed in big letters on the front door. No change can really happen unless those who serve in the upper echelons of these businesses get really real about where their bread is buttered. Organizations are built to serve their customer, after all. So, if a patient isn't identified as a customer, the organization at its very core is gonna have a lot of difficulty serving the patient. So, now what? If I want my organization to move forward in a way that is more patient-centric and less financially toxic, say, what to do? Here's thoughts after chatting with David Muhlestein. Four main steps: As I just said, you gotta get your current state unemotionally understood. For reals, who is the organization built to serve? So, first step is being introspective in the harsh light of day. Consider the timeline of your existential demise. Ha ha, this show is so uplifting. But unless organizations really think out 5 years, 10 years, 25 years and really internalize the existential threat, it's going to be hard to motivate change. I see this all the time. So do you. Inertia is real. Nobody does anything until they absolutely have to. Sidebar: But if you need an eventual demise to bring up at your next strategy meeting, I just saw a paper come out saying that by 2030, cost-related nonadherence could become a leading cause of death in the United States, surpassing diabetes, influenza, pneumonia, and kidney disease. This is as per a study by the nonprofit West Health Policy Center and Xcenda. Nonadherence … what does that mean? It means the patient is not doing their treatment. They are not going to the doctor or getting medical care or not taking their drugs. Meaning no one is making money off of all of those patients, especially when they're dead. This is where the rubber meets all of those excess profits everybody is reaping in the short term. I hope that was helpful for anybody trying to motivate change today.   Consider what legacy we want to leave behind. Do we all want to wait until we're forced to change to do so? Is this the healthcare system we want to leave behind to children and grandchildren? I mean, anybody who's got a loved one in the hospital with anything complex, fighting for their own patient records, on the phone for hours a day with insurance carriers while care is delayed with possibly devastating consequences, the family having to coordinate care and cross their fingers and pray they don't get a ridiculous bill for services that may or may not have been rendered and then use retirement savings to pay for them … if anyone is not looking to be a party to all of this, then let's think about our strategy moving forward and how it will change to meet the future we want to see. On to the evolve and change approaches: How exactly do you think about doing that? According to David Muhlestein, you can repair your current organization or remodel or rebuild. It sounds daunting, but as Dr. Eric Bricker said on our recent interview together (EP351) and as others have said as well, this is already happening in some regions across the country. There are pockets with real transformation. These changes are on the edges right now, but they're showing that this can and is possible.   You can learn more at healthmanagement.com.   David Muhlestein, PhD, JD, is chief research and innovation officer for Health Management Associates (HMA). He is responsible for the firm's self-directed research and supports strategic planning and innovation. David's research and expertise center on healthcare payment and delivery transformation, understanding healthcare markets, and evaluating how the broader healthcare system is changing. He is a self-identified data nerd and regularly speaks and writes about healthcare system evolution. David joined HMA via its acquisition of Leavitt Partners in 2021, where he was the chief strategy and chief research officer. Additionally, David is a visiting policy fellow at the Margolis Center for Health Policy at Duke University, adjunct assistant professor at The Ohio State University College of Public Health, and a visiting fellow at the Accountable Care Learning Collaborative. He previously served as adjunct assistant professor of The Dartmouth Institute (TDI) at the Geisel School of Medicine at Dartmouth College. David earned his PhD in health services management and policy, JD, MHA, and MS from The Ohio State University and a BA from Brigham Young University. 07:38 Is it an issue for the healthcare industry that it is one of the largest employers in the country? 08:42 “I think that we need to figure out what is an appropriate amount to spend on healthcare and get to that level.” 09:01 How do we not decrease the amount of healthcare we're receiving while paying less for that healthcare? 10:11 What are the two ways we can look at decreasing healthcare spend? 15:39 “I think that a regional approach may happen.” 16:56 “When somebody takes less, others are going to follow them.” 17:33 Who is really paying in our current healthcare system? 19:47 “Any sort of a model that you start with influences everything else that you do.” 20:09 What's the common challenge David Muhlestein sees in value-based care systems? 23:21 “There are countless things that you can do to improve the current system today.” 27:25 What are the three options for building up better healthcare? 28:19 David's advice for healthcare executives. 33:22 “To really lower the total cost of … healthcare, it's a 30-year process.” You can learn more at healthmanagement.com.   @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is it an issue for the healthcare industry that it is one of the largest employers in the country? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think that we need to figure out what is an appropriate amount to spend on healthcare and get to that level.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do we not decrease the amount of healthcare we're receiving while paying less for that healthcare? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the two ways we can look at decreasing healthcare spend? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “I think that a regional approach may happen.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When somebody takes less, others are going to follow them.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Who is really paying in our current healthcare system? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Any sort of a model that you start with influences everything else that you do.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's the common challenge David Muhlestein sees in value-based care systems? @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “There are countless things that you can do to improve the current system today.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “To really lower the total cost of … healthcare, it's a 30-year process.” @DavidMuhlestein discusses #healthcaretransformation on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley  

A bill now before the Colorado legislature will affect over 50,000 Coloradans who currently rely on health care sharing ministries as an alternative to health insurance.  Katy Talento, the Executive Director of the Alliance of Health Care Sharing Ministries, speaks to what's wrong with the bill, and where you can go to express your views opposing the bill.  For more information go to http://www.AHCSM.org and http://www.Leg.Colorado.gov to find the name of your state Representative and state Senator See omnystudio.com/listener for privacy information.

Administrative costs in the United States have a bad rap. You don't have to look too far to find an article about how there's now, like, 10 administrators for every 1 physician in this country. Or 3 to 4 billing people for every physician. Or find someone complaining about arduous prior auth processes and how long specialists sit on phones trying to get a prior auth approved while having a frustrating “peer consult” with a “peer” whose career has nothing to do with that specialty and, in fact, knows very little about it. Also consider the time that specialists' admin teams have to spend—or really any doctor's admin teams have to spend—when they are required to send documentation validating some prior auth request or appeal. They, in many cases, have to send this documentation via old-school, drop-it-in-a-mailbox mail … literally. This documentation can and often does amount to a sizable box full of paper patient records. They have to drag a box into their office and fill it up with paper to send to the insurance company to validate whatever appeal. Think about who prints out all that paper. Who does all this stuff? And who on the insurance side is unboxing it all and, I don't know, are they highlighting the good parts? Are they rekeying anything? What goes on there? Or here's another administrative cost: collecting and tabulating all the data needed to participate in some quality incentive program. Considering that each carrier has their own flavor of metrics … yeah again. Administrative burden, administrative costs. Or consider what Dan O'Neill was talking about in EP359 the other day. He was talking about IPAs (independent physician associations) and other managed care entities. These entities hold the contracts with payers on behalf of smaller provider organizations or solo practitioners. So, these smaller (usually) individual practices contract with the IPAs—you know, for leverage and all that. And then it's the IPA who then holds the contract with the payer. As Dan mentions, contracting with some of these IPAs is like an “I love 1990” flashback. The contracting process, again, transpires via mail. Not email, mind you. Mail. Like, stick-a-stamp-on-the-envelope mail.  So, in sum, there's a lot of pretty well-founded complaining about administrative costs in this country. A lot of this administrative stuff is truly inefficient and a fantastical waste of time—valuable clinician time. So, here we are freaking out about staffing shortages, overlooking that doctors at the heights of their careers are spending some percentage of their time not counseling, treating, or diagnosing patients but twiddling their thumbs on hold with one insurance company or another slowly burning out by the inefficiency of it all. Or doing pajama time, and we all know that too much pajama time means also burnout on a silver platter. Now consider this: Reducing admin costs are frequently cited as a fine way to reduce overall healthcare spending in this country. So then, let's get granular here. If we're trying to quantify admin costs, how you'd do that is to quantify how much each transaction costs. How much does it cost to send a bill and get paid for it? How much does it cost to file an appeal and a denial of a prior auth? Add all those transactions together and you get the full cost of the administrative burden. In this healthcare podcast, we're digging into a paper about admin costs written by David Scheinker, PhD (my guest today); Barak Richman, JD, PhD; Arnold Milstein, MD, MPH; and Kevin Schulman, MD, MBA.   I have the pleasure of speaking with David Scheinker, PhD (as I mentioned), who is the lead author on this paper. Dr. Scheinker is an associate professor of pediatrics and executive director of systems design and collaborative research at the Stanford Lucile Packard Children's Hospital. He is the founder and director of SURF Stanford Medicine at Stanford. David Scheinker's work centers around bringing together engineering PhD students and faculty with hospital administrators, leaders, doctors, nurses. The goal here is to design improvements to operations from an industrial engineering point of view. So, you can see how investigating administrative burden and costs and trying to reduce them fits in here. Before we begin, I just want to point out one thing: I alluded to this earlier when I mentioned staffing shortages. As reported by Gist a few weeks ago, health systems saw an 8% increase in labor costs per patient day; and many are budgeting for a negative operating margin. In the past, most administrative challenges were solved by throwing bodies at the problem. That is now untenable. This is one promise of technology. Tech can automate, replicate, and scale much of what has required human labor in the past. Tech is used to automate administrative functions in many other industries also, so there's a number of precedents for this. Now, just to underline a major takeaway from this conversation with Dr. David Scheinker, he reiterates a recommendation to eliminate a big proportion of administrative costs. I guess I should say spoiler alert here, but the major takeaway/recommendation is this: Standardize healthcare contracts between payers and providers. Every payer and every provider finds one contract template and uses it. I don't mean one template per payer or per provider, although that probably would be a revelation in and of itself. But I mean that all payers use one basic provider contract. A couple of specifics here: The template that I'm referring to (and that Dr. David Scheinker is referring to) consists of parameters. What do I mean when I say parameters? Consider what Airbnb does when you're looking for a place to stay, as an example. How many bedrooms (that's a parameter)? How many bathrooms (that's a parameter)? How many amenities (that's a parameter)? After everybody picks their standard set of parameters, at that point, all parties can negotiate and come up with whatever they want for what is the price of an extra bedroom or whatever value you're gonna assign to that parameter. Go nuts there, but from a data collection and analytic perspective and a getting paid perspective, it is way easier to do it that way—meaning it's way easier to execute and report when all of the contracts use the same parameters. Also, you can build tech to do a lot of that because you don't have to write algorithms with exponential variables. And anybody who has tried to write algorithms with exponential variables—and I am talking from firsthand experience here—it's a hot mess right out of the gate. You can learn more by connecting with David on LinkedIn and following him on Twitter.   David Scheinker, PhD, started his career as a research mathematician and switched to healthcare operations to work on an interdisciplinary team and have a more immediate impact. He is a clinical associate professor of pediatrics, the executive director of systems design and collaborative research at the Stanford Lucile Packard Children's Hospital, and a member of the Clinical Excellence Research Center (CERC) at Stanford University. He founded and directs SURF Stanford Medicine, which brings together students and faculty from the university with physicians, nurses, and administrators from the hospitals. He studies clinical care delivery, hospital operations, sensor-based and algorithm-enabled telemedicine, the socioeconomic factors that shape healthcare, and policy. 07:23 What's the quantitative administrative cost in an average transaction? 07:49 What's the quantitative administrative cost in a healthcare transaction? 08:43 What does the healthcare billing and administration cost add to the US's overall healthcare spend? 09:38 Is it possible to cut billing and administrative costs in healthcare? 11:01 “In some ways, the problem for healthcare should be simpler.” 12:14 What does the complexity of the current system look like in a doctor's office? 15:26 How did David go about studying healthcare administrative costs? 18:17 “It doesn't have to be simple; it should be standardized.” 21:41 What would be the pushback on standardizing contracts in healthcare? 22:35 Why is it possible to gain more value by losing customization in contracts? 24:11 “Never let a good crisis go to waste.” 24:33 “It's much easier in healthcare to build something new than to change something that exists.” 27:39 What benefits does telemedicine have to cutting administrative costs? 29:09 What is another significant benefit of using standardized contracts? 30:17 Why haven't standardized contracts become a common thing in the current healthcare system? You can learn more by connecting with David on LinkedIn and following him on Twitter.   @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts What's the quantitative administrative cost in an average transaction? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts What's the quantitative administrative cost in a healthcare transaction? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts What does the healthcare billing and administration cost add to the US's overall healthcare spend? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts Is it possible to cut billing and administrative costs in healthcare? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts “In some ways, the problem for healthcare should be simpler.” @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts What does the complexity of the current system look like in a doctor's office? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts How did David go about studying healthcare administrative costs? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts “It doesn't have to be simple; it should be standardized.” @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts What would be the pushback on standardizing contracts in healthcare? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts Why is it possible to gain more value by losing customization in contracts? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts “Never let a good crisis go to waste.” @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts “It's much easier in healthcare to build something new than to change something that exists.” @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts What benefits does telemedicine have to cutting administrative cost? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts What is another significant benefit of using standardized contracts? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts Why haven't standardized contracts become a common thing in the current healthcare system? @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #healthcarecosts Recent past interviews: Click a guest's name for their latest RHV episode! Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17)  

David Contorno the other day posted the life expectancy chart comparing the US to comparable countries. Spoiler alert: It's horrifying. You see Japan; you see Switzerland, Israel, Spain, Italy … basically everybody else in a cluster of pretty darn vertical lines: increasing life expectancies year over year without much cost increase at all. And then—wow!—off to the right, all by itself, you see the USA, costing nearly double the worst of the other countries with a life expectancy that is years lower. We pay a whole lot, and despite all of the advances in medicine and how much we pay, we don't seem to be getting the value for our dollar. We could dig into those poor outcomes that we pay for. If we were going to, I might mention our truly beyond-upsetting maternal mortality rates and also infant mortality rates, which are way above other comparable countries. We could talk about all of our issues with diabetes and obesity. But let's save all that for another day and just take one example that is really the quintessential example of what's going on. Let's chat about heart failure for just a sec. Here's some stats for you. They come from Dr. William Bestermann's Substack newsletter, and if you don't subscribe to it, you might want to. It's free.  Dr. Bestermann wrote: “Twenty-two percent of heart failure patients who are admitted to the hospital are dead within a year. Patients with [heart failure] generate a third of Medicare spending and 40% of Medicare fee-for-service deaths. Overall, heart failure patients have a mortality of 22%, compared [to] 4% for Medicare patients without heart failure. They are responsible for 55% of Medicare readmissions.” But here's some good news: In Denmark, investigators proved that using optimal medical therapy reduced heart failure admissions by 70% compared with usual care. Here's some more good news: There was a small, impoverished town near the coast of the Carolinas that had very few heart failure admissions. How did they accomplish that, you might wonder? Well, there was a nurse—one nurse—who was working under a grant. She was very dedicated. She had a list of all the heart failure patients in the area, and this was her job: making certain that every patient was on the best treatment for heart failure. She called the patients. She spent time with them. She had a trusting, caring, long-term relationship with them. That's it! That was the secret sauce. As Dr. Bestermann says, “Every poor community in our country could do that, but they don't.” So, this leads us to care gaps—dare I say, this country's seeming care gap fetish dealing with care gaps retroactively. In this healthcare podcast, I'm speaking with Carly Eckert, MD. It's kinda funny, actually. I originally wanted to get Dr. Eckert on the show to talk about care gaps and how to close them, but this show did not wind up going how I thought it was going to go because Carly Eckert is a physician by training who got really interested in the upstream causes of what she was seeing in clinical practice. Despite my best efforts, she refused to be lured into my closing care gaps conversation. So, instead, this conversation is about the construct of care gaps and thinking about them in context. Closing care gaps is a model of care and maybe not a particularly great one, relatively speaking. In fact, here's another name for the model of care called closing care gaps: care gap whack-a-mole. Care gap pops up … we whack it. Care gap pops up … we try to close it. Another care gap pops up … we try to close it. Another care gap … you get the idea. Carly Eckert has worked in epidemiology and public health and also clinical informatics for health systems and payers. She is currently leading a team at Olive AI working on network data analytics and machine learning algorithms. I recorded this show with Dr. Eckert prior to EP359 with Dan O'Neill. In that interview, which you should go back and listen to when you have a sec, Dan O'Neill cleared up a couple of things that I struggled with during this interview.  Here's the big one that I could not figure out: Why with the whack-a-mole? Why do we still insist as a nation on waiting for someone to show up in clinic to retroactively and reactively address a missed preventative care opportunity? Why don't so many more provider organizations create pop health programs that consider the whole person proactively? Why don't they take the time to operationalize whole-person care in a meaningful way? Why don't they do what that nurse was doing in the Carolinas? Ah, yes … to the surprise of exactly no one, it's all about the Benjamins. As Dan O'Neill put it, if all a provider organization is doing is slapping a sheet on a doc's desk every morning with a list of care gaps for all the patients that he/she will see that day, it's highly likely that incentives, or penalties to do anything else, are very weak. It's a sign that, from a paying for value perspective, we're not paying enough for value that it's worth it or maybe even feasible for any provider organization to take the time and capital expense to switch up their business model in any meaningful way. So, the provider gets a little bump or a little knock if they don't meet some quality standard. OK, great … so then they'll minimally tweak their workflow and have doctors within their 7- to 15-minute visit suss out and try to close care gaps. I don't want to say this is entirely negative. It's known that when provider organizations do close care gaps, patient outcomes do tend to get better—so, not arguing that. But there's opportunities that get left on the table with all this reactiveness. Bottom line: You insurers, you purchasers of healthcare, get to it. Pay for value, for real. If you're still just kinda paying mostly FFS with an icing of quality measures, maybe think a little bit harder about what's next that's really gonna end the whack-a-mole and bring about a more proactive and in-context mindset. But you provider organizations, if you don't fix this stuff yourself, you're gonna get doctors and other clinicians (as we're seeing) burning out and quitting because there's only so much you can jam into a 7- or 15-minute visit, number one. But number two, doing population health reactively like this is suboptimal—and everybody knows it. So, what winds up happening is dedicated doctors and nurses desperately want to do the right thing but simply do not have the time. And they watch patient after patient suffer for it. That sucks. So, fix it. Maybe find a nurse like they did in North Carolina. At the end of the day, it's probably cheaper to stand up a program like that than having to recruit all new doctors and hire traveling nurses when all of the current staff quits due to burnout and/or moral injury. You can learn more at oliveai.com. You can also connect with Dr. Eckert on LinkedIn and follow her on Twitter.   Carly Eckert, MD, MPH, is a product leader at Olive AI, the automation company creating the internet of healthcare. As a trained physician, epidemiologist, and informatician, Dr. Eckert brings a tremendous amount of clinical experience and relevant healthcare industry knowledge to her work. In her role, Dr. Eckert combines her expertise, data understanding, and deep passion to impact healthcare for all patients. Prior to her role at Olive, Dr. Eckert led product for multiple AI start-ups with a particular interest in socially responsible technology and community impact. 06:59 What is the true goal in making population health successful? 07:26 How does the clinical pathway need to manifest in population health? 08:00 How do we get a nonfragmented state of care? 08:25 What is the best model of care? 10:08 “Identifying and addressing care gaps is an important element of population health.” 13:01 Closing care gaps vs creating a nonfragmented system of care. 17:11 “I think you have to take small steps with people.” 18:18 “There's a lot of power in peer support.” 18:52 Why should provider organizations connect with peer groups? 20:39 “The key is that it's not going to be the same for everybody.” 24:43 Why is diversity of the workforce key to closing care gaps? 25:07 EP322 with Monica Lypson, MD, MHPE.25:11 EP347 with Ian Tong, MD.30:09 Where can providers improve transparency to help close care gaps? You can learn more at oliveai.com. You can also connect with Dr. Eckert on LinkedIn and follow her on Twitter.   @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc What is the true goal in making #populationhealth successful? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc How does the clinical pathway need to manifest in #populationhealth? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc How do we get a nonfragmented state of care? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc What is the best model of care? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc “Identifying and addressing care gaps is an important element of #populationhealth.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc Closing care gaps vs creating a nonfragmented system of care. @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc “I think you have to take small steps with people.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc “There's a lot of power in peer support.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc Why should provider organizations connect with peer groups? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc “The key is that it's not going to be the same for everybody.” @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc Why is diversity of the workforce key to closing care gaps? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc Where can providers improve transparency to help close care gaps? @md_carly discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc   Recent past interviews: Click a guest's name for their latest RHV episode! Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King

Before I get into the show today, let me just remind everybody about our mailing list, which you can sign up for on our Web site, relentlesshealthvalue.com. You might follow Relentless Health Value on LinkedIn or Twitter, which is a great option, for sure; but I wanted to point out that what you see there is abridged at some level. Meanwhile, if you subscribe to our mailing list directly (again, by going to our Web site, relentlesshealthvalue.com—it's over on the right sidebar where you can sign up for the mailing list), if you subscribe that way, each week you'll get an email with a full transcription of the whole introduction of the show with timed show notes. Also, we don't send out literally anything else beyond what I just described on a weekly basis. Also, you can unsubscribe easily and anytime you want. You just hit the unsubscribe in the email. Also, we don't share our list with anybody. We barely have time to look at it ourselves, so if you have any concerns there in that regard, please don't.  Last week's show (EP359) was with Dan O'Neill, and he talked about the four gradations of value-based payments, from paying purely for volume on one end of the continuum to paying purely for value on the other. When you have a moment (not now, but when you can), go back and listen to that show, as it adds some color to what we talk about in this healthcare podcast.  But in the meantime, one of the points that Dan O'Neill makes is that patients in this country won't gain the benefits of value-based care unless commercial insurers pay for value, for reals. After all, value-based payments are payments that incentivize value-based care. Without value-based payments, how does anyone expect to get value-based care? To belabor this point momentarily, a provider is not gonna switch up their FFS business model when insurers, especially commercial insurers, pay whatever for whatever with no reward going to providers who spend time and effort to create value and/or better outcomes for patients. I'm being super cynical here, I will grant you. But in this day and age of private equity and record profits by a consolidated healthcare industry, if I'm in charge of a provider organization just realistically here, Pramod John, PhD, says this really well in EP352. He's talking about drug development in that episode, but same thing here is true for medical care. If you indiscriminately pay Ferrari prices for Hyundais, you're gonna get a Hyundai for the price of a Ferrari.   To add insult to injury—and this is just one important reason why providers aren't really willing to invest in lifting outcomes—any value that they would manage to create is gonna be realized by the insurers. It's gonna go right back into insurers' pockets. Steve Schutzer, MD, talks about this in his episode (Encore! EP294) about the why and how to create a center of excellence. If, as a provider in a pure volume contract which is FFS, I work really hard to save downstream costs and complications for patients, some carrier is gonna bank the difference.   It's go time, all you self-insured employers out there. Pay for high quality. Make the carrot an orange-colored stick, as they say. Patients will benefit. Probably doctors and other clinicians, too, honestly: less moral injury and crappy workflows. In this healthcare podcast, I am talking with Jeb Dunkelberger. Jeb Dunkelberger is the CEO of Sutter Health | Aetna, which is a payvider. Payviders, by Jeb's definition, take on full risk. They have a full-risk insurance product, meaning they must switch up their business model and how they deliver care so that it works in a total capitation payment situation. We go deep on payviders the last time Jeb was on the show (EP348). But in this relatively short conversation, I wanted to talk to Jeb about the operational imperatives of moving to value-based care, moving to a care model that is aligned with value-based payments—what needs to switch up in the day-to-day to ensure that patients don't have care gaps that cause expensive trouble downstream, or patients at rising risk get taken care of promptly before something avoidable and/or acute (ie, expensive) happens.   There are three main things that Jeb talks about: Fixing up the clinical workflow Having care navigators Aligning physician comp to organizational goals Let me dig into each one of them briefly. 1. Fixing up the clinical workflow. There's basically five aspects to that: Ensuring that the right data is in the clinical workflow. Let's talk about this data for just one sec and we'll find actually one more reason that payers and purchasers need to get kinda engaged in this making sure members get care thing. Because data—data that payers have that is needed at the point of care. Like claims data. Please provide it to providers and actually insist that it gets used by clinicians making clinical decisions at the point of care. Ensuring that there are pick lists of drugs, with generic drugs first Making sure it's easy to get to pended orders that close care gaps right within the clinical workflow Empowering medical assistants and holding them responsible to create value for members Building referral management into the clinical workflow in pursuit of a nonfragmented patient journey 2. Having care navigators. I just want to remind everyone: This is even more important if the EHR doesn't support referral navigation. Also, Liliana Petrova talks about this extensively, the need for care navigators, in EP357. She's talking about it relative to telehealth, and she makes a really important point: If you want to ensure that the right patients are getting telehealth and also taking advantage of it to streamline their longitudinal care and make it less fragmented, you have to have navigators involved in scheduling. Otherwise, how's a patient supposed to know whether to go in person or telehealth or even that telehealth is available?  3. Aligning physician comp to organizational goals. We definitely get into this in some detail. We cover these three top-line operational must-haves in this episode, and you'll hear about them right from a CEO who is doing them right now. Besides this conversation, another resource I would highly recommend checking out is a recent article in Nature entitled “Deploying Digital Health Tools Within Large, Complex Health Systems.” While this article is about digital health tools (obviously by its title), 80% of the article is pertinent to deploying pretty much anything in a big provider organization, including an upgrade to value-based care delivery—and/or probably digital health tools are pretty requisite in any attempt to effectively remodel the clinical workflow in this way in 2022, so there's that, too.   For additional Relentless Health Value episodes on this topic of how to build an operational model that fulfills value-based care objectives, I'd listen to the show with Shawn Rhodes on the essentials for clinical integration (EP354)—also the show with Lisa Trumble (EP349) on what that clinical integration looks like from a care perspective. I am also going to refer you to the episode next week (EP361) with Carly Eckert, MD, MPH. So, check that out for sure. We talk about care gaps.  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. 08:36 What must a provider organization consider operationally when incorporating value-based care and value-based payments? 09:44 How can you use perverse incentives to encourage people to do the right thing? 12:25 How should clinical workflows operate to incorporate value-based care? 14:10 “How do you align patients?” 15:52 How should the EHR operate to maximize value-based workflow? 16:52 Why is taking action on claims data and clinical data together important? 20:26 “Have they actually solved the last mile of integrations?” 21:15 “Changing the behavior of a provider is an absolute art and science.” 22:57 “We have to do more.” 27:09 “That administrative headache … doesn't just end with the insurer.” You can learn more at sutterhealthaetna.com.   You can also connect with Jeb on LinkedIn and follow him on Twitter.   @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs What must a provider organization consider operationally when incorporating value-based care and value-based payments? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs How can you use perverse incentives to encourage people to do the right thing? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs How should clinical workflows operate to incorporate value-based care? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs “How do you align patients?” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs How should the EHR operate to maximize value-based workflow? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs Why is taking action on claims data and clinical data together important? @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs “Have they actually solved the last mile of integrations?” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs “Changing the behavior of a provider is an absolute art and science.” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs “We have to do more.” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs “That administrative headache … doesn't just end with the insurer.” @Jeb_Dunk discusses #valuebased #clinicalworkflows in this week's #healthcarepodcast. #healthcare #podcast #vbc #valuebasedcare #ffs Recent past interviews: Click a guest's name for their latest RHV episode! Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb  

Last week's show was with Wayne Jenkins, MD, from Centivo; and we talked about how insurance design, when not done well, can lead, in a nutshell, to mental and physical health problems for employees. This is a great lead-in to the conversation in this healthcare podcast with Dan O'Neill. And before I get into why it's a great lead-in, let me just start here—and don't roll your eyes. What is value-based care? Consider this delineation: There's value-based payments, and then there's the type of care that these payments incentivize. You would hope that a value-based payment would result in care that was of value (ie, great patient outcomes and patient satisfaction at a fair total cost of care). But those are two distinct things—the payment and the care. If we change the payment model but the provider behavior doesn't change in a way that actually improves patient outcomes and care, then what are we doing here? Or the converse: If we do not change the payment model, then how does anyone expect the care paid for is going to change? Employers or carriers who just meander along with the broad PPO network happily paying as much for low-value care as for high-value care and happily paying centers of excellence as much as non–centers of excellence … how is a provider who wants to spend time and money building out a practice to deliver better patient outcomes, how can they do that without overcoming some pretty fundamental business model challenges? This whole concept is one that my guest today, Dan O'Neill, has talked about and will talk about in this episode. Dan says the first step is for insurers, IPAs, managed care organizations to take an absolute chainsaw to their network management bureaucracy. There must be a clear door to a value-based payment model. It must be that if you're a provider or you're a physician practice (primary care practice, in particular), and you want to go down a value-based care path, there has to be a clear door and a pathway for you. I think I have a non-perfect litmus test for anybody with a value-based payment program who wants a heuristic to check if their value-based payment program is actually meaningfully impacting models of care in the marketplace: If most of the provider organizations who are part of that value-based program still incentivize and pay their doctors using FFS incentives like RVUs (relative value units), I'd step back and think about that for a piece. Contemplate that doctors, who are responsible for care decisions, still have every incentive to do everything that they would have done had the provider organization just been paid FFS. What's the point of value-based payments that extract exactly zero behavior change? And that is not a rhetorical question. So, back to the conversation from last week with Dr. Wayne Jenkins citing all of the things that can go horribly wrong when an employer's benefit designs are misaligned with the financial realities of their workforce. You get what you pay for, and I don't just mean that in terms of the dollars outlaid, since we all know in healthcare prices and quality have nothing to do with each other—I mean, in terms of what you choose to pay for and how you choose to pay for it. That's the macro of this whole thing, but indulge me as I get into the micro for just one sec. Let me just remind everybody about Goodhart's Law: “When a measure becomes a target, it ceases to be a good measure.” More on the why of this in the interview with Rishi Wadhera, MD, MPP, on the hospital readmission reduction program (EP326) and also what happens when we don't adhere to Goodhart's Law as we evaluate PCPs, which Rebecca Etz, PhD, talks about in EP295.   In this episode with Dan O'Neill, we go through where we're at on the continuum of value-based payments and how those payments are impacting the care, value-based or otherwise, that is incentivized by those payments. We tick through four gradations of value-based payments: A pure volume contract (otherwise known as FFS [fee for service]) A clinician bonus for achieving quality measures A piece of the savings (ie, MSSP [Medicare Shared Savings Program]) Global risk My guest, Dan O'Neill, is chief commercial officer over at Pine Park Health. Besides over a decade in healthcare tech and services, he was a policy fellow at the National Academy of Medicine and worked in the Senate on the Senate Health Committee. You can learn more at dponeill.com or connect with Dan on LinkedIn. Daniel O'Neill, MA, MS, currently serves as chief commercial officer for Pine Park Health, a value-based primary care group that delivers on-site care in senior living communities. Prior to that, Dan was a health policy fellow at the National Academy of Medicine, working primarily in the US Senate on legislation focused on surprise billing, anti-competitive contracting practices in the commercial market, and price transparency. Dan has also worked as a senior vice president with Change Healthcare and as an advisor to venture-stage healthcare services and technology firms. At Pine Park, Dan is responsible for risk-based contracting with IPAs and insurers and for the group's participation in CMS value-based care models, including direct contracting. Dan's research is available in NEJM Catalyst and on the Health Affairs blog, and he holds graduate degrees from Johns Hopkins University and Stanford University.   05:06 What is the spectrum of value-based contracts? 07:24 Why don't value-based contracts at the organizational level always trickle down to the provider level? 11:25 What are the two things that need to happen to drive outcomes in value-based healthcare? 15:24 How do insurers play into improving value-based contracts? 19:46 “There's a strong case to actually clamp down on prices.” 23:47 “Right now, we're still in a place where if you want to do something other than fee for service … you have to fight like hell.” 24:03 What's the first step to making value-based contracts more accessible? 24:27 What's the second step to making value-based contracts accessible? 25:23 Why are the incentives to change American healthcare pretty weak? 27:10 “Organizational change is just exceedingly difficult.” 28:45 What should you do if you want to start pushing organizations toward value-based contracts? 32:42 EP351 with Eric Bricker, MD.  You can learn more at dponeill.com or connect with Dan on LinkedIn. @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What is the spectrum of value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth Why don't value-based contracts at the organizational level always trickle down to the provider level? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What are the two things that need to happen to drive outcomes in value-based healthcare? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth How do insurers play into improving value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “There's a strong case to actually clamp down on prices.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “Right now, we're still in a place where if you want to do something other than fee for service … you have to fight like hell.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What's the first step to making value-based contracts more accessible? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What's the second step to making value-based contracts accessible? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth Why are the incentives to change American healthcare pretty weak? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “Organizational change is just exceedingly difficult.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What should you do if you want to start pushing organizations toward value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber  

First of all, anybody who thinks that your average citizen in the United States today is unaware of the financial double jeopardy of going to a doctor, going to an emergency room, getting a procedure is sorely mistaken. Americans today are well aware of the financial risk that they are taking by seeking healthcare in this country. To illustrate this point, let me read the first couple of sentences from a New York Times best-selling book review: “The illness narrative, ending in financial ruin and decreased quality of life, has become one of the classic 21st-century American stories. In her debut essay collection, Emily Maloney documents the … intersections of money, illness and medicine. For Maloney, the primary experience of receiving health care is not merely a bodily or spiritual event but always … a financial one. She understands … the relationship of money to being ill, … to managing an unfathomable amount of debt.” This is a New York Times best-selling book in the beginning of 2022.  Add to this something I saw Pete Scruggs write on LinkedIn a while back, which I found actionable. He said:   “Patients selling personal items or taking on credit card debt after medical procedures is a failure of creativity in providing healthcare. It is possible to build creative health plans that reduce costs for patients with expensive procedures by giving wise guidance at the time patients need it the most. “It is not enough for insurance to provide access to a wide range of health providers but effectively leave the patient in debt … after the procedures are done. It is possible to buy healthcare so well in the local community that employers can reduce cost dramatically at the time most needed by those using health services.” And lastly, let me quote from a recent article in JAMA by David Scheinker, PhD; Arnold Milstein, MD; and Kevin Schulman, MD, which says, “The financial consequences of an underperforming health insurance market (one that is not holding down … cost … ) diminishes the quality of life affordable to US employees and their families and the financial viability of employers not in the health care industry.”  So, in this healthcare podcast, I am speaking with Wayne Jenkins, MD, who is chief medical officer over at Centivo. Before his move into value-based healthcare about 10 years ago, Dr. Jenkins started his career as a radiation oncologist. He has also served as the chief clinician at a bunch of large health systems. I wanted to have Dr. Jenkins on the show to discuss a recent report which was published by Centivo that methodically dissects how financial toxicity is affecting patients. This includes how it affects choices that employees/patients/members are making both in terms of the care they decide they are willing to pay for or, more likely, the financial risks they're willing to take.  In short, the three key findings of the report are as follows: Workers face mounting healthcare affordability issues, and health plan cost sharing features such as high deductibles are an underlying cause. Just a quick spoiler here: Do you know the percentage of employees who are forgoing buying groceries in order to afford medical expenses left on their shoulders by their high-deductible health plan or by their health plan with excessive premiums? Going hungry isn't just for minimum wage workers. Medical expenses are a significant cause of mental health and well-being issues for both individuals and also families. The conventional wisdom that health plan members will never “trade off” certain offerings for greater savings is simply false. The big takeaway here, though, is that the situation that we have in this country today is not a secret among your average regular American civilian. They do fully understand that by entering a healthcare setting, they are very well trading off, in their attempt to be healthy and going to the doctor in pursuit of that aim, they are trading off their financial well-being. And that financial toxicity actually has health implications. If you can't afford groceries, for example, or your mental health suffers, we get ourselves rather rapidly into a downward spiral, as you may be able to see. Other episodes dedicated to the impact of financial toxicity and possible solutions are in the show notes. I'm just gonna mention here quickly, we talked to Marty Makary, MD, about his book called The Price We Pay (EP242). There's an interview with Marshall Allen (EP328) and then also a very interesting conversation with Mark Fendrick, MD (EP308).   You can learn more at centivo.com.   Wayne Jenkins, MD, is the chief medical officer at Centivo. He is an accomplished physician and executive with a proven track record of patient-centered, revenue-driven results. Over the course of his career, he has consistently transformed large, complex healthcare systems into market leaders that deliver quality and value in a dynamically changing environment. Prior to Centivo, he was the chief clinical officer for population health at Vanderbilt University Medical Center, where he provided clinical oversight of value-based care delivery and completed the formation of Medicare accountable care organizations (ACOs). Before his time at Vanderbilt University Medical Center, he served as the senior vice president and chief strategy officer of Orlando Health, as well as president of Orlando Health Physician Partners. Previously, Wayne was the chief of radiation oncology and then subsequently the medical director for the Florida affiliate of M.D. Anderson Cancer Center, a subsidiary of Orlando Health, Inc. Wayne holds a bachelor's degree from the University of Tennessee, an MD from Vanderbilt University School of Medicine, and a master's of health policy and administration from Johns Hopkins University. He is board certified in radiation oncology and was recognized in Best Doctors in America annually from 1994 to 2015. He has published 18 scientific articles and is often sought out to speak at state and national conferences. 05:23 How is financial toxicity in healthcare affecting patients? 07:02 How do we define a “normal” deductible in today's healthcare? 08:14 What's the point of having a deductible? What does a plan gain from a high deductible? 10:43 How does the cost of a patient's deductible correlate with their use of their health insurance? 12:51 EP308 with Mark Fendrick, MD.15:18 How is health insurance actually sometimes reducing patients' health? 16:24 What is the defining characteristic of those who are more adversely affected by high deductibles? 17:04 Why should CFOs consider plans with lower deductibles for their employees? 18:26 “Are there other ways to approach this in a marketplace, to get more value for what you're paying for so this problem can be addressed?” 21:56 How should employers contemplate health plans moving forward? 22:24 “Having the health plan choice gives more financial viability in addition to that open access.” 22:58 “In some sense, [that] can be a zero-sum game. Do you get it in the premium, or is it paid in the higher deductible?” 23:45 “I think there are value choices in the market that may help negate some of the problems that we were just discussing.” 25:33 “I think conventional wisdom may be left over from the '90s.” 26:49 Why does building these narrow networks have to be a science? 28:38 Does a narrow network adversely affect mental health? 32:20 “Narrow and excellent is not a bad choice for people.” You can learn more at centivo.com.  Wayne Jenkins, MD, of @Centivo_Health discusses health insurance plan design on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts How is financial toxicity in healthcare affecting patients? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts How do we define a “normal” deductible in today's healthcare? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts What's the point of having a deductible? What does a plan gain from a high deductible? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts How does the cost of a patient's deductible correlate with their use of their health insurance? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts How is health insurance actually sometimes reducing patients' health? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts What is the defining characteristic of those who are more adversely affected by high deductibles? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts Why should CFOs consider plans with lower deductibles for their employees? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts “Are there other ways to approach this in a marketplace, to get more value for what you're paying for so this problem can be addressed?” Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts How should employers contemplate health plans moving forward? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts “Having the health plan choice gives more financial viability in addition to that open access.” Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts “In some sense, [that] can be a zero-sum game. Do you get it in the premium, or is it paid in the higher deductible?” Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts “I think there are value choices in the market that may help negate some of the problems that we were just discussing.” Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts “I think conventional wisdom may be left over from the '90s.” Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts Why does building these narrow networks have to be a science? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts Does a narrow network adversely affect mental health? Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts “Narrow and excellent is not a bad choice for people.” Wayne Jenkins, MD, of @Centivo_Health discusses on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcarecosts Recent past interviews: Click a guest's name for their latest RHV episode! Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30)  

Here's the biggest problem with a lot of telehealth endeavors: Someone decides that they need to be doing telehealth, for whatever reason. Maybe there's a pandemic, for example. And the basic plan is this: Install some technology, give everyone a username and password and a link for patients, check that box, and move on to the next thing. My guest in this healthcare podcast, Liliana Petrova, has seen and talked about how, far too many times, the whole concept of telehealth is narrowed down to the exact moment where a patient and a doctor have a visit together. That's it … that transaction. There's little effort, if any effort, made to integrate telehealth into the existing clinical workflow, into the existing patient/customer experience, into the core business, into anything longitudinal. Telehealth becomes a weird island of a service only used by intrepid clinicians willing to put in the time and effort required to deal with its vagaries and inconveniences. Only used also by patients who manage to find the telehealth link buried on some Web site somewhere and then figure out how to schedule their telehealth appointments within a scheduling system mostly unable to accommodate virtual visits without a party-sized amount of technical expertise and, probably, chutzpah. There are consequences to this narrow and pretty slapdash thinking. One of them is that you have very few clinicians and patients willing to brave the organization's telehealth experience or lack thereof, so they don't use it. And then at some point the organization does a survey of how much telehealth is going on—and wow! Surprising news: Incredibly few are using telehealth. So, the conclusion is drawn that patients and/or clinicians don't want telehealth. What happens then? Further funding is withdrawn and/or the whole telehealth thing goes down on the chopping block. It reminds me of a cartoon I saw the other day. It was a picture of a bar chart showing some survey results. One of the bars in the bar chart was huge, and then the other one was, like, zero. It was a poll. There were two questions in the poll. Here are the two questions: Do you respond to polls, or don't you respond to polls? And as per the poll results in the bar chart in the cartoon, turns out, 100% of people respond to polls. Funny but, at the same time, true. Many organizations don't really think through the provenance of the “data” they're using to make really important decisions, and when it comes to telehealth, there's a lot of dirty data flying around. This dirty data, though, might be one explanation for the delta between the conclusions of all those studies showing that three out of four patients, always a comfortable majority of patients, intend to use telehealth versus the many health systems and/or provider organizations or even some doctors themselves sniffing and turning up their noses and saying that none of their patients are interested in using telehealth because no one is using telehealth in their office. Right. The only thing that's being anecdotally determined by these anecdotal conclusions is that patients don't like and/or even know about that office's telehealth solution. It says nothing of the larger trend. When organizations make decisions to not do telehealth well or at all because they didn't do it well and no one could figure out how to use it, then the value that telehealth could bring to both patients and clinicians is forfeit. Sad. Also, considering the X on the backs of some specialists and health systems in general these days, this could have longer-term consequences. Some good clinicians could find themselves way behind the curve after making what amounts to a very poor strategic decision. In this episode, I am speaking with Liliana Petrova, CEO of The Petrova Experience. Liliana is an expert on customer and patient experience. She hails originally from the aviation industry, where she was director of customer experience at JetBlue, where she built and maintained customer centricity across organizations. Today we're talking about telehealth. Last time Liliana was on the show (EP236), we talked about customer centricity—so go back and listen to that one if you're interested. In that show, we talked about, as one aspect, lobby design—the impact of having front desk people and clinicians literally barricaded behind cement and glass like they work in some bodega in a bad part of town that gets held up every other day. I never really thought about that and the message that it sends before.   Liliana served this past year on the NODE patient committee and did a whole lot of work exploring telehealth and its potential and challenges. NODE stands for the Network of Digital Evidence.  In this show, we go through the essentials to pull off a telehealth program that is actually going to deliver returns. In short, here's the ingredients: A telehealth “board” comprised of all the cross-disciplinary folks needed to pull this off: clinicians, IT, and also administrative peeps for a few very critical reasons that we talk about. Having executives on this board with enough power in the organization to define long-term goals that supersede all the short-term ones that usually define and plague organizations, especially public ones, is also very essential here. Redefining IT and the role of IT. This is an interesting one. Liliana talks about how the legacy role of IT is changing. IT leaders can no longer just be the help desk or maintainer of computers or manager of outsource contracts for the place far away that you call when you can't get on the portal. Today's IT teams need to think like they're a vital part of supporting the needs of patients and clinicians. After all, you can't have technology-augmented care when the IT group is shacked up in the basement doing their own thing. Identifying a physician ambassador for the telehealth internally (the telehealth program). Getting patient feedback. I was shocked, literally shocked, to discover that some of the most vocally “patient-centric” health systems do not collect patient feedback systemically. WTH, really? Liliana gets granular here. What might be the silver bullet? Patient navigation. We talk about this at some length. Map the end-to-end patient visit. Continuous improvement—you're never done. Also, March 8, 2022, is International Women's Day, by the way. This episode honors women in healthcare doing great things. You can learn more at thepetrovaexperience.com or join the patient NODE group by emailing Liliana at liliana@thepetrovaexperience.com. Liliana Petrova, CCXP, is a visionary and a proven leader in the field of customer experience and innovation. She pioneered a new customer-centric culture, energizing the more than 15,000 JetBlue employees with her vision. She has been recognized for her JFK Lobby redesign and facial recognition program with awards from Future Travel Experience and Popular Science. Liliana is committed to creating seamless, successful experiences for customers and delivering greater value for brands. In 2019, she founded an international customer experience consulting firm that helps brands improve their customer experience. The Petrova Experience focuses on three pillars of customer experience: organizational culture that inspires employees to be brand ambassadors, design and implementation of customer centric journeys, and technology implementations with customer experience value in mind. 06:59 Who should be on the telehealth board to incorporate telehealth successfully? 08:44 What is the population that you're serving, and how does telehealth serve that population? 09:45 “When they think of this as a project versus a program or a strategic imperative, then there is no business case.” 11:49 “How do you integrate telehealth in your core business?” 12:32 What does a CIO need to do to be best equipped to serve their organization? 14:05 Why are CIOs and CFOs naturally in conflict these days? 15:30 Why is it important to have a physician be an ambassador for telehealth implementation? 17:05 Why is it important to utilize patient feedback properly? 18:37 Why must the patient own their own health? 20:29 “The key is, if you start at the strategic level with cross-functional leaders, then the working team will also be cross-functional.” 21:49 “You won't have a successful telehealth experience if you don't think through the end-to-end experience.” 21:55 EP332 with Tony DiGioia, MD.23:40 Who is the digital navigator in implementing telehealth? 24:55 What is a digital navigator, and how does it show up in the telehealth journey? 30:55 Why is it important to have continuous growth in telehealth? You can learn more at thepetrovaexperience.com or join the patient NODE group by emailing Liliana at liliana@thepetrovaexperience.com. @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Who should be on the telehealth board to incorporate telehealth successfully? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the population that you're serving, and how does telehealth serve that population? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When they think of this as a project versus a program or a strategic imperative, then there is no business case.” @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “How do you integrate telehealth in your core business?” @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What does a CIO need to do to be best equipped to serve their organization? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is it important to have a physician be an ambassador for telehealth implementation? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is it important to utilize patient feedback properly? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why must the patient own their own health? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The key is, if you start at the strategic level with cross-functional leaders, then the working team will also be cross-functional.” @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth “You won't have a successful telehealth experience if you don't think through the end-to-end experience.” @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Who is the digital navigator in implementing telehealth? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is a digital navigator, and how does it show up in the telehealth journey? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why is it important to have continuous growth in telehealth? @LilianaPetrova discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16)  

So … let's start here. Mostly this whole episode is about the so-called “Big Three” PBMs that provide between the three of them pharmacy benefit services for 95% of insured Americans. PBM stands for pharmacy benefit manager, and the Big Three PBMs being ESI, otherwise known as Express Scripts; OptumRx, which is a part (a big profitable part) of United Health Group; and then also CVS. Yes, CVS is not just for your retail pharmacy needs; they are also a huge pharmacy benefit manager. Now, we get to the GoodRx part of our story. If you don't know how GoodRx works, I would strongly encourage you to go back and listen to “An Expert Explains” with Dr. Ge Bai from last year (AEE13). That said, here's the super short semi-reductive version to keep us all level set here. If you already know how GoodRx works, you can skip forward about four minutes.  So, first of all, let's all understand that GoodRx's business model only exists because the pharmacy supply chain dominated by these three big PBMs that we just talked about is such a cluster. GoodRx profits from that dysfunction. So, as I said, here's the short version of how they do that. It all hinges on so-called spread pricing, and this is what I mean by that. Patient goes into pharmacy with a prescription for generic drug X. The patient has insurance—good news! Pharmacist checks the computer and sees that this patient should be charged, I don't know, $50 for drug X. The patient's insurance carrier picks up, say, $30 of the $50 cost; and the patient is left with, say, a co-pay of $20. Who did that little math there in the computer? The PBM (the pharmacy benefit manager) did that math. That's their thing, these PBMs. They adjudicate claims. That's what this math is called. Anybody who goes into a pharmacy with a prescription, it's the PBM on the back end who figures out how much the patient owes and how much their insurance will pay and what the patient responsibility is, etc. Goodness, you might say. How much are the PBMs being paid to perform this useful service? Turns out, it's free. That's right … the Big Three PBMs do all this adjudication for free. No charge to plan sponsors. Isn't that nice? Except it's actually not free if you dig into it. The PBM is certainly getting paid by means of arbitrage. They're taking a little something something out of the middle of every single transaction. Here's what that looks like in the example aforementioned. Recall the patient's insurance paid $30, and the patient themselves paid $20. The question is, how much did that drug cost the PBM? Remember, that's commerce: Buy low, sell high, and all that. You buy something, and then you sell it for more than you bought it for. OK, so we're talking about a generic drug here. They're cheap (usually). So, let's just say drug X costs, I don't know, $5. The PBM pays the pharmacy $5 for that generic script—and you can see how much money the PBM just made right there. The patient and their plan sponsor got charged $50, and the PBM's cost of goods was $5. Multiply that profit margin by the billions of generic prescriptions in this country that run through insurance, and you have a tidy little business model there. UHG, the parent company of OptumRx, made $24 billion in profit in 2021. Not all of that was from generic drug arbitrage (ie, taking advantage of spread pricing), but some of it was. And $24 billion is an awfully big amount when you consider whose paychecks all those pennies were lifted from. PBM services are anything but free. PBMs are collecting massive windfalls in the so-called spread between what the patient and the plan pay and what the PBM is actually buying those drugs for. Here's another wrinkle: When a PBM contracts with a pharmacy, part of their contractual terms is that the pharmacy's list price for drugs cannot be lower than a certain amount usually having something to do with the PBM's rates. So, pharmacy list prices become artificially high as a result, meaning that cash-pay patients who just wander into a pharmacy and try to pay cash pay an artificially high price. Into this mess swoops GoodRx with a killer idea. They see all that money on the table that PBMs are cleaning up in that spread. They want a piece of that action. And in the beginning, PBMs were fully on board with this. They were fully on board because the market GoodRx was going after was the uninsured market, meaning untapped turf for PBMs. And because PBMs make so much money off of each transaction, PBMs are always hungry for more transactions (the Big Three PBMs, anyway). They love more transactions. The more more more with the transactions, the more more more with the money. So, GoodRx goes to the PBMs and says, “Hey … if a cash-pay patient shows up in a pharmacy, what price would you charge them for you to adjudicate that claim? You know how much money you have to pay the pharmacy, so what can the patient price be? What spread are you willing to accept? GoodRx will take a little off the top, but you can keep your spread on this new frontier of patients that you haven't historically had access to because … uninsured. Oh, by the way, we, GoodRx … we're gonna go around to all your competitors, too (just saying)—the other two PBMs—and we're gonna show their prices, too, in our GoodRx app at different pharmacies. So, you're gonna have to compete with other PBMs in this model.” This is why GoodRx cash prices for generics are so very very often less than what the patient will pay if they use their insurance. In the GoodRx app, PBMs have competition. So, by not using their insurance, patients often pay less for generic drugs—which, by the way, are 90% of the scripts written in this country—and also, as an added bonus, patients don't have to jump through all the weird and arduous prior auths or step therapies or other hurdles that a PBM might toss in the mix. So, from a patient perspective, using GoodRx could save money, save time, and you could get your drugs faster because you don't have to wait around for some prior auth to go through. But this was not what PBMs had originally thought they were signing up for. They were working with GoodRx to gain new market share from the uninsured market, not lose market share to more and more patients forgoing their insurance, meaning forgoing shelling out to the PBM their spread on the transaction. Cue my conversation today with Dr. Ge Bai. Ge Bai, PhD, CPA, is a professor of accounting at Johns Hopkins Carey Business School and a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. In this healthcare podcast, Ge Bai and I discuss the reactions of the Big Three PBMs to consumers getting all consumer-y when it comes to buying their generic drugs—despite the fact that, in my interview with Dr. Sunita Desai (EP334), she said that studies have shown that 67% of patients are unaware that they might be able to get a better price by not using their insurance and shopping around on GoodRx or Amazon or at a cost-plus pharmacy like Blueberry in Pittsburgh or Mark Cuban's new thing. Despite that, it means 33% (one-third) of patients are aware that they can price shop and potentially get a better price not using their insurance on generic drugs; and apparently, it's making some people at some PBMs nervous.   Check the ESI (Express Scripts) blog post about their new prescription benefit that automatically applies discounts. Hmmm … sounds like a defensive play to me? What do we make of this? That's my first question to Dr. Ge Bai in this episode.   Also, if you're really intrigued by generic drug goings-on, go back and listen to the show with Dr. Steven Quimby (EP344) when you have a chance. It's about the high cost of generic drugs, and we go deep into supply chain machinations.    You can learn more on Ge's Web site at Johns Hopkins University. You can also connect with her on LinkedIn. Ge Bai, PhD, CPA, is professor of accounting at the Johns Hopkins Carey Business School and professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on healthcare pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies. 08:45 What is ESI doing by automatically applying discounts to generic drugs? 10:00 Why are PBMs losing money when consumers don't use their benefit? 10:46 “GoodRx disrupted the ongoing game.” 11:04 How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? 12:13 Amazon pricing versus GoodRx pricing. 12:50 How much money is a PBM really making? 14:00 EP344 with Steven Quimby, MD.14:29 EP334 with Sunita Desai, PhD.14:43 How is future fear playing into the PBM business model? 16:55 Is there a negative consequence to subtracting from the bottom line in a PBM model? 17:50 “I think to have strong PBMs does not mean necessarily bad things for patients.” 19:39 What happens if everyone uses Amazon for drugs? 22:40 If every PBM gets their own discount cards, what will happen? 25:38 “We are actually witnessing a potential sea change.” 26:25 How do cost-plus pharmacies factor into the current market? 29:16 Is a profit shortfall inevitable? 29:35 “PBMs have to give a slice of their profit back to consumers. That's just reality.” 30:11 Can anything be done on the PBM side to generate a higher margin in the generic space? 31:41 “Naive plan sponsors are a big problem.” You can learn more on Ge's Web site at Johns Hopkins University. You can also connect with her on LinkedIn. @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing What is ESI doing by automatically applying discounts to generic drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Why are PBMs losing money when consumers don't use their benefit? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “GoodRx disrupted the ongoing game.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Amazon pricing versus GoodRx pricing. @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How much money is a PBM really making? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How is future fear playing into the PBM business model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Is there a negative consequence to subtracting from the bottom line in a PBM model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “I think to have strong PBMs does not mean necessarily bad things for patients.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing What happens if everyone uses Amazon for drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing If every PBM gets their own discount cards, what will happen? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “We are actually witnessing a potential sea change.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How do cost-plus pharmacies factor into the current market? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Is a profit shortfall inevitable? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “PBMs have to give a slice of their profit back to consumers. That's just reality.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Can anything be done on the PBM side to generate a higher margin in the generic space? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “Naive plan sponsors are a big problem.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Recent past interviews: Click a guest's name for their latest RHV episode! Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), 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)  

My guest in this healthcare podcast is Nikhil Krishnan, who is the founder of the Out-Of-Pocket newsletter. I was talking with Nikhil, and we identified—or, more accurately, he identified—five business models of digital health. What makes each model distinct is a few factors. If you weren't in the healthcare industry, you'd probably expect that I'm going to say that the biggest factor a business model must hinge on must have something to do with patient outcomes or care or something that has something to do with the hopes and lives of patients. Except no. Mostly, our models do not define themselves by attributes of their patients, except on one dimension: who is paying their bills. Who is paying has enormous downstream consequences that I don't think people outside of healthcare, or even people inside of healthcare, sometimes really appreciate. It's because of all of the perverse incentives. It's a tangled web we weave. For example, let's just say you're a start-up founder trying to cook up your unique selling proposition. You can't just decide you're gonna lower costs and improve patient care as general constructs. Because let's just say you do that—that's your USP (lower costs and improve patient care)—and then you try to sell your thing to Medicare Advantage plans or large provider organizations. Oh, right … Medicare Advantage plans or even commercial ones—they don't care about the total cost of care. Neither do provider organizations unless they take on sufficient risk to care, and many do not. In fact, as came out in that JAMA article the other day, it could be construed that entities such as these carrier health plans have a perverse incentive to see total costs of care go up. So right, you naively (you're the start-up founder again in this case study, don't forget) trot into some administrator's office with a great something or other to reduce total costs of care—and you'll get cast out upon your petard on the quick.  Every single day of the year in my world, I see people make this same mistake over and over again: not tailoring their product market fit to any particular market, with the recognition that some in this healthcare industry have a vested interest to see costs going up and some have a vested interest in costs going down. Either way, if we're talking about large organizations here and even some small ones, the money wins over patient care. So sad to have to say that, but listen to EP351 with Dr. Eric Bricker and you'll get all the context you need on that point.   Here's the thing, though. I don't know about you, but I can't tell you how many digital health start-ups I run across where I look at their decks or have a conversation with a founder, and I ask who their customer is. Is it employers or health plans or … ? And they don't know. They're gonna figure this out later. I don't get how to successfully do that. I'm indubitably wrong here given all of the pivots I hear about that seem to go OK, but the prospect of completely redefining my operational goals and operations and market positioning at some point in the future seems like a daunting and avoidable prospect. I would be remiss not to mention, however, the number of really good mission-driven healthcare companies out there really trying hard to figure out how to create a sustainable business, a fair profit, while at the same time serving patients really well. There are companies adding value commensurate with the dollars that they come by, and I certainly applaud everything that they are doing. At the same time, given all this, here's a message for all of you VCs and private equity etc—people with money—out there. Let me quote Dr. Vivek Garg here (@vgargMD on Twitter): “If you're financing care delivery without board-level focus on clinical outcomes, you're part of the problem.”   So, let's talk about these five business models that health and healthcare start-ups eventually settle themselves into after they figure out who their customer is. Nikhil Krishnan, my guest today, and I discuss how they can be financially viable and if we think they'll actually be able to provide superior patient outcomes. [Trumpets play here] In no particular order, this is what we've got for our five business models: Completely avoiding incumbents, creating a cash-pay ecosystem Better middleware (being the pipes, as I've heard so many times these past couple of weeks) Companies serving incumbents either by being a virtual front door for them or disrupting the competitive landscape somehow Joint ventures Old-school digital health who are now incumbents in their own space My guest in this episode, Nikhil Krishnan, has a bunch of things going on. He might be best known for his newsletter, Out-Of-Pocket Health, which you should certainly subscribe to. He's also working on a healthcare 101 crash course to teach newcomers about the Wild West we call American healthcare. Besides all of this, Nikhil does some early-stage investing.  You can learn more at outofpocket.health and with Nikhil's upcoming course.  Nikhil Krishnan is the founder/thinkboi at Out-Of-Pocket, where he's trying to make the business of healthcare more easily understandable and (hopefully) entertaining. He runs a newsletter (yes, yet another one) and an online healthcare community and does some digital health investing on the side. He's “extremely online,” and you can find him firing off obscure healthcare memes plus the occasional insight on Twitter at @nikillinit.     05:31 What are the different models of digital health? 07:17 What are the different motives for cash-pay digital health models? 13:08 “One of healthcare's original sins is that every solution deployed has been a custom solution for the end user.” 13:31 How willing will these companies be to share their data with third parties? 17:20 “I don't think selling tech to large incumbents is going to move the needle.” 20:27 “These companies, most of them are actually getting extra money for the more expensive stuff.” 22:11 How did joint-venture digital health business models come about? 25:50 Why do you see partnerships more on the payer/provider side? 26:41 Who are the old-school digital health companies that could be considered incumbents? 28:48 Why do so many digital health start-ups have a hard time pinpointing who will pay for their services? 31:22 “The ability to go through the idea maze is way faster now.” 34:08 “The field is wide open to help teach people how healthcare works.” You can learn more at outofpocket.health and with Nikhil's upcoming course.  @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast What are the different models of digital health? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast What are the different motives for cash pay digital health models? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast “One of healthcare's original sins is that every solution deployed has been a custom solution for the end user.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast How willing will these companies be to share their data with third parties? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast “I don't think selling tech to large incumbents is going to move the needle.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast “These companies, most of them are actually getting extra money for the more expensive stuff.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast How did joint-venture digital health business models come about? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast Why do you see partnerships more on the payer/provider side? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast Who are the old-school digital health companies that could be considered incumbents? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast Why do so many digital health start-ups have a hard time pinpointing who will pay for their services? @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast “The ability to go through the idea maze is way faster now.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast “The field is wide open to help teach people how healthcare works.” @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), 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  

In this healthcare podcast, we're gonna talk about the realities of setting up a clinically integrated network, otherwise known as a CIN. If only the whole process was unicorns and rainbows, but—as you likely suspected—it's not. Setting up a clinically integrated network is hard work, but the payoff for patients and clinicians alike can be worth fighting for. First of all, what is a clinically integrated network? It is a kind of ACO (accountable care organization). It is a legal entity that is a form of an ACO. So, every CIN is an ACO. But not all—in fact, most—ACOs are not CINs.  CINs enable coordinated care. Everybody in the network gets together to figure out how to enable clinicians to (for reals) follow their patients through multiple care settings and plan for an entire care journey. It can really help the patients navigate our crazy healthcare industry by giving them a trusted team that plots out a proactive path toward better healthcare outcomes and then make sure the patient stays on that path. It can be a really beautiful thing. Listen to EP349 with Lisa Trumble for real-world examples of the patient outcomes and experience a CIN can generate. All this for the patient while, at the same time, the total cost of care for Medicare patients goes down, I've heard, about 10% on average; but it can be more, as Lisa Trumble also talks about in episode 349 as aforementioned.  Alright … as we all know in healthcare, what's best for the patient doesn't, in so many cases, mean higher reimbursements. Sadly. So, what financial advantages does going through the time and trouble to create a CIN bring? There are basically four financial opportunities that can be realized with a CIN. I learned some of this from my guest today, Shawn Rhodes, who called strategically managing these four possible financial incentives “a delicate balance”; and as I get into some of them, you will see why. CIN Financial Opportunity #1: Similar to an ACO, if you're a CIN (because you are an ACO), you can participate in the Medicare Shared Savings Program, otherwise known as MSSP. The Medicare Shared Savings Program (MSSP) is the way that ACOs get paid a little something extra if they achieve savings goals for Medicare. The provider shares in the savings. Get it? And CINs are generally well equipped to realize these shared savings goals because to obtain the quality that you have to to pull off the shared savings, being clinically integrated really helps. CIN Financial Opportunity #2: Getting a gang of providers (doctors) together, you can do collective bargaining. So, back to basics with this one. You get a bunch of docs together in a region, then you all go to the big BUCAH plan—meaning the Blue Cross, the Cigna, the Aetna, Anthem, Humana—you go to them together and make your contracting demands, as opposed to each little doc practice going in all by yourself and trying to negotiate David and Goliath style. Now, what the payer might want from your collective crew there, the payer might insist on some kind of value-based agreement. Even if it's an FFS (fee-for-service) contract chassis, they'll attach some kind of quality or outcome component. So again, being organized in a CIN is a bonus either way. CIN Financial Opportunity #3: Your CIN can try to do direct contracting with local employers. Check out EP350 with Katy Talento for more on direct contracting. Actually, Lisa Trumble also mentions this in EP349.   CIN Financial Opportunity #4: Lastly, you can work with local hospitals' quality and efficiency programs. From a hospital financial perspective, they might be interested in the care that happens after an inpatient stay. If the outpatient care at an integrated skilled nursing facility, for example, is good, then the hospital could, for example, reduce readmissions. Now, caveat: I asked (maybe grilled is a better word) our guest in this episode, Shawn Rhodes, about this whole “prevent a readmission” business. Because on one hand, oh wow, you get a couple points back from having lower readmissions—which you can game all day long, by the way. Listen to the show with Dr. Rishi Wadhera (EP326) for more on how to not get dinged for readmissions even if you effectively have readmissions.   So, said another way, the crafty, albeit dubious, power move here if you're a hospital to maximize revenue is to let patients come back to the hospital after discharge but just don't call it a readmission. Call it, I don't know, observational. Then bill fee for service for the whole thing and get the reducing readmission financial incentives. At this point in the time-space continuum, everybody knows this stuff. This is not some kind of secret that I'm spilling here. Anyway, I bring this up because don't forget what I just said: The #4 CIN financial opportunity that Shawn Rhodes had mentioned is hooking up with a local hospital as part of their quality and efficiency program and the hospital looking to the CIN to reduce readmissions. Given the open secret on hospitals and readmissions, my Spidey sense just got really curious. So, when I pressed on this point, Shawn didn't talk about the CIN sharing any financial gains from the reducing readmission incentive program like I might have expected. Instead, he mentioned that having lower readmissions is a way for hospitals to get some negotiating leverage with payers. The next time your hospital's payer contract comes up, you can point to lower readmissions and then demand higher FFS fees. You also might be able to improve throughput of profitable service lines by reducing the number of patients who turn back up after their earlier procedure—which is another way, again, to increase FFS revenues, since the more patients you put through, the more revenue. This is why I like talking to people with a touchstone to the real world. You find out what the actual deal is. Now, I say all this to say that if patients get better care and their care journey is non-fragmented, it's a win-win. And CINs, like most ACOs, have been shown to trim the cost of care with great patient feedback. That's amazing. Just a quick spoiler here, but the seven parameters that Shawn Rhodes and I discuss in this episode which are essential for anyone who is looking to stand up a CIN or basically achieve success—and, I would guess, almost any value-based model—you gotta have an infrastructure that takes into account the following seven things: Patient-first and agile culture Interoperability Patient-centered processes Actionable information (not just data) Clinical integration Strategic planning and alignment of all stakeholders in the CIN Strong leadership My guest in this episode, Shawn Rhodes, has worked in performance and quality improvement for many years. He has worked at a CIN in Bowling Green, Kentucky; and he has overseen multiple value-based programs. Shawn currently serves as regional VP at Caravan Health. You can learn more at caravanhealth.com or connect with Shawn on LinkedIn.   Shawn Rhodes serves as regional vice president at Caravan Health, a services and technology company that helps hospitals and physicians who care for underserved population succeed in value-based care. Shawn collaborates with clients to develop tailored population health strategies and support their efforts to deliver the highest-quality, patient-focused care at the lowest cost. Prior to Caravan Health, Shawn served as the director of clinical integration for a clinically integrated network, Med Center Health Partners, where he oversaw value-based agreements (commercial, Medicare Advantage, Medicaid, BPCI, and employer health plans) with various payers along with ACO activities and quality improvement initiatives within the network. Before his work in value-based care, Shawn served as director of education and organizational development at Baptist Health Hardin, focusing on leadership development and cultural change through Studer Group initiatives. The early part of Shawn's career was spent in industrial equipment design and progressed into the automotive manufacturing industry working with Toyota and Honda on quality and process improvement. He then transitioned to the healthcare industry where he worked for eight years as a consultant specializing in coaching and mentoring hospitals to achieve improved quality, efficiency, and financial performance through process improvement, LEAN techniques, and reengineering. Shawn has a bachelor's degree in mechanical engineering and a master's degree in business administration from Western Kentucky University. He resides in Bowling Green, Kentucky. 08:08 What are the seven parameters to consider when standing up a CIN? 08:25 “Culture trumps strategy.” 09:10 “Communication and education are key components to starting that … process.” 09:26 “How do you get the information to the right person at the right time and the right place?” 09:36 What does interoperability need to look like in a CIN? 10:29 How do organizations communicate with the patient in a CIN? 11:07 Can a clinically integrated network work if it's not patient-centric? 11:37 EP332 with Tony DiGioia, MD.11:49 What's a must-have for a clinically integrated network to be successful? 13:41 “What does that data mean?” 15:34 EP315 with Bob Matthews.15:52 “You really need a go-to person.” 18:57 “The thing with team-based care is, you also have to have team-based accountability.” 20:54 “You've got to build some infrastructure around what you want to do.” 24:37 “Alignment is not an easy task by any means.” 25:15 “There has to be a group decision-making process.” 25:34 EP343 with David Carmouche, MD.25:41 EP341 with Gary Campbell.26:18 How do you define leadership? 27:49 “Start small, get some successes, and it will build as you go.” You can learn more at caravanhealth.com or connect with Shawn on LinkedIn.   Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork What are the seven parameters to consider when standing up a CIN? Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “Culture trumps strategy.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “Communication and education are key components to starting that … process.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “How do you get the information to the right person at the right time and the right place?” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork What does interoperability need to look like in a CIN? Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork How do organizations communicate with the patient in a CIN? Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork Can a clinically integrated network work if it's not patient-centric? Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork What's a must-have for a clinically integrated network to be successful? Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “What does that data mean?” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “You really need a go-to person.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “The thing with team-based care is, you also have to have team-based accountability.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “You've got to build some infrastructure around what you want to do.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “Alignment is not an easy task by any means.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “There has to be a group decision-making process.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork How do you define leadership? Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork “Start small, get some successes, and it will build as you go.” Shawn Rhodes, regional VP at @CaravanHealth, discusses #CINs on our #healthcarepodcast. #healthcare #podcast #clinicallyintegratednetwork   Recent past interviews: Click a guest's name for their latest RHV episode! Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), 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)

As a country, we spend approximately $500 billion on prescription drugs. Specialty drugs account for less than 2% of prescriptions but will cost us over $250 billion (that's in 2021)—so, 2% of prescriptions but half the spend. Specialty is the fastest-growing segment of healthcare spend and is a dominant issue that self-funded employers and other purchasers face. But let's dig into that $250 billion being spent on specialty drugs, shall we? I have to say, personally, that if we spent $250 billion but saved more than that in medical costs or if the patient quality of life went up measurably or if life expectancy or overall survival or whatever metric you used to assess quality … if that big spend produced even bigger returns/results, I for one would be like, “OK, trade-offs. Let's discuss.” But the thing is, clinical trials and real-world evidence alike suggest that there's a lot of patients who don't really benefit from the expensive drugs that they are taking or were prescribed, and even those who benefit might not get the results that they're hoping for or even de minimis expecting. In this healthcare podcast, I am talking with Pramod John, CEO of VIVIO Health; and he makes a couple of great points about all of this that I'll repeat here and then he's gonna say them again later in this episode but in context—and probably better. There was some research done that showed for a really popular, really expensive drug, only 2% of patients who took it got the expected, maybe promised, benefits. But 100% of the patients who took that drug got bad, in some cases dangerously bad, diarrhea. This situation is really kind of typical. A drug will work great for some people, mediocre for other people/patients, and not at all for, say, the remaining what might be majority of patients. So, you'll have 2 patients where the results are out of the park, 23 patients where results are pretty darn good, 25 patients reporting meh results but something you can actually still point to, and then maybe 50 patients who see absolutely no improvement in anything. So, here's an important point: Maybe there's, let's just say, 3 drugs or 10 drugs in this therapeutic category, and that same patient distribution is true for all of them—except different drugs may work for different people. So, by enabling access to all the drugs, you can see that patients have a better chance of being in one of those first groups where they actually get results because there's more drugs that they can try and different drugs work differently in different people. But now, let's consider the way that we pay for specialty drugs: One or two of them get on formulary typically, and then all the others are excluded. That said, the purchaser, patient, and/or taxpayer is gonna pay a whole lot of money for those drugs regardless of how well they do or do not work. And with fewer drugs on formulary, there's less of a chance that results gold will be struck. But we're gonna pay a whole lot of money, also in terms of human life, to deal with the direct and cascading side effects of drugs whether they do or don't work. I have to admit, I kind of have a new appreciation for so-called me-too drugs after this conversation. Let me just add that here for the record. My guest today and next week is Pramod John, who is the founder and CEO over at VIVIO Health. VIVIO contracts with self-insured employers and helps their employees/members/patients (whatever you call them) get the right drug. They actually expand access, and the employer saves money. After what I just said, you might be cottoning on to why. The show this week concerns the reality of specialty drugs and what the terms efficacy and effectiveness really mean because they might not mean what you think they mean. As inconceivable as that might feel, I learned something. You might, too. And there are implications—big implications—for all of this for patients/members/employees. Or you and your family. In this episode, we also define and discuss the terms NNT (number needed to treat) and NNH (number needed to harm), which are really important and, in my humble opinion, do not get discussed enough—especially with patients who need to know these things to make informed choices. Next week's show is also with Pramod John, and we get into how what we talk about here intersects with rebates and formularies. Come back for that. It's probably a 400-level class in specialty pharmacy rebating, but some of you will appreciate it. You can learn more at viviohealth.com or by emailing Pramod at pramod@viviohealth.com.   Pramod John, PhD, is the team leader of VIVIO, a public benefit corporation whose mission is to ensure that drugs work in the real world for the people on them and that their costs reflect the value provided. VIVIO's model has improved health outcomes and generated 35% to 40% savings on drug acquisition costs. It accomplishes this by answering three simple questions: (1) Is this the right drug? (2) Is it a fair price? and (3) Is it working for the patient? Before VIVIO, Pramod was founder of Oration PBC (acquired by PokitDok), which gave consumers control over their drug purchasing by capturing the prescription in the physician's office and providing real-time pricing options and automatic routing capabilities. Pramod was also vice president of strategy and innovation at McKesson, the world's largest healthcare company. At McKesson, Pramod helped develop solutions that leveraged advanced technologies and business process improvements to optimize healthcare delivery systems, infrastructure, and supply chains. Earlier, Pramod founded and served as CEO of PacketMotion, Inc, a venture-funded startup in the enterprise network information and policy management industry. VMware later acquired the company. In addition, Pramod founded netExaminer.com, a managed-vulnerability assessment company acquired by SonicWALL. Pramod earned his PhD in electrical engineering from the University of Illinois at Urbana-Champaign. He serves on the board of Wycliffe USA. He also serves on the advisory board of Folia Water and as a mentor at StartX. 05:34 What does a good response mean in pharmaceutical products? 06:06 “Different people get different utility out of something.” 06:31 Why doesn't efficacy mean what you think it means in terms of pharmaceutical products? 08:40 What is the difference between efficacy and effectiveness in Pharma? 09:10 Why aren't drugs' major side effects factored into a drug's efficacy and effectiveness? 10:14 “What's the benefit of this versus what's the harm in this?” 13:35 “Clearly as consumers, we all feel that we're special. But what about physicians?” 14:14 “The benefit itself—what does it have to be?” 15:18 EP334 with Sunita Desai, PhD.17:11 “We tend to think of things as a binary distribution—it works or it doesn't.” 18:22 “The default choice that we start with is often the wrong one.” 20:54 “It doesn't matter why if we can't fix the reason.” 22:02 “At some point, the question becomes, ‘Do we have any information?'” 22:36 Why do other developed countries pay less for their drugs? 24:21 How do we end up with crappy drugs on the market that don't really move the dial? 25:57 EP303 with Anna Kaltenboeck. 27:22 “We can build a better system. And that's what we do every day.” You can learn more at viviohealth.com or by emailing Pramod at pramod@viviohealth.com.   Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs What does a good response mean in pharmaceutical products? Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “Different people get different utility out of something.” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs Why doesn't efficacy mean what you think it means in terms of pharmaceutical products? Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs What is the difference between efficacy and effectiveness in Pharma? Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs Why aren't drugs' major side effects factored into a drug's efficacy and effectiveness? Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “What's the benefit of this versus what's the harm in this?” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “Clearly as consumers, we all feel that we're special. But what about physicians?” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “The benefit itself—what does it have to be?” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “We tend to think of things as a binary distribution—it works or it doesn't.” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “The default choice that we start with is often the wrong one.” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “It doesn't matter why if we can't fix the reason.” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs “At some point, the question becomes, ‘Do we have any information?'” Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs Why do other developed countries pay less for their drugs? Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs How do we end up with crappy drugs on the market that don't really move the dial? Pramod John discusses #specialtydrugpricing on our #healthcarepodcast. #healthcare #podcast #pharma #specialtypharma #specialtydrugs   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), 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

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

Katy Talento, Executive Director of the Alliance of Health Care Sharing Ministries, discussed the concept of health care sharing, including its relationship with Biblical principles, and shared how health care sharing works.  You can learn more at ahcsm.org.

Monday, December 27, 2021 In the final days of 2021, our own Kerby Anderson is hosting! He welcomes Carl Teichrib. They'll talk about her book, Game of Gods. Then Kerby will share his wisdom regarding today's top stories, and he'll take your calls. All of that before welcoming Katy Talento. She joins Kerby to share […]

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

When you run a business, one person you usually meet and hire is a health insurance broker. In theory, these brokers work with the employers to secure the best deals for health insurance to meet the company's health care objectives. However, in practice, the brokers serve as a sales force for the insurance companies who lavish them with bonuses, trips, and gifts. The seedy underbelly of the health insurance broker industry is that they are really not working to save money or get deals for their clients - the checks are written by the insurance carriers and that's who they answer to. Who do the brokers work for? You or the Carriers? I spoke to Katy Talento in episode 111 who runs a business where she unbundles health insurance for employers and helps them run an efficient and less expensive health care plan. One of the problems she saw is that insurance carriers bundle all these services and then charge a very large administrative fee to run the plan. Also, their plans rarely save you money as they build in enough profit to cover the agents who sell those plans - the brokers. That's the world that David Contorno is trying to combat with his company at ePowered Benefits. The business was founded with the intent of looking at real ways of not just unbundling but finding high quality and inexpensive ways to receive care. As Contorno said, "The only way to pay less for health care is to pay less for health care." Health Plans Are Gimmicks Through his 18 years of experience in the health insurance broker field, David points out that most of the various plans sold by insurance carriers are really just gimmicks that don't really change the cost of care. Whether it is an HMO, PPO, of some hybrid FFS plan - it ultimately just ends up being the same in failing to control costs. The reason is that the care comes from the same hospitals and with the same contracts no matter how they make the employers and employees pay with copays, deductibles, and coinsurance. Even HSAs (health savings accounts) which are held up as a way to control costs by putting the patient in charge, rarely bring about the cost control as advertised. This is primarily because even using an HSA and picking where you get your care still is within the framework of hospitals, insurance contracts, and provider networks which all have massively marked up prices. Only by leaving the insurance network entirely can one see real savings. Why Don't the Brokers Work for You? Simply put, the work that health insurance brokers do is to carry water for the insurance carriers. The carriers are the ones who pay their bonuses, provide them with expensive trips to Tahiti, and give them sales targets for selling their plans. The checks aren't written by employers but by the insurance carriers. So naturally, the brokers respond first and foremost to what the carriers want. This doesn't make them bad people but understandably their incentives are not aligned with those you'd hope. The reason most brokers don't even know they're working for the wrong people is best summarized by the quote from Upton Sinclair, "It is difficult to get a man to understand something when his salary depends on him not understanding it." David Contorno is the CEO and founder of ePowered Benefits. David spent 18 years as a traditional broker in health insurance but felt that it could be done in a better way.

  One of the scariest times for many workers is being presented with a bill for medical services. Even if they have insurance "coverage", the deductible or co-pay might be more than they can afford. For hourly workers in entry level jobs or low skilled positions, medical bankruptcy is a real fear. While barely making ends meet an additional bill for an ER visit or doctor's office stop can send you to collections and destroy your credit. Unfortunately, a lot of Americans are in this exact spot as they earn a living working these low paying jobs but have little medical security even if their employer provides them with insurance. A Plan for Those Who are Hourly Workers Just as I have recently spoken to people like David Contorno and Katy Talento who seek to make business owners more successful with their health plans by direct contracting, sometimes the employer is too small or has low hourly wages to provide health coverage that covers its employees. It's not that employers don't want to provide those benefits for its workers, but just that the packages offered by insurance carriers are too expensive or require large deductibles to make it possible for small businesses to afford. That's where Dr. David Berg and his company, Redirect Health come in to solve this problem. Redirect Health was designed specifically with small businesses in mind as it utilizes a combination of telehealth and primary care physicians to keep costs down, provide excellent preventative health, and protect workers from costly medical bills. By emphasizing primary care physicians, Redirect Health then helps find affordable alternatives to imaging, laboratories, medications, and the use of specialists to minimize the expensive components of health care. Redirect Health Has a Mutual Insurance Company Interestingly, Dr. Berg said they discovered early on that a lot of the insurance they wanted to provide for stop gap loss was costing them a fortune. By creating their own mutual insurance company, they could pool their risk and keep all the funds in house and spool it out at no gain to lower their overall costs. By having a fully transparent insurance carrier, they can offer savings that other companies are unable to provide. Additionally, Redirect Health also created their own third party administrator in order to streamline the claims process and better help them get a handle on where they can provide less expensive care. It is a really good way to understand where the opportunities are to move employees towards primary care solutions or lower costs solutions to their health care needs. Dr. David Berg is the CEO and co-founder of Redirect Health. A business dedicated to helping businesses provide high quality health care for hourly workers. show notes Episode 151: Today's show LinkedIn contact for Dr. Berg david.berg@redirecthealth.com Business Owner's Guide to Ending the Fight with Health Care: Dr. Berg's book on how to leverage health care as an advantage for your business. Redirect Health:  David Berg's company where he helps businesses provide care for their hourly workers. Episode 111: Katy Talento at All Better Health describes how she unbundles insurance. We Are Libertarians: The Paradocs is a proud partner and member of this outstanding podcast network. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

When you run a business, one person you usually meet and hire is a health insurance broker. In theory, these brokers work with the employers to secure the best deals for health insurance to meet the company's health care objectives. However, in practice, the brokers serve as a sales force for the insurance companies who lavish them with bonuses, trips, and gifts. The seedy underbelly of the health insurance broker industry is that they are really not working to save money or get deals for their clients - the checks are written by the insurance carriers and that's who they answer to. Who do the brokers work for? You or the Carriers? I spoke to Katy Talento in episode 111 who runs a business where she unbundles health insurance for employers and helps them run an efficient and less expensive health care plan. One of the problems she saw is that insurance carriers bundle all these services and then charge a very large administrative fee to run the plan. Also, their plans rarely save you money as they build in enough profit to cover the agents who sell those plans - the brokers. That's the world that David Contorno is trying to combat with his company at ePowered Benefits. The business was founded with the intent of looking at real ways of not just unbundling but finding high quality and inexpensive ways to receive care. As Contorno said, "The only way to pay less for health care is to pay less for health care." Health Plans Are Gimmicks Through his 18 years of experience in the health insurance broker field, David points out that most of the various plans sold by insurance carriers are really just gimmicks that don't really change the cost of care. Whether it is an HMO, PPO, of some hybrid FFS plan - it ultimately just ends up being the same in failing to control costs. The reason is that the care comes from the same hospitals and with the same contracts no matter how they make the employers and employees pay with copays, deductibles, and coinsurance. Even HSAs (health savings accounts)  which are held up as a way to control costs by putting the patient in charge, rarely bring about the cost control as advertised. This is primarily because even using an HSA and picking where you get your care still is within the framework of hospitals, insurance contracts, and provider networks which all have massively marked up prices. Only by leaving the insurance network entirely can one see real savings. Why Don't the Brokers Work for You? Simply put, the work that health insurance brokers do is to carry water for the insurance carriers. The carriers are the ones who pay their bonuses, provide them with expensive trips to Tahiti, and give them sales targets for selling their plans. The checks aren't written by employers but by the insurance carriers. So naturally, the brokers respond first and foremost to what the carriers want. This doesn't make them bad people but understandably their incentives are not aligned with those you'd hope. The reason most brokers don't even know they're working for the wrong people is best summarized by the quote from Upton Sinclair, "It is difficult to get a man to understand something when his salary depends on him not understanding it." David Contorno is the CEO and founder of ePowered Benefits. David spent 18 years as a traditional broker in health insurance but felt that it could be done in a better way. show notes Episode 150: Today's show Books suggested by David Cotorno LinkedIn contact for Contorno. ePowered Benefits: David Contorno's company where he helps clients save money through finding truly less expensive care. Benefits symposium: February 6-9 conference with guest speakers like Marty Makary speaking about how to improve health care. Free Market Medical Alliance: The organization Contorno is a part of that advocates for free market solutions in health care. Episode 111: Katy Talento at All Better Health describes how she unbundles insurance. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

Katy Talento is a veteran health policy advisor and the CEO of AllBetter Health. She obtained her BA degree from the University of Virginia and her MS in epidemiology from the Harvard T.H. Chan School of Public Health. Katy was the lead health policy advisor under the Trump administration where she helped increase healthcare price transparency and lower prescription drug prices among other objectives. After her time in DC, she went into healthcare consulting to help employers reduce healthcare spending. Tune in to hear all about why healthcare in America is so expensive, how to fight unfair medical bills (edit the financial contracts), how to save employers 20-40% on healthcare spending, and so much more on the current state of the American healthcare system. Visit her website: https://allbetter.health

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