Podcast appearances and mentions of Peter Hayes

Exploring the Complexities of Pharma Rebates with Ann Lewandowski In this Summer Short episode of Relentless Health Value, host Stacey Richter converses again with Ann Lewandowski about the intricate dynamics of pharmaceutical rebates, or as Lewandowski prefers, post-sale concessions.  The discussion delves into the nuances of these rebates, the impact they have on drug costs, and the hidden consequences for patients and plan sponsors.  They highlight articles and insights by Austin Chelko and Peter Hayes, touching on how rebates can disadvantage the pursuit of lower-cost generics and biosimilars, and can obstruct pharmacogenetic testing that ensures drug efficacy and safety.  The conversation also critiques the opacity of rebates, deemed trade secrets by pharma and PBM companies, and underscores the ethical and financial dilemmas posed by the current rebate-driven system. === LINKS ===

In this episode, Stacey Richter explores the impact of trust on healthcare outcomes, drawing from listener contributions and prior episodes of Relentless Health Value. The discussion underscores how trust or the lack thereof affects patients, clinicians, and healthcare systems. Key points include the importance of building trusted relationships, the detrimental effects of antitrust behaviors, and the broader implications for healthcare delivery. Stacey also highlights a bonus show featuring Charles Green on earning and maintaining trust. The episode concludes with an uplifting message about the collaborative and giving nature of the Relentless Health Value community. === LINKS ===

In this episode of Relentless Health Value, host Stacey Richter sits down with Peter Hayes to discuss the major forces driving change in the healthcare industry. Hayes outlines three critical factors: changing public opinion, heightened transparency, and new regulations such as the Consolidated Appropriations Act.  He emphasizes the unprecedented convergence of these elements, creating a pivotal moment for healthcare transformation. The discussion delves into the erosion of trust within the healthcare system and the growing public unrest over high costs and inefficiencies.  Hayes also highlights the role of state-level initiatives as experimental laboratories for potential national solutions. The episode concludes with a call to focus on root causes and collaborative approaches to restore trust and improve healthcare affordability and quality. === LINKS ===

This show from last year was one of the most popular episodes of the past year. And it's also extremely relevant right now, given all of the PBM (pharmacy benefit manager) goings-on, as well as ongoing litigation like the J&J lawsuit, etc. Listen to the show with Julie Selesnick (EP428) for more on that one. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Also, Brian Reid (EP456) in the episode from a couple of weeks ago. And he talks about how Mark Cuban's way of communicating and framing some of the issues with the big PBMs and just all of the perverse incentives in the drug supply chain. He says this way of communicating is “the chef's kiss.” So, besides the insights here that follow being relevant in and of themselves, there's also some lessons just in how those issues are teed up and communicated that we all can learn from. CEOs and CFOs … hey, this show is for you. Let's start here: What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion? These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There's one vital first step. That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits. Why can't much happen without you, CEOs and CFOs? Here's the IRL: In 2023, the healthcare industry has been financialized. There is a whole financial layer in between your company and its healthcare benefits. And unless the C-suite is involved here and bringing their financial acumen and organizational willpower to the equation, your company and your employees are currently paying hundreds of thousands, maybe millions, of dollars too much and doing so within a business model that deeply exacerbates inequities. There are people out there who are very strategically taking wild advantage of a situation where CEOs/CFOs fear anything to do with healthcare in the title and don't do their normal level of due diligence. You think it's an accident that this whole space got so “complicated”? HR needs your help. Bottom line, if you are a CEO or CFO and you do not know everything that Mark Cuban and Ferrin Williams talk about on the pod today … wow, are you getting shellacked. Mark Cuban uses a different word. Healthcare benefits are, after all, for most companies the second biggest line-item expense after payroll. But don't despair here, because all of this information is really and truly actionable. Others out there are cutting zeros off of their spend and actually doing it in ways that are a total win for employees as well. My guest today, Mark Cuban, is a CEO, after all; and when he looked into it, it took him T-minus ten minutes to figure out just the order of magnitude that his “trusted” benefits consultants and PBM and ASOs (administrative services only) and others were extracting from his business. He pushed back. So can you. But just another reason to dig into that financial layer wrapping around your employee health benefits right now, you might get sued by your employees. Below is an ad currently being circulated on LinkedIn by class action attorneys recruiting employee plan members to sue their employers for ERISA (Employee Retirement Income Security Act of 1974) violations. It's the same attorneys, by the way, from those 401(k) class action lawsuits. I've talked to a few CEOs and CFOs who are scrambling to get ahead of that. You might want to consider doing so as well. Now, for my HR professional listeners, considering that some of what Mark Cuban says in the pod that follows is indeed a little spicy, let me just recognize that the struggle is real. There are multiple competing priorities out there in the real world, for sure. And bottom line, because of those multiple competing priorities out there in the real world, it's really vital that everybody work together up and down the organization in alignment. Lauren Vela talks a lot about these realities here in episode 406. This is a longer show than normal, but it's also like a show and a half. Mark Cuban talks not only about his work with Mark Cuban Cost Plus Drugs, which is a company that buys drugs direct from manufacturers and sells them for cost plus 15%, a dispensing fee, and shipping. It's kind of crazy how so often that price is cheaper, sometimes considerably cheaper, than the price that plan members would have paid using their insurance—and the price that the plan is currently paying the PBM. Most Relentless Health Value Tribe members (ie, regular listeners of this show) will already know that, but what is also fascinating that Mark talks about is what he's doing with his own businesses and the Mavericks on other fronts, like dealing with hospital prices. In this show, we also talk the language of indie pharmacies, fee-only benefits consultants, TPAs (third-party administrators), PBMs, and providers doing direct contracting. There are, in fact, entities out there trying to do the right thing; and Mark acknowledges that. Ferrin Williams, PharmD, MBA, who is also my guest today, is chief pharmacy officer at Scripta and an expert in pharmacy benefits. She adds some great points and some context to this conversation. Scripta is partnering with Mark Cuban Cost Plus Drugs. Scripta has a neat Med Mapper tool and also services to help employees find the lowest costs for their prescriptions. If you are a self-insured employer, for sure, check out Scripta. Here are links to other shows that you should listen to now if you are inspired to take action. I would recommend the shows with Paul Holmes (EP397); Dan Mendelson (EP385); Andreas Mang (EP419); Rob Andrews (EP415); Cora Opsahl (EP372); Lauren Vela (EP406); Peter Hayes (EP346); Gloria Sachdev, PharmD, and Chris Skisak, PhD (EP390); and Mike Thompson (EP389). Also Mark Cuban mentions in this show the beverage distributor L&F Distributors. Thanks to Ge Bai, Andreas Mang, Lauren Vela, Andrew Gordon, Andrew Williams, Cora Opsahl, Kevin Lyons, Pat Counihan, David Dierk, Connor Dierk, John Herrick, Helen Pfister, Kristin Begley, AJ Loiacono, and Joey Dizenhouse for your help preparing for this interview. Also mentioned in this episode are Mark Cuban Cost Plus Drug Company; Scripta Insights; Julie Selesnick; Brian Reid; Paul Holmes; Dan Mendelson; Rob Andrews; Peter Hayes; Gloria Sachdev, PharmD; Chris Skisak, PhD; Mike Thompson; and Scott Conard, MD. You can learn more at Mark Cuban Cost Plus Drug Company and Scripta Insights. You can also connect with Scripta and Ferrin on LinkedIn.   Mark Cuban has been a natural businessman since the age of 12. Selling garbage bags door to door, the seed was planted early on for what would eventually become long-term success. After graduating from Indiana University—where he briefly owned the most popular bar in town—Mark moved to Dallas. After a dispute with an employer who wanted him to clean instead of closing an important sale, Mark created MicroSolutions, a computer consulting service. He went on to later sell MicroSolutions in 1990 to CompuServe. In 1995, Mark and longtime friend Todd Wagner came up with an internet-based solution to not being able to listen to Hoosiers basketball games out in Texas. That solution was Broadcast.com—streaming audio over the internet. In just four short years, Broadcast.com (then Audionet) would be sold to Yahoo! Since his acquisition of the Dallas Mavericks in 2000, Mark has overseen the Mavs competing in the NBA Finals for the first time in franchise history in 2006—and becoming NBA World Champions in 2011. Mark first appeared as a “Shark” on the ABC show Shark Tank in 2011, becoming the first ever to live Tweet a TV show. He has been a star on the hit show ever since and is an investor in an ever-growing portfolio of small businesses. Mark is the best-selling author of How to Win at the Sport of Business. He holds multiple patents, including a virtual reality solution for vestibular-induced dizziness and a method for counting objects on the ground from a drone. He is the executive producer of movies that have been nominated for seven Academy Awards: Good Night and Good Luck and Enron: The Smartest Guys in the Room. Mark established Sharesleuth, a research and investigation Web site to uncover fraud in financial markets, and endowed the Electronic Frontier Foundation's Mark Cuban Chair to Eliminate Stupid Patents, an effort to fight patent trolls. Mark gives back to the communities that promoted his success through the Mark Cuban Foundation. The Foundation's AI Bootcamps Initiative hosts free Introduction to AI Bootcamps for low-income high schoolers, starting in Dallas. Mark also saved and annually funds the Dallas Saint Patrick's Day Parade, the largest parade in Dallas and a city institution. In January 2022, he started Mark Cuban Cost Plus Drug Company as an effort to disrupt the drug industry and to help end ridiculous drug prices because every American should have access to safe, affordable medicines. Ferrin Williams, PharmD, MBA, is chief pharmacy officer of Scripta. With 15+ years' experience in the pharmacy industry, Ferrin brings a unique perspective to Scripta that spans the retail pharmacy, pharmacy benefit manager (PBM), and broker/consulting sectors. Her expertise ranges from pharmacy operations and services to innovative clinical programs, pharmacy audit, alternative payer funding, and specialty drugs. As chief pharmacy officer, Ferrin leads the company's clinical strategies organization responsible for devising innovative cost-containment strategies for prescription drugs, ensuring Scripta clients, members, and their providers are provided with best-in-class clinical insights and tools. Ferrin earned her bachelor's, Doctor of Pharmacy, and MBA degrees from the University of Oklahoma.   06:29 What was Mark Cuban's own journey as a self-insured employer with Cost Plus Drug Company? 07:44 What did Mark find when he decided to go through and look through his company's benefit program? 09:12 “When you think it through, you start to realize that money is being spent primarily by your sickest employees.” —Mark 10:02 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks? 13:00 What is the role of insurance in healthcare? 14:30 “If you can't convince them, confuse them and hide it.” —Mark 15:24 The reality behind getting a rebate check. 16:21 Why are rebates going away, and why isn't that changing PBM earnings? 19:05 How do you get CEOs and CFOs to dig into their benefits plan? 20:59 Does morally abhorrent move the needle? 21:33 “What we're trying to do is just simplify the [healthcare] industry.” —Mark 24:19 What's been changing in consumer behavior? 25:04 “Transparency is a huge part of building that trust.” —Ferrin 25:19 Why CEOs and CFOs really have the power to change healthcare. 32:29 What are Cost Plus Drugs' plans to expand? 39:21 Where is the future of the prescription drug market going? 42:09 What will happen to the prescription drug market in 10 to 20 years? 48:40 The wake-up call self-insured employers should be acknowledging now. 52:02 Where is the real change in the healthcare industry going to come from?   You can learn more at Mark Cuban Cost Plus Drug Company and Scripta Insights. You can also connect with Scripta and Ferrin on LinkedIn.   @mcuban and Ferrin Williams provide advice for #CEOs and #CFOs of #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #healthcareoutcomes   Recent past interviews: Click a guest's name for their latest RHV episode! Rob Andrews (Encore! EP415), Brian Reid, Dr Beau Raymond, Brendan Keeler, Claire Brockbank, Cora Opsahl, Dan Nardi, Dr Spencer Dorn (EP451), Marilyn Bartlett, Dr Marty Makary  

Peter Hayes talks to Paul Byrne on his stage 4 prostate cancer diagnosis and his photography exhibition. See also peterhayesphotography.com Hosted on Acast. See acast.com/privacy for more information.

Joe Bowditch has been a familiar face on major Australian racetracks for more than 34 years. He's still plying his trade from a Victorian base at 47 years of age, and still riding winners. The evergreen jockey has crammed a lot into more than three decades of race riding in four states. The Joe Bowditch story makes for an interesting podcast. Currently under suspension,   he was happy to give me some time on the phone last weekend. He spoke to me from a Bundalong property owned by his great mate Luke Nolen. Joe talks about his recent Flemington win on Brazen Lady and acknowledges the support he receives from the Ellerton/Moodie stable. He talks of a long and successful association he's had with another Cranbourne trainer Robbie Griffiths.  Joe descends from a famous Riverina racing family. He shares memories of his father Des and uncles Barry and Wally- all accomplished jockeys. He remembers a wonderful friendship with trainer Ray Guy who was to have signed him up as an apprentice. When Ray died suddenly in 1992, his son Bryan became Joe's master. Joe recalls having been All Our Mob's strapper when he won at Rosehill the day after Ray's passing. The jockey recalls travelling to Mudgee to ride his first winner thirty one years ago. He looks back on his first couple of metropolitan winners.  Joe talks about a loan-out to the famous Lindsay Park operation in SA. Colin Hayes had retired but still had a presence. He talks of the quality of horseflesh he got to work with including a Melbourne Cup winner. Joe reflects on his working relationship with both David and Peter Hayes. Peter's death in a light plane crash impacted the entire staff at Lindsay Park. He remembers two star apprentices who came through the system during his time at the famous Angaston operation.  The jockey comments on the fact that the bulk of his career winners have been on the Morphettville track. Joe looks back on his first Gr 1 success in 2004. He had to change his tactics when the pace slowed suddenly in the middle stages of the SA Derby. He's ridden better horses than  Conservatorium but says the genuine gelding remains his all time favourite. He talks about his narrow defeat on a future multiple Gr 1 winner in the 1996 Fulham Park Plate. Joe's had his share of nasty falls. He talks about a crash at Morphettville in 2000 that left him with a long list of injuries. He looks back on an association with On A Jeune in 2004. He won a Cranbourne Cup on the gelding and went on to ride him in the Melbourne Cup of the same year. Joe looks back on a brief stint at Corowa as stable rider for the legendary Riverina trainer Richard Freyer. He talks of a surprise phone call from his former master Bryan Guy- a call that led him to a six year stay in Queensland. Joe reviews the highs and lows of that Queensland sojourn- some major wins and one serious race fall. The veteran jockey delights in talking about his association with the brilliant mare Viddora, the highlight of his long association with trainer Lloyd Kennewell. Joe summarises Viddora's wins in the Moir Stakes and Winterbottom Stakes. He says she was unlucky not to have added another Moir Stakes to her CV. He talks of exciting trips to Dubai and Hong Kong with the daughter of I Am Invincible. Joe finished among the tailenders on Viddora in the 2018 Everest, but won't forget the experience. He closes by paying tribute to wife Jen and his four children from two marriages- Heidi (21), Callam (19) and the dynamic duo (Jake 5) and Frankie (3). Great to catch up with a long serving and thoroughly dedicated professional jockey.

For a full transcript of this episode, click here. I'm gonna encore this episode with David Scheinker, PhD, for several reasons; but here's a big one: Why are we as an industry not doing what David Scheinker suggests in this episode? Why are we not doing, I don't know, kinds of logical things to reduce admin burden in this country when everyone agrees admin burden is a problem? But let me back up for a moment for context. Two things happened since this show originally aired. One is that I was invited to a fireside chat by the Advisory Board to talk with Abby Burns, one of the amazing hosts over at Radio Advisory; and we talked about value in the healthcare industry. And if you define value as benefit divided by costs, and you can cut costs—like cut admin burden costs in half—then you have created some really nice communal value, which we talked about at length during that aforementioned fireside chat. Here's the other thing that happened since this show originally aired. I read the book by Mike Leavitt, mainly because Steve Schutzer, MD, kept talking about it. The title of the book is Finding Allies, Building Alliances. Maybe I will do a book report about this at some point, but let me share a couple of key quotes just to get the party started here. Mike Leavitt wrote, “A diverse alliance, well led and well managed, can bring resources to bear on a problem that no organization can match—even the largest of organizations. The synergy of resources—from financial to intellectual—can deal effectively with a wide range of issues confounding organizations today.” I found that very interesting. Here's the second quote, which deals with what the top reason is that such diverse alliances may wish to hook up. “[It's] a common pain: A shared problem that motivates people and groups to work together in ways that could otherwise seem counterintuitive.” Hmm … so, back to administrative burden. Let's review the facts that David Scheinker, PhD, shares in the interview that follows. He says any given transaction will cost provider organizations 14% of the total transaction costs to manage to get paid. Yes, it costs 14% of a transaction merely to get paid for the transaction. This is a big reason why both Peter Hayes, in the episode with him (EP424), and also Marshall Allen (EP425) talk about for why cash prices can be a whole lot less than going through insurance prices because you can skip a lot of insurance burden. Now, on the payer side, add to that 14% an additional 5% to 15% to pay said transaction. That 30% of healthcare is waste stat that keeps getting tossed around. Listen to the show with Will Shrank, MD (EP413) for more on that. But, yeah … here's 20% to 30% of every transaction that is waste. And we haven't even gotten into redundant care or inappropriate back surgery yet. Our industry spends up to 30% of our money just trying to get paid and pay. Here's a case study for you. You know who has already solved for this whole “it's really hard to get paid and pay” dilemma? Derivative traders. It used to cost derivative traders $100,000 to do a contract, any given contract. And they worked together and got this down to $5000 by doing some of the stuff that David Scheinker talks about in the show. And, I don't know, I feel like the healthcare industry could also do this, too, if they wanted to. But there are a whole bunch of reasons why our industry cannot seem to get together and be as ruthlessly practical as derivative traders—or banks, who have figured out how to work together to process credit cards to reduce their own common pain. Here are but a few of the reasons, potentially, why the healthcare industry doesn't get together to reduce administrative burden in some of the ways that Dr. Scheinker talks about. 1. Some organizations actually make a lot of money off of that transactional waste. As but one example—and not to just pick on one, but we don't have all day—how about some RCM (revenue cycle management) companies who may or may not be owned by the same vertically integrated stacks as the payers themselves? As I have said any number of times, one person's—or potentially an entire country's, as the case may be—one party's waste, is somebody else's honeypot; and I am not sure if this is any exception. 2. Legacy technology and data systems and all the sunk costs therein 3. As Kaye Davis and Katrina Hubbard reminded me about the other day, there are some serious regulations in healthcare due to everybody being a vendor of CMS that adds a layer of regulatory complication to many collaborations. Also, state laws sometimes have an unintended side effect of making it tough to collaborate. Now, are there any precedents for this type of collaboration in the healthcare industry? Yeah, actually Surescripts, which, don't forget, was created by an alliance of PBMs (pharmacy benefit managers) who worked together because they all wanted to enable e-prescribing and needed a joint platform to do it. Look, I could say a lot about this one, but nonetheless, so much of what gets talked about in the show today with Dr. David Scheinker is very, very actionable. Just want to note that since David Scheinker was on the show, he and his team have done some major research over the past few years into ways that contracts can be standardized. If enough of you reach out and say that you're interested, we, for sure, can have David come back on the show and discuss. David Scheinker, PhD, is a clinical professor of pediatrics. He's the executive director of systems design and collaborative research at Stanford Children's Health. He also founded and directs SURF Stanford Medicine. And with that, here is your original episode. Administrative costs in the United States have a bad rap. You don't have to look too far to find an article about how there's now, like, 10 administrators for every 1 physician in this country. Or 3 to 4 billing people for every physician. Or consider what Dan O'Neill was talking about in episode 359. He was talking about IPAs (independent physician associations) and other managed care entities. As Dan mentions, contracting with some of these IPAs is like an “I love 1990” flashback. The contracting process transpires via mail. Not email, mind you. Mail. Like, stick-a-stamp-on-the-envelope mail. So, in sum, there's a lot of pretty well-founded complaining about administrative costs in this country. A lot of this administrative stuff is truly inefficient and a fantastical waste of time. So, here we are freaking out about staffing shortages, overlooking that doctors at the heights of their careers are spending some percentage of their time not counseling, treating, or diagnosing patients but twiddling their thumbs on hold with one insurance company or another slowly burning out by the inefficiency of it all. Or doing pajama time, and we all know that too much pajama time means also burnout on a silver platter. So then, let's get granular here. If we're trying to quantify admin costs, how you do that is to quantify how much each transaction costs. How much does it cost to send a bill and get paid for it? How much does it cost to file an appeal and a denial of a prior auth? Add all those transactions together and you get the full cost of the administrative burden. In this healthcare podcast, we're digging into a paper about admin costs written by David Scheinker, PhD (my guest today); Barak Richman, PhD, JD; Arnold Milstein, MD, MPH; and Kevin Schulman, MD, MBA. I have the pleasure of speaking with David Scheinker, PhD (as I mentioned), who is the lead author on this paper. Just to underline a major takeaway from this conversation with Dr. David Scheinker, he reiterates a recommendation to eliminate a big proportion of administrative costs. I guess I should say spoiler alert here, but the major takeaway/recommendation is this: Standardize healthcare contracts between payers and providers. Every payer and every provider finds one contract template and uses it. I don't mean one template per payer or per provider, although that probably would be a revelation in and of itself. But I mean that all payers use one basic provider contract. A couple of specifics here: The template that I'm referring to (and that Dr. David Scheinker is referring to) consists of parameters. What do I mean when I say parameters? Consider what Airbnb does when you're looking for a place to stay, as an example. How many bedrooms (that's a parameter)? How many bathrooms (that's a parameter)? How many amenities (that's a parameter)? After everybody picks their standard set of parameters, at that point, all parties can negotiate and come up with whatever they want for what is the price of an extra bedroom or whatever value you're gonna assign to that parameter. Go nuts there, but from a data collection and analytic perspective and a getting paid perspective, it is way easier to do it that way—meaning it's way easier to execute and report when all of the contracts use the same parameters. Also, you can build tech to do a lot of that because you don't have to write algorithms with exponential variables. Also mentioned in this episode are Abby Burns; Michael Leavitt; Steve Schutzer, MD; Peter Hayes; Marshall Allen; William Shrank, MD; Kaye Davis, MPH; Katrina Hubbard; Dan O'Neill; Barak Richman, PhD, JD; Arnold Milstein, MD, MPH; and Kevin Schulman, MD, MBA. You can learn more by connecting with David on LinkedIn and following him on X (Twitter).   David Scheinker, PhD, started his career as a research mathematician and switched to healthcare operations to work on an interdisciplinary team and have a more immediate impact. He is a clinical professor of pediatrics, the executive director of systems design and collaborative research at Stanford Children's Health, and a member of the Clinical Excellence Research Center (CERC) at Stanford University. He founded and directs SURF Stanford Medicine, which brings together students and faculty from the university with physicians, nurses, and administrators from the hospitals. He studies clinical care delivery, hospital operations, sensor-based and algorithm-enabled telemedicine, the socioeconomic factors that shape healthcare, and healthcare policy.   10:39 What's the quantitative administrative cost in an average transaction? 11:05 What's the quantitative administrative cost in a healthcare transaction? 11:58 What does the healthcare billing and administration cost add to the US's overall healthcare spend? 12:53 Is it possible to cut billing and administrative costs in healthcare? 14:17 “In some ways, the problem for healthcare should be simpler.” 15:30 What does the complexity of the current system look like in a doctor's office? 18:42 How did David go about studying healthcare administrative costs? 21:34 “It doesn't have to be simple; it should be standardized.” 24:50 What would be the pushback on standardizing contracts in healthcare? 25:43 Why is it possible to gain more value by losing customization in contracts? 27:20 “Never let a good crisis go to waste.” 27:41 “It's much easier in healthcare to build something new than to change something that exists.” 30:47 What benefits does telemedicine have to cutting administrative costs? 32:17 What is another significant benefit of using standardized contracts? 33:26 Why haven't standardized contracts become a common thing in the current healthcare system?   You can learn more by connecting with David on LinkedIn and following him on X (Twitter).   @David_Scheinker of @SURFStanfordMed discusses administrative burden on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dan Mendelson, Dr Benjamin Schwartz, Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick

For a full transcript of this episode, click here. I've been in a couple of meetings lately. In one case, a healthcare company came up with a strategy and deployed it; and the strategy didn't go as planned. The other one, it did go as planned—it worked great. Of course, I'm coming in on the back end like a Monday morning quarterback here; but the plan that failed, I have to say, I wasn't surprised. Had they asked me ahead of time, I would have told them to save their money because the plan was never gonna work, even though the strategy looked like kind of a straight line from here to there. Nor was I shocked by the success of the other plan, even though this one that triumphed had what looked like five extra steps and was slightly counterintuitive if you looked at it cold, without understanding the way the healthcare industry actually works. Here's my point: It might feel like the healthcare industry is chaos monkey central and impossible to predict actions and reactions—and, for sure, there's always unknowns and intersecting variables—but it's not a complete black box. The trick is, as you know and I know, you gotta understand what other stakeholders are up to. You gotta get a bead on what they're doing and what their incentives are because then you can better predict actions and potentially reactions. So, let me state the obvious (that's why listeners tune in to this show as I just said, and it's what we aim to shine a light on here at Relentless Health Value): the pushes and the pulls and the forces. What's going on outside of the organizations or the silos that we work within day-to-day. Because if you're looking to sell to, partner with, not be obstructed by [insert some stakeholder here], then it's very vital to be keyed in on what they're doing or what their customers are doing or what their customers' vendors are doing. This show should feel like it gives you a measure of control (or at least that's my hope) or a method to find the measure of control. And I hope you succeed. That's why I continue to put out these shows. The RHV tribe members want the same thing I want—to fix the healthcare industry for patients and for members—so, thanks for being here and for making actionable the insights that you might find here. I have been so looking forward to doing a show with Ben Schwartz, MD, MBA, orthopedic surgeon and prolific writer of deeply thoughtful and insightful posts on LinkedIn. In this healthcare podcast, we are talking about bundled payments. And today's your lucky day if you think you know a lot about bundles, because most people who listen to this show at least know enough to be dangerous. So, that's our starting point, which is why I asked Dr. Schwartz to talk to me about what most people find surprising about bundles and bundled payments. There are four surprises that we go through in the show today. Listen to the show or read the transcript to find out exactly what they are. So, no spoiler alert alert. But relative to these surprises, we get into the four types of bundles that may or may not be available. And those four types of bundles are: 1. CMS bundles such as the BPCI (Bundled Payments for Care Improvement) and the CJR (Comprehensive Care for Joint Replacement) bundles, and we talk about the current state of said BPCI bundles, which are being sunsetted probably because so many efficient clinical teams are being penalized for getting too efficient. They become victims of their own success the way the program is currently designed, wherein the goalposts keep shifting. 2. Commercial bundles—ie, a bundle that is offered by a commercial carrier such as a BUCA (ie, Blue Cross Blue Shield/UnitedHealthcare/Cigna/Aetna/Anthem) carrier 3. Direct bundle—a bundle that is paid for directly by a plan sponsor such as a self-insured employer 4. Condition- or diagnosis-specific bundle. These types of bundles do not spiral around a surgical intervention at their core, which most of the current bundles do. This may describe CMS's recently announced “Making Care Primary” initiative, but we'll have to see about that. Speaking about the #3 kind of bundle, the employer-direct bundles, especially for musculoskeletal (MSK), let me share a post by Moby Parsons, MD, that I thought captured the entrepreneurial spirit of some of these orthopedic surgeons who are seeking employers to direct contract with and cut out the middleman, etc (which, by the way, is the main topic of an entire show upcoming with Elizabeth Mitchell from the Purchaser Business Group on Health). But Dr. Parsons wrote: “When our bundle business has sufficient growth to ensure the absolute sustainability of our practice against declining reimbursements … in a fee-for-service system, I am getting this tattoo. Don't tell my wife. [And the tattoo is ‘Free Yourself.']” My guest today, aforementioned, is Dr. Ben Schwartz. He's an orthopedic surgeon in the Boston area still in full-time clinical practice. He's grown very interested in healthcare innovation, healthcare technology, and does some advising and investing. Dr. Schwartz also writes a great Substack called Dem Dry Bones. After you listen to this show, please go back and listen to the one with Steve Schutzer, MD (EP294) talking about how to create a Center of Excellence and also the one with Rob Andrews (EP415) about how and why if you are a plan sponsor you might want to consider direct contracting with quantifiably amazing provider groups. Also, if you are an ortho or involved in MSK care, I might suggest following Karen Simonton on LinkedIn, as well as Moby Parsons, MD, and, for sure, of course, my guest today, Dr. Ben Schwartz. Also mentioned in this episode are Moby Parsons, MD; Elizabeth Mitchell; Steve Schutzer, MD; Robert Andrews; Karen Simonton; Peter Hayes; Al Lewis; and Cora Opsahl.   You can follow Dr. Schwartz on LinkedIn and read his blog on Substack.   Benjamin J. Schwartz, MD, MBA, is a fellowship-trained orthopedic surgeon with over 15 years of experience. He has served numerous healthcare leadership roles on both a local and national level with a focus on developing and implementing evidence-based, high-quality musculoskeletal care delivery pathways. Dr. Schwartz is vice chair of the Practice Management Committee for the American Association of Hip and Knee Surgeons and helps advance knowledge of musculoskeletal conditions as a member of the Hip and Knee Content Committee for the American Academy of Orthopaedic Surgeons and editorial board member/elite reviewer for The Journal of Arthroplasty. Dr. Schwartz has extensive experience in value-based care, having personally achieved over $400,000 in savings during his first year in the CMS BPCI-A program. He has received awards for clinical care and professionalism and was named a Castle Connolly Top Doctor in 2022 and 2023. In addition to his clinical work, Dr. Schwartz maintains a strong presence in healthcare technology and innovation as advisor and investor to early-stage digital health companies. He is frequently sought after by clinicians, founders, and venture capitalists for his ability to bridge the gap between real-world medicine and start-ups/entrepreneurship. Dr. Schwartz's passion is thoughtful implementation of technology and innovation to improve healthcare quality, accessibility, costs, and outcomes.   06:07 Where are we in the development of the bundled payments space? 08:09 What are the four types of bundled payments? 09:52 How can bundled payments create perverse incentives? 11:04 What are the positives in bundled payments, and how can they help push us toward value-based care? 13:02 What is surprising about bundled payments? 18:50 EP415 with Rob Andrews. 27:03 How do Centers of Excellence connect back to bundled payments? 29:00 EP346 with Peter Hayes. 30:29 EP294 with Steve Schutzer, MD. 33:38 EP331 with Al Lewis. 33:43 EP372 and EP373 with Cora Opsahl. 37:13 What does Dr. Schwartz think the future is for bundled payments?   You can follow Dr. Schwartz on LinkedIn and read his blog on Substack.   @BenSchwartz_MD discusses #bundledpayments on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379)  

For a full transcript of this episode, click here. First of all, I just want to start out this pod and really thank everyone listening and for showing up for a show like this one. You do it and you are here because you care about patients/members. It's just so easy to feel like we'll never be able to do enough, and that's a rough, rough feeling. Please take a moment to truly hear how grateful I am for you being here and for doing all that you do and that you try to do. I saw on the interwebs the other day a Marcus Aurelius quote. What he said was, “Be satisfied with even the smallest progress.” And I think this is really important to remember because nobody working in the healthcare industry, especially today, is ever probably gonna get anything close to a perfect solution. So instead, just aim for progress—even the smallest amount—and feel good about that, please. This show is an important one for anybody either in the business of healthcare delivery or buying healthcare delivery services. It's an exploration of what works and what doesn't work and how what works can easily become what doesn't work in the face of the real world. This peril of cutting clinical “waste” perilousness all starts with the whole “Hey, let's make some money, so we gotta scale and be efficient. We gotta do our thing at as low as possible a cost and maybe grow as fast as possible. We gotta keep our investors happy or pay off the debt we got saddled with or pay that giant management fee we're being charged or compensate the C-suite at the level they've grown accustomed to.” So again, the “let's be efficient and get everything repeatable” has entered the building. The first point my guest today, Kate Wolin, ScD, makes about all of this—and this is exactly the same point that Rik Renard made in episode 427—efficient to what endgame? Now, it turns out, surveys show, only a small, small percentage of healthcare delivery solution providers are measuring outcomes of pretty much any kind. So, how do we even know if cutting so-called waste is actually waste at all? I mean, in the absence of any actual measures—here's a hypothetical for you—someone could look around: “Hey, I see these nurses. They're all just sitting around chatting with patients and, I don't know, talking about throw rugs? What is this? An episode of HGTV? Who cares if a patient with diabetic neuropathy has throw rugs in their hallway? Let's tell these nurses chop-chop, get them on the computer using AI to be efficient, right? Let's get rid of that clinical waste.” I just made a point in the most sarcastic way possible, but the bottom line is this: It's actually really efficient to not engage patients in these ways, right? Patients, they talk slow, they ask questions that seem irrelevant, and they're time-consuming. It's very efficient to not build relationships or foster trust or, I don't know, assess fall risks … but whatever is going on is also going to fail in that model—from a patient outcome standpoint at least. Here's a quote from Sergei Polevikov, with some light edits. He wrote on LinkedIn: Primary care is not scalable in the same way as Scrub Daddy or Bombas Socks. That's something not taught in MBA and CFA programs. Someone should have told Walgreens, CVS, Amazon, and Walmart. They also probably should tell a whole bunch of point solutions and payers. Also, some health system execs or pharmacy leaders might also want to get that memo. What I really liked about the conversation with Kate Wolin in this healthcare podcast is that she retains optimism in the face of all of this. She offers advice for how to navigate the balance between mission and margin in a way that's better for patients and also sustainable financially. She talks about three points: 1. Founders and investors being in alignment and the essential nature of that 2. The importance of having clinical leadership and a team dynamic that enables innovation but in a clinically sound way 3. How you gotta measure what matters and do it in a way that inspires a mission-driven culture If we're talking about relevant shows to listen to next after you listen to this one, please do not forget episode 331. This is where Al Lewis teaches us how to evaluate wellness vendors and health solutions, but it also teaches us how to be a good wellness vendor or health solution. Also, do come back and listen to the encore with Jerry Durham next week about front desks and the total care experience. Lots of really bad avoidable things happen if the front desk isn't considered—and it isn't often considered. For sure, also listen to the show with Kenny Cole, MD (EP431); that's a must-listen. Then again, the show with Rik Renard (EP427) came up several times in this episode. The show with Jodilyn Owen (EP421) also gets brought up; that's a great cautionary tale there to keep in mind for mission-driven entrepreneurs and investors. And then, I also recommend J. Michael Connors, MD. He writes a lot of stuff in a newsletter along these lines. Last, last, last … Please go to our Web site and subscribe to the weekly email. I am planning on doing a few invite-only sessions for email subscribers. Plus, the weekly email is a really very convenient way to get the episode transcripts and stuff. And if you don't get it, you're making your life less efficient. So, go fix that. Kate Wolin, my guest today, trained as a behavioral epidemiologist and has done research in chronic disease prevention and management. She launched and led a digital health start-up and sold it to Anthem. She's been in the digital health start-up space largely at the intersection of science and product strategy ever since. Also mentioned in this episode are Rik Renard; Sergei Polevikov; Walgreens; Amazon; Walmart; Al Lewis; Jerry Durham; Kenny Cole, MD; Jodilyn Owen; J. Michael Connors, MD; Carly Eckert, MD; and Mike Pykosz. You can learn more by following Dr. Wolin on LinkedIn.   Kate Wolin, ScD, is a behavioral epidemiologist who left academic medicine to launch and lead a digital health start-up, which she bootstrapped to profitability before selling to Anthem. She has since been a C-suite leader, investor, and advisor to digital health start-ups and enterprise organizations on bridging clinical and behavioral science with product strategy and execution. She has been named as a Forbes Healthcare Innovator That You Should Know and a Notable Woman in STEM by Crains. Dr. Wolin is a Fellow of the Society of Behavioral Medicine and the American College of Sports Medicine and teaches entrepreneurship at Kellogg.   06:24 Irrespective of money, what works in clinical care and population healthcare? 09:51 EP361 with Carly Eckert, MD, PhD(c), MPH. 10:26 Why is creating a gathering place and sense of community important in clinical care? 12:46 “Sometimes, we make this about the clinical provider. It always makes me think about the rest of the people in an ecosystem that create trust.” 13:49 EP297 with Jerry Durham. 14:11 Where can things go wrong when we start to think about the margin in respect to the clinical care that works? 16:47 EP427 with Rik Renard. 19:35 “We're actually very unspecific in what we're trying to achieve a lot of times in these digital health programs.” 24:00 “Are you aligned as a founder, as a business with your investors on the pace of growth and what is feasible … ?” 25:30 Why is Dr. Wolin optimistic about achieving growth and still providing value? 28:17 Why is it important to ask why something is being done? 30:39 EP421 with Jodilyn Owen. 34:35 How are people motivated, and how can you use that to reduce turnover? 35:21 Why measuring what matters and communicating that is important.   You can learn more by following Dr. Wolin on LinkedIn.   Kate Wolin, ScD, discusses #clinicalwaste on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes  

For a full transcript of this episode, click here. There's this meme that's going around on the interwebs with the caption, “Sometimes the shortest distance in between two places isn't a straight line.” What? Yeah, because actually there's three dimensions in the real world. So, when we all consider the real world, understanding the contours of reality and aligning with them is the only way to devise a winning strategy—not only if you're timing rubber balls getting dropped off straight or curved slopes. I'm saying this because I've seen (and you've seen) a whole lot of great ideas fail because someone draws a very elegant straight line on a whiteboard, calls it the fastest and most efficient way to get from here to a desired outcome … and then the plan ultimately fails. What contours am I talking about taking into account right now? Oh, pretty much the entirety of US healthcare. If you combine the complexities and perverse incentives of the industry itself plus the art and science of medicine plus epidemiology and social determinants and I'm probably forgetting other dimensions, you have contours that are mountain ranges. Not considering the reality of those elevations and just thinking there's some kind of straight line here to be found is really a kind of delusion. Now, investors and C-suites may like these delusions, but let's just get real: It's not gonna actually work out as written. One case study that I am talking about is digital health solutions or pharma companies even or pretty much anyone who thinks that the fastest way to increase sales is to talk about the product, let's just say as one example. That's the straight line to growth: Talk about the product. Another one is stripping away things that feel like they're a waste of time in the name of efficiency without actually checking if you're cutting into essential stuff. I talk about this at length with Kate Wolin, ScD, in an episode coming up. Jodilyn Owen has a thing or two to say on this point in episode 421 also. But let me be clear: I'm not talking about anyone listening to the show today making this mistake, at least wholesale. We all make it incrementally; it's hard to avoid. But you get this. That's why you're here. You get that the fastest path anywhere is truly understanding the problems faced by customers. And then it's showing how the product or whatever you're doing helps solve those problems. No one cares how efficient or safe your thing is if it's accomplishing something that no one cares about, no one gets paid for, and/or can figure out how to deploy or use. This is what the entire episode last week, episode 430 with Barbara Wachsman, was about. Why is all of this relevant? It's actually what makes Relentless Health Value relevant, frankly. Many listeners—and shout-outs to Nate Walker and MaryCarol Evans—say that this is why they listen to Relentless Health Value and what Relentless Health Value helps them with: finding those contours, understanding reality so that it can be aligned with. And on the show today, Kenny Cole, MD, I gotta say, could be really impactful in this regard as well as in others. Nate Walker wrote, “[Relentless Health Value] inspires me every day to stay true to my desire to make a difference in healthcare for patients by adding transparency and helping to connect the dots within this fragmented system.” MaryCarol Evans has alluded to the same thing multiple times as well and often highlights that Relentless Health Value helps her think through and identify the small things that are possible—she says there's plenty of them—that have a huge impact on the lives of plan members. Dr. Kenny Cole is from Ochsner Health System, and I love this conversation today because it has lessons for anybody working in a clinic or managing a clinic who wants to learn from a master. But it also is really interesting for anyone who's trying to work with, alongside of, or sell to a clinical practice or health system that is pulling away from the status quo, that is standardizing care and working as a team, one that is earning the trust of its patients, and also one that is figuring out how to reinvent the business model of healthcare such that clinical pathways and care flows are aligned with financial viability. That's really, obviously, the holy grail here. We talk today about how to achieve clinical and financial success, even if the financial models are all over the map. We talk about how to create a practice model or a clinical model that might appeal to clinicians and keep them from being burnt out while, at the same time, ensure that patients are getting the kind of outcomes everyone can be proud of and the place doesn't go bankrupt either. This episode reminded me a lot of the conversation with Scott Conard, MD (EP391)—there's lots of complementary points. The shows with David Carmouche, MD (EP316, AEE15, EP343) from when he was at Ochsner are also pretty relevant here. Some of the points that Dr. Kenny Cole makes today also align very much with what Rik Renard (EP427) was talking about a few weeks ago. But regardless of where you sit or what you're trying to do, this show is a great one to really get a bead on the lay of the land to find the actual shortest path between here and there, which is not gonna be (most likely) an obviously straight line. Dr. Kenny Cole makes, I'm gonna say, four main points by my counting; and they are as follows: 1. Clinical teams have to deliver care wherein outcomes are measurable, and it has to be done in such a way that those clinical teams are accountable for the outcomes that are generated. 2. Clinical teams need to really see with their own two eyes and believe that a clinical goal that they've been given is possible. 3. Care flows are critical here, which means getting everyone on the same page about what best-practice care looks like and operationalizing how that clinical excellence will be achieved. 4. Building trust with patients and connecting with patients cannot be underestimated, and care flows need to not only standardize care so that it can be delivered quicker and easier but also facilitate patient relationships. Dr. Kenny Cole is a primary care internist. He sees patients one day a week. The other days, he serves as a system vice president for Ochsner Health, which is a large integrated delivery system. In this role, he designs and develops new care models. If I'm making recommendations for what to listen to next, I'd go with episode 412 with Robert Pearl, MD—he talks about a model to lead healthcare transformation and clinical excellence. Then episode 391 with Dr. Scott Conard gets into what happens in the real world when the financial model is misaligned with excellent care. Lastly, episode 343 with Dr. David Carmouche. Oh, two last things and new topics: First, thanks to Santos-L-Halper, Nina Lathia, and KC64789 for some really nice reviews this month. I read them. They make me happy. Thanks so much for leaving them. And lastly, heads up that Rule of Three (ro3) has an annual March Healthcare Classic that is currently ongoing. It's pretty cool what they do. They have a very august panel that debates which trends will reign supreme in their impact on healthcare in 2024. The committee includes: ·      Dr. David Carmouche, SVP Healthcare Delivery, Walmart Health ·      Eric Gallagher, CEO, Ochsner Health Network ·      Leah Binder, CEO, The Leapfrog Group ·      Anisha Sood, Chief Financial & Strategy Officer, First Choice Health Follow along with the experts through the ro3 March Healthcare Classic at https://ro3.com/healthcare-classic/. Also mentioned in this episode are Jodilyn Owen; Barbara Wachsman; Nate Walker; MaryCarol Evans; Scott Conard, MD; David Carmouche, MD; Rik Renard; Robert Pearl, MD; Nina Lathia, RPh, MSc, PhD; Josh M. Berlin; Rule of Three, LLC; Eric Gallagher; Leah Binder; Anisha Sood; John Rodis, MD, MBA, FACHE, CPHQ; Bob Matthews; Marty Makary, MD, MPH; Sanat Dixit, MD, MBA, FACS; and Rob Andrews. You can learn more at Ochsner Health. You can also follow Dr. Cole on LinkedIn.   Kenny Cole, MD, began his role as System VP, Clinical Improvement, for Ochsner Health in New Orleans in September 2019. He is a practicing primary care internist with advanced degrees from LSU Health Sciences Center and Dartmouth, as well as executive training from Harvard Business School. Prior to joining Ochsner Health, Dr. Cole was the chief clinical transformation officer for Baton Rouge General Medical Center, where he designed, developed, and implemented a completely reimagined multidisciplinary team-based model of primary care that focused on aligning clinical with financial outcomes. His current work at Ochsner Health built on that prior foundation to design and help develop Ochsner 65 Plus, a group of redesigned primary care clinics focused on the needs of older adults.   07:38 Is there an optimal care pathway where there might be a lot of treatment variability? 11:01 Why doesn't Dr. Cole like the terms “noncompliant” and “nonadherent”? 11:45 EP412 with Robert Pearl, MD. 13:50 Why is it important to start with the end in mind? 17:20 How do you scale clinical excellence? 20:21 EP315 with Bob Matthews. 21:15 EP242 with Marty Makary, MD. 23:49 Why is it important simply to demonstrate what's possible for better health outcomes? 24:58 EP427 with Rik Renard. 26:10 How do we reinvent the business model of healthcare? 27:50 EP415 with Rob Andrews. 30:06 EP391 with Scott Conard, MD. 38:37 Dr. Cole is published in various healthcare journals; check out his most recent article.   You can learn more at Ochsner Health. You can also follow Dr. Cole on LinkedIn.   Kenny Cole, MD, discusses #accountability for #healthoutcomes on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse  

For a full transcript of this episode, click here. We have been spending a bunch of time here on Relentless Health Value talking about PBMs (pharmacy benefit managers) lately and pharmacy benefits, but we are moving into a new topic area. It sort of kicked off three weeks ago with the pod with Rik Renard (EP427) on the importance of care flows if you are a digital health vendor trying to get consistent outcomes. But then I actually went back to the PBM/pharmacy benefits topic to talk with Luke Slindee, PharmD (EP429) and Julie Selesnick (EP428) because, you know, the J&J lawsuit. But now we're back on the “let's talk about digital health and point solutions” bus. I wanted to talk today about the trend to sell to employers and advice for digital health solutions who want to sell to employers, but there's a little bit of advice here for employers themselves. At a minimum, this conversation affords a little bit of transparency to employers about what's going on on the other side of the table. So, as I just said, in this healthcare podcast we talk about selling to employers. Why sell to employers is probably a first question. Well, one reason Barb offers is because that's where the money is. It's like that Willie Sutton quote. Someone asked him why he robbed banks, and he replied, “Because that's where the money is.” I mean, hospitals know this. Have you seen their commercial rates and their multiples over Medicare? Payers know this, too. Payers who use their ability to raise commercial rates as leverage to get lower MA (Medicare Advantage) rates for themselves … they know this. So, yeah. Why wouldn't a point solution entrepreneur take a page out of that business model? It's saying the quiet part out loud, but … yeah, I guess it's good to know when you're the numero uno healthcare industry sugar daddy (or sugar mommy, as the case may be). Every employer listening right now has already opened up their phone and started an email to me. Barb gets into four pieces of advice for entrepreneurs looking to sell to employers: 1. There has to be a market that has a need for what you are selling, and there won't be a market with a need unless the problem you're solving for is big enough—and right now, I am recapping things that Barb says on the show—because when she talks about whether the problem is big enough, she means as per the employer and maybe because the fallout from that big problem accrues to the employer in a way that the employer fully appreciates. As I say in the pod that follows, the ground is littered with entrepreneurs, often really smart people who oftentimes I truly admire. These are individuals who found a problem for patients (or sometimes even clinicians) and solved for it and then discovered that no one will pay them for whatever they've done, because we can't forget that, in the healthcare industry, one person's waste is somebody else's profit. There is show after show here at Relentless Health Value that showcases the sacred honeypots where these perverse incentives lie, so if you are an entrepreneur, please follow the dollar and see where it leads before getting too far. That would be my advice. I'd recommend the show with Rob Andrews (EP415) and the one with Jodilyn Owen (EP421) as a great place to start. One comment about the whole “it's gotta be a need that employers appreciate” point that Barb makes which caught my ear, she rhetorically asks, “Should HR purchasers be buying solutions that improve health and well-being?” And the short answer is no. Barb says none of that should be the primary driver. The primary driver, Barb mentions, should be about optimization of human capital to drive business outcomes. She says every decision a business makes should be about maximizing business outcomes. Now, I could take this a bunch of different ways; and viscerally it has, again, kind of a “quiet part out loud” vibe. But in certain ways, it also means buying decisions should be bigger than just cutting costs. First of all, no one is arguing here that cutting wasteful spending isn't always a good thing; but neither are cost-containment strategies that undermine employee health to the extent that they can't complete their work role or their job. Listen to the show with Nina Lathia, RPh, MSc, PhD (EP426) for more on this cost containment versus value-based purchasing, specifically in the pharmacy benefit space, but same rules apply pretty much everywhere. 2. Be truly differentiated in terms of what you're trying to sell. Barb gives a bunch of examples of “secret sauces” she thinks are kind of compelling right now. 3. Navigate the internal politics of the employer. And this is kind of Selling 101, but find a champion and help them navigate their own organization. We talk at length about how long the sell process can take, especially in some of these jumbo employers. 4. Manage your investors as closely as you manage your possible clients. And this is an interesting point that also comes up in the conversation with Kate Wolin, ScD, that's coming up in a few weeks. Also in this conversation, we have a sidebar about PMPM (per member per month) and performance guarantees and just some nuances about how to get paid. Oh, and one last point here: If you are an entrepreneur who is thinking about selling to brokers, employee benefit consultants, or practice leads, do listen to the show with AJ Loiacono (EP379), which I encored a couple of weeks ago. My guest today, Barbara Wachsman, has had experience in every single element of the healthcare ecosystem. She has worked in public health. She's worked for an HMO. She's worked for a hospital system. She's run benefit consulting practices and also spent the last dozen or so years at Disney running strategy and benefits. Today she is a limited partner in several private equity funds at Frazier Healthcare Partners. Oh, and hey, you might want to subscribe to our weekly email, which includes this introduction transcribed as well as links to the full episode transcribed. We also sometimes send out invitations to Zoom meetups and other ways to get involved or support us in our quest to get Americans better healthcare. So, go to relentlesshealthvalue.com and get yourself on that list Also mentioned in this episode are Rik Renard; Luke Slindee, PharmD; Julie Selesnick; Rob Andrews; Jodilyn Owen; Nina Lathia, RPh, MSc, PhD; Kate Wolin; AJ Loiacono; Elizabeth Mitchell; David Claud, MD, PhD; Al Lewis; Kenny Cole, MD; and Cora Opsahl.   You can learn more at Frazier Healthcare Partners. You can also follow Barbara on LinkedIn.   Barbara E. Wachsman, MPH, is the former director of strategy and engagement for enterprise benefits for the Walt Disney Company. In this position, she led the strategic initiatives and designed the programs that addressed Disney's long-term healthcare and goals and objectives, headed operations of large on-site clinics and full-risk physician partnerships, and was the creator of the Strategy Lab, the home for innovation in healthcare delivery. She is a speaker on the national stage regarding direct contracting and the value of primary care. Barbara currently serves as a senior advisor to an $8 billion growth-buyout private equity firm specializing in healthcare and as head of employer strategy for a virtual primary care company with a unique medical practice model. She sits on the Boards of the Duke-Margolis Center for Health Policy Institute and the QueensCare Foundation, serving the low-income and underserved population of Los Angeles. She remains a senior advisor and founding member of the Employer Healthcare Innovation Roundtable (EHIR) and is a faculty member of the EHIR Academy. Barbara serves on the Executive Committee of the American Board of Medical Specialties and on the Advisory Boards of several healthcare start-ups as well as the corporate board of a large metabolic health company. She is also an advisor to the Purchaser Business Group on Health and to the Silicon Valley Employers Forum. Barbara received her Master of Public Health and Master of City Planning/Architecture degrees from the University of California, Berkeley, and is a Phi Beta Kappa graduate of Scripps College, where she received her bachelor of arts degree.   06:55 Why have people cottoned on to selling to employers, and is it a good direction to focus? 07:28 What are the three ways healthcare gets paid for in America? 07:46 Where is the profit in the healthcare system? 08:32 What does an entrepreneur really need to understand in order to sell to employers? 13:05 “It really is about producing a productive employee.” 17:49 Why it's not enough to understand the market but you must also differentiate. 21:01 What's the biggest misunderstanding entrepreneurs have about per member per month? 24:10 What companies are standing out right now as differentiators? 28:02 Why is it important to also show that you are improving quality? 28:51 EP331 with Al Lewis. 28:55 EP427 with Rik Renard. 29:33 EP372 with Cora Opsahl. 30:07 Why is it important to find a strong champion who will advocate for you as a partner? 35:05 Why is it important to manage your investors and set appropriate expectations around the timeline of a sale? 36:21 What's the lesson to be learned behind Livongo?   You can learn more at Frazier Healthcare Partners. You can also follow Barbara on LinkedIn.   Barbara Wachsman discusses #digitalhealthvendors selling to #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley

For a full transcript of this episode, click here. In this healthcare podcast we're talking about pharmacy acronyms or terms like AWP and WAC, and, not really an acronym, but we'll also talk pharmacy list prices, rebates, discounts. We also have NADAC, but that's slightly off to the side for reasons we'll get to in a sec. Most of these acronyms refer to a number with a dollar sign in front of it, and it's hell on wheels to figure out if and/or to what extent that number reflects what is going on in the real world, especially if you are a patient or a plan sponsor and all you see is the list price that Pharma puts out on one side of the storyboard, and then what the patient pays or (if you're lucky) what the plan pays for the drug on the way other side of the whole chain of events. What's a black box a lot of times for patients and plan sponsors is what goes on in the middle, wherein many middle people get their mitts on the transaction. Real quick here, let's run through the Mister Rogers' neighborhood of all of these middle people right now; and we're gonna do this really briefly. Most of you are already going to know most of this, but I just want to remind you so that when my guest today, Luke Slindee, and I kick into the conversation about the acronyms and the terms and we try to follow the dollar … yeah, you can put a name to a face. Alright, so first we have pharma manufacturers. The pharma manufacturer—and this is largely gonna be true whether it's a branded drug or a generic pharma manufacturer—but the manufacturer sets a list price. This list price is gonna be called an AWP or a WAC price, and we're gonna get into the differences and what those terms actually mean in the show that follows. But Pharma decides their price point. They go to wholesalers with that price. Wholesalers say they want a discount to purchase the product. Some kind of rebate or discount is negotiated. Now the wholesalers have the drug, and they get calls from pharmacies. Pharmacies have patients who have scripts for that, so the pharmacies need to buy the drug. What price does the pharmacy now pay the wholesaler for the drug? Short answer: It's nuts. It's nuts how the wholesalers decide what to charge the pharmacies for the drug. We talk about that in the interview that follows, but suffice to say that now we have the list price turning into whatever price the pharmacies wound up paying to get the drug from the wholesalers for. Any way you cut it, the wholesalers are making some money. Okay … now we get to the part where we're figuring out how much the patient or the plan sponsor will pay to pick up that drug that started at the pharma manufacturers and went to the wholesalers and now is at the pharmacy. How much are the patients gonna pay? How much are the plan sponsors gonna pay? If you spend any time in the real world (not the drug supply chain world), what you'd expect to happen next is that the patient would go into the pharmacy and the pharmacist would charge a markup and/or a dispensing fee on the price that they bought the drug from the wholesaler for. That'd be normal. And this can be the case when patients pay cash. Listen to the show with Mark Cuban (EP418, along with Ferrin Williams, PharmD, MBA), who started a pharmacy called Cost Plus Drugs. Get it? Their prices are cost plus. You have had other pharmacies for years doing similar things, like Blueberry in Pittsburgh. They get the drug. They buy it from a wholesaler or etc. But they buy the drug for some price, and then they sell it to their customers (ie, patients) at their cost plus. But most of the time in pharmacy supply chain world, things don't work that way because many patients have insurance. When a patient walks into the pharmacy, someone has to figure out how much the patient owes and how much their insurance will cover, right? So, enter PBMs (pharmacy benefit managers). They originally started out doing this math (ie, adjudicating claims), figuring out what the out-of-pocket will be for the patient and then what the insurance will cover. Then drugs started to get really expensive and a few other developments, and then, all of a sudden, we have PBMs negotiating with Pharma for how much of a rebate the PBM is going to demand for the PBM to put the manufacturer drug on formulary. The PBM also is determining how much they will pay the pharmacy for said drug on behalf of plan sponsors, in addition to doing the math for how much the patient will pay. So, let me say that again because it kind of begs a “what now?” with eyebrows sky-high as the appropriate response to what I just said, especially if you think through the ramifications here, ramifications which I discuss at length with Vinay Patel (EP241); Benjamin Jolley, PharmD (EP422); Scott Haas (EP365); Paul Holmes (EP397); and others. So, again, the PBM is not just adjudicating claims. They are also negotiating rebates from Pharma so plan sponsors do not have to pay the full amount that the wholesalers paid Pharma and that the pharmacies paid the wholesalers, which maybe is a lot of money. The PBMs are like, “Hey, Pharma. You need to give me a piece of your action because we, the PBM, have big market power. I serve 100 million patients or something. So, if you want access to my 100 million lives, you gotta shell it out. You gotta shell me out some rebates.” So, fine, Pharma gives the PBM some amount of money in the form of a rebate. And it has to work that way, if you think about it, because the drug was originally sold to the wholesaler. You see what I'm saying? So, the pharma company has to give the PBMs a separate rebate amount. This is in addition to how much the PBM told the plan sponsor the plan sponsor owes for the drug, which is also paid to the PBM. But now, PBM is also still in charge of adjudicating the claim. So, they're telling the pharmacy how much to charge the patient. Somehow or another also, the PBM also got itself in charge of deciding how much money the pharmacy itself would be reimbursed by that PBM. In the rest of the world, the pharmacy might tell the PBM, “Hey, this is the price.” But not in pharmacy supply chain world. In pharmacy supply chain world, the PBM tells the pharmacy how much it's gonna pay. The end. And this, my friends, is how so often pharmacies get themselves in the pickle of having to pay the wholesaler one price to get the drug while they get reimbursed a totally different price to dispense the drug. And because independents have very little negotiating leverage on actually either side of that equation, they so very often buy high and sell low. Please listen to the shows with Benjamin Jolley (EP422) and Vinay Patel (EP241), where we get into this in a lot of detail. But I just want to emphasize this point: All of that whole drug supply chain I just went through, where the manufacturer sells to the wholesaler who sells to the pharmacy and the PBM pays the pharmacy and the patient is paying something and the plan sponsor is paying something—many of the middleman transactions in there happen under the cover of darkness a lot of times. If I'm a plan sponsor, do I have any idea how much the PBM paid the pharmacy for any particular drug? Unless you're good at looking at the NADAC numbers (more on this coming up), no. I do not have any idea what a fair price for that drug actually is and how much people are making on the back of that drug as it goes through the supply chain. And this, my friends, is how come spread pricing can exist. Because spread pricing is when the PBM charges the plan sponsor more than they are paying the pharmacy, pocketing the difference, and then calling what they pocket a trade secret—even if it's the plan sponsor whose butt is on the line to make sure that what the PBM is pocketing is fair and reasonable compensation. I mean, if only J&J had listened to this show (EP428). Here's a link to the lawsuit, which is about J&J paying ridiculous amounts in spread pricing. If what I just said is really confusing, I'm gonna validate that and say, “Yeah, it is really confusing.” And to a certain extent, that might be the main point. Where there's mystery, there's margin and all of that. Here's what Dawn Cornelis said on LinkedIn in response to an article about the lawsuit: “Data accessibility lies at the heart of mitigating a fiduciary lawsuit. It all begins with gaining access to your data. But let's be clear—it's not an easy feat. The major hurdle? Procuring accurate data from your TPA [third-party administrator]. And that's just the first step. The subsequent challenge involves analyzing this data, a task best handled by a skilled healthcare data analyst—yet another formidable undertaking.” The one acronym in this whole stew that is not questionable at all is the NADAC. So, let's talk about the NADAC for a moment, the National Average Drug Acquisition Cost Price Benchmark. I was really thrilled to get Luke Slindee to be my guest today—or one reason I was so thrilled—is because Luke works for the accounting firm who, on behalf of CMS (Centers for Medicare & Medicaid Services) and the federal government, administers this NADAC, the National Average Drug Acquisition Cost. (Here's a good NADAC explainer if you're interested.) In brief, NADAC was jointly developed by the Centers for Medicare & Medicaid Services, and it calculates the average price that pharmacies pay for prescription drugs. NADAC is based on a retail price survey. My guest today, as aforementioned, is Luke Slindee. He is a second-generation pharmacist. His family owned a pharmacy in Minnesota when he was growing up. Now he is a senior pharmacy consultant for Myers and Stauffer, which is the accounting firm that calculates the NADAC Price Benchmark on behalf of CMS and the federal government. Also mentioned in this episode are Mark Cuban; Ferrin Williams, PharmD, MBA; Blueberry Pharmacy; Vinay Patel; Benjamin Jolley, PharmD; Scott Haas; Paul Holmes; Dawn Cornelis; Capital Rx; Myers and Stauffer LC; Adam Fein; Joey Dizenhouse; Steven Quimby, MD; and Antonio Ciaccia.   For additional information, go to data.medicaid.gov. You can also follow Luke on LinkedIn.   Luke Slindee, PharmD, is a second-generation pharmacist with a background in independent pharmacy, chain pharmacy, data analytics, and prescription drug pricing. He currently supports public drug pricing transparency benchmarks and is an advocate for pharmacy reimbursement reform and antitrust enforcement in healthcare.   09:52 Why is it important for plan sponsors to understand the going rate for every point in the supply chain? 10:21 How do manufacturers come up with a list price? 10:40 What does AWP stand for? 10:59 What does WAC stand for? 11:06 How are AWP and WAC numbers chosen by the manufacturer? 13:22 What is the difference between AWP and WAC? 14:54 How much are wholesalers paying to manufacturers? 16:43 How much is the pharmacy paying for branded drugs from a wholesaler? 17:34 Why might pharmacies be buying drugs for less than what wholesalers are paying? 18:17 Substack article by Benjamin Jolley, PharmD, on this topic. 19:22 EP423 with Joey Dizenhouse. 20:33 Why do things get weird when a PBM gets involved? 21:58 How does all of this work for generic manufacturers? 25:20 EP344 with Steven Quimby, MD. 26:15 How did Civica Rx come about? 32:21 What's the difference between the NADAC and the AWP value? 36:04 Luke discusses the downstream effects to pharmacies.   For additional information, go to data.medicaid.gov. You can also follow Luke on LinkedIn.   Luke Slindee discusses #followingthedollar through #WAC, #AWP & #NADAC on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392)

For a full transcript of this episode, click here. This show is different, so if you've already listened to or read all about the gory details of the J&J and/or the DOL v BCBS lawsuits, this is not gonna be a repeat of that information. Julie Selesnick, my guest today, does cover the very, very top line about these two cases. But after that, we move on fast—because what I wanted to get to today was not the potential landslide of legal action that may or may not be confronting plan sponsors or payers or even brokers today. I did not want to really even talk about the CAA (Consolidated Appropriations Act) and its inarguable adjacency here. I just feel like there's been a lot of talk about these topics already. What I wanted to get to, and fast, is … now what? If I'm a plan sponsor or actually, again, an EBC (employee benefit consultant) or broker, now what? What should I be doing and thinking about right now? To that end, I could not have been more thrilled to get a chance to talk to Julie Selesnick, who is an attorney deeply entrenched in helping plan sponsors and others understand and comply with fiduciary responsibilities. I want to get to this interview quickly (the conversation with Julie), so this intro is gonna be on the short side; but let me just summarize a few of the points that Julie makes during the interview that follows. First, we talk about the first step for pretty much everybody: Get your data, plan sponsors. But once you have that data, you also kinda have to use it. You can use it to ensure that you're paying claims right, which is what most do. As a result of these two lawsuits, it's also increasingly clear that you also have to use that data to ensure that the prices you're paying for things (like generic specialty meds, for example) are fair and reasonable. To get the data now, you may have to renegotiate administrative services agreements; and you might need to take a closer look at the disclosure agreements you're getting as a result of the CAA. And, by the way, it's not just brokers or EBCs who have to complete these disclosures. It's all covered entities that you, plan sponsors, paid more than $1000 to. Then we get into … okay, once you have the data and you've analyzed it, what are some in general things that could very well need to happen? And if the reason that they don't happen is because they weren't even considered, then plan sponsors have some risk exposure; and the brokers/EBCs who serve them might have some conflicts of interest. And it would be very interesting what would or could happen if a plan sponsor was able to back into those conflicts of interest, because if data clearly shows that something should be happening and it is not—and it is not even on the docket to be considered—if I'm a plan sponsor, I'm for sure gonna be wondering why. And maybe I'm gonna look into that and fast. Listen to the show with AJ Loiacono (EP379) from two weeks ago for more on some of the more egregious broker/EBC conflicts of interest, which could explain, potentially, the J&J lawsuit as well as definitely explains the earlier one in Osceola. And also, by the way, if you're sitting there wondering to yourself how exactly J&J managed to pay upwards of $10,000 for a drug that can be purchased for cash for something like $50, listen to the show next week with Luke Slindee, PharmD. We run through the exact pharmacy supply chain machinations that make all of this (and more) possible. But I got off track. What I was talking about is the things that could easily wind up being called for when the data is analyzed: 1. Carving out specialty generics, especially drugs or infusions, from the larger pharmacy benefit manager 2. Your payment integrity vendor should not be the same vendor who is processing claims. Talk about a conflict of interest. I do not need to be an attorney—and I need to know absolutely nothing about anybody's data—to tell anybody who's listening that if you have the same vendor or two vendors with the same parent company who are both processing your claims and then auditing their own work … yeah, fix that. 3. Shut down any cross-plan offsetting. And we get to this in the show if you don't know what cross-plan offsetting means. Lastly, we get into a bunch of stuff that plan sponsors might want to consider as they consider how to administer their plan, like, for example, setting up a health and welfare committee that has an independent fiduciary expert on said committee. I'm gonna say that's a good idea! As I have mentioned, my guest today is Julie Selesnick. Julie is senior counsel over at Berger Montague's Employee Benefits and ERISA group. Also mentioned in this episode are AJ Loiacono; Luke Slindee, PharmD; Justin Leader; Chris Deacon; Bridget Mulvenna; Mark Cuban; Olivia Webb; and Dawn Cornelis. You can learn more at Berger Montague. You can also follow Julie on LinkedIn.     Julie Selesnick has been practicing law since 2001 and has over 20 years of experience in complex dispute resolution forums representing plaintiffs and defendants. Julie has a wide variety of litigation, arbitration, and mediation practice, including first-chair jury and bench trial experience, representing some of the largest companies in the United States as well as small companies, labor unions, individuals, and classes of plaintiffs. Julie's current practice is a mix of class litigation on behalf of individuals, union funds, and employers, and a legal consulting practice advising self-funded health plans and service providers to self-funded health plans on minimizing litigation and regulatory risk, issues arising under ERISA, fiduciary obligations and best practices, and CAA compliance, including negotiating service provider contracts and business associate agreements, drafting plan documents and advising on plan design; helping health plans gain access to participant claims data, helping service providers draft and plan fiduciaries obtain § 408(b)(2)(B) compensation disclosures, assisting plans with ensuring their prescription drug data collection and reporting is properly conducted and copies are provided to plan fiduciaries, and ensuring proper review, MHPAEA Comparative Analysis reports on nonquantitative treatment limitations.   05:48 What's happening with the J&J lawsuit? 07:38 What's going on with the DOL v BCBS case? 08:49 What do these cases mean for plan sponsors? 09:21 Why is engaging with claims data critical? 12:30 EP408 with Chris Deacon. 14:20 EP379 with AJ Loiacono. 16:58 What's one solution to avoiding a conflict of interest? 18:02 Why there's still not a total understanding about what to do with claims data once acquired. 20:58 NADAC (National Average Drug Acquisition Cost) to check pharmacy prices. 21:31 What advice do plan sponsors need to know that never gets recommended to them when dealing with conflicting interests? 27:02 EP337 with Olivia Webb. 28:41 EP285 with Dawn Cornelis. 30:24 “As a fiduciary, your money should only go to pay your plan's benefits, not to other plan benefits.” 30:59 What's Julie's advice to advisors? 33:17 “Giving nonconflicted advice … is something you really can only do if you have no conflicts.” 35:57 What's Julie's advice for administering whole plans?   You can learn more at Berger Montague. You can also follow Julie on LinkedIn.   Julie Selesnick discusses advice based on the J&J and DOL v BCBS lawsuits on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372)  

For a full transcript of this episode, click here. Hey, Relentless Health Value Tribe, thanks so much for being here this week. I gotta say, I really appreciate all of you who write and tell me that you kick off your Thursdays by listening to this show every week. You just pop open your app and you listen to the show. Because yeah, we're a pretty sure thing over here. If the guest was boring or if the guest was talking about stuff that I already know and probably you already know, the guest would not be on the show. So, listening to Relentless Health Value every week is a hugely easy way to just keep up with what's going on and, at the same time, get a pretty holistic deep dive into how all of the various parts of the industry fit together and how they ultimately impact patients and anybody who is at risk to pay for their care. One thing that you'll notice about the guests who we invite to come on Relentless Health Value, they are usually not the ones who are merely going to recite a very well-curated point of view that is fully in line with some marketing pitch. It would be easy enough, honestly—it would be so much easier—to just invite all of the bigwigs who we get pitched. I get 50 pitches a day from PR teams who want to get their executives to come on the show because they want to get their message out to you, Relentless Health Value Tribe. You, for sure, have a reputation of being industry movers and shakers. Although it would be super easy for me to phone it in and let them have their way with you, I've never been one to take the easy way. I want to find those individuals to be guests who are willing to share actionable insights to actually tell the truth. I'm really not into someone hijacking this platform for their own self-interest when that self-interest is not aligned with anything that I would consider a win-win for patients. You'll probably find more actionable insights here than listening to talk tracks, even if you're just listening to figure out what to include in your pitch to some of these industry insiders. I'm gonna tell you that repeating their marketing spin or their party line isn't probably gonna sell much. What they will say in public and what they really want to do are so very often sadly at counterpoint. So, come here for the real story. Alright, so let's get to the conversation that we're gonna have today, which is about and for digital health vendors' or virtual care providers' point solutions (they go by many names) and also for anybody who is a customer of said solutions. If we're taking it from the top here, let me just make a Captain Obvious point. These digital health vendors, they kind of have to perform better than the traditional community health providers. Otherwise, they have no reason to exist, really, right? Purchasers would just go with the local gang of care providers. So then, what does “perform better” actually mean? Let's discuss. I'd say perform better means to offer better measurable patient outcomes probably, both clinically and patient reported. I'd also say it means to offer more affordability. Also, better engagement, accessibility, and maybe all of this at a better cost profile for purchasers such as employers or health plans that are taking on actual risk. So, if all things are equal, again, why the heck would an employer or other purchaser even bother? It couldn't even be considered, honestly, a member benefit from a regular benefit perspective if the local standard of care is superior or just as good. Now, if any clinical entity is looking to actually achieve better performance in any or all of the ways that I just mentioned with any level of consistency and in a way that is profitable for them and their investors, you got to do a few things. And one of them is to design and implement care flows, care processes, pathways—again, you can pick a name and define it how you like. But bottom line, there needs to be a standardized way to deliver high-quality care that is measurable. Here's Ali Khan, MD, MPP, who is chief medical officer over at Oak Street Health, talking about this. He says: “At Oak Street Health we think about standardization as a 70/30 split. It is important that the largest aspects of what your care team does are standardized. (...) The bulk of the work that we do is to make sure not only that we set standards, but that we also disseminate standards, coach standards, review standards, and then update and iterate those based on the things we learned. Our standards are constantly evolving and improving.” Okay, so said another way, gotta have and use care flows. This doesn't seem like rocket science, but yeah, that is a blue's clue for what's coming up here. So, how are most digital health vendors doing when it comes to care flows performing better? Rik Renard and Thomas Vande Casteele from Awell have done a survey with a group called Health Tech Nerds and have dug into the usage of care flows among, specifically, digital health vendors. Given everything aforementioned, I wasn't surprised to hear that 84% of digital health vendors use care flows in 2023 … 84%. But it was kind of shocking, to be honest, to hear that in 2023, only 16% use care flows that they feel are based on evidence and the science of medicine. If you don't follow the latest science, then outcomes, both clinically as well as probably patient-reported outcomes, won't be of the “perform better” variety. Oh, boy. Also, only 7% of respondents have the ingredients to build a 360-degree picture of how their flows impact finances and quality of care. And I say that because only 7% can and do measure four things. And here's the four things: 1. Performance metrics such as patient engagement and compliance rates 2. Financial metrics such as revenue per patient/per member 3. Clinician-reported outcomes 4. Patient-reported outcomes, or PROMs Seven percent. That is less than one out of ten of these digital health vendors. There are other higher, but still pretty sad, percentages that measure combinations of the above four factors; but only 7% measure all of them. And if you don't or can't measure what you're doing, then you wind up with what my guest Rik Renard calls black box care, which is another way of saying if you don't measure it, you can't manage it. Because think about it, if you have black box care, well, the solutions to perform better are also a black box. If you don't know the problem, good luck finding the solution to it. A few things as we contemplate all of this. First of all, as Stacy Mays pointed out to me, if that digital health vendor is working for different payers or different purchasers, those different payers or purchasers might demand different care flows; and those different care flows might ladder up to different ultimate goals. The hard part about being a digital health vendor employed by a payer or a purchaser is that your customer is the boss of you. So, complication. The other relevant conversation I had is with David Claud, MD, PhD, who told me that many employers/customers evaluating healthcare vendors, like on-site clinics, do not have the clinical expertise to meaningfully evaluate the quality of care; so, they tend to focus more on cost and service. When this happens, you kinda wind up with a race to the bottom, where being really nice and being cheap are more important than actually delivering high-quality care that no one can measure anyway. And the last point that I'll bring up is what Sanat Dixit, MD, MBA, FACS, brought up the other day; and I love how he put it. He said doctors don't tend to caucus well. And coming up with care standards and best practice care flows means getting everybody to walk the same pathways. Bottom line, it's really pretty hard to be a digital health entrepreneur these days. Coming up here, I have a conversation with Barbara Wachsman. Barbara was the managing director over at Disney. She's worked for PE (private equity) as well as being executive director over at PBGH, the Purchaser Business Group on Health. So, that's upcoming in a couple of weeks. But the point that Barbara makes, which I think is really apropos here, she said that, in the United States, we desperately need really talented and great digital health vendors, great entrepreneurs, ones who actually can deliver real results and do it at a fair price. So, my hope is that we get better at these care flows. Now, I say all this to say, let's take the conversation today as an opportunity for both entrepreneurs, vendors, as well as customers like employers and other purchasers or payers. It's an opportunity to recognize and work together where there's room for improvement and also place value on achieving that headroom. As I mentioned earlier, in this healthcare podcast I am speaking with Rik Renard from Awell. Rik has a background in nursing and healthcare management. He joined Awell four years ago and now manages strategic accounts. For more on this topic, listen to the show with George Mathew, MD, MBA, FACP (EP253).   Also mentioned in this episode are Ali Khan, MD, MPP; Oak Street Health; Thomas Vande Casteele; Stacy Mays; David Claud, MD, PhD; Sanat Dixit, MD, MBA, FACS; Barbara Wachsman; George T. Mathew, MD, MBA, FACP; Yubin Park, PhD; Jessica H. Green, MPH; Thyme Care; Better Health; Wellinks; Bob Matthews; Emily Kagan Trenchard; Robert Pearl, MD; and J. Michael Connors, MD.   You can learn more at Awell and CareOps. You can also follow Rik on LinkedIn and X (formerly Twitter).   Rik Renard transitioned from a nurse practitioner to a start-up operator. Currently leading strategic accounts at Awell, Rik focuses on helping large care organizations make their care flows work harder than their care teams. As the coauthor and driving force behind CareOps, a vibrant community of over 4000 healthcare professionals focused on enhancing care flows, he imparts insights on designing and improving care flows. His expertise is grounded in over five years of hands-on experience, during which he has successfully implemented over 50 care flows in various medical areas, including oncology, musculoskeletal disorders, and cardiovascular care. These efforts have significantly improved patient outcomes and efficiently freed up time for healthcare teams. Holding a master's degree in health care management and policy from Ghent University, Rik combines his educational background with real-world experience to make a tangible impact in healthcare.   09:26 Why should clinicians care about care processes and care flows? 12:05 Why do care flows and care processes have a bad reputation? 12:31 What components does a good pathway include? 14:51 Why pathways need to be looked at as a process of continuous reconfiguration. 17:15 Who did Awell survey about care processes and flows? 18:42 How many clinicians were using care flows, and what did those care flows look like? 25:45 EP315 with Bob Matthews. 26:44 EP392 with Emily Kagan Trenchard. 28:21 EP412 with Robert Pearl, MD. 30:01 “Just document something.” 30:14 What was a shocking find from this care process survey? 31:06 Is AI the answer? 34:13 Why is it important to get the foundation of data correct before introducing AI? 34:51 How should employers use this information to vet vendors?   You can learn more at Awell and CareOps. You can also follow Rik on LinkedIn and X (formerly Twitter).   @rikrenard discusses #digitalhealthvendors and #patientoutcomes on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen    

For a full transcript of this episode, click here. Here on Relentless Health Value, we have done a bunch of shows lately on how some weird PBM (pharmacy benefit manager) and pharmacy goings-on impact plan members, patients, and also independent pharmacies. During the conversation with Benjamin Jolley, PharmD (EP422), for example, Benjamin mentioned that he thinks some of these contract terms that really hurt independent pharmacies are signed by employers at the urging of their brokers or employee benefit consultants (EBCs). Think about this. You have these huge vertically integrated PBMs who own their own retail pharmacies and/or mail order. You have EBCs that work with employers who, a lot of times, do not understand the contracts that they are signing. This is a recipe for what AJ Loiacono talks about on the podcast encore today: just how much those EBCs and brokers are, in some cases, being compensated to get employers to sign contracts that allow PBMs to corner the market and take all the profit. Even if you listened to this encore in 2022, you might want to revisit it and consider what AJ says in the context of these recent shows with Ge Bai, PhD, CPA (EP420); Joey Dizenhouse (EP423); Mark Cuban and Ferrin Williams, PharmD, MBA (EP418); and Benjamin Jolley, PharmD (EP422), as I just mentioned. Also keep in mind the shows with Scott Haas (EP365) and Paul Holmes (EP397) from earlier … Olivia Webb (EP337) as well. This show with AJ Loiacono is different than others you may have heard with him because in this healthcare podcast, we are not talking about PBMs. We're talking about brokers and EBCs. So, say I'm a self-insured employer. Here's the big question: Is my broker or EBC helping me make the right decisions, or is he or she helping me make decisions that will make them the most money? While there are some amazing and totally above-board EBCs and brokers out there, unfortunately, caveat emptor is a thing. Buyer beware, that is. Too many self-serving and I'm sure very charming sharks are out there circling plan sponsors. It is currently a fact that some EBCs and brokers and even TPAs (third-party administrators) or PBMs or others take hidden kickbacks or fees or percentages. They make a lot of money, maybe the most money, in these secret ways. All this money, money paid in secret backroom deals—let's not lose track, these dollars increase the total prices paid by plan sponsors and employees. Now, I say this to say that my guest today, AJ Loiacono, calls 2022, right now, a “magical moment” for plan sponsors—and for straight-shooting EBCs and PBMs and all the others who are actually doing the right thing by their clients also. It's because of the Consolidated Appropriations Act (CAA), which states quite clearly that plan sponsors can ask their healthcare and benefits service providers to disclose the money that they are making off of the plan—all of the money, not just the direct fees. The CAA went into effect December 2021, and contrary to what some people have said or may believe, it is in force right now. The field memo went out on 12/31/2021. So, the CAA is the rule right now. And in fact, the CAA makes it imperative under ERISA (Employee Retirement Income Security Act) to do what I just said: Plan sponsors must disclose the monies that they are paying out on behalf of employees and ensure that those fees are reasonable and free from conflict. If you're the fiduciary of the plan, you gotta disclose all these indirect and direct compensations of the people that you are paying or the people that you are paying who may be kicking back dollars to other people you are working with, unbeknownst to you. The Department of Labor is putting as much emphasis right now on healthcare as they put on 401(k) plans in the early 2000s, so this is a big deal—or it should be—for plan sponsors. So obviously, in order to comply with the CAA, self-insured employers should be requesting from their EBCs and brokers or others that they disclose, in writing, how much money they are making off the plan. You can see why this disclosure would be necessary if the plan sponsor is responsible to determine if those payments are reasonable and seem to be free from conflict, right? You can't evaluate something you do not know about, and if you don't know about it, the plan sponsor is the one at risk. Ignorance is not an excuse here. Here's one example: What if the EBC or TPA is collecting a $40 payment per prescription from the PBM? Wait … what? Some plan sponsor is paying $40 per script in, I guess you'd call it, a commission? Yes, that is a rumored example—$40/Rx. It is basically full-on arbitrage, and if anyone disagrees, let me know why and how it's not. Or let's say the EBC is making, say, $6 per script payable by the PBM, and this sum should be mailed quarterly to a PO box in another state. This was a condition, by the way, for a PBM to win an RFP (request for proposal) that the EBC wrote and picked the winner of. Yeah, you as the plan sponsor really probably want to know that this is going on because it's your butt on the line. So, in sum, the CAA is in effect right now. Penalties can be levied right now against plan sponsors. For a deep dive into the CAA, listen to the show with Christin Deacon (EP342) from 2021. So, what's the process if I'm an employer plan sponsor? Step 1: Request in writing the dollars that your EBC or broker is making off of you. Similar to the advice that you'll hear often on this show, ask for actual dollars, not a percentage of this or that. Ask for how much money did you (broker or EBC) make off each program that you recommended to us, and what did that total up to. Once you make that request, the EBC/broker/TPA (whoever you're asking) has 30 or 90 days to respond, depending on who you ask. But if they do not respond, then you, the employer, should report them to the Department of Labor. Keep this in mind: Once that EBC or broker is reported for failure to comply by anybody, meaning likely some other employer, it is only a matter of time before that information becomes public. And the second that info becomes public, I guarantee you that there's some attorney out there just waiting to file a class action lawsuit against every other self-insured employer who uses that EBC/broker because everybody else out there is now out of compliance. Right? I'm not a lawyer and I am certainly not a class action ambulance chaser, but even I can figure out that strategy. AJ Loiacono is the CEO of Capital Rx, which is a PBM 2.0, as they call it. To see how the CAA is playing out, you can read about one real-life example of a school district's lawsuit against an insurance consultant. Also mentioned in this episode are Benjamin Jolley, PharmD; Ge Bai; Joey Dizenhouse; Mark Cuban; Ferrin Williams, PharmD, MBA; Scott Haas; Paul Holmes; Olivia Webb; and Chris Deacon. You can learn more at cap-rx.com and find resources through law firms.   AJ Loiacono is a serial entrepreneur with over 20 years of experience in pharmacy benefits, finance, and software development. As the CEO of Capital Rx, his mission is to upgrade America's healthcare infrastructure to deliver the highest level of client service and patient engagement while reducing total cost of care. AJ has spent his career studying the pharmaceutical supply chain and developing solutions that have continually redefined the pharmacy benefit industry to achieve this goal. Before Capital Rx, AJ was a co-founder of Truveris, where he served for eight years as CEO, CIO, and a board member, leading the company to record growth (Deloitte FAST 500 and Crain's Fast 50). Prior to Truveris, AJ co-founded SMS Partners, a joint venture with Realogy (RLGY), and in 2010 exited the partnership with a buyout. In his first venture, AJ started Victrix, a pharmaceutical supply chain consultancy, which was successfully sold to Chrysalis Solutions in 2007.   07:09 Who can get in trouble for mismanaging employee funds? 07:48 “When you talk about conflicts of interest, they're everywhere.” 13:13 “You're paying for access.” 13:34 Why is it important to request that they disclose direct and indirect compensation? 14:04 What are the layers to these hidden fees and compensations? 18:13 What is a reasonable fee for a good plan admin? 19:27 “I think people need to take a step back and say, ‘How many different ways are they getting compensated?'” 24:50 “The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.” 25:06 “For every good broker consultant, there's a horrible individual lurking out there and it's easy to figure out: Ask for them to disclose their fees.” 28:08 “You can't win if you can't even pay the house fee to come in.” 31:35 Why do you need to ask for disclosure, and what do you need to ask specifically? 32:21 What are some of the characteristics of a good plan consultant?   You can learn more at cap-rx.com and find resources through law firms.   AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai  

For a full transcript of this episode, click here. Here's something Randy Vogenberg, PhD, wrote the other day; and I made some light edits: Research has documented the unintended impacts of poor pharmacy benefit strategy. Examples include increasing costs of care, bankruptcies, and member satisfaction declines. And, yeah … agreed. Also, probably health problems if we're talking about a member unable to access a drug they really need. I heard the other day about how so many patients who have had organ transplants have a hard time getting their transplant rejection meds. What?! I just can't even with that one. On the other hand, you could have a plan that pays for all manner of drugs, cost-effective or not, appropriate or not. And now we have premiums that no one can afford, and everybody loses for the exact opposite reason. These are the downsides that happen when pharmacy purchasing gets itself into a suboptimal place. And this can happen for many reasons, but one of them is when there is not a concerted effort to buy pharmaceuticals in a value-based way. Now, here's some reasons why employers may have a rough time paying for value (ie, paying a fair price for drugs that work). Here's one reason: Most employers do not have the power to influence the price of a medication. So, any given employer could decide, based on some cost-effectiveness analysis, that the price of a drug is too high. But it's not like they can march into Pharma HQ and haggle. It's more of a take-it-or-leave-it kind of thing. Here's a number two reason why value-based pharmacy purchasing can be tough: Pharmacy spend is siloed a lot of times from medical spend. So, the pharmacy vendor is only concerned about cost and denies access to even drugs that are proven to reduce medical spend. Why wouldn't they do that? The PBM (pharmacy benefit manager) was hired to reduce pharmacy spend. The end. Who cares how many ER visits or disease exacerbations transpired? That's the medical director's problem, not theirs. Here's the number three reason why value-based purchasing is rough: The time horizon an employee is with an employer, which is not one day—and it's not a lifetime. Why did I say one day? I have heard more than once that the actuarial time horizon that some pharmacy plans use to determine if a drug is cost-effective is one day. If the drug doesn't accrue any benefits in one day, well then, it's a cost. It's not effective. On the other hand (and also problematic in the real world), sometimes cost-effectiveness analyses are done with a timeframe of the patient's lifetime. And, yeah … there aren't many employers who have employees for a lifetime—like, they're 85 years old and still on the employer's dime—so the time horizon can't be too short. But if it's a really expensive med that will, at most, prevent something that's not gonna happen anytime soon (heart failure, kidney failure, a stroke), these are things that an employer may pay for but likely is never gonna see the cost benefit of because that benefit will happen 30 years from now when the patient is on Medicare. And here's a fourth reason why value-based purchasing is tough: The FDA is approving drugs based on evidence from one study (ie, not a ton of evidence). And these drugs are also really expensive. So, some of the above issues are solvable; some are less solvable. With this in mind, let's tick through some advice that my guest today, Nina Lathia, suggests if you want to offer members a value-based formulary. 1. Have a stated goal. And maybe that stated goal is to meaningfully improve health of plan members while maintaining access, satisfaction, and affordability for said plan members and the plan. 2. Think holistically about healthcare spend, not just pharmacy spend. 3. Know what the value-based price of a drug has been calculated to be. I talked about this at length in the show with Anna Kaltenboeck (EP303). Also, Bryce Platt, PharmD, has written about this a lot. 4. Look into risk-based deals with Pharma and/or installment payments and/or some of these other interesting payment models that are emerging. Luke Prettol linked to one of them the other day. 5. Set good decision-making precedents that include shared decision-making with members/patients. This means communicating with employees and plan members about what you are doing to make good drug purchasing decisions and evaluate the clinical pros and cons of expensive drugs for any given patient. There are genetic tests now that can be done to determine if a drug is ever going to work for a patient, were these tests even done. I mean, from a patient standpoint, some of these drugs have horrible side effects; and they might be being prescribed by a doc who's not an expert in that condition. If I'm a patient and there's a genetic test I could take before I pay a ton of my own money and subject myself to what might be some pretty nasty side effects (you know, all the things that you hear about at the ends of those pharma ads on TV, right?), this could be, in the right hands, a patient benefit. This feels very different from prior auths administered by a vendor doing all kinds of stuff, where it's hard to make any connections to clinical value or patient upside, even if you squint at it sideways and use your imagination. And, yeah … this is easy to say and really hard to do. One definition I want to chuck in here for you: If we're talking about a cost-effectiveness analysis, cost-effectiveness analyses calculate how effective is the drug, minus side effects at diminishing the so-called burden of illness—burden of illness meaning the financial and health costs of the disease itself or its exacerbations. Nina Lathia, my guest today, is a pharmacist by training who has worked in hospital pharmacies. She earned a PhD in health economics. Currently she's doing consulting work, helping purchasers make value-based decisions about pharmacy spend and managing formularies. Specialty Pharmacy Playlist: https://lnns.co/uNZ3moCaQMb Hit the subscribe button to add it to your podcast player. Also mentioned in this episode are Randy Vogenberg, PhD; Anna Kaltenboeck; Bryce Platt, PharmD; Luke Prettol; Olivia Webb; Pramod John, PhD; Scott Haas; Aaron Mitchell, MD, MPH; Keith Hartman, RPh; Erik Davis; Autumn Yongchu; and Berkley Accident and Health.   You can learn more by emailing Nina at nina.lathia@healthcaredecisionmaking.com. You can also connect with her on LinkedIn.   Nina Lathia, RPh, MSc, PhD, has spent over 15 years helping healthcare payers achieve value on their drug spend. As the chief executive officer of Healthcare Decision Making, Nina works with public and private healthcare payers, helping them to make evidence-based decisions about their pharmaceutical benefits that lead to improved health outcomes and long-term financial sustainability of their health plans. Her focus is on providing independent, actionable advice for healthcare payers on reimbursement decisions related to expensive new drug therapies. Nina is a frequent public speaker and commentator on employer-sponsored pharmacy benefits design, value-based healthcare decision-making, and evidence-based medicine. Nina honed her skills in value-based assessment of drug therapies when she was a senior technical advisor at the National Institute for Health and Care Excellence (NICE) in the United Kingdom from 2014 to 2017. She has also worked as a clinical lecturer at the University of Toronto. Her work has been published in a number of high-impact peer-reviewed journals. Nina holds a master's degree and doctorate in health economics from the University of Toronto.   06:34 What does cost containment mean? 07:43 Why is it important to consider health outcomes? 10:00 What does value-based purchasing mean in Pharma? 11:09 What are the principles of cost-effectiveness analysis? 12:50 Pharmacy plan time horizons versus employer time horizons. 14:42 Why is it increasingly important for payers to take a more global look at health and cost outcomes? 16:14 Why is the first step establishing a value-based price for drugs? 16:43 Why is the second step thinking about risk-sharing agreements with manufacturers? 18:57 LinkedIn article by Bryce Platt, PharmD. 19:20 What should an employer do if there's only one drug option and the price is too high? 21:20 What's a specialty carve-out solution? 21:26 EP352 and EP353 with Pramod John, PhD, of VIVIO. 22:10 Why should employers get more comfortable with saying “no” to certain drugs? 25:36 Why is patient engagement key? 28:23 What does “good” look like for employers implementing drug-spend changes? 29:51 EP337 with Olivia Webb.   You can learn more by emailing Nina at nina.lathia@healthcaredecisionmaking.com. You can also connect with her on LinkedIn.   Nina Lathia discusses #costcontainment and #valuebasedpurchasing in #pharma on our #healthcarepodcast. #healthcare #podcast #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai, Andreas Mang  

This is a special episode of the podcast that is recorded in front of a live audience at Orvis, Stockbridge.We have Brett O'Connor talking casting tips, Paul Jennings tells us about mullet and Peter Hayes gives a detailed talk on the work he and Don Stazicker have done on the behaviour of trout and the flies we should consider using on the river.This was recorded with no rehearsal, re-takes or prepared notes. I just let the conversation flow in the direction it took.I hope you'll enjoy this episode that is fun to listen to and is packed with information.

For a full transcript of this episode, click here. This show today is for physicians or other clinicians or providers who are still taking insurance—those who are going about their day being pretty normal ... but at the same time, they're noticing one and/or two things potentially going on. Here's thing one: They may be seeing patients struggling to afford care, especially patients with commercial insurance and huge deductibles. And/Or thing two: They may have patients actually coming in and asking to pay cash. It's definitely becoming known in some circles that about half the time the cash price for something is actually cheaper than the “negotiated” rate with an insurance carrier. And this has really become an actionable insight for patients who haven't yet met their deductible, and some high percentage of patients—maybe upwards of 90% of patients—won't meet their deductible in any given plan year. So, all of this is probably some pretty obvious foreshadowing, but let's run through two maybe quick reasons why a practice might want to contemplate ways to make it easier for patients to pay cash when it is, in fact, cheaper for that patient to pay cash than it is for them to go through their insurance. Now, a clarifying point here: We are not talking here about that patient always paying cash heretofore … like, never using their insurance ever again, even if they get hit by a bus. No. We're talking about the patient coming in for some office visit or service, and today, they want to pay with a wad of money they take out of their wallet and hand you. That is the end of the transaction that we're talking about here. So, here's the first of let's just say two reasons that a practice might want to entertain taking cash from insured (technically, at least) patients. First reason: We have a situation in this country where 48% of insured commercial patients say that they are delaying or forgoing care due to cost or fear of cost. Sometimes I say this 48% number to a clinician, and they will reply, “Well, that's not in my practice or in my hospital; our patients show up.” To which I reply, “Yeah, because the patients abandoning care are not the patients that are coming in. They are abandoning care.” Now, the second reason a “normie” practice might want to be thinking about how to help patients get the best possible price here is maybe less intuitive, but it's a financial motivation for the practice. I just saw Eric Vanderhoef. He wrote on a Listserv recently, and this is what he wrote: Patient no-shows and cancellations cost healthcare providers as much as $7500 per month. That's a loss of $375 per patient. Hmmm … okay. Keep this in mind: The whole cancellations costing providers upwards of $7500 a month would help reduce this. Coincidentally, I was talking to Paula Muto, MD (she's the founder of UBERDOC) about this exact same topic the other day—just the crazy no-show rates that many practices experience—and she made some really good points, which are exactly in line with the Tebra report Eric Vanderhoef referenced above. She said that if a patient knows exactly how much a physician visit is going to cost—because they're paying cash and the price is set between the doctor and the patient, so the price is the price, the end—no-shows will go down, and this is especially true when the appointment is tomorrow and not six months from now when appointments are booking these days. It's kind of not normal for anybody to know what's gonna be happening in lives six months from now, so no wonder patients fail to show. Dr. Muto is recommending maybe having a couple of slots open every day for patients who want to pay cash. Doing this could help improve some—not all, for sure, but some—practice cash flow issues which are caused by the no-show thing or the getting paid by the insurance carrier net whatever months later after a billing fight kind of thing. And it's also a win-win for patients with high-deductible plans, especially those patients who are coming in asking to pay cash. In the conversation today, Marshall Allen, my guest, explains how to, in a simple enough way, operationalize the ability of a practice to take cash. There's a form that you'll need for insured patients. You'll actually need a cash price. It's also a marketing opportunity. For example, you can get listed with entities that connect consumers to practices that take cash, like UBERDOC, but there's also a growing movement of employers, especially in some parts of the country, who are looking around for providers who will do direct contracting or cash prices. In fact, I just saw a study the other day: “New polling conducted by Marist … found that 94 percent of adults agreed that hospitals, insurance companies and doctors should ‘be legally required to disclose all of their prices, including discounted prices, cash prices, and insurance negotiated rates across hospitals and across plans in an easily accessible place online.'” Alright, if I know you, you are thinking right now about all of the reasons why this won't work. So, let me head you off at the pass. My guest today, Marshall Allen, solves for the most common issues that everybody brings up, including the big kahuna issue, the “I am contractually forbidden by a health plan to allow patients to pay cash.” You will need to listen to this podcast for the answer. Now, there are, of course, other hairballs to untangle that we do not address today. As Marshall Allen says, there are layers of dysfunction here. One bit of weirdness is something that David Schreiner, PhD, told me about the other day. David is CEO of Katherine Shaw Bethea Hospital in Dixon, Illinois; and he's also the author of a new book entitled Be the Best Part of Their Day: Supercharging Communications With Values-driven Leadership. David said that sometimes hospital payer contracts have the payer reimbursing the hospital for a percentage of overall charges. Yes, you heard that right. The hospital totes up, using their charge master rates, the total amount of billings for the entire year; and the carriers pay a percentage of that total. So, the hospital has a big incentive to keep charge master rates as high as possible. If some patients pay lower cash amounts, then their carrier reimbursement (the hospital's carrier reimbursement) will drop. Probably some math there, I guess, because if it's determined that patients aren't actually showing up for services due to cost, then they might be getting paid a percentage of zero by the carriers; but point taken still. There are, for sure, considerations to be thought through; and, for sure, having contracts like this is one of them. I was talking to Lauren McAteer the other day, and she told me when she worked for a hospital and went to meetings, sometimes she'd bring in a hospital gown and hang it over a chair in the conference room to make it harder to not consider the patient perspective and think about how decisions impacted patients. Good idea, because where there's a will, there's often a way. My guest today, Marshall Allen, probably needs no introduction. But I ask Marshall for the skinny on how he started Allen Health Academy, and you will hear him introduce himself. So, in the interest of eschewing redundancy, let's do this thing. Also mentioned in this episode are Eric Vanderhoef; Paula Muto, MD; David L. Schreiner, PhD; Lauren McAteer, CCXP; Benjamin Jolley, PharmD; David Scheinker, PhD; William Shrank, MD; Jerry Durham; Leon Wisniewski; Cristin Dickerson, MD; and Dutch Rojas. You can learn more by signing up for Marshall's newsletter at marshallallen.substack.com. You can also go to Allen Health Academy or to Marshall's site.     Marshall Allen has spent more than 17 years investigating the healthcare system as a journalist. He is the founder of Allen Health Academy and the author of Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. His book and his health literacy videos, The Never Pay Pathway, are helping working Americans save hundreds and thousands of dollars—per healthcare encounter. Marshall is a two-time finalist for the Pulitzer Prize and winner of the Harvard Kennedy School's Goldsmith Prize for Investigative Reporting and dozens of other journalism awards. For more information, visit allenhealthacademy.com and sign up for his newsletter at marshallallen.substack.com.   07:04 What Allen Health Academy is doing. 11:01 What's the problem with the system now? 14:19 EP363 with David Scheinker, PhD. 14:27 EP413 with Will Shrank, MD. 14:34 What's the hack Marshall Allen shares for insured patients paying cash? 15:06 How can patients cite HIPAA to pay cash instead of using their insurance? 19:00 What's the first recommendation Marshall Allen has when dealing with healthcare billing? 21:26 EP297 with Jerry Durham. 21:48 What are the other benefits of a clinic accepting cash payments? 25:36 Why do we need to have more direct pay happening? 26:36 How should a medical provider set a cash price? 27:12 Research tools for fair pricing: fairhealthconsumer.org, BILLY, colonoscopyassist.com, Jason Health, Green Imaging. 32:36 How do you find the win-win between a patient and a doctor? 32:51 What's the final tier of partners in creating more direct-pay opportunities? 34:30 What's Marshall Allen's opinion on having to pay credit card fees?   You can learn more by signing up for Marshall's newsletter at marshallallen.substack.com. You can also go to Allen Health Academy or to Marshall's site.   @marshallallen discusses operationalizing cash payments for #clinicalpractices on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai, Andreas Mang, Karen Root (Encore! EP381)  

Ch. 19: "Check, Mate." Novelized by Scott Chernoff, narrated by Will Forte. Epilogue: "Epilogue." Novelized by Anita Serwacki, narrated by James Urbaniak. Interview: Aristotle Athari. Will Forte is best known for being a cast member on Saturday Night Live for eight seasons, where he first created MacGruber, and for creating and starring in Last Man on Earth. Scott Chernoff has previously written for Conan, Rick and Morty, and BoJack Horseman. James Urbaniak is known for voicing Dr. Venture in The Venture Bros. and for his appearances in movies like The Fabelmans and Oppenheimer. Anita Serwacki is a former writer for The Onion. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

For a full transcript of this episode, click here. This inbetweenisode is me geeking out, so if that's not your thing, you've been warned. There's a term I'd like to encourage anyone interested to look up. It's the narcissism of small differences. It explains a lot. The narcissism of small differences is the idea that those who, maybe in theory, should be friends/BFFs working side by side toward the same major goal are not. We divide ourselves into these micro-camps. Why? It's a thing to get really narcissistic about small differences. Consider vegans and vegetarians who are so often all up in each other's business in really nasty ways. Who knew whether or not someone decides to eat cheese could create such enmity? Or there's subreddits on Reddit dedicated to people fighting about fantasy football. You would think that everyone who plays fantasy football would be friends, except … not. There are apparently major schisms in the fantasy football world. Or consider branches of the same religion who are at war with one another. Consider people in the same political party fracturing over who is the very most whatever … pick something. So, now let's talk about the narcissism of small differences and how it's relevant when we're thinking about helping patients in the United States get better healthcare for an affordable price. We have these gigantic corporate entities right now very industriously vertically integrating to control supply chains and cornering markets buying up physician practices and using every trick in the book to extract maximum profitability from patients and taxpayers and employers. Achieving some kind of tipping point where these incredibly well-orchestrated and well-funded profit machines are driven back will only happen when enough people, individuals, amass behind that tipping point. It will take more than a village. And my ardent request here is to—I don't know—we quit it with the narcissism of small differences. Do not succumb. “When you cling to ‘my way' you preclude your ability to synthesize, cooperate, support, or even—in [some] extreme cases—peacefully co-exist with other members of your tribe. You destroy a fundamental reason for belonging in the first place: community.” That last bit was a quote from a blog post by Frances Cole Jones. I love the community who I interact with most on LinkedIn, and there's also some Listservs and some Slack groups that I love. Even X and Threads, for the most part, are lovely nests of great people trying to understand one another and further a common cause. I guess when you get into the kind of wonky stuff that you and I get into, there's a finite group of us who are even reading these Tweets or posts or whatever they are. It's a “small junior high school,” as one of my clients used to call it a long time ago. But there's also often enough that somebody who swoops down and in the name of ... something … slams a 95% aligned cause. It's like two people agreeing on the restaurant to go to lunch, but one wants to go there and get a rice dish or because it's closer to their house and the other wants to go there because the restaurant serves a great tortilla—and the two of them fight over what's the right reason to go to that restaurant or what the best item is on the menu. This is literally a metaphor that describes some of the sniping that I have seen, that you have seen amongst mostly aligned folks trying to figure out how to put patients over profits. I mean, guys, go to the restaurant. Once you're there, you can place separate orders. Work together to just get to the restaurant. It's certainly easier to say than do, but if we're aware of this and we focus on the points of agreement and maybe just think a little bit about whether the points of difference really even matter—in real life, not theoretical philosophy life—because a lot of times, they don't. And then divided we fall. I think a lot about small difference narcissism-ing when someone comments derisively that a post or an article puts too much emphasis on … I don't know, transparency or employers or mental health or … pick something. But here's the thing: In the village, everybody is gonna have different number one priorities. That's why it takes a village. Maybe I'm wrong, but I'm thinking it's not a zero-sum game. Just because someone is angling hard for patient empowerment or consumerism or whatever doesn't make it harder for anybody else to promote patient health literacy or better quality measures or integrated behavioral health. Probably it will make it easier, since both are trying to figure out how to put patients over profits. Both are pushing in the same direction, albeit one is headed northwest and the other one might be angled really far northeast. Point is, everybody will get momentum as long as we're all roughly headed northbound. Now, caveat and sidebar: There are people emphasizing things because they're actually working on them, and then there are people promoting things because it's good marketing. Jeff Hogan wrote about this at the beginning of January, and I agree with him here. Here's what he had to say, and then I'm gonna connect it back to what I think is a really important point about the narcissism of small differences. Jeff wrote: Over the course of the last month [I have] been asked no fewer than 20 times about exactly which conferences [I am attending] … this year. … All of my conference intentions are focused on one question: What will this conference do to promote a complete change in our healthcare paradigm … focused on superior [patient] access and outcomes as well as payment reform and care transformation? Said a different way, is this conference literally a honey pot for those who have screwed up the existing system and who are merely virtue signalling …? Who is speaking at this conference? Is it representatives of the same health systems and the same payors [and perpetuating] legacy moats and monopolies or is it a conference promoting change makers, risk takers and provider models and systems embracing risk and [healthcare] transformation? … What kind of change and innovation ever came out of an echo chamber? Challenging my friends and healthcare influencers to think carefully about their choices. Conferences create the opportunity to leverage great ideas and movements. We're finally seeing first followers having expanded influence. Are you one of them? So, talking about that conference that happens at the beginning of January, I heard that a CEO of a major PBM (pharmacy benefit manager) stood up in front of that room and used the word transparency or a synonym six times in five minutes. Check out this LinkedIn post/video and this article as to why my eyebrows are sky-high on what transparency actually means for the CEO when you look at what this PBM is actually doing. If you look at quarterly reports again of some of these big entities, the cover of that annual report has lots of wonderful patient-centric words on it—while if you look at how those entities are actually making money, it is in direct conflict with those words. Now, there's always going to be nuances here … always. And that's what makes this very subjective and very personal. Everyone doing well by doing good is going to have a marketing statement, and it wouldn't be a marketing statement if it didn't sound amazing, right? The nuance or the question is: To what degree are they actually achieving that marketing statement? What's the line that separates pure spin from an acceptable level of achievement of the marketing statement? Because we want to support the organizations that are trying here while, at the same time, make sure that we're kind of quarantining those who are just all talk in ways that confuse the marketplace and don't help patients get affordable quality healthcare, just like Jeff just said. I gotta say, sometimes I struggle here myself. This is why I wrote a manifesto (EP399 and EP400). And you might struggle, too. It's probably no coincidence that sometimes the loudest individuals advocating for patients over profits are retired. And, throwing no shade here, I love the whistleblowing and the truth telling. But I think we have to be a little careful because who is actually gonna do the changing and the tipping point reaching are those who are still working for a living on or about the healthcare industry. And when I say “working for a living,” I mean we're taking money and putting it in our pockets. We need to pay the rent and go on vacation every now and then. And we need money to pay for our family's healthcare. If we didn't take money, if we just volunteered, that cash might have funded more patient care or maybe made that care or premiums more affordable. Every one of us is a cost center if we think about it from the standpoint of the patient or plan member. Every one of us. If you did it for free, the money could accrue to patients, right? I also keep in my mind that there are, for sure, individuals within any of these profit-seeking, financially motivated, maybe not patient-motivated organizations; and these individuals have a job to do the good that that organization is doing. These are the ones who are actually working on pilots that actually work or doing work with social determinants of health or behavioral health that are actually (again) working. While I dislike the overall impact potentially of the one who is paying their paycheck, I gotta keep in mind that the more successful this individual is within that corporate entity, the more good that that entity is gonna wind up doing. I think about this because, again, my main concern is doing better by patients, helping the sort of insurgents within some of these entities. These entities should be held accountable, no doubt; but the people who work within them should—I don't know—I still want to encourage them to do better. The goal is to help patients, not catch up some good people in a quest to punish their boss. So, it's always a matter of degrees. It's always nuances. It's always how much value got delivered back for the dollars that we took in compensation for the work that we did. What did the work we do add up to? In my personal case—and I covered this in the manifesto (again, EP399 or EP400)—I worked really hard, by the way. I was sweating bullets when I was creating that manifesto. I was not sure whether I was gonna get skewered. It really was hard, and it took some major soul searching to create (again, EP399 and EP400). What I try to do, I usually shoot for trying to get patients better outcomes in a way that is cost neutral. The work that I do most of the time (ie, my day job) is probably not gonna lower costs. It's not gonna lower costs. It's just not within the parameters of what I do, and it's not within the parameters of my expertise. Others who I count on to do their thing here, they might be working the opposite angle—the care might be the same, but costs are reduced. Again, a fine way to go. Maybe some of you have figured out how to get patients better care at lower costs. That's the holy grail … and big kudos. But not everybody can do it. It's just not possible a lot of times on any number of levels that we don't have time to get into today. Again, all of this is why I wrote my manifesto for how I reconcile my own self and determine what “having personal integrity” means to me and for me and also for my company. And maybe over the years I've made some choices that I wouldn't make again—but those choices ultimately have wound up funding this podcast, so maybe that's my redemption potentially. I don't know. We all live and learn, and we can't start to hate ourselves because we haven't been perfect. A lot of times, you don't realize the ultimate impact of something until after you've done it. And at that point, you just gotta regroup and try again and do better this time. We all just have to contemplate patient impact. On the other hand, there are often conversations with very motivated entrepreneurs that I've had where the words affordability, impact on patient premiums, access, or better actual measurable health … these words don't come up. At all. Or you talk to somebody else who works at one of these behemoth payers or hospital systems or whoever, and those words do not come up. At all. Again, tracking back to the narcissism of small differences here, are we fighting with someone who is basically 95% aligned with what we're trying to do? Or is this somebody on the other side who's really not in the village because they do not have the same overall intent? The point I'm making here in this inbetweenisode is simply that if we're thinking about this from the standpoint of the patient, then every one of us who isn't retired or independently wealthy or volunteering, we all have a great opportunity to do some amazing work. But we're also all living in glass houses, and if somebody really wants to get all small difference narcissistic about it, they probably could very self-righteously take out most of us. This isn't some kind of cartoon where all the good guys all look the same and everything is black-and-white and there's no nuances. I'm belaboring these points because if we want to build a village, we cannot do so without contemplating who we choose to let in it and who we're gonna beat up on LinkedIn or wherever. But we can be a motley bunch and still work together, as long as we accept each other for the imperfect souls that we are and what we can in the aggregate add to the common cause. There's no “one size fits all” for what we want for ourselves and what we want our legacy to be. I wanna just track back for one sec to that earlier comment I made about people who work for a company that's actively working to take as much money out of the system as possible and give it to their shareholders at the corporate level … because here's an actual case study example of that, and maybe it will be helpful. The other day, I was talking to an actuary who worked for a large (again) payer. And this actuary was trying to figure out ways to create win-wins for plan members within the constraints of his job. This actuary, if he can figure out the math, given the scale of members that he'll reach, he could have a really large positive impact even if he only changes the trajectory of his math by a fraction of a percentage point. I want this guy on my team and in my tribe. He is trying to help, and he has the power to incrementally fix some stuff that is gonna matter to potentially millions of people. I'm not gonna kick him out of my village anyway because of who pays his paycheck. Conversely, I'm gonna try to encourage him to spread his way of thinking to the other actuaries that he works with. Or I get emails all the time (all the time) from people, especially at the beginning of their careers; and they're looking to find a job where they can make an impact. These are smart, ambitious young job searchers, and I hear from them so often I actually have a very long template response that I've been poking away at for years. And I always tell them some variation of many of the things that I have said on this podcast. Often enough, though, I'll get a response back that's something like, “Wow! Thanks so much. This was all so helpful. After much thought, I've decided I'll go work in private equity (PE). I'm gonna go work for a private equity firm so I can fund start-ups who are gonna make a difference for patients.” They may go on, and they mention how they were reading the Slack channel of one of these many groups where they don't talk about the stuff that we talk about on Relentless Health Value. They talk about the thrilling world of start-ups and health information technology and scaling and AI and repeatable whatever. Hold your judgment. I am managing to keep mine in check. I consider that Iora Health (now One Medical) and ChenMed really help a lot of patients. There are some great new companies out there. People also have made lots of money at some of them. Nuances. Choices. Also, who's their leadership? Now, it's inarguable that anyone that's working for a profit-seeking missile of a publicly traded company or a PE-funded company is going to have to contend with a moral framework that is more of a money framework than a moral framework. Same thing goes for anyone working at a huge, consolidated hospital system like the ones that get written up in the New York Times for all kinds of egregious stuff. This money focus may be irrevocably misaligned with the values of someone who works there, and the person may ultimately quit because it becomes too much cognitive dissonance. And if and when they quit, great. They're at a different place in their journey. Maybe they listened to Relentless Health Value long enough and began to realize some of their employer's Kool-Aid might not taste quite right. For them to get to the next stage of their journey and have the impact that they may ultimately want to have, they kinda had to start out in the belly of the beast—and I won't hold that against them, especially if they were able to alter the trajectory of the organization or help patients along the way while they were there. Here's another example to think about as we think about the narcissism of small differences and who gets to be in the village and who we're gonna tell to talk to the hand. I was talking to a friend of my dad's who literally was going to die from a neuroendocrine cancer. He had weeks to live, maybe not even plural. He was given a new immunologic cancer drug. And it's now two years later, and he's still here and in remission. According to the package insert of this drug, he'll probably have 47 months, almost four years, of extra life. Yeah, that drug was expensive. I opened my mouth to say something, and my dad's friend … he kinda shushed me. He said, “Do not say anything bad about the pharma company or my doctors at the big, consolidated health system where I got my care. I am alive, and I should be dead.” This is why I started Relentless Health Value and why I continue to do this thing. It's because almost everything in the healthcare industry along the good-for-patients curve is a matter of degrees. Tip too far in one direction, and we start to cost more than the value we put out in exchange. Tip too far in the other direction, we go out of business. Everything I talk about on Relentless Health Value is in the service of helping myself and you and anybody else I can reach. It's in the service of us figuring out how all of these nuances work in the real world—to help figure out who gets what when and how that might impact patients caught in the crossfire. It's to help figure out my own path forward that I can be proud of, and maybe I can help others trying to do the same. But at the end of the day, we're all gonna make slightly different choices and evaluations. Please don't let the narcissism of small differences prevent us from creating a village large enough to fix healthcare for patients. Also, it's just a nicer way to exist. Also mentioned in this episode are Frances Cole Jones; Jeffrey Hogan; Eric Bricker, MD; Iora Health; and ChenMed. 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.   00:42 What “the narcissism of small differences” means. 02:18 How does this narcissism of small differences show up in the effort to fix the healthcare industry? 05:26 Quote from Jeff Hogan. 10:12 “What did the work we do add up to?” 16:31 Why we shouldn't judge someone for working within the “belly of the beast.”   For more information, go to aventriahealth.com.   Stacey Richter discusses small differences and #healthcaresystem fixes on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai, Andreas Mang, Karen Root (Encore! EP381), Mark Cuban and Ferrin Williams  

For a full transcript of this episode, click here. Here's a quote from Ann M. Richardson, MBA. She wrote it on LinkedIn, and I love it: Quiet the noise that doesn't add value. Surround yourself with intelligent and respectful people who can deliver endless opportunities. Celebrate brilliance and new beginnings. Together, we've got this. Thanks for this beautifully stated call to action (I wish I would have written it myself) because it is also precisely the goal of Relentless Health Value and my hope for the Relentless Health Value Tribe—those of you who have connected with each other by way of this podcast vis-à-vis LinkedIn, or maybe you've met each other at an online or live event. For sure, subscribe to the weekly email to get notified of such goings-on. Now, this aspirational vision doesn't mean putting the onus on just any given individual to fix the systemic failings that get talked about on the podcast, but we can start somewhere. We can sit with ourselves; we can ask ourselves some big questions. We can decide the legacies we want to leave and what we want our life's work to add up to. That is what this show should, I hope, help you accomplish. And, yeah … together, we've got this. In this healthcare podcast, I am speaking with Peter Hayes; and we talk about five realities of 2024 for hospital chains, integrated delivery networks, health systems. Now, to make one thing very clear, as I have said many times on many Relentless Health Value shows: Not all hospital chains or hospitals are the same. There are large, consolidated, extremely rich, extremely politically and economically powerful organizations who are called health systems. And then there are rural or urban institutions that are barely scraping by and serving huge vulnerable patient populations. And despite the many aforementioned names for hospital chains and their associated outpatient facilities and owned physician groups and urgent care centers, all these names for these big care delivery entities are flabbergastingly meaningless because they do not separate the consolidated rich ones from the very desperately not rich ones. Today on the show, we're talking about the first kind of health systems: the big rich consolidated ones which are taking over every geography where there's money to be made. These are the ones where you read about their bad behavior in the New York Times or hear about them in YouTube videos like this one. Peter Hayes talks about the five things that these behemoth entities may really need to start thinking hard about, even in the face of their fierce and often-unrelenting market power and the political hold that they have over many local communities and all the regulatory capture that goes along with that. So, here's Peter's list in a nutshell—the five things to get real about: 1. Health systems need to get real about the CAA (Consolidated Appropriations Act) and its implications that plan sponsors only pay “fair and reasonable” prices for medical services. Now, before I dig in on this, jargon alert: When we say plan sponsors, that means entities such as self-insured employers—sponsors of health plans, if you will (the purchasers, the ones who are actually paying the bills). Peter explains the quick version of what the Consolidated Appropriations Act is in the show that follows, so do listen. But for more info on this really, really meaningful bit of legislation that is the law as of 2021, go back and listen to the episodes with Chris Deacon (EP342 and EP408) or check out the myriad of LinkedIn posts from Jeff Hogan. Also, others like Darren Fogarty, Justin Leader, Jamie Greenleaf, and others have some great words of wisdom that you will be able to find that really explain what the point is of the CAA, the Consolidated Appropriations Act, and its sprawling implications. 2. To survive on reduced commercial reimbursements, health systems need to get real about becoming ruthlessly aggressive in driving administrative and technology efficiencies. 3. They need to get real about pivoting from fee-for-service reimbursement to episode-based care based on taking real downside risks for good clinical outcomes. They need to pivot from a mindset of maximizing patient revenue to maximizing patient health. They need to move from a sick care reimbursement model to a healthcare reimbursement model based on health. 4. They need to get real about being completely transparent and accountable in reporting how they are using the value of their tax-exempt status. Similarly, they need to account for and report how they're using the estimated $55 billion in net margins that they're realizing off the 340B drug program. 5. They need to get real about quality and patient safety. We still have about 46% of our hospitals that have a C or lower Leapfrog rating. And, by the way, the chance of having a fatality on an avoidable error is 90% higher at a C or lower-rated Leapfrog entity versus a Leapfrog entity that has an A or a B. Now, some of you—and by some of you, I mean practically everybody listening—are thinking of reasons why any one of these “get real about” things is arguable or how one of the above is not holding up in some market. I think Peter would tell you the same thing that I would: You're not wrong. But trying to predict a zeitgeist or the next pet rock never works well because it's always a confluence of right time/right place where the whole is way more than the sum of its parts. Think about Malcolm Gladwell's The Tipping Point. It's about how small changes can have enormous effects if the context is right. So, now contemplate these five things that Peter brings up. All these forces are pushing in the same direction. Put it all into a stew where 48% of Americans have delayed or forgone care due to cost. Listen to the show with Wayne Jenkins, MD (EP358) for more on that. Or, you have the article John Tozzi just wrote in Bloomberg. Here's a quote: “In one California community, teachers have to pay an extra $10,000 a year to upgrade to insurance that covers the local hospitals. Teachers who can't afford it … give birth outside the county.” Meanwhile, insurers are making record profits, along with hospital CEOs and C-suites. At the same time, you know who I think is the third-biggest group with medical debt in this country? Yeah, it's people who work in hospitals—nurses, others. There's this frothing lack of trust for hospitals and what goes on there: 30% of physicians do not trust the leadership of their health system. And no wonder. There are examples of healthcare executives sitting up there in their palatial offices acting more like mobsters than the nuns they took over the hospital from. So, to orient your context, you are here. Peter Hayes is the newly retired former president and CEO at the Healthcare Purchaser Alliance of Maine. He is a national presence in healthcare strategy, innovation, and a keynote speaker. For more on the wild-ass problems with hospital pricing, check out this list of shows. But, spoiler alert, some of these are hair-raising. Encore! EP249: The War on Financial Toxicity in North Carolina as a Case Study Everybody Should Be Keeping Their Eye On, With Dale Folwell, North Carolina State Treasurer EP395: Consolidated Hospital Systems and Cunning Anticompetitive Contracts, With Brennan Bilberry EP390: What Legislators Need to Know About Hospital Prices, With Gloria Sachdev, PharmD, and Chris Skisak, PhD EP389: The Clapback When Hospitals Cannot Constrain Their Own Prices, With Mike Thompson 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 EP394: Spoiler Alert: It Is Counterintuitive Which Hospitals Offer the Most Charity Care, With Vikas Saini, MD, and Judith Garber, MPP Also mentioned in this episode are Ann M. Richardson, MBA; Chris Deacon; Jeffrey Hogan; Darren Fogarty; Justin Leader; Jamie Greenleaf, AIF, CBFA, C(k)P; Wayne Jenkins, MD; John Tozzi; NASHP (National Academy for State Health Policy); Gloria Sachdev, PharmD; Chris Skisak, PhD; Leon Wisniewski; Cora Opsahl; Rik Renard; John Rodis, MD; Rob Andrews; Al Lewis; Eric Bricker, MD; Vikas Saini, MD; Judith Garber, MPP; Lown Institute; RAND Corporation; Dale Folwell; Brennan Bilberry; and Mike Thompson. You can learn more by following Peter on LinkedIn.   Peter Hayes recently retired as the 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 recognized as a thought leader in innovative, strategic benefit design for the past 25+ years. He has received numerous national awards in recognition of his commitment to working collaboratively with healthcare providers and vendors in delivering health benefits that are focused on value (high-quality efficient care). He has been successful in this arena by focusing on innovative solutions for patient advocacy, chronic disease management, and health promotion programs. Peter has also been involved in healthcare reform leadership roles on both the national and regional levels with organizations like Center for Health Innovation, Care Focused Purchasing, and Leapfrog. He's also co-founder of the Maine Health Management Coalition 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.   08:04 Why do hospitals need to get real about the implications of the Consolidated Appropriations Act? 10:09 What is considered fair pricing for hospitals? 13:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD. 15:59 The medical transparency tool, Billy. 16:34 How does lowering prices become more challenging with consolidated hospital systems? 18:07 What is one of the solutions available to combatting this now? 19:31 Why do hospital systems need to get real about administrative and technology efficiencies? 22:27 EP373 with Cora Opsahl. 26:51 Why do hospitals need to get real about pivoting from fee-for-service reimbursement to episode-based care? 30:16 EP415 with Rob Andrews. 30:53 Why do hospitals need to get real about the 340B program and their tax-exempt status? 35:38 EP394 with Vikas Saini, MD, and Judith Garber, MPP. 38:19 What are the ethical and moral issues that are coming to a head with healthcare costs? 39:03 Why do hospitals need to reexamine their care quality and patient safety? 40:05 “We just need to make sure that the health industry is as accountable as some of our other industries.” 42:53 Why does Peter think it's going to take regulation to move the dial?   You can learn more by following Peter on LinkedIn.   @pefhayes discusses #hospitalsystems and what their executives need to do on our #healthcarepodcast. #healthcare #podcast #pharma #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai, Andreas Mang, Karen Root (Encore! EP381), Mark Cuban and Ferrin Williams, Dan Mendelson (Encore! EP385)

Ch. 17: "The Apple PowerBook 5300ce." Novelized and narrated by Tony Zaret. Ch. 18: "President Maverick." Novelized by Daniel Powell, narrated by Michael Torpey. Interview: Hannah Pilkes. Tony Zaret is a New York-based stand-up and improvisational comedian. Michael Torpey is an actor, writer, and comedian known for his appearances on Veep, Orange is the New Black, Inside Amy Schumer, and Late Night with Jimmy Fallon. He currently hosts Paid Off on truTV. Daniel Powell is a writer and producer known for co-creating Inside Amy Schumer and producing I Think You Should Leave and That Damn Michael Che. Hannah Pilkes is an improvisational comedian who was a New Face at the 2023 Just For Laughs festival. Follow her on Instagram at @hannahpilkes. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Ch. 15: "Just Call Me Captain Plan-It." Novelized by Jason Reich, narrated by Mae Whitman. Ch. 16: "Preparing for the Final Stand." Novelized by Caroline Eppright, narrated by Beanie Feldstein. Interview: Oscar Montoya. Mae Whitman is an actor known for her roles as Ann Veal in Arrested Development, Amber Holt in NBC's Parenthood, and Annie Marks in Good Girls. She also voiced Tinker Bell in Disney's Tinker Bell films and Katara in Avatar: The Last Airbender. She has appeared in numerous films, including 1996's Independence Day as the President's daughter! Jason Reich is a four-time Emmy-award-winning writer who has written for The Daily Show with Jon Stewart and Full Frontal with Samantha Bee, and he was the head writer of The Jim Jeffries' Show. He was also one of the writers of America (The Book). Beanie Feldstein is an actor known for starring in Booksmart, Lady Bird, and Neighbors 2: Sorority Rising. She also appeared as Monica Lewinsky in the third season of America Crime Story: Impeachment. Caroline Eppright is a former writer for The Tonight Show Starring Jimmy Fallon. Oscar Montoya is a writer and improviser who has performed with the Upright Citizens Brigade. He has appeared on Reno 911! and Bless the Harts. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Ch. 13: "My Marriage Was Also Named Abort." Novelized by Jeb Lund, narrated by Josh Johnson. Ch. 14: "The Rogue, the Coif, and the Partial Can of Diet Soda in an Empty Blended Scotch Bottle." Novelized by Chris Messick, narrated by Jon Wurster. Interview: Lisa Gilroy. Josh Johnson is a stand-up comedian and former writer and performer for The Tonight Show Starring Jimmy Fallon. He has released two comedy specials on Comedy Central and Peacock, and his other credits include CONAN, @Midnight, and Kevin Hart's Hart of the City. Jeb Lund is a former reporter for Rolling Stone, The Guardian, and Gawker, and he has contributed to Esquire, GQ, and The New Republic, among many other publications. Jon Wurster is the former drummer for American rock band Superchunk and a comedy writer known for his appearances on The Best Show with Tom Scharpling. Chris Messick is a writer and musician. Lisa Gilroy is a writer and improviser known for her viral online videos and her appearances on Comedy Bang! Bang! The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Ch. 11: "The Tank of Forbidden Mysteries." Novelized by Andrew Lin, narrated by Andy Daly. Ch. 12: "Even as the World Ends, People Are Still Jerks." Novelized by Dave Croatto, narrated by Chris Parnell. Interview: Lilly Sullivan. Andy Daly is a writer and performer. He's currently producing The Andy Daly Podcast Project, which includes Bonanas For Bonanza. He's appeared in Comedy Central's Review, Veep, Eastbound & Down, Black-ish, The Good Place, The Office, Modern Family, Silicon Valley and more. Follow him on ⁠Twitter @TVsAndyDaly⁠ and ⁠Instagram @tvsandydaly⁠. Andrew Lin is a writer and cartoonist. Check out his work at  ⁠http://mountainofsadness.blogspot.com Chris Parnell is an actor and comedian best known for his 8-year tenure as a cast member on Saturday Night Live, voicing Jerry Smith on Rick and Morty, and voicing Cyril Figgis on Archer. He also had a recurring role on 30 Rock as Dr. Leo Spaceman. Dave Croatto is a writer and editor who previously wrote for MAD Magazine, The Onion, and Billy on the Street. Lilly Sullivan is a writer and improviser who has appeared in the 2022 feature Spirited, as well as TV shows like Righteous Gemstones and I Think You Should Leave. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Ch. 9: "The Few, The Proud, The Smithereens." Novelized by Chase Mitchell, narrated by Adam Pally. Ch. 10: "Nothing Blows Up for a Sec." Novelized by Shek Baker, narrated by Maurice LaMarche. Interview: Clark Jones. Adam Pally is a comedian and actor known for starring as Max Blum in Happy Endings and as Dr. Peter Prentice in The Mindy Project. He has also appeared on Last Week Tonight with John Oliver, Californication, and The Colbert Report, among many other shows and films. Chase Mitchell is a comedy writer who was written for The Tonight Show Starring Jimmy Fallon and Inside Job, among others shows. Maurice LaMarche is a comedian and voice actor best known for voicing Lrr, Morbo, and Calculon from Futurama and various roles in Frozen, Zootopia, Looney Tunes, and more. He also voices Sam the Toucan in the Froot Loops commercials. Shek Baker is a writer and comedian. Clark Jones is a stand-up comedian who has been listed as one of the top 11 comedians by BET.com and has appeared on HBO's "Crashing", "Night Train with Wyatt Cenac" on Starz, and the "2 Dope Queens" podcast. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Ch. 1: "The Arrival." Novelized by Steve Agee, narrated by David Pressman. Ch. 2: "In Which Jeff Goldblum Rides His Bike Like a Boss and Earth Is Invaded by 15-Mile-Wide Space Cookies." Novelized by Liz Lent, narrated by Craig Ferguson. Interview: Kenny Stevenson David Pressman is an actor known for Krapopolis, It's Always Sunny in Philadelphia, and appearing in, you guessed it, Independence Day. Steve Agee is best known for playing John Economos and being the on-set portrayal of King Shark in the DC Extended Universe's The Suicide Squad and Peacemaker. He has also appeared on New Girl and was a writer for Jimmy Kimmel Live! Craig Ferguson is best known for hosting CBS's The Late Late Show with Craig Ferguson and for starring as Nigel Wick in The Drew Carey Show. Check his new show on iHeartPodcasts, "Joy, A Podcast" here. Liz Lent is a writer and painter. Check out her work on Instagram @lizlent. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Ch. 7: "Come Sail Away." Novelized by Maura Quint, narrated by Vir Das. Ch. 8: "Rubble, Rubble, Toil and Trouble." Novelized by Josh Gondelman, narrated by Paget Brewster. Interview: Seth Herzog. Vir Das is an actor, musician, and India's biggest stand-up comedian. He has released numerous specials on Netflix and recently won the International Emmy Award for his most recent special, Vir Das: Landing. Maura Quint co-founder of Tax March and runs the popular Twitter account @behindyourback. She has been a contributor to The Onion and McSweeney's. Paget Brewster starred as Special Agent Emily Prentiss on CBS's Criminal Minds and Sara Kingsley on Fox's Grandfathered. She has also appeared in Friends, Community, and Modern Family, among numerous other shows and films. Josh Gondelman is a writer and comedian who was the head writer and executive producer for Desus & Mero. He previously wrote for Last Week Tonight with John Oliver, for which he won 4 Emmy Awards, and has contributed to The Marvelous Mrs. Maisel. He also performs stand-up and has been a regular contributor to NPR's Wait Wait...Don't Tell Me. Seth Herzog has appeared on Late Night with Conan O'Brien, Chappelle's Show, and The Tonight Show with Jimmy Fallon, and regularly performs live comedy. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Ch. 5: "Hot City Nights." Novelized by Mickie Cathers, narrated by Jake Johnson. Ch. 6: "Pops and the Choppers." Novelized by Mike Wilson, narrated by Kevin Sussman. Interview: Will Hines. Jake Johnson is an actor known for starring as Nick Miller in New Girl. He has also voiced a Spider-Man in Spider-Man: Into the Spider-Verse and its sequel, and he has appeared in 21 Jump Street, Jurassic World, and many other films. Mickie Cathers is a writer based out of Philadelphia. Kevin Sussman is an actor best known for playing Walter on Ugly Betty and Stuart Bloom on The Big Bang Theory. Mike Wilson is a writer living in Chicago. Will Hines has appeared on Brooklyn 99, Crazy Ex-Girlfriend, Broad City, Inside Amy Schumer, Conan, and is a big macher at the UCB Theater. Follow him on ⁠Instagram⁠. The Novelizers was created by Stephen Levinson, produced by Stephen, Chris Karwowski, Rob Kutner, and Suchetas Bokil. Editing, mixing, and mastering by Chris. Improv booking by Christine Bullen. Music by Cole Emoff. Art direction by Crystal Dennis with illustrations by Barry Crain. Intro narration by Robin Reed. Interviews by Kevin Carter. Special thanks to Luke Dennis and Peter Hayes at WYSO Public Radio in Yellow Springs, Ohio. Follow The Novelizers on Instagram and Twitter, or at thenovelizers.com. The Novelizers is a work of parody, unauthorized by 20th Century Studios, The Walt Disney Company, or Independence Day. © 2023 The Novelizers and respective authors.

Gong - Tiny Galaxies / My Guitar Is A Spaceship / Ship Of Ishtar Screens 4 Eyes - Patterns Screens 4 Eyes - Trip To The North Poppy - Church Outfit The Vacant Lots - Evacuation The Vacant Lots - Endgame King Gizzard & The Lizard Wizard - Swan Song (Extended Mix) Jah Wobble, Jon Klein - Monitor TV's Daniel - Watching You Yo La Tengo - Stockholm Syndrome (Bunker Session) The Cowboys From Hell - Cuidado P. Paul Fenech - Jager Ya New Model Army - Wonderful Way To Go (Orchestral Version) (Live) New Model Army - 1984 (Orchestral Version) (Live) The Dollyrots - A New England זולי והחזזיות - אושוויץ זולי והחזזיות - ז.א.פ Clt Drp - Desire, 1 On 1 Crime & The City Solution - Rivers Of Blood James Priest - Electric Sex Machine (Bill Mcclintock) Sleaford Mods - Big Pharma Sleaford Mods - My 18hr Girdie Egonx - להתרסק Egonx - Kazataka Orchestral Manoeuvres In The Dark - Slow Train זאב טנא, דוד גרוסמן - אוד מוצל מאש Goat - Join The Resistance Lol Tolhurst, Budgie, Jacknife Lee - Los Angeles (Feat. James Murphy) Army Of Skanks - Mind Control Kap Bambino - Hong Kong Garden Skold - Peek-A-Boo JS Rafaeli - Jesus Gonna' Make Up My Dying Bed The Jeffrey Lee Pierce Sessions Project - The Stranger In Our Town (Feat. Peter Hayes, Leah Shapiro & Humanist) Psychedelic Porn Crumpets - All Aboard The S.S. Sinker Zounds - Can't Cheat Karma Wargasm (UK) - Modern Love Army Of Skanks - Exorcism מיטב אמני ישראל - עם אחד, שיר אחד הפה והטלפיים - עם אחד

Welcome to the 200th episode of the podcast!In this special edition I sit down with Peter Hayes and Don Stazicker to talk about about their latest book, The Flies That Trout Prefer.We discuss what they found from years of detailed observation and how they shared their findings with readers. Peter and Don have drilled down into why trout behave in the way they do, their preferences when feeding and have even explored the eye sight of fish.They have left no stone unturned and will make you look at fly selection and behaviour of trout in a completely different way.This couldn't be a better episode to celebrate a small milestone for this podcast.Buy The Flies That Trout Prefer HERE

Twins President Dave St Peter kicks off the show in advance of the Twins/Blue Jays series, some Taylor Swift conversation in the middle, then the Athletic's Dan Hayes continues our focus on Twins playoff baseball for the remainder of the hour!

An arms-control advocate accepts an invitation to the dacha of a hard-partying North Korean power broker. There, through a haze of smoke and propaganda, they identify some common ground and set out to test a hypothesis: That it's possible for Americans and North Koreans to work together toward peace. The result is a tense but extraordinary moment in the relationship between North Korea and the West, a rare example of collaboration that has been almost entirely lost to history.This episode features Peter Hayes and Lyuba Zarsky, co-founders of the Nautilus Institute for Security and Sustainability, and David von Hippel, an energy expert who worked with Peter in North Korea.

Wesley Davis grew up in the woods of Mount Holly. But there was always one place where he could get high above the trees: the fire tower on top of nearby Ludlow Mountain, at Okemo. He's been curious to learn more about the history of these remote towers scattered across Vermont peaks ever since.Reporter Sabine Poux searches for answers in the early 1900s, when timberland owners and railroads ruled the Vermont landscape. And, she arrives at the doorstep of a couple that found a lifetime of artistic inspiration as fire tower lookouts in southern Vermont.We compiled a map of Vermont fire towers past and present. Find it here.Sabine Poux reported this episode, and did the mix and sound design. Josh Crane produced and edited it. Additional support from Sophie Stephens, Corey Dockser and Joey Palumbo. Angela Evancie is Brave Little State's Executive Producer. Our theme music is by Ty Gibbons; other music by Blue Dot Sessions.Special thanks to Mark Haughwout, Ron Kemnow, Peter Hayes, Alan Thompson, Keegan Tierney, Prudence Doherty, Juls Sundberg and Liam Elder-Connors. And thanks to Danielle Kovacs and the Robert S. Cox Special Collections and University Archives Research Center at the University of Massachusetts for UMass Amherst Libraries for finding the copy of Visitors, Hugh Joudry's radio play.Ask a question about VermontVote on the question you want us to tackle nextSign up for the BLS newsletterSay hi on Instagram and Reddit @bravestatevtDrop us an email: hello@bravelittlestate.orgCall our BLS hotline: 802-552-4880Make a gift to support people-powered journalismLeave us a rating/review in your favorite podcast appTell your friends about the show!Brave Little State is a production of Vermont Public and a proud member of the NPR Network.

Among the most striking exhibits at the Auschwitz museum are undoubtedly the mountains of loot stolen from Jews murdered upon arrival. Shoes, suitcases, spectacles, and more fill entire rooms in the former barracks of the main camp. Surviving the Shoah when their owners did not, they constitute a potent proof of the Nazis' abiding concern with material gain. In this talk, author and historian Peter Hayes traces the ways by which the German corporate world became deeply implicated in—and in many respects indispensable to—the Nazi regime's persecution, exploitation, and murder of Europe's Jews. He argues that these developments stemmed inexorably from decisions made and actions taken by the nation's leading corporate executives in 1933, at the very outset of Nazi rule. Hayes is author or editor of 13 books, including the best-selling “Das Amt und die Vergangenheit” and “Why? Explaining the Holocaust,” which has been translated into several foreign languages including German, Slovak, Spanish, and Chinese. He is currently completing (with Stephan Lindner of Munich) “Profits and Persecution: German Big Business, the Nazi Economy, and the Holocaust.” Series: "Library Channel" [Humanities] [Show ID: 38423]

Among the most striking exhibits at the Auschwitz museum are undoubtedly the mountains of loot stolen from Jews murdered upon arrival. Shoes, suitcases, spectacles, and more fill entire rooms in the former barracks of the main camp. Surviving the Shoah when their owners did not, they constitute a potent proof of the Nazis' abiding concern with material gain. In this talk, author and historian Peter Hayes traces the ways by which the German corporate world became deeply implicated in—and in many respects indispensable to—the Nazi regime's persecution, exploitation, and murder of Europe's Jews. He argues that these developments stemmed inexorably from decisions made and actions taken by the nation's leading corporate executives in 1933, at the very outset of Nazi rule. Hayes is author or editor of 13 books, including the best-selling “Das Amt und die Vergangenheit” and “Why? Explaining the Holocaust,” which has been translated into several foreign languages including German, Slovak, Spanish, and Chinese. He is currently completing (with Stephan Lindner of Munich) “Profits and Persecution: German Big Business, the Nazi Economy, and the Holocaust.” Series: "Library Channel" [Humanities] [Show ID: 38423]

Among the most striking exhibits at the Auschwitz museum are undoubtedly the mountains of loot stolen from Jews murdered upon arrival. Shoes, suitcases, spectacles, and more fill entire rooms in the former barracks of the main camp. Surviving the Shoah when their owners did not, they constitute a potent proof of the Nazis' abiding concern with material gain. In this talk, author and historian Peter Hayes traces the ways by which the German corporate world became deeply implicated in—and in many respects indispensable to—the Nazi regime's persecution, exploitation, and murder of Europe's Jews. He argues that these developments stemmed inexorably from decisions made and actions taken by the nation's leading corporate executives in 1933, at the very outset of Nazi rule. Hayes is author or editor of 13 books, including the best-selling “Das Amt und die Vergangenheit” and “Why? Explaining the Holocaust,” which has been translated into several foreign languages including German, Slovak, Spanish, and Chinese. He is currently completing (with Stephan Lindner of Munich) “Profits and Persecution: German Big Business, the Nazi Economy, and the Holocaust.” Series: "Library Channel" [Humanities] [Show ID: 38423]

Before and during WWII, German corporations went from the abandonment of Jewish colleagues, through profiting off the dispossession and murder of Jews, to working Jews to death. The leading executives of these companies embodied the “thoughtlessness,” the indifference to the people on the receiving end of their deeds. The actions taken by most of them, weren't just a means to keep their businesses running , but an opportunity to profit and shine - a "banality of evil" with deadly and lucrative results. In this episode, we hear about some of these executives, and some of these companies - several of which still manufacture and distribute products we may find ourselves using today.Featured guest: Peter Hayes, Emeritus professor at Northwestern University, and the former chair of the academic committee at the United States Holocaust Memorial Museum.

Peter Hayes's book Why? Explaining the Holocaust (Norton, 2017) explores one of the most tragic events in human history by addressing eight of the most commonly asked questions about the Holocaust: Why the Jews? Why the Germans? Why murder? Why this swift and sweeping? Why didn't more Jews fight back more often? Why did survival rates diverge? Why such limited help from outside? What legacies, what lessons? An internationally acclaimed scholar, Hayes brings a wealth of research and experience to bear on conventional views of the Holocaust, dispelling many misconceptions and challenging some of the most prominent recent interpretations. Joe Tasca is a host and a reporter for the NPR affiliate in Providence, Rhode Island. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/new-books-network

Peter Hayes's book Why? Explaining the Holocaust (Norton, 2017) explores one of the most tragic events in human history by addressing eight of the most commonly asked questions about the Holocaust: Why the Jews? Why the Germans? Why murder? Why this swift and sweeping? Why didn't more Jews fight back more often? Why did survival rates diverge? Why such limited help from outside? What legacies, what lessons? An internationally acclaimed scholar, Hayes brings a wealth of research and experience to bear on conventional views of the Holocaust, dispelling many misconceptions and challenging some of the most prominent recent interpretations. Joe Tasca is a host and a reporter for the NPR affiliate in Providence, Rhode Island. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/history

Peter Hayes's book Why? Explaining the Holocaust (Norton, 2017) explores one of the most tragic events in human history by addressing eight of the most commonly asked questions about the Holocaust: Why the Jews? Why the Germans? Why murder? Why this swift and sweeping? Why didn't more Jews fight back more often? Why did survival rates diverge? Why such limited help from outside? What legacies, what lessons? An internationally acclaimed scholar, Hayes brings a wealth of research and experience to bear on conventional views of the Holocaust, dispelling many misconceptions and challenging some of the most prominent recent interpretations. Joe Tasca is a host and a reporter for the NPR affiliate in Providence, Rhode Island. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/military-history

Peter Hayes's book Why? Explaining the Holocaust (Norton, 2017) explores one of the most tragic events in human history by addressing eight of the most commonly asked questions about the Holocaust: Why the Jews? Why the Germans? Why murder? Why this swift and sweeping? Why didn't more Jews fight back more often? Why did survival rates diverge? Why such limited help from outside? What legacies, what lessons? An internationally acclaimed scholar, Hayes brings a wealth of research and experience to bear on conventional views of the Holocaust, dispelling many misconceptions and challenging some of the most prominent recent interpretations. Joe Tasca is a host and a reporter for the NPR affiliate in Providence, Rhode Island. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/german-studies

Peter Hayes's book Why? Explaining the Holocaust (Norton, 2017) explores one of the most tragic events in human history by addressing eight of the most commonly asked questions about the Holocaust: Why the Jews? Why the Germans? Why murder? Why this swift and sweeping? Why didn't more Jews fight back more often? Why did survival rates diverge? Why such limited help from outside? What legacies, what lessons? An internationally acclaimed scholar, Hayes brings a wealth of research and experience to bear on conventional views of the Holocaust, dispelling many misconceptions and challenging some of the most prominent recent interpretations. Joe Tasca is a host and a reporter for the NPR affiliate in Providence, Rhode Island. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/jewish-studies

Peter Hayes's book Why? Explaining the Holocaust (Norton, 2017) explores one of the most tragic events in human history by addressing eight of the most commonly asked questions about the Holocaust: Why the Jews? Why the Germans? Why murder? Why this swift and sweeping? Why didn't more Jews fight back more often? Why did survival rates diverge? Why such limited help from outside? What legacies, what lessons? An internationally acclaimed scholar, Hayes brings a wealth of research and experience to bear on conventional views of the Holocaust, dispelling many misconceptions and challenging some of the most prominent recent interpretations. Joe Tasca is a host and a reporter for the NPR affiliate in Providence, Rhode Island. Learn more about your ad choices. Visit megaphone.fm/adchoices Support our show by becoming a premium member! https://newbooksnetwork.supportingcast.fm/genocide-studies

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

As we head into 2023, our conversation reflects on the recent performance drivers of munis and outlines expectations for the year ahead. We also focus on risk factors and considerations when it comes to positioning within munis. Featured are Peter Hayes, Head of Municipal Bonds for BlackRock, and Kathleen McNamara, Senior Municipal Bond Strategist Americas for the UBS Chief Investment Office. Host: Daniel Cassidy

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

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

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  

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