Podcast appearances and mentions of nicole bradberry

Play Episode Listen Later Oct 19, 2023 43:10

I just want to stop here and have a gratitude moment. I wanted to thank the Pittsburgh Business Group on Health for inviting me to do the keynote at their annual symposium. It was a big honor. But in doing so, I had the opportunity to play clips from both the podcast and also from people who helped out and gave me a custom clip special for the occasion. So, thanks to Matt Ohrt; Jodilyn Owen; Justina Lehman (who provided a clinical pathway example); Andreas Mang; Larry Bauer; Rob Andrews (my guest in this episode); Nicole Bradberry; Amy Scanlan, MD; Rebecca Etz, PhD; David Muhlestein, PhD, JD; Lisa Trumble; and Doug Eby, MD, MPH, CPE. If you'd like a copy of that presentation, which is all about care gaps and the impact of care gaps especially as it might relate to self-insured employers, click here to request it. I also again want to thank Havarti Risk Services and Keith Passwater for a super nice donation to support the show, as well as Employees First. Please support these organizations who have supported us and help us keep the lights on over here. I am so looking forward to the show today. It is with Rob Andrews, who is the CEO of the Health Transformation Alliance (HTA), which is a group made up of jumbo employers. I had wanted to get Rob on the show ever since I heard him say at the thINc360 conference in DC earlier this summer, “Morally abhorrent doesn't move the needle. What moves the needle is financial implications.” This interview was my chance to ask Rob Andrews, what are these financial implications of which you speak that move needles? Financial implications to whom? What kinds of financial implications are we talking about? And when that needle moves, what happens? In the show that follows, Rob says that when you improve the health of employees and dependents and actually just the health of the community, you as an employer improve your financials directly and also indirectly, which Rob talks about relative to maternal health outcomes as his exemplar because, as a case study, it's undeniably superb. It's really interesting how employers in a geography wind up footing indirectly a rather shockingly large bill for babies and uninsured or underinsured moms or moms on Medicaid avoidably going to the ICU and the NICU, which the hospitals tally up as hundreds of thousands of dollars in billed charges. The term million-dollar baby is a term, after all. Listen to the episode that follows for more on these indirect costs and how they happen, but let me focus on the direct bucks out of pocket right now because … yeah, study after study shows that, for self-insured employers, if you pay for the right things and you steer to the right providers in the right care settings known to actually improve health, a self-insured employer and the member do a whole lot better than if the employer kind of laissez-faire pays for any manner of things provided by anybody who can manage to submit a billing code—even if that billing code comes with a too-good-to-be-true discount. Rob talks about how the HTA has data to suggest that if you, as a self-insured employer, lean in on paying for the right things, readmissions go down 29%. Total cost of care is 15% lower. Drugs cost 25% less. So, none of this is theoretical, as we talk about how employers can create a win-win—better health, lower costs. There are jumbo employers in the HTA right now who are doing this. I love how Will Shrank, MD, has put it; and I'm paraphrasing, but it's a point that keeps getting reiterated in episode after episode here on Relentless Health Value: There's a difference between paying for what you want and just negotiating allegedly cheaper prices. Buying things is not a strategy. And that is true no matter what price you think you're paying. Also not a strategy is buying things and then cost shifting to plan members, by the way. I love how Josh Butler uses a grocery analogy to describe but one possible flashpoint. Strategy, on the other hand, means addressing root causes. It's a considered plan of action to achieve an optimized ambition. Here is the strategic stepwise that Rob offers on this: 1. Discern the difference between rumor and data. Get your data and get it objectively analyzed by an objective third party, self-insured employers. Similar to what Justina Lehman was talking about last week (EP414), then you have what you need to figure out the delta between the worst performers and the best performers on a risk-adjusted basis. 2. Now that you know what normal is and what good looks like, gang up and negotiate contracts that hold intermediaries accountable for outcomes and with performance guarantees. Address root causes and the excess and wasteful spend, in other words. Listen to the show with Dr. Will Shrank (EP413) for more on wasteful spend. 3. Be transparent with consumers/employers about relative quality. Educate them. You may also want to reward members who go to see those high-quality docs and/or make it expensive for them to go to the worst performers. There are lots of win-win case studies here on how well this works. Rob Andrews and I talk a bunch, as aforementioned, using maternal outcomes as a case study for lots of the points made; and this was done for several reasons. One is that, for some employers, maternity is a large chunk of their healthcare spend; so avoidably bad outcomes for moms and babies here is not only scandalous, as Rob Andrews puts it, in a country as wealthy as ours but also really costly—and many times avoidably so. Keeping even one mom and/or one baby out of the ICU or NICU can save hundreds of thousands of dollars. I said this already, and it's a brutal number worth repeating. But the good news is that there are really cost-effective pathways that actually work to keep moms and babies out of the most expensive care settings money can buy. Jodilyn Owen (on an episode coming up in about three weeks) talks about one of them in detail: how her maternal health clinic, which serves ZIP codes with, let's just say, a lot of social determinants of health going on, moms in her clinic have a lower rate of NICU admissions than even the fancy ZIP codes nearby. So, this can be done. Purchasers of healthcare just have to demand that it happens and pay for it to happen. Rob Andrews talks about this, and he also talks about why it is quite unlikely that payer or provider organizations themselves are gonna pick up this torch and make this happen unilaterally of their own volition. Now, he offers some nuance, and you should listen to that nuance. You can learn more by emailing Rob at randrews@htahealth.com. Robert E. Andrews is the chief executive officer (CEO) of the Health Transformation Alliance (HTA), an original author of the Affordable Care Act, and a former member of Congress. As CEO of the HTA, Robert oversees the strategic direction of approximately 60+ major corporations that have come together in an alliance to do one thing: fix our broken healthcare system. Formed by four founding members in September 2015, the HTA member companies collectively are responsible for more than 8 million employees, dependents, and retirees with an annual healthcare spend of $30+ billion. Through Robert's leadership, the HTA has launched value-driven solutions specifically designed to improve patient care and economic value through world-class data and analytics, pathbreaking pharmaceutical solutions, high-quality medical networks, and robust consumer engagement initiatives. To date, the cooperative has saved its member companies well over $2 billion in healthcare costs. Robert's leadership has been equally important in the HTA developing programs addressing racial and ethnic disparities in healthcare, mental health issues, and safe return-to-work programs following the pandemic. Robert served as a member of the United States House of Representatives for nearly 24 years. Upon his departure from Congress, President Barack Obama praised Robert's service as “an original author of the Affordable Care Act … and a vital partner in its passage and implementation.” 07:29 How did Rob get to his current role? 09:11 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this. 10:36 Why economic consequences move the needle, and why sometimes they don't. 12:36 Why the best way to address costs isn't to re-shift costs but to address them directly. 14:34 Why compensation that isn't dependent on outcomes is a problem. 18:09 “Strategy's not what people say; it's what they do.” 21:40 How do you operationalize saving money with better outcomes? 29:46 How do employers turn conflict into collaboration? 31:41 What is the win-win-win structure among employers, payers, and providers in Rob's eyes? 34:13 To whom should the task of risk adjustment fall? 38:03 “Better contracts do improve outcomes.” You can learn more by emailing Rob at randrews@htahealth.com. Rob Andrews of HTA Health discusses how employers can save money and get better #healthcareoutcomes on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #healthcare Recent past interviews: Click a guest's name for their latest RHV episode! Justina Lehman, Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4)

Tracing the Roots of a Healthcare Revolution with Nicole Bradberry | Ep. 28

Healthcare Trailblazers

Play Episode Listen Later May 29, 2023 31:41

In this episode, we dive deep into the world of healthcare to explore the transformative power of value-based care. We are thrilled to have Nicole Bradberry, a renowned healthcare expert and thought leader, as our guest. Nicole will share her invaluable insights into how Medicare Advantage (MA) evolved with the introduction of the Centers for Medicare & Medicaid Services (CMS), and the key differences between MA and Accountable Care Organizations (ACOs).In this episode, we discuss the origins of Medicare Advantage plans, how they have shaped the healthcare landscape, and their ongoing impact on patient care. Nicole also shares proven strategies to increase patient engagement rates and offers practical tips on how doctors can embrace value-based care.Whether you're a healthcare professional, policy enthusiast, or simply interested in understanding the future of healthcare, this video offers an informative and engaging look at the genesis of value-based care and its potential to revolutionize the industry. Don't forget to like, comment, and subscribe for more enlightening content!AboutNicole Bradberry is a highly accomplished healthcare executive with a proven track record of success in leading and transforming healthcare organizations. As a strategic visionary with over 20 years of experience, Nicole has garnered a reputation for her expertise in value-based care, population health management, and health information technology.Nicole holds a Bachelor of Science in Industrial Engineering from the University of Florida and an MBA from the University of North Florida. She began her career as a consultant with Accenture, where she honed her skills in the healthcare sector. Since then, Nicole has held several key leadership positions, including serving as the CEO of the Florida Association of ACOs, where she significantly impacted the development and implementation of accountable care organizations in the state.Nicole's commitment to value-based care and patient-centric healthcare has earned her numerous accolades and recognition as a thought leader in the industry. As a speaker and advocate for healthcare transformation, she is passionate about sharing her knowledge and experience to inspire others and drive meaningful change in the healthcare system.Learn more about Nicole Bradberry LinkedIn: https://www.linkedin.com/in/bradberry/Learn more about Previva Health Group:LinkedIn: https://www.linkedin.com/company/previva-health-group/Website: https://previva.com/

INBW34: The Absence of Collaboration Between Healthcare Stakeholders: What It Means

Behavioral Healthcare Executive Podcast

Play Episode Listen Later May 26, 2022 19:15

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

Episode 027 – Nicole Bradberry, MIND 24-7 co-founder and chief innovation officer

Play Episode Listen Later Apr 28, 2022 11:10

Nicole Bradberry, co-founder and chief innovation officer for Arizona-based MIND 24-7, discusses the company's tiered approach to emergency and crisis mental and psychiatric health and substance use disorder care. Bradberry explains how having a background in value-based care has helped shaped the MIND 24-7 leadership team's vision for what they want the company to be, as well as the organization's working relationships with other providers, law enforcement, and emergency responders. Finally, Bradberry shares MIND 24-7's approach to expansion into new markets. * * * Music credit: Straight Through by Groove Bakery | groovebakery.com Music promoted by www.free-stock-music.com Attribution-NoDerivatives 4.0 International (CC BY-ND 4.0) creativecommons.org/licenses/by-nd/4.0/

music co founders arizona mind chief innovation officer bradberry nicole bradberry

EP347: Rolling Out Healthcare Initiatives That Actually Get Uptake With the Populations You Aim to Serve, With Ian Tong, MD, About the Black Community Innovation Coalition

Play Episode Listen Later Dec 2, 2021 34:29

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

Encore! EP288: The “Big Three” PBMs Spinning Up GPOs—What? With Mike Schneider

Play Episode Listen Later Nov 25, 2021 29:53

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

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EP346: How Did Health Systems Get Addicted to the Inflated Prices They Charge Employers and Some Patients? 2021 Update, With Peter Hayes, President and CEO of the Healthcare Purchaser Alliance of Maine

Play Episode Listen Later Nov 18, 2021 36:15

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

ceo amazon california pr talk spoilers healthcare patients md charge maine alliance nonprofits prices irs employers medicare addicted medicaid cms crappy health systems erase digital health six sigma inflated leapfrog health innovation healthimpact hannaford healthcare solutions care plans marshall allen al lewis lee lewis purchaser peter hayes jason wells joe connolly katy talento brandon weber rob austin national business group nikki king nicole bradberry john marchica

EP345: Can Pharma Imagine How Our Health System Will Look in the Future? With Paul Simms

Play Episode Listen Later Nov 11, 2021 31:36

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

americans healthcare md web os ceos dilemma iq innovators eq reuters pharma healthcare system r d health systems simms aq clay christensen care plans marshall allen al lewis lee lewis joe connolly brandon weber nikki king nicole bradberry john marchica

EP344: The High Cost of Generic Drugs, With Steven Quimby, MD

Play Episode Listen Later Nov 4, 2021 33:27

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

americans phd healthcare md cpa depending billions big pharma mayo clinic refer pharma r d high cost generic ehr pbms goodrx quimby generic drugs care plans marshall allen al lewis lee lewis joe connolly vinay patel brandon weber nikki king nicole bradberry john marchica

EP343: What Provider Leadership Teams Need to Know to Operationalize Value-Based Care, With David Carmouche, MD

Play Episode Listen Later Oct 28, 2021 30:10

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

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EP342: How the Consolidated Appropriations Act (CAA) and ERISA Fiduciary Requirements Are an Anchor for Self-insured Employers to Navigate the Complexity of Healthcare, With Christin Deacon

Play Episode Listen Later Oct 21, 2021 36:38

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

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EP341: How to Cut Administrative Waste AND Attract and Retain Doctors and Nurses, With Gary Campbell

Play Episode Listen Later Oct 14, 2021 32:50

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

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EP340: How Digital Front Doors Can Enable Value-Based Care, With Kristin Begley

Play Episode Listen Later Oct 7, 2021 32:06

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

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AEE17: Employers and Reference-Based Pricing—David Contorno's Latest Thinking

Play Episode Listen Later Oct 5, 2021 9:20

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

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EP339: Helping Employers Navigate the Perilous Medical-Industrial Complex, With David Contorno

Play Episode Listen Later Sep 30, 2021 30:46

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

america ceo new york new york times north carolina national healthcare forbes plan humanity ceos commerce navigate cfo stockholm employers broker habitat business leaders affordable care act united way ascend cfos perilous leadership award ppo lake norman healthcare marketing contorno medical industrial complex care plans marshall allen al lewis lee lewis cvs aetna health underwriters joe connolly e powered benefits brandon weber nikki king insurance thought leadership nicole bradberry john marchica

EP338: Ideas to Meet Rural Healthcare's Tough Challenges, With Nikki King, DHA

Play Episode Listen Later Sep 23, 2021 34:28

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

EP337: A Patient-First Specialty Pharmacy, Not a Money-First Specialty Pharmacy, With Olivia Webb

Play Episode Listen Later Sep 16, 2021 32:37

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

money healthcare patients md iv employers webb pharma digital health massachusetts general hospital pharmd biologics pbm pbms goodrx ochsner care plans marshall allen al lewis specialty pharmacy lee lewis joe connolly bob matthews brandon weber nicole bradberry john marchica

EP336: The Barbarians at the Gate—Who Are They and How Do They Cause Trouble for the Healthcare Industry Status Quo? With Brandon Weber

Play Episode Listen Later Sep 9, 2021 32:37

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

united states ceo new york americans gate trusted status quo barbarians nava healthcare industry anecdotally vts care plans marshall allen al lewis lee lewis joe connolly bob matthews brandon weber nicole bradberry brian klepper john marchica

INBW30: A Hot Take on Healthcare Stakeholders Not Collaborating

Play Episode Listen Later Sep 2, 2021 7:36

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

god american google healthcare hot takes collaborating stakeholders digital health commonwealth fund care plans marshall allen al lewis lee lewis joe connolly bob matthews nicole bradberry john marchica

AEE16: The Destruction of Primary Care—A Short History, With Brian Klepper, PhD

Play Episode Listen Later Aug 31, 2021 9:53

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

ceo health new york times phd healthcare journal wall street journal washington post principal destruction primary ama cms primary care digital health healthtech short history cbs evening news hmo health affairs ruc kevinmd pcps care plans marshall allen klepper al lewis lee lewis rvus joe connolly bob matthews listserv employee benefit news national business coalition nicole bradberry brian klepper john marchica

EP335: Why Is Private Equity Willing to Pay $55,000 per Patient to Primary Care Start-ups? With Brian Klepper, PhD

Play Episode Listen Later Aug 26, 2021 33:01

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

ceo health new york times phd healthcare startups patients journal wall street journal washington post principal expert specialist ama private equity primary care digital health pcp cbs evening news apc hmo ffs hmos health affairs ruc kevinmd industrialized pcps care plans marshall allen klepper al lewis carbon health ebita lee lewis alex jung joe connolly bob matthews listserv employee benefit news brian klepper national business coalition nicole bradberry john marchica

EP334: Do Consumers Ditch High-Cost Providers After Shopping With Price Transparency Tools? With Sunita Desai, PhD

Play Episode Listen Later Aug 19, 2021 33:29

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

EP333: Actually Using Care Plans in the Real World, With (in Order of Appearance) Jeff Hogan, Darrell Moon, Dr. Grace Terrell, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy

Play Episode Listen Later Aug 12, 2021 18:35

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

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EP325: The Show in Which Dr. Mai Pham Disagrees With Three of My Value-Based Care Premises

Play Episode Listen Later Jun 10, 2021 37:11

First of all, a shout-out to all of you listeners who have shared this show with colleagues and LISTSERVs—really appreciate it. It's because of you and your efforts to share that Relentless Health Value maintains its spot as one of the top podcasts reaching health care executives, executives who take the insights shared by our guests to drive actual change and transformation across our industry. So, thank you. Leaving a rating and/or a review on iTunes is also the bomb and really helps our RHV team stay motivated and keep it going. Weekly shows take a ton of work! Feedback is super appreciated. On to the topic this week: Who has read that white paper put out in February by the University of Pennsylvania, specifically, Penn's Leonard Davis Institute for Health Economics? It's called “The Future of Value-Based Payment: A Road Map to 2030.” I mentioned this paper last week, too. So, if you still haven't read it, go back after this show and take a look. There's links in show notes. As with every interesting white paper, while you're reading it, you start thinking of more questions. That's why I was thrilled to get a chance speak with Mai Pham, MD, MPH. She is one of the paper's authors, a physician, and a trained health services researcher. Dr. Pham is a former chief innovation officer at the Centers for Medicare & Medicaid Services (CMS). She also spent time at Anthem doing value-based care (VBC) work for the enterprise on a national level. Further, she's the parent of an autistic child and founded the Institute for Exceptional Care to transform health care for people with IDD (meaning intellectual developmental disabilities), which I'll get to in a second. Here's some highlights from my discussion with Dr. Pham: Markets get distorted when insane quantities of dollars rush in. I'm thinking about Medicare Advantage and all of its attendant suppliers right now. Think about all of the amazing brainpower captivated by figuring out how to upcode at scale, which, by the way, only a minority of the time corresponds to actual spend. Dr. Pham has some words on this. Attaining value-based care results and adoption has a big problem. As a policy maker, you can't just keep trying to sweeten the value-based care pot. You don't want to plow even more money into the system. So, at a certain point, we all have to get real and realize that for the cost-driving entities in this country—those IDNs (independent delivery networks) with huge market clout—to get on the VBC bandwagon, value-based care probably has to be a mandate; and it also will mean making FFS (fee for service) much less attractive. Thirdly—and here's something I never considered—commercial prices drive up Medicare prices. You have hospital systems pointing to growing disparities between commercial rates when they negotiate for higher Medicare rates, when the hospital systems themselves created those deltas with their private-sector negotiations. Lastly, we chat national versus local health care reform and about indie doctors and the “why” behind consolidation. It aligns quite a bit, our conversation in this health care podcast, with the insights from the show last week with Nicole Bradberry and Kelly Conroy (EP324). The last 6 minutes of this podcast is Dr. Pham's insight about the scope and impact of not caring adequately for people with neurodevelopmental disabilities. We're talking about somewhere between 10 and 16 million people, as Dr. Pham notes for perspective. That's the number of new cancer cases each year. Collectively, we spend as a country somewhere between 1% and 2% of the GDP all in on this patient population. You can learn more at ie-care.org. Hoangmai (Mai) H. Pham, MD, MPH, is a general internist and national health policy leader. She was vice president, provider alignment solutions, at Anthem, Inc., responsible for value-based care initiatives at the country's second-largest health insurance company. Prior to Anthem, Dr. Pham served as chief innovation officer at the Centers for Medicare & Medicaid Services, where she was a founding official, and the architect of Medicare's foundational programs on accountable care organizations and primary care. She was co-director of research at the Center for Studying Health System Change and has published extensively on provider payment policy and its intersection with health disparities, quality performance, provider behavior, and market trends. Dr. Pham serves on numerous advisory bodies, including the National Advisory Council for the Agency on Healthcare Research and Quality, the Maryland Primary Care Program, and the National Business Group on Health, and was a member of the Board Executive Committee at the Health Care Transformation Task Force. Dr. Pham earned her bachelor's degree from Harvard University, her MD from Temple University, and her MPH from Johns Hopkins University, where she was also a Robert Wood Johnson Clinical Scholar. 04:22 What are the nuances within the promises of value-based care? 05:34 “For the first 10 years of … value-based care, it was right in order to generate momentum and get as much participation as possible.” 06:41 “When you leave yourself open to tackling prices, now you open up a whole world of possibilities in terms of how you could redirect sources.” 08:00 “Not all providers are the same.” 09:24 “It's time to stop tracking the phenomenon and actually pay for change.” 10:29 “We haven't done our best to actually make the alternative to value-based payment as bad as it could be.” 12:14 What's the path forward in value-based care, especially for specialists? 15:43 “There has been tremendous business opportunity in Medicare Advantage, not to the benefit of the trust funds.” 17:13 “As a citizen, I gotta ask, ‘How much is enough?'” 19:03 “It's not like we're talking about replacing a really superlative gold standard.” 19:34 EP263 with Andrew Eye from ClosedLoop.ai. 22:02 “It's not just about taking dollars away from certain subsectors; it's about reallocating some of those dollars.” 23:34 “Policy making itself tends to be siloed.” 25:02 “This is about paying some people in health care modestly less.” 25:35 “Most of the costs are driven by fixed costs.” 29:25 “Value-based care is not what has driven consolidation.” You can learn more at ie-care.org. @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc What are the nuances within the promises of value-based care? @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “For the first 10 years of … value-based care, it was right in order to generate momentum and get as much participation as possible.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “When you leave yourself open to tackling prices, now you open up a whole world of possibilities in terms of how you could redirect sources.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “Not all providers are the same.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “It's time to stop tracking the phenomenon and actually pay for change.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “We haven't done our best to actually make the alternative to value-based payment as bad as it could be.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “As a citizen, I gotta ask, ‘How much is enough?'” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “It's not like we're talking about replacing a really superlative gold standard.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “It's not just about taking dollars away from certain subsectors; it's about reallocating some of those dollars.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “This is about paying some people in health care modestly less.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “Value-based care is not what has driven consolidation.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

university health future leaving pennsylvania healthcare institute md policy agency harvard university medicare centers anthem gdp mph penn johns hopkins university temple university collectively digital health pham valuebased attaining medicare advantage premises ffs disagrees value based care health economics idd closed loop healthcare research national advisory council vbc medicare medicaid services medicare medicaid services cms idns leonard davis institute robert wood johnson clinical scholar national business group nicole bradberry

EP324: ACOs (Accountable Care Organizations): Do They, in Fact, Improve the Quality of Care and Reduce Costs? With Nicole Bradberry and Kelly Conroy

Play Episode Listen Later Jun 3, 2021 33:50

Recently, the University of Pennsylvania Leonard Davis Institute of Health Economics, or LDI, put out a white paper called “The Future of Value-Based Payment: A Road Map to 2030.” Spoiler alert: Next week’s show is with Dr. Mai Pham, an author of that paper; and it’ll be a great show—so, tune back in next week. But, in the meantime, that paper made some really interesting points about ACOs (accountable care organizations). For example, they say that the average ACO shows a net savings of

university spoilers future healthcare digital health conroy acos aco health economics reduce costs quality of care accountable care organizations ldi nicole bradberry

EP322: Cherry Picking, Lemon Dropping, and Other Learnings for Value-Based Care Models, With Monica Lypson, MD, MHPE

HealthcareNOW Radio - Insights and Discussion on Healthcare, Healthcare Information Technology and More

Play Episode Listen Later May 13, 2021 30:30

Imagine if innovators in other businesses operated in the way that some health care status quo doomsayers finger wag. So much for failing fast, iterating, and folding learnings into something that might work better. I don’t like to see screeds that seem to advocate an approach of “try it a few times at a minimum half-heartedly, fail, and then just quit, because obviously anything worth doing should be that easy.” Pieces fell into place with me as I was speaking to Monica Lypson, MD, MHPE. Dr. Lypson is an expert in a bunch of things, but one of them is thinking about next-generation primary care and health equity and what that might look like in value-based care (VBC) metrics. I asked her if because of some of the negative potential perverse incentives to these patient populations whether we should throw out the VBC baby with the bathwater. Her response was succinct and amounted to, “And go back to what? FFS? Because that’s worked out so well?” All this being said, there are big issues with value-based care right now that we really need to take a hard look at and think critically about. But that critical thinking, to be considered innovative and productive, really should inform creative thinking: What do we learn and do better next time? Cherry picking and lemon dropping is a very real potential problem with value-based care. To find out what that means, you’ll have to listen to the interview. Another issue is who gets to decide what the measures and standards are. Who determined what is high-value and low-value care? And is that determination relevant to all communities and all care settings? Then ferreting out from there the potential loopholes for people to game the system because, despite all the virtue signaling that goes on around here, it is amazing sometimes the raw ingenuity exhibited when it comes to gaming the system. Dr. Lypson brought up some points that I have not heard so succinctly before. One of them is that a national framework is pretty necessary here to enable local initiatives. You can’t have a local program, for example, help the homeless get homes when, on a national level, dollars are siloed into firewalled buckets. So, trying to take health care dollars and apply them to housing takes two years and an act of Congress—because it literally takes two years and an act of Congress, or at least someone with more time and authority than a local care team. For more insight into this topic, listen to also the upcoming interview with Mai Pham as well as Nicole Bradberry and Kelly Conroy. Also, the recent interview with Dr. Rich Klasco (EP321), Jeff Hogan (EP309), and Dr. Mark Fendrick (EP308). This is a huge, complicated topic that will take everyone sitting at the table thinking creatively to solve, incrementally, one step forward at a time. Monica Lypson, MD, MHPE, is currently vice dean for education at Columbia University Vagelos College of Physicians and Surgeons. She has practiced in a number of primary care settings, including the Department of Veterans Affairs. MHPE stands for Master of Health Professions Education, by the way. You can connect with Dr. Lypson on LinkedIn. Monica L. Lypson, MD, MHPE, FACP, serves as a professor, vice-chair of medicine, division director of general internal medicine at The George Washington University School of Medical and Health Sciences. She will join Columbia University’s Vagelos College of Physicians and Surgeons as vice dean for medical education on June 1, 2021. Her work focuses on innovations and improvements in health professions education and assessment, health equity, workforce diversity, faculty development, medical care delivery, and provider communication skills. Dr. Lypson most recently served as director for medical and dental education for the Veterans Health Administration, where she oversaw undergraduate and graduate medical education across the nation within the Department of Veterans Affairs. 04:08 Is value-based care good for underserved communities? 05:09 “If you create perverse incentives, you actually might make known health care disparities worse … to meet the demands’ value.” 06:29 “There actually might be systematic and structural ways that the health care system might say … we’re not interested in taking care of you.” 07:12 “The incentive to have a good outcome is not there; the incentive to have another visit is there.” 08:33 “If you don’t have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots.” 08:55 “The only indictment I have on the fee-for-service system is that it’s gotten us to where we are right now.” 09:30 What are the must-haves for a value-based system that creates the patient outcomes we need? 09:58 What is a whole health model? 10:43 EP319 with Grace Terrell, MD. 11:08 EP312 with Douglas Eby, MD, MPH, CPE. 16:25 “We want to move money around with the accountability of the patient outcome. We want to be responsible stewards of that dollar.” 17:14 What does it mean to keep an equity framework? 20:48 Do we know the impact of independent physicians closing their offices? 25:20 What do we need to be mindful of when constructing a value-based system of care? 27:52 “The large health care system needs their community partners at the table.” You can connect with Dr. Lypson on LinkedIn. @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc Is value-based care good for underserved communities? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “If you create perverse incentives, you actually might make known health care disparities worse … to meet the demands’ value.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “There actually might be systematic and structural ways that the health care system might say … we’re not interested in taking care of you.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “The incentive to have a good outcome is not there; the incentive to have another visit is there.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “The only indictment I have on the fee-for-service system is that it’s gotten us to where we are right now.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What are the must-haves for a value-based system that creates the patient outcomes we need? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What is a whole health model? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “We want to move money around with the accountability of the patient outcome. We want to be responsible stewards of that dollar.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What does it mean to keep an equity framework? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What do we need to be mindful of when constructing a value-based system of care? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “The large health care system needs their community partners at the table.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc

PopHealth Week: Nicole Bradberry, Chief Executive Officer and Chairman of the Board of FLAACOS

Play Episode Listen Later Apr 24, 2021 27:54

Hosts Gregg Masters and Fred Goldstein meet Nicole Bradberry Chief Executive Officer and Chairman of the Board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for Accountable Care Organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value healthcare space. They discuss ACOs, value based healthcare initiatives and innovative models in the mental health space. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play HealthcareNOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

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@FlaACOs CEO @NicoleBradberry Weighs in on ACOs, Value Based Care & Innovation

Play Episode Listen Later Apr 16, 2021 28:00

On today's show our guest is Nicole Bradberry Chief Executive Officer and Chairman of the Board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for Accountable Care Organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value healthcare space. We discuss ACOs, value based healthcare initiatives and innovative models in the mental health space. Nicole Bradberry is the Co-Founder / Chief of Growth and Innovation Officer for Vinifera Health. Vinifera runs Mental Health Crisis and Urgent Care Centers with a focus on immediate access, quality care and the understanding that mental health and substance abuse drive significant health cost. Prior to Vinifera, Nicole was the Founder and Managing Parter for Cura Health Management which creates and manages ACOs and other value-based healthcare entities. Cura Health was recently sold to Healthlynked where she still remains as an advisor. In addition she founded the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for Accountable Care Organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value healthcare space.

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Florida Association of ACOs CEO @NicoleBradberry on Value Based Healthcare

Play Episode Listen Later Apr 15, 2021 28:00

On today's show our guest is Nicole Bradberry Chief Executive Officer and Chairman of the Board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for Accountable Care Organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value healthcare space. We discuss ACOs, value based healthcare initiatives and innovative models in the mental health space. Prior to launching FLAACOs Nicole led the successful transition of Captify Health to a specialty network benefits management solution prior to selling it to a large revenue cycle company, Continuum Health Alliance where she also served as their Chief Growth Officer. Nicole leverages her strategic relationships and strong leadership, operations and technology background to develop innovative products and growth strategies for healthcare providers as they transition to value-based healthcare. She has led the strategy and design behind the development of scalable population health tools and a professional service model that enabled physicians to successfully participate in value based contracts such as ACOs. On today's episode we learn more recent developments at both FLAACOS and ValueH including her plans to innovate in the mental health space.

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ACOs and Value Based Healthcare Nicole Bradberry, FlaACOs CEO Weighs In

HealthcareNOW Radio - Insights and Discussion on Healthcare, Healthcare Information Technology and More

Play Episode Listen Later Sep 4, 2019 27:00

On PopHealth Week our special guest making an encore appearance is Nicole Bradberry, Chief Executive Officer of theFlorida Association of Accountable Care Organizations (FLAACOs). Nicole provides both a regional and national update on the status and performance of ACOs. In addition, Nicole previews the upcoming annual FLAACOs conference in Orlando, Florida on November 7th and 8th 2019. For more information on the agenda, speaker line-up and key themes featured at the conference, clik here. Join your peers at this crucial time for ACOs and related value based healthcare initiatives. ==##==

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PopHealth Week: Nicole Bradberry, FlaACOs CEO Weighs In On ACOs and Value Based Care

Play Episode Listen Later Aug 24, 2019 26:50

Hosts Fred Goldstein and Gregg Masters, MPH meet Nicole Bradberry, FlaACOs CEO as she weighs in on ACOs and Value Based Care. Want to stream our station live? Visit www.HealthcareNOWRadio.com. Find all of our show podcasts on your favorite podcast channel and of course on Apple Podcasts in your iTunes store or here: https://podcasts.apple.com/us/podcast/healthcarenow-radio/id1301407966?mt=2

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Nicole Bradberry, FlaACOs CEO Weighs In On ACOs and Value Based Care

Play Episode Listen Later Jun 14, 2019 27:00

On PopHealth Week our special guest making an encore appearance is Nicole Bradberry, Chief Executive Officer of the Florida Association of Accountable Care Organizations (FLAACOs). Nicole provides both a regional and national update on the status and performance of ACOs. In addition, Nicole previews the upcoming annual FLAACOs conference in Orlando, Florida on November 7th and 8th 2019. For more information on the agenda, speaker line-up and key themes featured at the conference, clik here. Join your peers at this crucial time for ACOs and related value based healthcare initiatives. ==##==

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Accountable Care, ACOs the Value Based Economy via @NicoleBradberry CEO @FlaACOs

Play Episode Listen Later Oct 25, 2018 32:00

On PopHealth Week, wednesday, October 24th, 2018 our guest is Nicole Bradberry, the CEO of the Florida Association of ACOs (FlaACOs) joins Fred Goldstein and Gregg Masters to review key takeaways from the 5th Annual Gathering of FlaACOs which convened in Orlando Florida. FlaACOs member ACOs include some of the top performing ACOs in the United States according to the Center for Medicare and Medicaid Services (CMS). Nicole will recap some of the key highlights from the session and weigh in on the state of the valued based healthcare economy, including plans for lauch of a national association of value based healthcare operators. Join us.

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ACOs, Accountable Care and the Value Based Economy with @NicoleBradberry

Play Episode Listen Later Oct 24, 2018 30:00

Wednesday, October 24th, 2018 on PopHealth Week Nicole Bradberry, the CEO of the Florida Association of ACOs (FlaACOs) joins Fred Goldstein and Gregg Masters to review key takeaways from the 5th Annual Gathering of FlaACOs which convened in Orlando Florida. FlaACOs member ACOs include some of the top performing ACOs in the United States according to the Center for Medicare and Medicaid Services (CMS). Nicole will recap some of the key highlights from the session and weigh in on the state of the valued based healthcare economy, including plans for lauch of a national association of value based healthcare operators. Join us.

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Health Reform, Whitewaters & ACOs with @NicoleBradberry CEO @FlaACOs #FLAACO18

Play Episode Listen Later Sep 18, 2018 31:00

The Annual gathering of the Florida Association of ACOs (FlaACOS) CEO Nicole Bradberry joins Fred Goldstein and Gregg Masters on September 12th, 2018 at 3PM ET/12 Noon PT to discuss recent developments in the ACO space and preview the upcoming 5th Annual Meeting in Orlando, FL. Nicole Bradberry, serves as the CEO of the Florida Association of ACOs and President, Florida Market, Navvis Healthcare. The Florida Association of ACOs (FlaACOs) convenes in Orlando, October 18th and 19th for their fifth annual meeting. Join us!

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Those Whitewaters of ACOs! @NicoleBradberry CEO @FlaACOs weighs in. #FLAACO18

Play Episode Listen Later Sep 12, 2018 30:00

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#FLAACOS18: Meet Craigan Gray MD MBA & Amy Holm Kotch MHA Salient Health

This Week in Accountable Care

Play Episode Listen Later Aug 29, 2018 10:00

The Florida Association of ACOs (FLAACOS) convened in Orlando, Florida October 2017. Curated and led by industry thought leader Nicole Bradberry, the FLAACOS gathering attracts the best and brightest minds active in the Florida accountable care and value based healthcare initiative markets. For more information, follow @FLAACOS and check out the conference agenda and lineup for 2018. The conference is scheduled October 19th & 20th in Orlando, Florida. In this interview Fred Goldstein, MS, President, Accountable Health, LLC, chats with Craigan Gray MD, MBA,Chief Medical Officer, and Amy Holm Kotch, MHA of Salient Health. More about Salient ACO, here. Segment produced and directed by Gregg Masters, MPH, Managing Director, Health Innovation Media.

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Meet @NicoleBradberry CEO @FLAACOS on Accountable Care and the Journey to Value

Play Episode Listen Later Aug 31, 2017 32:00

Our guest of This Week in Accountable Care for Tuesday's, August 29th 2017 broadcast is Nicole Bradberry, the CEO of FLAACOs - the Florida Association of Accountable Care Organizations (ACOs). More about Nicole and FLAACOs: Nicole Bradberry is the Chief Executive Officer and Chairman of the Board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for Accountable Care Organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value healthcare space. Ms. Bradberry is also the Chief Executive Officer for Zinnia Healthcare, a healthcare consulting company focused on helping early and mid-stage companies develop business models and go-to-market strategies, specifically around the transition from fee-for-service to fee-for-value payment models. Ms. Bradberry leverages her strategic relationships and strong leadership, operations and technology background to develop innovative products and growth strategies for healthcare providers as they transition to value-based healthcare. Join Co-founder of National ACO, Dr. Alex Foxman and Gregg Masters, publisher of ACO Watch for an informative conversation with one of the ACO industry's leadng voices and best in class state association of ACOs.

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Nicole Bradberry on Accountable Care and the Journey to Value

Play Episode Listen Later Aug 29, 2017 31:00

Our guest of This Week in Accountable Care for Tuesday, August 29th 2017 at 5PM Pacific/8PM Eastern is Nicole Bradberry, the CEO of FLAACOs - the Florida Association of Accountable Care Organizations (ACOs). More about Nicole and FLAACOs: Nicole Bradberry is the Chief Executive Officer and Chairman of the Board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for Accountable Care Organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value healthcare space. Ms. Bradberry is also the Chief Executive Officer for Zinnia Healthcare, a healthcare consulting company focused on helping early and mid-stage companies develop business models and go-to-market strategies, specifically around the transition from fee-for-service to fee-for-value payment models. Ms. Bradberry leverages her strategic relationships and strong leadership, operations and technology background to develop innovative products and growth strategies for healthcare providers as they transition to value-based healthcare. Join Co-founder of National ACO, Dr. Alex Foxman and Gregg Masters, publisher of ACO Watch for an informative conversation with one of the ACO industry's leadng voices and best in class state association of ACOs.

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.@FLAACOs 2016: Meet Master Curator @NicoleBradberry

Play Episode Listen Later Nov 17, 2016 9:00

At the 3rd Annual Meeting of the Florida Association of ACOs (@FLAACOS), Fred Goldstein, MS co-host Health Innovation Media chats with FLAACOs Presidentand conference curator extraordinaire Nicole Bradberry. Learn about the role of FLAACOs supporting the development of core competencies to success in the Medicare Shared Savings Program and an overview of the Association's annual gathering. For more information, check out the Florida Association of ACOs here. Produced by Gregg Masters, MPH for Health Innovation Media.

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@FLAACOs CEO @NicoleBradberry weighs in on ACO results and 3rd Annual Conference

Play Episode Listen Later Sep 19, 2016 32:00

On the Friday, September 16th, 2016 broadcast of PopHealth Week our special guest was the CEO of a pioneering state organzation enabling the success and support of Accountable Care Organizations in the the state of Florida, Nicole Bradberry. During the broadcast we'll get this industry veteran and innovator to weigh in on the significance of the recent CMS results reporting of ACOs participating in the Medicare Shared Savings Program (MSSP). and a preview of the upcoming 3rd Annual FLAACO gathering in Orlando, Florida. For more information click here, and for a summary take on CMS's results reporting click here. And for our prior chat's with Nicole, click here, and here.

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Meet Nicole Bradberry, CEO FLAACOs

Play Episode Listen Later Sep 16, 2016 31:00

On Friday, September 16th, 2016 our special guest is the CEO of a pioneering state organzation enabling the success and support of Accountable Care Organizations in the the state of Florida, Nicole Bradberry. During the broadcast we'll get this industry veteran and innovator to weigh in on the significance of the recent CMS results reporting of ACOs participating in the Medicare Shared Savings Program (MSSP). and a preview of the upcoming 3rd Annual FLAACO gathering in Orlando, Florida. For more information click here, and for a summary take on CMS's results reporting click here. And for our prior chat's with Nicole, click here, and here.

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FLAACOs 2015: Meet Master Curator Nicole Bradberry

Play Episode Listen Later Oct 26, 2015 10:00

At the 2nd Annual gathering of the Florida Association of ACOs, Founder and CEO Nicole Bradberry shares her perspectives on the emergence of the Association including the dynamics unleashed by the Affordable Care Act driving the move into value based healthcare. Listen as opines on market dynamics and where things are going as we transition from a volume based to value oriented ecosystem. Produced and directed by Gregg Masters for Health Innovation Media.

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Meet Nicole Bradberry

Play Episode Listen Later Apr 23, 2014 31:00

On the Wednesday, April 23rd 2014 at 11AM Pacific/2PM Eastern my special guest is Nicole Bradberry, President/COO of Orange Health Solutions/MZI Healthcare and CEO of the Florida Association of ACOs. Nicole an innovator in the accountable care space, is making an encore appearance on the show with some rather timely and interesting news following the recent acquisition of MZI Healthcare. We'll hear more about the investment enabling the transaction and the market significance of fueling the combination. More about Nicole: 'Nicole Bradberry brings an innovative vision and a deep knowledge of healthcare, technology and business solutions. Previously, she was a founding Executive and Chief Information Officer for Rise Health, where she led the design and implementation of a full primary care transformation suite of products which included proprietary technology and transformational business solutions. In this role, she led her team to win the prestigious U.S. Department of Health and Human Services health data award for IT innovation. Prior to Rise, Nicole spent 16 years leading operations and information technology programs for UnitedHealth Group and Cigna HealthCare. While there, she served as business lead for the technology transformation of the country’s largest dental and vision services company, led the national deployment of healthcare quality and affordability programs, and was responsible for the successful integration of many major health plans.' Join us!

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Nicole Bradberry, CEO of Florida Association of ACOs