Podcast appearances and mentions of vikas saini

From selling deceased patients' body parts to denying cancer treatment over upfront payments, the Lown Institute's annual Shkreli Awards spotlight the most egregious examples of profiteering and dysfunction in American healthcare. Dr. Vikas Saini, President of the Lown Institute, walks us through 2024's (dis)honorees and what they reveal about the state of our healthcare system.We cover:

You remember a guy named Martin Shkreli? If his name rings a bell, it's probably because back in 2015, he jacked up the price of an old drug — from around $13 a pill to $750. The media dubbed him “the pharma bro,” and he became a symbol of brazen pharmaceutical greed. Now, he's the namesake for the Shkreli Awards — a kind of Oscars for the most outrageous examples of greed, fraud, and general brokenness in American health care. Every year, a health care think tank called the Lown Institute ranks the top ten worst stories and holds an award ceremony to “honor” the winners. We're bringing you highlights from this year's ceremony – featuring things like human bones for sale without the consent of the deceased or their families, phantom urinary catheters, and so much more – and some reflections from the Lown Institute's president, Dr. Vikas Saini. “Showing all these stories together paints a picture of a health care system in desperate need of transformation,” Saini said at the ceremony. “Not just because the stories are shocking, but because often what they're depicting, like Martin Shkreli's infamous price hike, is perfectly legal.” Here's a transcript of this episode. Send your stories and questions. Or call 724 ARM-N-LEG.Of course we'd love for you to support this show. Hosted on Acast. See acast.com/privacy for more information.

The murder of a healthcare CEO has led to an overdue conversation about health insurance in the US. The reaction to the news is revealing a visceral anger about the unfairness and dysfunction of how we pay for healthcare. What makes our system so frustrating for people? And what are the solutions? On Say More this week, host Shirley Leung turns to Casey Ross, an investigative reporter with Stat News and Dr. Vikas Saini, a cardiologist who runs the Lown Institute here in Massachusetts. Email us at saymore@globe.com. See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place. To Read The Full Article Including Links Mentioned, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. This first part you are listening to right now zeros in on Shawn's first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met. Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you're done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources. The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there's two more takeaways there. So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase. If you're still with me for this Part 1—and I hope you are, because … wow, it's a wild and tangled journey—here's an outline of where this first part of the discussion is headed. So, for the sake of posterity and having this introduction transcribed in your inbox (be sure to sign up for the free newsletter), here you go. Here's the outline. Visit the full article to read more. 05:25 Shawn's three takeaways from the 340B program. 06:04 What is the intent of the 340B program? 08:22 Read the full 32-page report of the Energy and Commerce Committee.  09:17 Why does Medicaid have to get the best price? 13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s? 15:11 Why do more than half of acute care hospitals now qualify for 340B? 18:18 How has hospital consolidation affected 340B? 20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals? 24:11 How is a 340B designed for hospitals to make a profit? 28:45 Why isn't there a real patient definition in 340B? 31:46 Why is 340B still popular among policymakers? 33:05 Are 340B dollars being used in underserved communities? 33:57 EP394 with Vikas Saini, MD, and Judith Garber, MPP.

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)

Overtreatment is a big problem in American health care. The proliferation of unnecessary medical tests and procedures not only harms patients but costs the United States billions of dollars every year. Between 2019 and 2021, Medicare spent as much as $2.4 billion on unnecessary coronary stents alone. At some hospitals, it's estimated that more than half of all stents are unwarranted. For this week's episode of The Dose podcast — the latest in our series on the affordability of health care — host Joel Bervell talks to Vikas Saini, M.D., a cardiologist and the executive director of the Lown Institute, a think tank that examines overspending and overtreatment in the health care system. Dr. Saini unpacks how health care practices are misaligned with patient needs and discusses strategies for “rightsizing” U.S. health care.

I couldn't resist the “who's suing who” because, yeah, you can't go wrong with Aretha Franklin references. Back on the pod we have Chris Deacon, who is going to give us a rundown of the legal goings-on going on right now that impact self-insured employers, carriers, hospitals, and taxing authorities like cities. Chris breaks down the legal activity into three main categories, and then we discuss some examples of lawsuits in each category. So, here's the outline of our upcoming conversation: 1. Breach of Fiduciary Line of Cases Against Carriers a.    Bricklayers vs Anthem Class Action b.    Mass Laborers vs Blue Cross Blue Shield c.     Member vs Cigna 2. Carrier vs Hospital (upcoding) and Hospital vs Carrier (underpayment) a.    United vs TeamHealth b.    TeamHealth vs United 3. Taxing Authority vs Nonprofit Hospitals a.    Tower Health line of cases in Pennsylvania b.    Pittsburgh vs UPMC This episode itself is a little on the longer side—and I didn't want to edit too many of Chris's words of wisdom—so I'm gonna make this a little bit shorter, this intro. But just one point that I'll make, and this is about the first category of legal activity wherein self-insured employers mostly try to pass the “who is actually the fiduciary” hot potato to carriers, ASOs (administrative services only), and TPAs (third-party administrators). And the carriers, ASOs, and TPAs are like, “It ain't us.” Moving forward here, I'm just gonna say carriers as a catchall for carriers, ASOs, and TPAs to save myself a mouthful. But bottom line on this topic, I just want to underscore something that Chris makes clear later on in the show: Plan sponsors (ie, self-insured employers) are the fiduciary, the sole fiduciary, at least according to the carriers who are getting sued right now. This is the position that you can see them taking in every lawsuit that I have seen. What the carriers say also, as a follow-on, is that if there is any contractual language between the carrier and the employer that violates the CAA (Consolidated Appropriations Act) or any other regulations, it is or was the employer's responsibility to not sign the contract. It's not the carrier's responsibility to point out that there's stuff in their own contract that's in violation for the employer to sign. And this includes contracts that don't give self-insured employers the right to their own data, which is pretty much a rate critical for any and all CAA compliance. As Justin Leader wrote the other day in reference to the bricklayer case, “To get to the point of filing the suit, there was a solid 2 years of failed negotiations [for the bricklayers to get their own claims] data.” Two years trying to get claims data that is necessary for a fiduciary to have from a carrier who is saying essentially, “Good luck with that. You're the ones that signed our contract.” Here's one of Chris Deacon's latest LinkedIn posts about this topic. And here's another one from Jeff Hogan that was interesting. Also, here's the link to the earlier episode with Chris (EP342), where we dive into the deep end on the topic of the CAA, which was signed into law at the beginning of 2022 and states that self-insured employers have certain rights and responsibilities based on their role as the fiduciary of their health plan. For more on the Member vs Cigna case, check out the encore episode with Dawn Cornelis (Encore! EP285). The show with Vikas Saini, MD, and Judith Garber, MPP (EP394) comes up where we talked about hospitals and their charitable giving. And lastly, I mention the show with Suhas Gondi, MD, MBA (EP404) about who is on the board of directors of hospitals, big nonprofit hospitals in particular. My guest in this healthcare podcast, Chris Deacon, is a lawyer by training. She ran the state health plan for the state of New Jersey, which covered about 820,000 public-sector lives. She now has an independent consulting firm, VerSan Consulting.   You can learn more at versanconsulting.com and connect with Chris on LinkedIn. You can also email her at cdeacon@versanconsulting.com.   Chris Deacon has a deep understanding of the fiduciary role health plan administrators hold and should be leveraging in order to drive value for their plan sponsors and members. An attorney by training, Deacon formed VerSan Consulting, LLC, in order to educate and engage employers to be more prudent purchasers of healthcare. From creative procurement methodologies and demanding contracts to population health initiatives and primary care investment, Deacon believes that large employer-sponsored health plans have not only an opportunity but an obligation to drive healthcare transformation that delivers value for the market. Prior to founding VerSan Consulting, Deacon ran one of the largest health plans in the country for the New Jersey Department of Treasury, which covered over 820,000 public-sector lives, including state employees, teachers, and uniformed professionals. During her tenure, Deacon was credited with helping the state save over $3 billion through a number of initiatives, including enhanced oversight, payment integrity programs, procurement strategy, and strict accountability for the vendors with which the state engaged. Deacon has also served as a deputy attorney general and then special counsel to Governor Christie where she oversaw the Department of Banking and Insurance, Economic Development Authority, and Treasury. She holds a JD from Rutgers Law School and bachelor's degree in international affairs from The George Washington University.   04:47 What does the current legal landscape look like, and how does it bode for the future? 07:24 “We need to catch the legal framework up with the current reality.” 19:53 How is this first circuit decision affecting who might be found liable in future cases? 21:38 What happened in the Member vs Cigna case? 24:49 Are we heading in the direction of the employer having fiduciary responsibility? 25:47 What's happening in the Carrier vs Hospital cases? 28:49 Who's really paying the price for the current business practices being examined in court? 30:00 What's happened in the Tower cases?   You can learn more at versanconsulting.com and connect with Chris on LinkedIn. You can also email her at cdeacon@versanconsulting.com.   @VerSan_cdeacon discusses current legal affairs in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #hcmkg #healthcarepricing #pricetransparency #healthcarefinance   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249), Eric Gallagher, Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285)  

Does more healthcare mean better care? In this episode, Vikas Saini discusses overuse in healthcare, which consists of unnecessary services that cost resources to the system and its users. He also highlights the importance of providing a space for providers to build a trusting relationship with their patients. He explains how this results in more efficient care, less overuse, and better outcomes. Tune in and learn more about how healthcare can benefit from a quality approach more than a quantity one! Learn more about the Institute of Healthcare Improvement on its website. Learn more about your ad choices. Visit megaphone.fm/adchoices

Let's cut to the chase. You've gotten to the point where you have a gang of physicians/clinicians/physician practices who have expressed a desire to work together. What do you need to know right now? Eric Gallagher, CEO of the Ochsner Health Network, is my guest in this healthcare podcast; and I largely asked him the same question that I had asked Amy Scanlan, MD, from the UCHealth/Intermountain clinically integrated network in Colorado in episode 402 a couple of weeks ago. The question I asked both Eric and Dr. Scanlan is: What are you doing to help align physician practices into an integrated model? How are you going about that? Now, let me remind you, Ochsner Health Network is practically long in the tooth when it comes to clinically integrated networks; and it also exists in an environment that is unique, as are most local markets. But Ochsner's local market is mostly Louisiana, which has an older population and a huge Medicare Advantage penetration. That is quite a different local market from what's going on in Colorado, which is the location of Dr. Scanlan's joint. As we all know, different stages of any journey require different solution sets; and different local markets certainly require different solution sets. But what was so interesting to me was to notice that despite the market differences and the where-are-we-in-the-transformation-journey differences, how many of the things that you'll hear about in this episode are in the same spirit as the stuff that we talked about in that earlier show with Dr. Scanlan. Eric Gallagher lists three things that he says are essential in the transformation journey: 1. Making sure that physicians, care teams, and those working directly with patients are part of the transformation process, both from a practice standpoint but then also from a financial standpoint. This makes so much sense when I state it explicitly here, but so frequently, it doesn't happen. So frequently there's a value-based care team that tinkers around in a silo and then an announcement comes over the loudspeaker one day that henceforth we shall add some more clicks … but trust us, it's important for some reason we aren't going to bother to tell you about … you'd be bored by it or you wouldn't understand it. Even if this was not the intention (and it probably wasn't), the result is going to be the bad taste in your mouth that I just left you with. Eric Gallagher's #1 here, that everybody be part of the transformation, might be the umbrella really over the first thing that Dr. Scanlan talked about in that earlier episode, which was to make sure to give practices the tools that they need to succeed—not what you think they need but what you've discerned they actually need because you've listened to them. It's a bidirectional exchange here with everybody working together. Eric adds some new ground to that. He says that to make sure that everybody can productively contribute to this transformation process (and probably know what tools they may need), it's vital that everybody understands the “why” behind what the organization needs to do, meaning educating physicians and other clinicians in the business of medicine and the financial reasons for the “why” with the whatever. Insulating docs from the real world here helps no one, and it's not really viable actually in the world that we live in today … … which is a callback to the point that Denver Sallee, MD, made also in episode 402, which, in a nutshell, was that he thinks that unless docs, as a gang, start learning a lot more about the business of medicine, that we'll continue to see this value extraction and financial toxicity and moral injury–inducing environments that we see right now. Dr. Sallee wrote, “I needed more education in order to truly help patients.” So, let me posit that this “everybody works together and gets educated together” step can help the practice and help patients in a myriad of ways, both at the practice level and at the patient level and also probably at a national level. 2. A recognition that practice transformation requires process transformation and thinking about things very differently. Now, all of a sudden, we are getting paid to coordinate care. We must work as a team because there are people on staff who can influence social determinants of health, for example. We have a vested interest to create a community board advocating for food banks and sidewalks and air pollution controls so all the kids who play soccer don't wind up with asthma. Ochsner actually set up a school because they realized educated communities are healthier communities. Dr. Scanlan's clinically integrated network? They're much earlier in the journey. They're at the point where they're working hard to get participating practices the tools that they need to succeed and help doctors and other clinicians help patients through what Dr. Scanlan calls the “in-between spaces”—the times between appointments. But all of this really rolls up to the point that Eric Gallagher is making about everybody working together and recognizing that practice transformation requires process transformation. 3. The culture change that's necessary among physicians and other clinicians (pretty much everybody), and Dr. Amy Scanlan leaned into this one, too—hard. Both brought up the same nemesis: inertia. And the requirement to change culture can't be underestimated, and the change management that's required here cannot be phoned in. Culture eats strategy for breakfast, lunch, and dinner, as they say. My two macro-level takeaways after talking with Eric Gallagher today and Dr. Amy Scanlan earlier are that, even though the local market and the nuances of any given particular practice have such a huge impact on what's going to work at an operational and tactical level, if we stay up in the strategic zone, there's some best practices and points to ponder which are likely possible to universalize. Now, emphasis on the “stay up in the strategic zone.” I was just talking to another person today with yet one more story amounting to “it didn't work because it never was going to work,” wherein, in this case, apparently a very large payer is running around attempting to do a pilot in an attempt to learn exactly and specifically how to operationalize something, and then their plan is to roll out this one model nationwide. So, something works in one local market at one practice, and we're just gonna assume if it worked there, it's gonna work everywhere. And, yeah … good luck with that. After you listen to this show, listen to episode 402 with Amy Scanlan, MD, as I have mentioned multiple times. Episode 343 and episode 316 with David Carmouche, MD, would be good to check out. Also episode 393 with David Muhlestein, PhD, JD, and episode 394 with Vikas Saini, MD, and Judith Garber, MPP.   You can learn more at Ochsner Health Network.     Eric Gallagher, chief executive officer for Ochsner Health Network (OHN), is responsible for directing network and population health strategy and operations, including oversight of performance management operations, population health and care management programs, value-based analytics, OHN network development and administration, strategic program management, and marketing and communications. Prior to joining Ochsner in 2016, Eric held leadership positions in healthcare strategy and execution—including roles at Accenture, Tulane University Health System, and Vanderbilt University and Medical Center. A New Orleans native, Eric earned a bachelor's degree in human and organizational development from Vanderbilt University and an MBA from Tulane University.   08:14 What does everyone need to be on the same page about when it comes to clinical integration? 13:42 “For physicians, we really have to overcome this threat to physician autonomy.” 16:52 “Health inequity is really just societal inequity.” 19:24 What is the principal agent problem? 20:00 “There are things health systems can do that are probably outside of their traditional field of responsibility.” 20:09 Why did Ochsner Health Network start a couple of schools? 20:42 What can empower a care team in a value-based care model? 21:53 Why is it important to transform into a team-based model? 23:24 “In the DNA of our organization, resiliency runs strong.” 26:01 Why is building an effective care model easier than building trust with patients? 26:14 What is Eric's advice to physicians trying to integrate right now? 28:50 How do you get everyone on the same side of aligning for integration?   You can learn more at Ochsner Health Network.   Eric Gallagher of @OchsnerHealth discusses #clinicalintegration for #physicians on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Suhas Gondi, Dr Rachel Reid, Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde  

So, let me just cut to the chase here with very little preamble, and all of this is a setup to the interview that follows, although it is not really what the interview that follows is all about. A mentor of mine used to say, you can't legislate the heart. Let me also suggest you can't give someone in finance financial incentives and then expect them to not prioritize financial incentives. It stands to reason that if the healthcare industry is found to be quite attractive to those who are money focused, then do I need to say this? The money focused amongst us will, of course, do the whatever to the extent that they can make money. They aren't gonna be throwing their backs into quality or cost effectiveness or taking care of patients. They are throwing their backs into making money. Is anyone shocked? Now, don't get me wrong; I'm not a Pollyanna. And in this country, in order to run a healthcare business, you have to make money; otherwise, you'll go out of business. So, do well by doing good and all of that. But how much money is too much money? This is an important line to figure out because that's where you are doing well but you've stopped doing good—you've tipped into financial toxicity. You are taking more than the good you are doing, and the net positive becomes a net negative. But complicating fact of current life, it's becoming increasingly obvious that in order to stand up a practice that can take advantage of value-based care payments—payments where primary care docs mainly at this time can get paid more and likely more fairly to care for patients well—you need a lot of infrastructure. You need data, you need tech, you need a team. Translation: You need money, maybe a lot of money, to invest in all of this. And let me ask you this: Who has a lot of money in this country? Here's the point of everything I just said: These are the external realities that hit anyone trying to do right by patients from every direction. But on the other hand (or maybe different fingers on the same hand), as Amy Scanlan, MD, says in this healthcare podcast, physicians are the backbone of this system. Dr. Scanlan talks in the interview today about the opportunity, and maybe the responsibility, that physicians have here for patients; but also the Eric Reinhart article comes up again about rampant physician moral injury (unpaywalled link with my compliments). Right now might be a great time to read something from Denver Sallee, MD. He wrote to me the other day. He wrote, “Like many physicians, I did not have much understanding of the business side of medicine, as I mistakenly thought as long as I helped take great care of patients that I was doing my job. More recently, it became apparent to me that by ceding the management of medicine to nonclinical administrators and to companies interested primarily in value extraction for the benefit of shareholders that I needed more education in order to truly help patients.” Today as aforementioned, I'm talking with Amy Scanlan, MD, who is chief medical officer of the clinically integrated network (CIN) that is the new joint venture between Intermountain Health and UCHealth in Colorado. We talk about what it's like to be in the kind of messy middle of transformation to integrated care in a clinically integrated network, trying to figure out how to help physician practices and the CIN itself navigate the external environment in a way that empowers different kinds of practices at different points in their transformation journey that empowers physicians to be in charge, and considering clinical and financial outcomes (ie, the business of healthcare). Dr. Scanlan brings up four main factors to consider when plotting strategy from here to there: 1. Give practices the tools that they need to succeed—not what you think they need but what you've discerned they actually need because you've listened to them. 2. Many times, these tools will consist of some combination of data, tech, and also offering the team behind the scenes to help doctors and other clinicians help patients through what Dr. Scanlan calls the “in-between spaces”—the times between appointments. 3. Medical culture really has to change, and in two ways: doctors learning how to be part of and/or leading functional teams and building functional teams. Because there are teams, and then there are teams. Well-functioning teams can produce great results. Nonfunctioning teams, however, are, as Dr. Scanlan puts it, just a series of handoffs. And don't forget, handoffs are the most dangerous times for patients. The DNA of team-based care—real team-based care—for better or worse, are the relationships between team members, between physicians who work together, between doctors and patients, between clinicians and clinicians. So, fostering relationships, creating opportunities to collaborate and talk, is not to be underestimated. How do you re-create the doctors' lounge in 2023? 4. Getting out from underneath the long shadow of fee-for-service incentives, specifically the paradigm that only patients who get mindshare are the ones in the exam room. Value-based care, integrated care is as much contemplating the patients who don't show up as the ones who do. This is a really big mind shift, much bigger than many realize.   You can learn more by reaching out to Dr. Scanlan on LinkedIn.     Amy Scanlan, MD, serves as chief medical officer for the new joint venture CIN between UCHealth and Intermountain Health—a physician-led, clinically integrated network of more than 700 primary care providers from UCHealth, Intermountain Health Peaks Region, the University of Colorado School of Medicine, and multiple independent practices along the Front Range. Dr. Scanlan trained as a family practice physician and has continued to practice for the past 25 years. She has worked as a physician-owner in a small independent practice and has held multiple leadership positions as part of large health systems. She has served on numerous health system committees spanning quality, innovation, recruitment, and credentialing. She is very familiar with value-based care models, having been part of an accountable care organization (ACO) practice for the past 15 years, as well as participating on an ACO Practice Performance and Standards Committee and serving on a local ACO board. She received a bachelor's degree with honors from Wesleyan University in Connecticut. She obtained her medical degree from Case Western Reserve University in Cleveland, where she received the Kiwala Award for Research in Family Medicine. Her residency was completed at St. Anthony's Family Medicine Residency program in Denver. She is currently board certified by the American Board of Family Medicine and NCQA (National Committee for Quality Assurance) certified in diabetes.   06:33 How is Dr. Scanlan thinking about the transformation process and the shift to value? 09:14 “It is really trying to think about, how do we help practices get there?” 11:46 “The hard part is the in-between spaces.” 14:10 “Team-based care done badly is really just a series of handoffs.” 15:50 “We have to get to that point where the culture of collaboration is more pervasive.” 19:57 “How do we as healthcare providers step in and solve this problem?” 20:04 Why do providers have a responsibility to step in and try to fix the healthcare system? 20:20 Article (unpaywalled) by Eric Reinhart, MD, PhD. 21:50 Why do physicians need to be accountable for the cost of care as well as outcomes? 23:37 Why does physician burnout give Dr. Scanlan hope? 24:25 What is the solution to changing fee-for-service incentives? 25:42 What are some of the challenges facing changing incentives? 27:14 Why is data so important? 28:53 EP393 with David Muhlestein, PhD, JD. 30:11 “It's important to understand that we are in the middle of this change.” 31:16 Dr. Scanlan's advice for those trying to stand up a CIN.   You can learn more by reaching out to Dr. Scanlan on LinkedIn.   Amy Scanlan, MD, of @uchealth discusses real-world #clinicalintegration on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber  

Somebody wrote on Twitter the other day that he was gonna give a talk on the use of evidence in drug policy, and Barrett Montgomery replied, “That'll be a short talk then!” So, let's talk about the IRA (Inflation Reduction Act) for a moment, specifically the “CMS can negotiate for drugs for Medicare patients” part of the IRA. There's one topic I don't hear discussed what I would consider maybe often enough. Will these negotiations result in pricing that is evidence based? Will good drugs that companies developed using less taxpayer money for R&D, drugs that positively impact the patient lives or have spillover benefits for society or save downstream medical costs, drugs that have solid comparative evidence data, drugs that are a meaningful therapeutic advancement over competitors ... will these drugs be priced in line with that value? Everything I just mentioned, by the way, are things that CMS is supposed to take into account during its negotiations. So, that's what this show is all about. To have this conversation, I invited Dr. Peter Neumann on the podcast because Dr. Neumann (along with his two coauthors, Joshua Cohen and Daniel Ollendorf) just wrote a book about pharmaceutical pricing entitled The Right Price. I convinced Dr. Neumann to come on the show and talk about what the likely impact the IRA will have on these right drug prices. And short version, Dr. Neumann told me that “presumably drugs that offer more therapeutic advances will do better under these negotiations.” Here's a really, really top-line summary of the negotiation provisions that are in the IRA: CMS will negotiate prices on the highest gross spend top 10 Part D drugs in 2026, 15 Part D drugs in 2027, and 15 drugs from Medicare Part B and D for 2028. Small molecule drugs become negotiation contenders after 9 years, and biologics after 13 years. Once a generic or biosimilar comes out (ie, the patent is well and truly expired), then this negotiation provision is no longer in play. Now, CMS is given some discretion over how it's going to do things, and they will issue guidance and figure out how to implement the law over the next couple of years. As with so many things (and Chris Deacon talked about this recently on LinkedIn), it's how that law is operationalized that actually determines if it achieves this “right price” goal and/or—and Dr. Neumann, my guest in this healthcare podcast, makes this point really clearly, too—maybe the point of the law is as much about cost containment, frankly, as it is about achieving value-based “right” prices. And cost containment and value-based pricing are not the same thing. I'm gonna do a show on this coming up. So, what are the likely effects of the IRA pharma price negotiation provisions? And not talking about the whole IRA here and the cadre of other stuff like patient out-of-pocket caps and inflation caps. This show is complicated enough just talking about the negotiation portion and just talking about its potential to achieve pricing based on “value.” Here's a summary of likely impact of Medicare drugs being negotiated, some of which we talk about in this episode. There's “seven-ish” main implications: 1. “Some Medicare patients will benefit substantially from negotiations …, as a reduction in the drug's price will result in lower coinsurance and liability during the deductible phase.” Okay … this makes sense. 2. “Overall, negotiations are projected by the CBO [Congressional Budget Office] to reduce premiums, resulting in lower costs for all Medicare beneficiaries.” References: CBO estimates drug savings for reconciliation. Committee for a responsible federal budget. Accessed April 11, 2023. https://www.crfb.org/blogs/cbo-estimates-drug-savings-reconciliation  Congressional Budget Office. Estimated budgetary effects of Public Law 117-169, to provide for reconciliation pursuant to Title II of S. Con. Res. 14. Published 2022. Accessed April 11, 2023. https://www.cbo.gov/system/files/2022-09/PL117-169_9-7-22.pdf Okay … so, this #2 here is kind of thought provoking, especially when it's unclear at this time whether the negotiated price will refer to the list price, the AWP (average wholesale price), or the rebated price (ie, the price after rebates are applied). There are many, many implications if the negotiated price is before or after rebates, just given how “addicted” plans are to rebates and use the rebates, and cost shifting to patients, in a convoluted and super-inefficient way to try to keep premiums down. Listen to the show with Chris Sloan (EP216) for more on this. 3. There's more incentive to go after biologics than small molecule drugs—obvious, due to the 9-year versus 13-year thing. There's additionally some incentive for rare-disease and orphan drugs, most of which are biologics, in other parts of the IRA. 4. More interest in drugs for non-Medicare markets (ie, drugs for diseases of younger populations, perhaps) 5. Possibly less pharma innovation, fewer drug launches Oh, boy, with this one. Listen to the show with Mark Miller, PhD (EP380), for many, many nuances here. But let me give you a few things to think through, and I'd start with four words: We are chasing Goldilocks. There are two ends of the spectrum, and neither are good. On one end, Pharma charges way too much and the system gets bankrupted while pharma shareholders get rich. On the other side of the spectrum, there's not enough returns for any investors to invest in new drug development. It's all about moderation—finding the sweet spot in the middle—something the healthcare industry has a super hard time with. Bottom line, we want to incent meaningful innovation, drugs that actually work. If we pay a ton of money for drugs that don't work particularly well, then what's the incentive to find good drugs? As per my earlier point, if this legislation does as was intended, then good drugs should get rewarded and less comparatively effective drugs should be less rewarded. Let's cross our fingers, shall we? 6. Will Pharma raise its launch prices because the negotiations center on discounts? A higher price times the discount means a higher discounted price, after all. This one could be exacerbated by the part of the IRA that mandates inflation caps. There is some evidence that higher launch prices are already happening. 7. Manufacturers wait to launch until they have all their indications ready to go. If you didn't understand this, we explain in more detail during the interview. 8. There are incentives for Pharma to jack up commercial prices. Because they're making less money in Medicare, they try to make more money in the commercial market. But as Dr. Neumann says, you'd think that if Pharma could do that, they already would have done it. Or let me say that a different way: You'd think that if Pharma could have raised their commercial prices more than they already have been raising their commercial prices, they would have already done it. So, I think whether cost shifting actually increases here is a sizable question mark. 9. There's also less incentive for Pharma to innovate me-too kinds of drugs. If a drug in the same class for the same disease is being negotiated, then a new drug coming out in that same category might sort of have to charge a price similar to the negotiated price of the other drug. Dr. Peter Neumann, my guest in this episode, has a background in health economics and currently directs a research center that's focused on health economic issues. His group does a lot of work trying to understand the cost effectiveness of drugs and other health interventions. Other shows you should, for sure, listen to here are the ones with Mark Miller, PhD (EP380); Anna Kaltenboeck (EP303); Bruce Rector, MD (EP300); Scott Haas (EP365); and Chris Sloan (EP216). These shows offer context and adjacencies that are extremely relevant right now if you're gonna understand the potential impact of the IRA. Here's a quote from the book The Right Price (written by Dr. Peter Neumann and his coauthors, Joshua Cohen and Daniel Ollendorf) that I thought summed up some of the issues here very nicely: If there existed a Rorschach test for drug prices, it might conjure one of two images. Some people might perceive prices as a compass directing companies to invest in products that people value most. Aligning prices with value is akin to a “true north” orientation of the compass's arrow. Failure to link prices with value sends misleading signals to drug producers. Others might regard drug prices as a wall preventing patients from accessing the drugs they need. For them, the barrier should be as low as possible. But aligning prices with value might have little effect in lowering the wall. How then to accomplish that goal?   You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.   Peter J. Neumann, ScD, is director of the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center and professor of medicine at Tufts University School of Medicine. He is the founder and director of the Cost-Effectiveness Analysis Registry, a comprehensive database of cost-effectiveness analyses in healthcare. Dr. Neumann has written widely on the role of clinical and economic evidence in pharmaceutical decision-making and on regulatory and reimbursement issues in healthcare. He served as co-chair of the 2nd Panel on Cost-Effectiveness in Health and Medicine. He is the author or coauthor of over 300 papers in the medical literature and the author or coauthor of three books: Using Cost-Effectiveness Analysis to Improve Health Care (Oxford University Press, 2005); Cost-Effectiveness in Health and Medicine, 2nd edition (Oxford University Press, 2017); and The Right Price: A Value-Based Prescription for Drug Costs (Oxford University Press, 2021). Dr. Neumann has served as president of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). He is a member of the editorial advisory board of Health Affairs and the panel of health advisors at the Congressional Budget Office. He has also held several policy positions in Washington, DC, including special assistant to the administrator at the Health Care Financing Administration. He received his doctorate in health policy and management from Harvard University.   09:33 Is it imperative that drugs whose patents are expiring have their prices negotiated? 10:50 “We need innovation; we want to encourage innovation.” 11:01 Does this new law strike a balance between innovation and price regulation? 11:21 How are we assessing cost effectiveness and innovation in the drug space? 12:29 What's the problem with the current drug markets? 13:14 Why can't you rely on the drug market for the cost effectiveness of a drug? 14:13 Why very expensive drugs do not equate to poor value. 15:06 What are the likely outcomes of the IRA? 18:33 How does pharmacy budget factor into high-value drugs? 19:26 “Value-based pricing doesn't mean necessarily lower spending overall.” 22:59 What are the types of drugs that will be excluded from the IRA? 23:22 Who will the law create problems for? 24:44 What have pharmacy benefit managers (PBMs) been doing to move forward with the new law? 26:04 What are plan sponsors doing right now? 28:32 What are the most important value metrics according to Dr. Neumann?   You can learn more at cevr.tuftsmedicalcenter.org or by reading The Right Price.   @PeterNeumann11 discusses #drugprice #negotiations on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein  

I hope you listened to episode 399, which was Part 1 of this two-part exploration of my manifesto, meaning my aims and my path or framework to achieve those aims. Regarding the first part of my manifesto, episode 399 from two weeks ago, here's the tl;dl (too long, didn't listen) version; but please go back and listen to that show (Part 1) because it's about you—and it's a compliment and a thank you, and you deserve both. Just to quickly recap, Part 1 of my manifesto is that I started this show because I want to, and wanted to, provide information to those in the healthcare industry trying to do the right thing by patients, to get you the insights that you might need to pull that off, to create a Coalition of the Willing, as I've heard it called. When we get reviews like the one from Megan Aldridge, a self-proclaimed Relentless Health Value binge listener, I feel very gratified because it makes me feel like I'm chipping away at this mission and in a non-boring way. Thank you, Megan. Along these lines, there was also a recent review from Mallory Sonagere, who says she listens to learn new things and to be a little sharper at how she approaches her day job. And just one more I'll mention: I loved the review from Mark Nixon calling Relentless Health Value the best healthcare podcast out there. Every review like this I take as validation that maybe I can count some measure of success toward achieving the mission to empower others on their journeys to make it better for patients or to transform the healthcare industry. But this whole endeavor to create a manifesto is also borne out of me struggling personally to figure out what “having personal integrity” in this business actually means when it comes to deciding what to do and what not to do, when it comes to deciding who or what to try to help or support or who or what to step away from either passively or actively. I mean, how this podcast gets funded is my business partner and I pay for it with money from our consulting business and from some tech products that we have on offer. Who do we choose to take on as clients, and what are we willing to do for them or help them with? These are questions that literally keep me up at night. And this is what this episode, Part 2, is all about. It's about my struggle and how I attempt to navigate my own path forward. And holy shnikeys, it's tough to find a path, especially when you have the sort of perspective that I've wound up with over these past however many years. It can feel like no matter what I do, there's negatives as it relates to the Quadruple Aim. You raise one of the quadrants, and something else for somebody else certainly has the potential to be negatively impacted. We cannot forget here in the short term, but, for sure, often in the longer term as well, it's a zero-sum game. Every dollar someone takes in profit under the banner of improving health or even saving money is a dollar that someone else paid for. Is the amount of profit fair? Where'd that money come from? Is there COI (conflict of interest), and if so, what's the impact? I think hard about things like this. An inescapable fact is that there has been a financialization of the healthcare industry, and that includes everybody who also gets sucked into the healthcare industry whether they want to be or not (ie, patients/members and plan sponsors and, oftentimes, physicians and other clinicians, too). But the financialization of healthcare means that most everybody at the healthcare industry party has a self-interest to either make money or save money. And sometimes the saving money means saving money for themselves, not necessarily anything that is ever gonna accrue to patients or members. Now let's say I'm trying to determine if I want to take on a new client or decide if I personally want to promote or do something or other. This self-interest that abounds all around matters here because it means it is often very tough to find some kind of “pure” initiative to hitch your wagon to. The crushing reality that we all face is you gotta earn a living. The other reality is that often the person that benefits from the thing you want to do (ie, the patient) is not gonna pay for it. And frequently, physician organizations won't either. If everybody was lining up to pay to get something fixed, the problem would not be a problem, after all. But the only way your moral compass is the only moral compass in play is if you're doing whatever you're doing for free, really, or by yourself—and thus you are not encumbered by anybody else or any self-interest beyond your own … and your own motives are the only motives that you can control. I hear all the time initiatives and coalitions and advocacy organizations and even research funded by grants … these things also get bashed as suspect because who'd that money come from and whose “side” are the funders on. Nikhil Krishnan wrote on LinkedIn the other day (and I'm gonna do a little bit of editing, but yeah). He wrote: “Patients have low trust in healthcare because they think every stakeholder is incentivized not in their best interest. Many patients think the hospitals want to keep them sick, the [carriers and plan sponsors] don't want to pay their claims, the drug companies want to keep them on their meds, etc. And we can't pretend like that … isn't true.” Every party, every stakeholder has some measure of self-interest. They have to; otherwise, they'd be out of business. It's all a matter of degrees. No big group, no entire category gets to stand on the high ground here when you think like a patient. There's great hospitals and great people who work at hospitals, and then there's people doing things that cause a strikingly large percentage of patients to fear going to the hospital for clinical and/or financial reasons. Pick any other stakeholder and I'd tell you the same thing. Any other stakeholder. It's basically up to us as individuals to do the right thing. In every sector of the healthcare industry, there's good eggs and there's bad eggs and there's eggs in the middle just doing their day jobs as instructed. Personally, I want to be a good egg, and that's what my manifesto is all about. Let me dig into this a bit further for just a sec and then I'll continue with my personal manifesto for how I find my own path of integrity through all of this confusion. Here's another anecdote. Stuff like this I make myself crazy thinking about: I was listening to a podcast, and one of the guests said, “I wanted to get my MPH [Master of Public Health] because I felt a personal calling to be altruistic.” Then, 120 seconds later, he says something like, “So then, when it came time to pick my internship, I hunted around to find the one that paid the most money—and that's how I wound up working for an HMO in the '90s.” Consider how that strikes you. How do you feel about that guy right now, who, by the way, has gone on to support some very interesting and probably impactful initiatives? There's this commonly used phrase, “Let's do well by doing good.” So, back to that HMO intern. Let's just say we all agree that these HMOs were not unconflicted organizations. We all know they had a reputation for putting profits over members, and a reason they went out of business was because they denied care. They refused to pay claims for patients who had AIDS. And it turns out that the friends and families of people with AIDS are incredibly well organized and sued the crap out of the HMOs, which may have expedited their demise. You know what the intern was doing at the HMO? He was helping them with data analytics, and his personal goal was to use that data to improve patient outcomes. So, okay … here's the thought experiment: Do we want this HMO taking money that they're gonna take anyway and then not adding the value that they potentially could add with their data because they don't have any smart, dedicated, highly compensated interns working there to keep the ship pointed in a decent direction? I mean, I guess if I know I'm gonna spend a dollar as a member of that plan, I'd prefer to get as much as possible for my dollar that is already being spent. Maybe from that perspective, this guy is doing well by doing good. You see how this gets messy when you take a theoretical statement and then apply everyone's real-world prejudices and predilections to it. Here's a last point to ponder, and this is another thought experiment … so, just heads up and then I'll get to the point here: Say you are asked to help with a program run by a Medicare Advantage (MA) plan to provide those in need of transportation a ride to their annual wellness exam. Do you help? Those who listen to this show will fully understand there's a lot of self-interest involved in getting patients to the annual wellness exam because … risk adjustment. Also, star ratings. Listen to the show with Betsy Seals (EP375 and EP387) if you need the full story here. Short version is, MA plans can't upcode, either fairly or aggressively (if they are so inclined), if the patients don't show up for their annual physical. So, there's a lot of money for them at stake. But, then again, are physicals important for patients? Do they improve patient care and health? If we think yes, then again, is this doing well by doing good to help patients get to their appointments? After literally years of asking myself questions like this—and most of them were not thought experiments—I came up with my manifesto. And there are three parts to it, and I will go through each of them. But here's my manifesto in full: If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients. Here's how I think about the first part of my manifesto: If the thing results in a net positive for patients, then I'll do it. And keep in mind, I could talk about this for seven hours; so everything I'm saying is oversimplified to some degree and has as many nuances as there are stars in the sky. So, to calculate the net-positive impact, I think through what good the thing could do and weigh that against the negatives. And there are always negatives because, most of the time, the work that I do anyway has to get paid for by somebody and that somebody has some self-interest. Self-interest means that they are attaining something that furthers their business goals. Let me list two major upside/downside contemplations: 1. How much good does the thing actually do for patients? I think about this. What's the value here? Is it a little? Is it a lot? Will this thing be a distraction for clinicians, because time is often the most precious currency? If we're talking about some kind of navigation or utilization management, what's the reason someone wants to do this? Is the reason clinically and, for reals, evidence driven? Or are we predominantly doing this to enrich shareholders or save plan sponsors money in ways that are not a win-win for patients in the clinic right now trying to get cancer treatments for their kid? I try to think like a patient and be as impartial as possible. 2. Money. Where's the money for this thing coming from, and who wins in this particular initiative (ie, is it a win-win and patients win something worthwhile)? Now, the company doing the funding has got to win, too; otherwise, they wouldn't fund the thing. That's where it gets subjective, and, as aforementioned, do I care if the company in question wins if the patient wins, too? Or is this company so damn evil at its core that I am willing to sacrifice the opportunity to do a good thing for patients in order to not have anything to do with said possible funding entity. Or am I cutting off my nose to spite my face because this is a really important thing for patients and this particular company is the only one that's gonna fund it? Because tragedy of the commons or whatever else. Again, this gets dicey really fast. Let me poorly paraphrase a little exchange I saw on LinkedIn the other day that had me completely preoccupied during my work-from-home midday walk around the block for at least three days. Somebody wrote (maybe that Master of Public Health intern), “Given how intractable it feels to me to try to reduce healthcare spend, I think I'm going to try to help patients get more value out of the dollars that are currently being spent by them or on their behalf.” Do you think that's a worthy goal? Well, not everyone does. Somebody in T-minus 8 seconds responded, “That's a toxic way of thinking. Everyone who is not actively working to reduce healthcare spend by putting patients in cash-pay models is part of the problem.” This is a good segue into the second part of my manifesto. The first part is: If the thing results in a net positive for patients, then I'll do it. Here's the second part: The timeframe is short-term or medium-term. And here's what I mean by that. My main focus is helping patients right now. This is what this has to do with the aforementioned exchange on LinkedIn wherein someone was trying to figure out how to get more out of the dollars we're currently spending and someone else said that's toxic, because we should rip it all down and build a better model. There's incremental change, and then there's disruptive change. These two things are not mutually exclusive. Apparently, Mr. This Is Toxic doesn't agree with me, but as I said in the last episode, there's that Buckminster Fuller quote: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” And sure, I like to aspire to that as much as the next person. But does aspiring to a big hairy goal mean completely forgoing any incremental ways that patients can be helped immediately, like right now? If you ask me—and you're listening to this, so you de facto asked me—incremental change will probably actually support and beget disruptive change. So, incremental versus disruption is not a battle royale. These things are not diametrically opposed. They're probably actually aligned. I could go on a tangent here to explain why, but I'm not going to … except to say tipping points. But forget about that for a sec. Here's the more basic question: If all parties are interested in transforming healthcare, legit, how does someone trying to do it incrementally, or improve value for patients right now, in any way negatively impact someone trying to be disruptive and/or trying to change financial models? Keep all this in mind and now let me get back to my manifesto. I'm worried about patients, and I'm worried about them largely right now, short term to medium term. So, if I have the opportunity to help a patient—and I think about my two grandmothers (God rest their souls) here, but both of them would have died in the healthcare system multiple times in avoidable ways had my family not been there advocating for them—if I have the opportunity to help a patient, I will do so as long as I believe that the impact is a net positive in the shorter term. Disruption is a longer-term operation. Some have said it's a generational change. When I see stuff like Toxicity Guy wrote on LinkedIn, I really try to understand what his point is, as I always try to understand what people's points are. Could he be arguing that no one should work to improve care right now or try to maximize what we get for the bucks that we've already been shelling out? And, if so, for what reason … so that what happens? So that resentment about poor-quality care builds up to a boiling point such that everybody shuns the status quo and moves to a new care model and financial models faster? Is that the aim of Toxicity Guy? To force a let-them-eat-cake moment for the purposes of triggering a faster revolution? I've probably thought about this guy's motives and his potential impact harder than he has. In my manifesto, in my worldview, I don't let grandmas suffer right now so that someone else has a better narrative, even if I am in full support of what that person is trying to do and the mission that they are on, which, by the way, is a longer-term one. This gets me to the third part of my manifesto: The assumption is that transforming the healthcare industry will take a village and I am not alone. When I state this outright, it's gonna seem self-evident; but sometimes it's hard to not push blame here like Toxicity Guy, so I say this sort of in his defense. Here's the point of contemplation: There's maybe four big parts of the healthcare industry at a minimum. We have those trying to fix SDoH (social determinants [or drivers] of health). We have those trying to fix medical morbidity (ie, are patients on evidence-based pathways and taking meds appropriately, limiting polypharmacy side effects/cascades). Once a patient is in the healthcare system, what happens then? Then we have those working hard to improve behavioral/mental health. And lastly, everything going on with what I'm gonna call FDoH (financial determinants of health)—patients making decisions or having decisions made for them due to financial implications for them or for somebody else. Lots of stuff rolls up under these categories, but even just listing out these four things, we got a hell of a lot of work to do to improve the lot of patients and taxpayers and make it easier to do business in this country. I always try to keep in mind that it will take a village. Just because someone is working on getting patients housing or eating better does not imply that they don't care about employers struggling to curb claims billing waste, fraud, and abuse—and vice versa. It's just not everybody can do everything. For me personally, I tend to focus my attention on helping as many patients as possible get on what would be for them the optimal treatment plan or best care pathway. That does not mean I'm anti-someone working on getting more competition in the payer space. Nor does it mean I'm against trying to curb the price of overpriced (as per ICER [Institute for Clinical and Economic Review]) pharmaceutical products or legislate to rein in hospitals doing stuff that, in my book, they should not be doing. I am all for getting all of these things done. I just do not have the bandwidth or the depth of expertise to do everything myself. I would suspect that no one does. As my grandma used to say (and anyone who attended a slumber party seance in eighth grade might know), many hands make light work. You get 15 girls each holding out but two fingers, and you can lift up your friend, no problem. When I keep in mind that it takes a village, it helps me curtail the tendency to become paralyzed in my quest to help patients because I can see a potential problem it might create somewhere else in the industry or somewhere else down the line. I have to trust that one of my fellow villagers is holding down that end of the fort. Here's a quote from J. Michael Connors, MD, that he wrote in his newsletter: “When you point one finger, three are pointing back at you … It's like everything you learned in kindergarten seems to be so applicable to our approach to healthcare. Sadly, the game of finger pointing and pushing blame on others is killing real innovation in healthcare.” This is so real, which is why inherent in my manifesto here is my efforts to remember we are all on the same team (all the good eggs, anyway). That it takes a village, that there will be some things that some people are doing that I maybe don't fully agree with. There might be groups who don't accomplish much. There are certain people doing well (ie, doing self-interested things) but, at the same time, creating a better place for patients. As long as, in general, we are all following the same North Star, we'll achieve much more spending our time focused on our own missions and not worrying about what other people are doing. And when I say “not worrying about what other people are doing,” I mean people in the “good egg” village. I do not mean I intend to stop calling out conflicted and net-negative self-interested behavior, because this is what some people in the village should hopefully have their eyes on and get busy working against. The village here, it's a Venn diagram. At the point where other people's circles intersect with my mission or what I think would be better for patients, these are the people I can work with and collaborate with. These are the people that I'd take their business or I'd try to help them if I can. My manifesto is to determine when something is a positive for patients and then to find others who will win as a result of that thing happening. Then I can study why this is a win for those others, which is always going to be some self-interested why. And then I can think through what the negatives are if their self-interest comes to fruition. Is it still a net positive? If yes, proceed. Look, this making it better for patients, this transforming healthcare, it is hard, dispiriting work. It's a long slog. I'd like to suggest we encourage each other. Can we be the wind beneath each other's wings when we find a kindred spirit? Can we focus on the points of intersection and spend our energy deepening what's going on there? So again, here's my manifesto: If the thing results in a net positive for patients, then I'll do it. The timeframe I'm concerned about … short-term, medium-term. The assumption is that it will take a village to transform healthcare and I am not alone. I feel kind of exhausted having finished that. But let me ask you this: What is your manifesto? If you have one or if you have thoughts on this, go to our Web site and click on the orange button to leave a voice message. My hope is to do an upcoming show sharing what you think.   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.   03:16 “It's a zero-sum game.” 03:26 Is the amount of profit fair? 03:37 What is an inescapable fact of the healthcare industry? 03:54 What does the financialization of healthcare mean? 04:19 Why does the self-interest in healthcare matter? 06:18 “It's basically up to us as individuals to do the right thing.” 10:03 What is the first part of Stacey's manifesto? 10:18 How does Stacey calculate the net positive of an impact? 10:41 What are two major upsides/downsides that Stacey contemplates? 13:31 Why are incremental change and disruptive change not mutually exclusive? 17:40 “I always try to keep in mind that it will take a village.” 19:19 Why finger pointing is killing innovation in healthcare.   For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses our #healthcarepodcast and where she sees the path moving forward. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355)  

Well, this episode became extremely relevant again after that Cigna case bubbled up in the news. Here's the “too long, didn't read” version: Attorneys filed a class action lawsuit against Cigna, alleging that the carrier is overcharging for lab services or did overcharge for lab services. The plaintiff is an individual member of a Cigna plan. The complaint tells a pretty wild story. On the Explanation of Benefits (EOB) that this member received for lab services, the amount billed was over $17,000. My understanding is, this member went to Labcorp to get those lab services. Cigna claimed it had negotiated a discount of over $14,000 for those lab services, meaning the remaining balance was something like $2700. OK … good news, I guess. Instead of the lab services costing $17,000, they cost $2700 to the plan and member. Except Cigna said to this member that they were only gonna pay $471 on the member's behalf. This left the member with the responsibility to fork out over $2000 in deductible and coinsurance payments. I'm rounding the numbers here for brevity. So, in sum, member's told she owes $2000+ out of pocket for charges that were allegedly originally over $17,000. Now, a couple things: The cash price for an uninsured customer at Labcorp for the same services was $449, according to the complaint. Also, weirdly, on the Explanation of Benefits, Cigna allegedly said that the lab services provider was not Labcorp. It was “Health Diagnostic Lab” (or everything I just said in all caps with some letters missing) instead of the actual provider Labcorp. Then the plot thickens … The lawsuit alleges that this “HLTH DIAG LAB” is a pseudonym for Cigna Healthcare of Arizona and that this Cigna affiliate used their pseudonym to create a fake invoice. This is also a quote from the complaint. Bottom line, and this is the real point I wanna make here, the actual out of pocket to the payer was something less than $500, $600, you would think. But it appears that the plan was hoping to get almost 5x that out of the plan member. And had this plan member met her deductible that year, I would speculate that this 5x would have come out of the pocket of the plan sponsor. Either way, 5x margin? That's some pretty sweet returns. Look, the point I'm making here isn't about this particular case. It's about the totality of the thing. This case just got a whole bunch of attention because, as Julie Selesnick put it on LinkedIn recently, “This case … hits all the high notes—overcharging, keeping the spread, fraudulent billing.” But think about this for a second. You think this was an isolated incident? That someone in Arizona had a brainstorm to juice their quarterly earnings and set up a whole company to jack up one person's lab payments? I don't know. What do you think? As Lee Lewis mentioned on LinkedIn, while this case has a lot going on, a member getting charged $2500 for what should cost $450 or whatever … he wrote, “I've seen worse.” I say all this to say: Plan sponsors? Hi there. Are you getting your claims data, and are you having it audited for stuff like this? And by whom are you having your claims data audited for stuff like this? And that's not a rhetorical question. I mean, here we have a well-respected payer opening up (allegedly) a reseller of lab services sending allegedly fake invoices. That's one way to vertically integrate, I guess. Here's another way you can vertically integrate that maybe we all should be aware of: companies that provide audit services that many plan sponsors use to check if claims have been paid properly. Those same auditing companies, these same companies oftentimes have another book of business besides their auditing claims for plan sponsors work. They also work with provider organizations doing revenue optimization. Right. They help providers maximize their revenue, revenue that is coming from … claims they send plan sponsors. Sometimes when I talk about this stuff, I feel like I'm in a cartoon—like that meme with all the Spider-Men pointing at each other and nobody knows who is actually Spider-Man because everybody is dressed up in the same costume pointing and saying the other guy is the one causing the problems here. As Dawn Cornelis says in this episode today, approximately 30% of healthcare spending (ie, healthcare payments) are some combination of fraud, waste, and/or abuse. It's a $1-billion-a-day problem. In this episode, we dig into the three main issues that Dawn tends to find when looking at the claims that were going to hit the checkbook of a plan sponsor as per their payer or TPA (third-party administrator): 1. Claims that were not paid correctly: Turns out, 5% to 10% of claims just aren't paid right. There's a whole motley crew of errors that can transpire, but bottom line, the bill was for $10 and somehow the plan sponsor was gonna pay $15. Or they double paid. 2. Things that, if we knew about them, we could do better in the interest of the member: Jeff Hogan put this really well on LinkedIn the other day. He wrote, “Today's purchaser fiduciary needs great analytics to prioritize the needs of their members … including wasteful and abusive vendors, site of care, cost/quality variation in health systems.” Do labs that the plan is being charged $2500 instead of $450 go here or in the next problematic category? I'm not sure. 3. Claims that are just wrong: They should never have been sent in the first place. We also talk about kind of a different issue entirely: the hidden fees that are buried in some of these payer contracts, which felt like a reprise, frankly, of the conversation I had with Paul Holmes a few weeks ago in episode 397 talking about PBM (pharmacy benefit manager) contracts and all the hidden fees and, ultimately, probably costly provisions buried in them that plan sponsors are on the hook for—a lot of times very unknowingly.   You can learn more at claiminformatics.com or by emailing Dawn at d.cornelis@claiminformatics.com.     Dawn Cornelis is a professional in healthcare cost containment with 30+ years of dedication to combatting improper payments, fraud, waste, and abuse. She has led the industry in developing healthcare transparency technology platforms and services. As a result of her efforts, hundreds of millions of dollars of improper payments were delivered through pre- and post-payment technology programs. She is an expert in the field of healthcare claims data, with an emphasis in audit and recovery, and has navigated the payment systems of all of the national healthcare carriers. Furthermore, she approaches each project with integrity and attention to detail while cultivating long-term client relationships. In 1993, Dawn cofounded the first audit and recovery firm and served for 17 years as the chief operating officer of Claim Recovery Services while representing some of the best Fortune 100 companies. In 2017, Dawn cofounded ClaimInformatics, a healthcare technology company that offers a SaaS-based solution product to support health plans in the marketplace that addresses the new transparency regulations. She developed and trademarked multiple technologies and has a United States Patent Pending named CONTINUITY OF CARE (Publication #20150127370). Dawn currently serves as a member of the Self-Insurance Institute of America's price transparency committee, which focuses on legislation and education for self-funded entities. Over the course of her career, Dawn's efforts have supported national and local organizations spanning financial, healthcare, union, and government sectors. With her years of healthcare knowledge, Dawn is a proven expert, consistently delivering excellence.   06:57 The story in the data. 07:33 Who's submitting these claims? 08:04 The three problems with the data. 10:54 The varying factor between carrier systems to stop fraud, waste, and abuse. 11:32 Why carriers don't push for better systems to stop inappropriate dollars. 13:28 The difference between fraud, waste, and abuse. 14:46 “When it becomes the norm, that's what's very bothering.” 15:10 The barriers or hurdles in the marketplace. 17:38 What we don't know about but could do better at when looking at the data. 19:10 “It's not so much the health system and what they are charging. It's about … what the contracted rate is agreed to. That's what drives our costs.” 20:04 “Data's fixed for itself.” 22:49 Identifying and eliminating fraud. 22:54 The lack of enforcement behind preventing illegal billing. 26:01 How providers ensure they aren't inadvertently harming employers and patients through billing.   You can learn more at claiminformatics.com or by emailing Dawn at d.cornelis@claiminformatics.com.   Check out our encore #healthcarepodcast with Dawn Cornelis of @claiminformati1 as she discusses saving billions through healthcare billing. #healthcare #podcast #digitalhealth #healthtech #healthcarebilling   Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard

This week and in episode 400 of Relentless Health Value, at the encouragement of the Relentless Health Value team, I'm gonna do two shows entitled “My Manifesto,” Part 1 and Part 2. In other words, why did I start Relentless Health Value and what's the goal around here? I started contemplating this mission to define the mission thinking about how healthcare will ultimately be transformed and my role (if any) in all of this—or, more accurately, your role as a listener of this show and, often enough, someone who has the ability to take action. You there, listening right now, you are the alchemist who will transform the words that you hear here into something tangible. And that is how this show makes a difference. It is through the Relentless Health Value Tribe, and you, whether you realize it or not, are a very special person. But before I continue along this complimentary vein, let me back up for just one sec and talk about how I realized how special you are to begin with. It's a funny thing because I get asked all the time who listens to this show, sometimes with a “Who listens to this show?” vibe. I mean, we talk about complicated topics; and when I say we talk about complicated topics, I mean we hurl ourselves right in the middle of them. Acronyms and 400-level perplexities abound. I used to say who listens to this show when asked—and this is absolutely true—I used to say that more than 40% of you are senior-level executives with decision-making authority, which might mean you are a doctor or a nurse or other clinician and a leader of some kind, either formally or informally. You could work at a provider organization, a payer, a digital health company (big or small). Maybe you make policy, you're a researcher, private equity … You're an EBC (employee benefit consultant) or work in benefits at an employer. Maybe you do something in the population health space. You could be a legislator looking for insight. A journalist. Right? We get around. But while the audience of this programme is big (very big by some standards), I run across healthcare industry peeps often enough in decision-making roles who listened to half a show one time and decided it wasn't for them. It took me a long time to put my finger on who listens and who does not, and this was also the moment that I started thinking about our listeners as a tribe. The people who listen 99% of the time are listening to figure out how to do the right thing for patients or members. They want to know how what they do fits into the larger picture, this larger healthcare ecosystem. And they want to know this for actionable reasons. I mean, frankly, this is a lot of the reason why I started this show to begin with: because I found myself in a similar situation (still am, truth be told). I started to understand that doing something in healthcare is like a game of pachinko. The action, which might feel like it logically should result in X good thing for patients, bounces around in this black box that is the healthcare ecosystem and may pop out the other side in ways that are the opposite of what was originally intended. I want to have positive impact, right? All of us do, or you wouldn't be listening right now. And that is the common thread that holds us all together—besides, of course, being smart, capable, curious, and incredibly charming individuals. And I say all this with evidence: Every single person I have met who listens to this show on the regular meets all of these criteria. You are great people, and it is a distinct honor and a privilege to spend time with you every week. I am proud, really proud of what this group of individuals has accomplished. We have moved needles, and we have pushed agendas. Now, I know you people. You are going to be doing one of two things right now. Twenty percent of you are gonna be smiling and thinking about the program you started or the work that you did and the accolades that followed. Or maybe you're just simply aware of what you've done because you have data, or patients or members or family members thanked you and you saw that look in their eyes and you knew how much what you did meant for them. Or you work for a company that is laser focused on some kind of disruption, and it's small enough that you can clearly see your impact. But there's a lot of you (the majority of you, frankly) I get on the phone with, and you're less sure if you've actually had any impact. You are frustrated—and a little depressed maybe—because you see all this madness and ways patients are harmed all around you. You see maybe decisions that you realize have a deleterious (ie, bad) impact on patients or members. You are now eyes on, and now you feel largely powerless. I will tell you the same thing that I tell every member of the Relentless Health Value Tribe who says this. I don't doubt it might be more difficult to see the impact you are having if you work for a larger company or if you work for one of these incumbents, especially when you have a recognition that there might be other departments or other individuals doing things that you may not be fully aligned with. But do not doubt that you have impact and that that impact is meaningful. I was talking to Larry Bauer, and he told me with a lot of conviction (and he's one that would know) that you, Relentless Health Value listeners, you are the innovators. You are the ones who spot problems, and you tinker around with available resources and you figure out how to make it just even a little bit better for patients or members. Think about it this way and just hang with me through this: CEOs do not actually drive what happens in their organizations. The big bosses set up the incentive structures and are the tip of the spear (or whatever that metaphor is) for sure. But an organization's behavior is decided by 10,000 probably tiny little decisions each and every day … 100,000 decisions by the employees of that organization. It's the sum of all those micro choices, those micro moments, that determine the impact that that organization has on those it serves. I saw a meme the other day: “When people travel to the past, they worry about radically changing the present by doing something small. Few people think that they can radically change the future by doing something small in the present.”     Who your boss is doesn't matter is my point. If you are touching things in the middle of that pachinko game, you have power. Right? We are all decision makers here, and we are not synonymous with the companies that we work for. We are not the Borg. Would it be nicer and faster if there wasn't an ongoing financialization of the healthcare industry? If boards of hospitals and private equity and C-suites all would put their “mission before margin” hats on for a change? Yeah, that would be ideal. Would it be nice if the disrupters among us had more market penetration? Sure … the good ones, absolutely. And probably the best path forward is to get ourselves over to a company that's building a new model to make the current one obsolete, to quote Buckminster Fuller. But it's not like it's an either/or. In addition to having a long-term vision, maybe we can do something in the meantime here. I'd rather that some patients and members get treated some amount of better right now as well as envisioning a new model to make the current one obsolete. We each might be pressing forward, I don't know, 0.01% at a time; but let's just consider that 0.01% in this country is 35,000 people plus their families and ~$300 million when it comes to healthcare in the US. Multiply that impact by everybody listening right now—there are thousands of you. So please do not dismiss the impact that you have, no matter who you work for: thinking critically, considering the larger picture, recognizing the impact that your organization has in big ways and in small ways and then making big and small choices and decisions that are aligned with your values and your integrity. Sometimes people will talk to me about what they want their legacy to be, and this is kinda it. So, how to deepen that possible impact that any of us might have? It is always the highlight of my day when I hear that one of you has found somebody else in the RHV Tribe and the two of you (or three of you or four of you) have struck a deal to do something. You've collaborated in some way. The larger organizations everybody might work for … maybe they're on board or half on board, but again, we are not our companies. I love it when I hear that a physician organization hooked up with somebody at a payer and figured out how to do a pilot or collaborate on something, not going through the official Contact Us forms or whatever but by finding somebody on the same mission in that other organization and then everybody working up the chain in their own organizations from the inside. So many different individuals who work for so many different parts of the healthcare ecosystem listen, and there are lots of synergies to explore, especially if we stop thinking at the organizational level and start thinking about what we individually want to achieve. It's possible to help each other, to find the overlapping bit of the Venn diagram where interests align and something can get done. And I'll talk about that more in Part 2. Here's from Malcolm Gladwell's The Tipping Point. He wrote: “If you want to bring a fundamental change … you need to create a community … where … new beliefs can be practiced and expressed and nurtured.” This, maybe in sum, is the ultimate goal of Relentless Health Value: to provide that loose-knit community so that those in the Relentless Health Value Tribe who want to can find like-minded people across the industry to work with, the ones who are also just as well informed and understand how this ecosystem knits together—meaning you can more easily work with them to find points of mutual interest that are net positive for patients. There was a point in my podcast career where I thought having a really broad audience of listeners from all across the industry was kind of a problem because it makes it really hard to answer the question, “Who listens to your show?” But now I realize it's a huge accelerant to our potential impact. As I was recording this, I realized I probably should do one thing here; and that is at some juncture, I will probably make an RHV Tribe directory or something. So, go over to our Web site and sign up for the weekly email, which you can do on the Web site, because whenever I get around to doing that, I will start with everybody on the mailing list (because I have your email address). I'll send out a notice or something and ask if you'd like to be part of that directory. This is Part 1 of my manifesto. Next week (hopefully, if I can get my act together) or, if not, the week after that, I will bring you Part 2. In the meantime, thank you from the bottom of my heart for being who you are and doing what you do. It is going to be Relentless Health Value listeners who turn this oil tanker of a healthcare industry around. I guarantee it.   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.   00:47 What is your role as the listener of this show? 01:27 How did Stacey realize how special our listeners are? 01:56 Who are our listeners? 03:15 Why did Stacey start the Relentless Health Value podcast? 04:10 What have the listeners of the Relentless Health Value podcast and its guests accomplished? 05:13 What is Stacey's advice to listeners that feel powerless? 06:22 “It's the sum of all those micro choices … that determine the impact that that organization has on those it serves.” 09:22 “There are lots of synergies to explore.” 10:51 Sign up for our weekly email here.   For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses why she started our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard  

Yeah, so while the commercial payer marketplace is completely boring, the reasons it's boring are not. Let me walk you through this conversation I have in this healthcare podcast with Jacob Asher, MD. First, we establish that the relative number of each carrier's commercial members in California don't seem to change year over year … and this has been true for years. When you rank order carriers by member count, the song remains the same. It's Groundhog Day. Here's a link to the 2022 CHCF (California Health Care Foundation) enrollment almanac, which shows for the large group market, Kaiser has captured and retained just over half of enrollees. Anthem comes in next with 14%, Blue Shield gets 9%, and then bringing up the rear we have UHC, Aetna, Cigna, Centene, and all others in descending order splitting the remaining 21%. Hmmm … intriguing, the whole idea that these relative member counts remain so consistent. Then Dr. Asher and I dissect what is anybody actually doing to cut into the Kaiser market share or try to grab share from the two blues plans, if anything. Dr. Jacob Asher was a great guy to have this conversation with. He was a practicing head and neck surgeon with Kaiser Permanente, and then he also served on the Permanente Medical Group Board of Directors. Then he changed careers and became a full-time health plan chief medical officer for, first, Anthem, then Blue Cross, then Cigna, then UHC (UnitedHealthcare). Now he's “retired” and reflecting back on unsolved and unaddressed issues within healthcare. And we've covered one here: Why is the commercial payer market as boring as it appears to be in California? Now, after I had this conversation with Dr. Asher, I called up Wendell Potter, who everybody already knows (EP384), and Lauren Vela, who everybody also probably already knows, but she has spent her career at various employer coalitions and now works at a big employer transforming their health benefits (and she lives in California). I learned a few things that really helped me frame my thoughts on some of the issues that surfaced in the conversation that I had with Dr. Asher and that you'll hear today. So, let's get to it. Why doesn't the relative market share of the big payers change year over year in California in the commercial space. May I present six reasons: 1. Everybody I talked to—Dr. Asher, Wendell Potter, Lauren Vela—first thing right out of the gate that practically everybody mentioned is employer inertia. Trying to get an employer to switch carriers is like trying to pull Excalibur from its stone. And right, not so surprising, it's disruptive and obnoxious for employees and also benefit teams if carriers are switching all the time. 2. EBCs (employee benefit consultants). They have deals with carriers and others, and they also have a lot of power over employers. Listen to the show with AJ Loiacono (EP379) and Paul Holmes (EP397) for more on this. 3. As Wendell Potter put it, “The commercial market is [as a whole] stagnant. No real growth nationally. And in many states, the real money for carriers is not in the self-funded market; so they don't care much about aggressively competing for market share.” Given that chart that just came out the other day showing the insane relative gross margins that carriers are making on Medicare Advantage patients, which is over double other lines of business … yeah, totally. 4. Just keep this in mind before we barrel into reason #4 here for a stagnant and maybe not exactly competitive market. Kaiser excluded, all of the rest of the California payers have what amounts to largely the same provider network. I'm exaggerating slightly here, but largely the same hospitals, the same consolidated integrated delivery networks. And one thing that's pretty clear (not just in California but across the country): Plans who bring the most members get the best prices from these hospitals and other provider organizations. Also, as Dr. Asher mentions in the show today, he never saw an employer buy on quality. Most were far more concerned about discounts. So, right … we have some circular reasoning here or circular logic. The big plans get the best prices, and then, because they have the best prices, they maintain their market share. But wait … there's more to this one, and it's not just big gets you lower prices. Remember from episode 395 with Brennan Bilberry? He talked about the concept of the Most Favored Nation (MFN) anticompetitive clauses in hospital contracts. This concept is also super relevant here for payers as well if you think about it. This MFN Most Favored Nation anticompetitive clause, this is where a big hospital and “big carrier” have a chat … in a back room. The hospital agrees to not give any other carrier a lower price than the “big carrier.” These MFN clauses are, of course, terrible for competition and plan sponsors and any patient with cost sharing. A lot of states have started to ban, restrict, and limit these clauses. The DOJ brought a case in Michigan about this, and here's a great federal government summary of the problem: “The department and the state of Michigan alleged … that the MFN clauses in [Blue Cross Blue Shield of Michigan's (BCBSM's)] contracts with Michigan hospitals decreased competition among health plans. Some … clauses required hospitals to charge competitors more than the hospitals charged BCBSM, often by a specified percentage. Moreover, BCBSM often agreed to raise the prices that it paid hospitals, in part to obtain [the] MFN clauses.” Oh, hey … I'll let you raise your price so I can have a Most Favored Nation clause, just as long as I get a lower price, which is higher than it was originally. And this was actually back in 2013. I have no insight at all or knowledge, or I am not suggesting in any way that what was going on in Michigan is going on in California. However, this anticompetitive practice is common enough. If you're interested in how common, count the lawsuits. 5. Employers are unaware a lot of times of how they are being charged more than what might be appropriate. And they are largely unaware of options other than Blue Cross, United, Cigna, Aetna … the big payers. 6. As Dr. Asher talks about and which I never really thought about, Kaiser doesn't have Medicaid patients. [Correction: Kaiser does have some Medicaid members—just less than others.] And because their network and hospitals to a large extent are closed, they also don't have uninsured patients to a large extent. So, no charity care to speak of and, therefore (at least as it is posited), they can be cheaper because they don't have to cost offset. So, their price advantage has a structure element here that could make it even more untouchable. So, there's your six reasons. You can start to see basically all of these things solidify into the same thing. It's less about trying to get new business and more about locking in the existing business. It's not really a secret that this market is rock hard. Plans realize that. They realize that the cost of keeping an enrollee is cheaper than acquiring a new enrollee. So, carriers focus sales and marketing efforts on holding on to their existing customers, especially the coveted jumbo accounts. Interestingly (and I was talking about this with Lauren Vela), the more clinical programs a carrier has deployed for an employer, the more the carrier is locked in there. So, the more the clinical value proposition resonates, the more clinical stuff that gets integrated. Changing plans becomes even more disruptive, and employers are even more likely to remain where they are. So, there's more to clinical programs than payers catching themselves a little PMPM (per member per month) something something upcharge recurring revenue or trying to get new business. It's also locking in customer retention. Is any of this specific to California? Some of it is—like a lot of the Kaiser stuff—but most, not. Meaning a lot of the country doesn't exactly have a functioning commercial small group or large group marketplace either. To a certain extent, it's no wonder big employers don't change plans that often. Why would they bother, given probably fairly incremental differences between these big payer carriers? I realize I'm scrambling out on a limb here and making assumptions, but to achieve more than incremental improvements, a BUCA (Blue Cross, United, Cigna, Aetna) would need to invest all kinds of resources into being that shining star. And why would they do that when nobody can take down Kaiser? And for all the reasons that we just talked about, it's a hard row to hoe to grab new clients. There's a lot of ramifications to this, but this show can't be seven hours long.    You can learn more by connecting with Dr. Asher on LinkedIn.   Jacob Asher, MD, completed a residency in otolaryngology–head and neck surgery at the University of California, San Francisco, after receiving degrees from Brown University and the Boston University School of Medicine. Dr. Asher then practiced as an ENT (ear, nose, and throat) surgeon with Kaiser Permanente in Northern California and also served on the board of directors of The Permanente Medical Group, where he focused on physician compensation reform, member satisfaction initiatives, and retirement benefits. After transitioning to full-time health plan management, Dr. Asher served as a California commercial market medical director between 2008 and 2022 for Anthem Blue Cross, Cigna, and UnitedHealthcare. In those roles, he supported membership growth and retention in both fully insured and self-funded product lines and promoted value-based reimbursement, including capitation. He has led utilization management teams, collaborated with internal and external population healthcare advocates, and worked to develop clinical initiatives that sought to achieve the Triple Aim. In his role as the clinical face of the health plan to the local market, he worked with network colleagues on accountable care organization partnerships and hospital and physician contract renewals with integrated pay for performance, supported Obamacare exchange participation, engaged in quality improvement collaboratives, and supported regulatory compliance efforts. Currently, Dr. Asher is serving as a mentor for the Stanford Master in Medical Informatics program while exploring innovative solutions to healthcare delivery.   10:00 What is the competitive picture of California's health plans? 11:28 What was everyone doing in order to get market share? 15:07 EP387 with Betsy Seals. 15:22 EP379 with AJ Loiacono and EP397 with Paul Holmes. 15:26 Why is it difficult to take market share? 16:16 Who was Dr. Asher pitching to and why? 18:49 Did employers ever buy plans for quality? 22:43 What does this look like from the payer perspective? 27:01 What improvements have there been to engagement in health plans? 29:07 Have plans gotten better at communicating with employers? 30:38 Why is it hard to compare the Kaiser world to the non-Kaiser world? 33:00 EP390 with Gloria Sachdev, PharmD, and Chris Skisak, PhD.   You can learn more by connecting with Dr. Asher on LinkedIn.   @JacobAsher18 discusses California's #commercialpayer marketplace on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak  

If this were a video show, I would stare into the camera with steely eyeballs right now and say that I have a special message for employer CFOs. If you aren't a CFO, pretend that you are so that you get the full effect here. So, now that we're all CFOs, let's pull up the company P&L (Profit and Loss) statement. This is what keeps us all up at night, right? Making sure that the net profit line at the bottom looks good. We could decide to lay off a few people. Reorg something or other. Beat up a vendor. Stop buying the gold paper clips. We also could go over and have a strident conversation with sales leadership about what they can do to jack up their sales revenue. Top line begets bottom line, after all. Or, here's another idea: In this healthcare podcast, I am speaking with Paul Holmes, who is an ERISA (Employee Retirement Income Security Act) attorney with a specialty in PBM (pharmacy benefit manager) contracts, especially the PBM contracts from the big PBMs that get jammed in employer plan sponsor faces by whomever and which they are told look fine and that the employer plan sponsor should just go ahead and sign. Now, if we, meaning all of us CFOs, sign that paper, or someone on our benefits team signs the paper … fun fact, our company just spent 30% to 40% over market for our pharmacy benefits. That contract we just signed contains all kinds of expensive little buried treasures—treasures accruing to the PBM and other parties, to be clear, and coming at our expense. There's 17-ish very common treasures in your typical PBM contract, and none of us will ever spot them unless we know what we are looking for. But let's dig into this for a sec, especially for all of us newly minted CFOs because the real ones already did this math. Say our company spends whatever—we're a bigger company, and we spend $100 million a year on our drugs. That's a minimum of $30 million that we got taken for … $30 million a year. That's a metric load of our cold hard cash that got dumped out back and burned. Because of the huge dollars at stake (30% to 40% of drug spend), it's certainly the advice of almost anybody that you talk to who's an expert in PBM contracts to have a third party—not your EBC (employee benefit consultant), which we'll get into in a sec, but somebody else (a third party)—review every PBM contract. I mean, what's the worst that can happen for anybody considering having an independent third party review their PBM contract? It costs a couple grand in lawyer fees, and they give it a stamp of approval. Knowledge is power, and now we know. But let's just say this third-party review doesn't happen. We all go with a “devil may care” about this whole PBM overcharging us by 30% to 40% possibility. And let's say the PBM contract is, in fact, a ride on the Hot Mess Express, but we don't know it. Here's two pretty bad downsides, especially now, this year, since the passage of the CAA (the Consolidated Appropriations Act) at the beginning of 2022. Number one bad thing: Plan sponsors may get sued as per the CAA for ERISA violations. It's not just the company paying that extra $30 million, or 30% to 40%, right? It's also employees. This is risk exposure, bigly. Just like it was on the 401(k) side of the house, which Paul Holmes, my guest today, mentions later on in the interview. He talks about just how much those lawsuits cost and, yeah, exposure. As I mentioned three times already, today I am speaking with Paul Holmes about PBM contracts in all their stealthy glory. The one thing I came to appreciate is that these things are works of art … if you're into those paintings of pretty flowers where, if you look hard enough, you spot a skull tucked in the greenery (memento mori). Paul is a longtime ERISA attorney. He has dedicated his career to helping plan sponsors in their negotiations with PBMs and trying to help them reduce drug spend, especially drug spend that isn't actually paying for drugs. Here's a link to an article we discuss about how a school district in Florida is suing their longtime EBC for taking $2 million a year in alleged secret payments. We also mention an episode with AJ Loiacono (EP379). And along similar lines, Jeff Hogan mentioned on LinkedIn the other day, “It's pretty amazing that just in the course of the [past few] weeks, I'm reading, seeing, and hearing about big new CAA breach of fiduciary duty cases.” So, Paul Holmes says this more eloquently, but if you're a plan sponsor, definitely get your PBM contract reviewed and maybe consider working with an EBC who's happy to sign the disclosure statement that your lawyer has provided without disclaimers. Oh, hey … one last thing and new topic. Here's a cool goings-on: Right now, the March Healthcare Classic is in full swing. Each spring, Josh Berlin's rule of three team collaborates with other experts to predict which major trend will find itself at the top of the healthcare agenda over the next 12 months. This year, their selection committee includes Anisha Sood; Danny Brywczynski; David Carmouche, MD; Shaheed Koury, MD; and Stephanie Mercado. Check it out and weigh in yourself should you choose to do so.   You can learn more by emailing Paul at pbh@williamsbarbermorel.com.   Paul B. Holmes, JD, is a seasoned ERISA lawyer with nearly 40 years of specialization in that field. Paul joined Williams Barber Morel recently, after 31 years with Nixon Peabody LLP and Ungaretti & Harris LLP. Paul has extensive and unique experience in representing large employers and Taft-Hartley welfare funds in their selection, contracting, auditing, and litigation with large pharmacy benefit managers (PBMs). Paul has logged over 8000 hours during the past four to five years, advising large employers and Taft-Hartley welfare funds managing their prescription drug benefit plans. This work includes active oversight of the request for proposal (RFP) process for selecting a PBM, the negotiation of final PBM contracts (including pricing, rebates, and audit rights), and regular audits of PBM compliance with their contracts. He was selected, through a peer-review survey, for inclusion in The Best Lawyers in America (2020 and 2021) in the field of Employee Benefits (ERISA) Law. Paul received his bachelor's degree from Bradley University and his Juris Doctor degree from the University of Illinois College of Law.   06:06 What are Paul's usual observations when a PBM contract crosses his desk? 06:57 “If you just sign … one of their model contracts …, you're probably gonna pay 30% to 40% above market on your drug spend.” 10:35 What is a PBM lawyer? And why is it important to find an ERISA PBM lawyer? 15:37 EP379 with AJ Loiacono. 16:05 Who is on the hook for the cost of the PBM contracts? 20:36 What's the problem with most ERISA lawyers today? 22:28 Lawsuit about PBM contract. 27:15 What's Paul's advice for benefits consultants? 31:11 How much might a plan sponsor be paying their consultant versus what a consultant might be making from a PBM?   You can learn more by emailing Paul at pbh@williamsbarbermorel.com.   Paul Holmes discusses #PBMContracts on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson  

There are two facets of the Humira biosimilar market and launch that Anna Hyde, my guest in this healthcare podcast, talks about. One is market dynamics. The second is provider and patient confidence. These two concepts are tangled up together and cannot be separated. But let me back up a sec and explain, although Anna Hyde covers this really well and offers context in the interview that follows. So, first facet: market dynamics. This means fostering competition so the price of something goes down. That is the basis of capitalism. After all, you need competition to get in there and try to steal customers from each other by scuffling over price. In 2023, there's supposed to be 12 biosimilar products for Humira that come out. So, we'll see scuffling and lower prices? Hmmm … maybe not so fast. Second intertwined facet: provider and patient confidence that the biosimilars are as effective and have similar side effects (ie, there is confidence that the biosimilars are actually, for reals, interchangeable with the so-called reference product [ie, Humira]). Bottom line, if providers and patients are not confident in the biosimilar, then no prescribing is gonna happen. Couple those provider and patient clinical concerns with a concern about manufacturer financial assistance. If providers and patients are worried that the out of pocket will be too high and the biosimilar manufacturers are not gonna offer any financial assistance, then, again, no confidence, no prescribing. So, if either or both of these concerns is present and the no prescribing is the result, this vote of no confidence means there will be no or limited uptake of the biosimilars. And what does the no uptake mean? It means no lower prices. Having competition per se isn't gonna lower the prices because the monopoly remains the monopoly. It's having uptake of the competition that will erode the monopoly. It's having patients who are willing to migrate to the competitive products. And this is pretty vital here because, right now, there's a lot of cynicism out there about this biosimilar launch and that it is not really going to lower the cost of these drugs much for plan sponsors. And, you know, is anyone terribly surprised given it sure seems like AbbVie, who is the manufacturer of Humira, still has a lot of dominance in the market? “How do they still dominate the market even though their patent thicket years are officially over?” you might ask. For one, they have payers over a barrel because members who need the Humira molecule are still 100% on Humira. Thus, AbbVie can still demand contract terms for Humira like the demand that Humira has the lowest patient out of pocket for patients or has an equivalent out of pocket to any formulary biosimilars. And this is currently going on. (Listen to the show with Dea Belazi [Encore! EP293] for why that matters so much from a market dynamics standpoint.) A second reason why Humira can still dominate the market even after their patent expiry is that plans and PBMs (pharmacy benefit managers) are, as Chris Sloan put it in episode 216, “addicted to rebates”; and Humira offers big rebates, which they will likely increase to match any pricing pressure from biosimilars. Here's a quote from the Goodroot white paper on this Humira biosimilars business, which is otherwise known as the “hottest topic in pharmacy.” Goodroot says, “Given the cost-rebate power play—and the monetary loss that PBM[s] ... assume when rebate dollars are removed—we don't anticipate any significant shift to biosimilars or cost savings as Humira biosimilars become available.” So ... doom? Not so fast. The Goodroot white paper continues with this next quote, and this is exactly what Anna Hyde also talks about and gives some historical proof points for, actually. Goodroot says, “There may be a tipping point in biosimilar pricing where the net cost differential will be significant enough to force [plan sponsors/payers] to make their PBMs prefer the biosimilars.” And then the white paper says exactly what Anna Hyde also says, and which I reiterated moments ago: “[For this tipping point to happen], this significantly lower net price must be coupled with a significant shift in market share to make up for the loss of [the] Humira rebate.” Let me translate that: Provider and patient uptake has to happen here for the prices in this therapeutic category to go down across the board to meet that tipping point. Anna Hyde gives some great advice, and this advice is all summed up on a landing page on the Arthritis Foundation Web site. This landing page includes advice for health plans, and a big part of that advice is to communicate clearly with physicians and other providers and also, essentially, with members and patients. Patients cannot find out that they just got switched to a biosimilar when they get a different box in the mail with a different med with a different delivery device that they have never seen before with a needle that's gonna pop out from some mystery location. This is a Fail (with a capital F) for all kinds of reasons that could ultimately undermine the whole Operation Biosimilar some plan is trying to pull off in an effort to try to lower prices to a tipping point so everybody can save money. There is evidence to suggest that, over time, biosimilars can reduce costs—maybe a lot. But for this to happen, it's gonna take really a thoughtful approach filled with bidirectional communication with providers and patients. Cannot forget this step. If everybody's on the same page, it may take a bit; but market dynamics will eventually kick in and prices will go down across the board. Everybody wins. My guest today, Anna Hyde, is VP of advocacy and access over at the Arthritis Foundation. She's a federal lobbyist and helps advance legislation and policies so patients can have better access to affordable medications and specialists. If you're looking for more insights into topics we discuss today, I suggest listening to the encore with Dea Belazi (Encore! EP293) about co-pay assistance programs; the show with Chris Sloan (EP216) about how plans get addicted to rebates; and if you really want to take a deep dive, check out this playlist of eight specialty pharmacy episodes. Listen to all of these shows and you will know more than 99% of healthcare insiders about who is kicking back to who and where the dollar is going in the specialty pharmacy market—which is essential background information if you're planning to evaluate the impact or the potential impact of these biosimilars.   You can learn more by emailing Anna at ahyde@arthritis.org and connect with her on LinkedIn.    Anna Hyde is the vice president of advocacy and access at the Arthritis Foundation. She oversees both the federal and state legislative programs, in addition to grassroots engagement. Her focus is to raise the visibility of arthritis as a public health priority; build support for federal and state legislation that ensures access to affordable, high-quality healthcare; and enhance patient engagement in the policy-making process. Anna previously served as senior director of advocacy and access, managing the federal affairs portfolio and overseeing the state advocacy team. Prior to joining the Arthritis Foundation in 2014, Anna worked as senior manager for federal affairs at the American Congress of Obstetricians and Gynecologists, where she managed a portfolio of issues, including appropriations, physician workforce, and health IT. She began her health policy career as a Congressional Fellow for Energy and Commerce Committee members, where she drafted legislation and staffed committee activities. Anna received a bachelor's degree in history from Southern Methodist University and taught junior high and high school history before moving to Washington, DC, in 2007 to pursue a master's degree in political science from American University.   07:38 What does a successful biosimilar market depend on? 09:07 Why does uptake seem to reduce prices? 10:24 How important is the relationship with the healthcare provider? 11:35 Where are we in getting these biosimilars to market? 13:02 Are there differences between the reference product and biosimilars? 19:26 Why does the way you approach the patient matter? 22:36 Why do providers feel like they don't have a lot of agency in the biosimilar conversation? 24:50 What should health plans be thinking if they want to go down the biosimilar path? 27:36 “Our goal is to keep a feedback loop such that no patient falls through the cracks.” 28:21 What is the “nocebo” effect? 31:27 What is Anna's advice to plan sponsors on communicating with providers and plan sponsors?   You can learn more by emailing Anna at ahyde@arthritis.org and connect with her on LinkedIn.   Anna Hyde of @ArthritisFdn discusses the #humira #biosimilar market and launch on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326)  

Well, this episode is suddenly incredibly relevant again just with all the stuff going on with co-pay maximizers. If you're gonna understand maximizers, though, you really have to start here. In a nutshell, this whole thing is a battle royale between co-pay cards and patient assistance programs offered by pharma companies versus co-pay accumulators and co-pay maximizers deployed by health plans and PBMs (pharmacy benefit managers). I just want to start by getting everyone grounded on a few really key points. #1: Drug abandonment is a thing. Patient goes into the pharmacy to pick up their Rx and the out of pocket is too expensive, so they leave without their drug. This can happen on the first fill, like, “Oh, wow, I guess I don't really need that new drug my doctor just told me I should pick up.” Or it can happen downstream, like in January when, all of a sudden, a deductible kicks in. But in all cases, we have a patient getting sticker shock on the out of pocket for a med and then going without the drug … or pill splitting or rationing or doing other things to save money. #2: How PBMs shake rebates out of pharma manufacturers is to use what I just said (that whole abandonment possibility) as a leverage point. Pharma goes into a PBM that controls access for drugs for, I don't know, 100 million lives. The PBM says, “Hey, you, Pharma! If you want to be on our formulary, you gotta kick out this much in rebates.” Pharma says, “No, that is too much rebate. I cannot pay it.” PBM says, “Well, then … OK, you're not on formulary or you are poorly positioned on formulary. And let me translate what that means. Now the out of pocket for your drug will be so expensive that patients are gonna walk out of the pharmacy without your drug because I, the PBM, have control over patient out of pocket and I will make it very expensive.” From a pharma's standpoint, all those patients that aren't picking up the drug … that means a loss of market share. And that market share can translate into a lot of lost revenue for the pharma company. And thus begins the whole war of the co-pays/out of pockets. So now, let's fast-forward through the past, say, 10-plus years. It'll be like one of those movie montages with the action sped up so fast you don't need words to see what's going on … except this is an audio podcast, so I guess you do need words. Alright, so this is what happens next: Pharma starts raising its prices combined with there's more super expensive specialty pharmacy drugs. Reaction by the PBMs to this was to try to get more aggressive with Pharma demanding increasingly high rebates and other concessions, keeping in mind the prize and leverage point that the PBMs offered Pharma to secure those PBM rebates was lower co-pays or out of pockets for patients. Again, it's a well-known fact that the higher the patient out of pocket, the lower the market share of the drug because the higher the patient cost, the more patients abandon at the pharmacy counter. It's the old supply and demand curve at work. At a certain point here in all of this, the pharma companies start to get really pissed about their dwindling net prices as rebates start going up and up and their market share kind of doesn't because the PBMs are keeping the money and maybe not passing it along to plan sponsors or patients. It's a zero-sum game fight over the money, and Pharma feels like the PBMs are getting more than their share. And they're pretty smart, these pharma manufacturers. So, Pharma comes up with a Houdini move to escape PBMs holding Pharma hostage for rebates by using their control over how much patients pay or don't pay at the pharmacy counter. Fasten your seatbelts and let the games begin. Pharma decided to hand out co-pay discount cards. Then Pharma doesn't have to pay PBM rebates to get lower patient out-of-pocket costs. They can finesse lower patient out-of-pocket costs all by themselves. Take that, PBMs! Except now, the PBMs see this—and they raise. Enter co-pay accumulators and also co-pay maximizers. For this part of the extravaganza of game theory at its finest, I'm gonna let Dea Belazi, PharmD, MPH, my guest in this episode, explain further. However, one more thing to point out before we begin. In the olden days, this whole war of who has leverage over who transpired in the context of small molecule drugs in competitive markets a lot of times. So, like Lipitor versus Crestor and the brands all cost, like, $100 a month and, maybe, there was a generic equivalent. If the health plan made it too expensive for a patient to get one of those drugs, they usually made another one in the same class attractive financially. So, the patient had (theoretically, at least) options; and the stakes were also a lot lower. The dollar volumes that we're talking about here were a lot lower. Now this same war is being fought on the specialty side of the house, where drugs cost thousands or tens of thousands a month and the patient may have but one option. So, if it's made to be financially toxic for a patient to get that one drug, the patient has to choose between their family's health and dipping into their 401k in order to afford their out-of-pocket costs. Or going bankrupt. Or dying. And when I say “or dying,” that is not hyperbole. There are studies that clearly show the mortality rates for patients who have trouble affording their meds are worse. In these cases, Pharma can be, sort of authentically, a hero who steps in and helps patients who are functionally uninsured because they can't afford the co-pays and deductibles that their plan sponsors have put in place to actually use the insurance that they are paying handsome premiums to have. Pharma can step in and help via these co-pay discount cards or coinsurance programs or through patient assistance programs helping those with lower incomes. So, there's no question in the short term that when a patient desperately needs a drug and their insurance is insufficient, a pharma manufacturer can be a knight in shining armor financially. But only if this were so simple, like this is some kind of spaghetti western with the good guys and the bad guys. Now let's think about this co-pay/out-of-pocket assistance offered by Pharma with a longer timeframe or a more systemic timeframe in mind. How is it that Pharma can have prices that are as high as we all know they are? Right?! It's because enough patients don't abandon the med at the pharmacy counter or, these days, in the infusion clinic. So, the lower Pharma can drive the patient out of pocket for a really expensive drug, the more they have a certain amount of impunity to raise the drug prices. This is a lot of the argument against price caps on out of pockets just in general, by the way. They matter for patients. They save lives. But they also have the consequence of kind of getting rid of what is often seen as a big control point checking pharma prices from zinging even higher than they already are. Bottom line, we have a catch-22 on our hands—and the patient is stuck in the middle. If you're a patient and you need your miracle drug (and a lot of patients call these drugs their miracle drugs), Pharma is your hero … at least right now. However, Pharma is also now able to raise their prices even more next year; and now you really need their out-of-pocket support because the price of the drug is so high your employer/taxpayers can't afford the rising drug spend and even more cost gets shifted onto patients. It becomes like Stockholm syndrome. But again, no white hats and black hats here. This whole thing is one of those incomprehensible art house films with lots of plot twists and in every other scene, you start to feel for the character you just hated 10 minutes ago … because while Pharma is getting busy raising prices, you have PBMs and nothing-for-nothing plan sponsors also up to their own machinations. Like, hey, here's one that's quite a marvel: PBM double-dipping. If the PBM can get Pharma to pay the patient deductible and then also get the patient to pay the patient deductible … Hmmm … By the way, that was a backdoor introduction to accumulators. And then later on, maximizers showed up on the scene. I just want to say that with maximizers, not all are created equal. I can certainly see their value for patients when they are deployed by companies and plan sponsors as part of their benefit designs with an explicit goal of helping members and the plan itself (nothing for nothing) afford expensive drugs it's clear that the patients need. But … I have to say, and I'm not well versed enough yet in how this maximizer business has evolved to comment on whether some of what is going on is still a net positive for some members and patients. Some of these PBMs have opened up entirely separate maximizer companies, which, for sure, they are upcharging employer plan sponsors to use. And the whole point of these separate entities is to get as much cash out of Pharma as possible while they, I don't know, may or may not pass that cash on as savings to patients and members. I need to do a show on this coming up. There's a new bill in the House, by the way. It's called the HELP Copays Act, which I don't think is just aimed at accumulators. If you didn't understand what I just said, you will after you listen to this episode. With that, here's Dea Belazi. Dea is president and CEO over at AscellaHealth. He is a pharmacist by training who has worked for Pharma, and then he worked at a health plan, spending a lot of time in the PBM space. In other words, he's seen this tangled web from pretty much every angle. We kick right into the conversation talking about accumulators.   You can learn more at ascellahealth.com.   Dea Belazi, PharmD, MPH, has led the development and management of AscellaHealth's global specialty pharmacy benefit and healthcare services for nearly a decade. As a visionary and architect of change, leading the AscellaHealth shift from pharmacy benefit management to specialty pharmacy solutions, he has played a key role in the company, achieving a staggering four-year growth of more than 1556%. Previously, he served as a senior executive and played a key role in the growth and expansion of PerformRx, a PBM owned by Keystone First Health Plan. Additionally, Dea held a leadership position at FutureScripts, an Independence Blue Cross company that was sold to Catamaran. A respected industry professional and thought leader, Dea is often invited as a reviewer for multiple medical journals and holds a seat on the board of directors for numerous healthcare-related companies. Based on his impressive career and growing reputation, he was chosen to serve on FierceHealthcare's Editorial Advisory Council. Dea was most recently recognized as an Ernst & Young Entrepreneur of the Year 2022 Greater Philadelphia Award Finalist; he is also a 2022 Philadelphia Titan and a 2021 Philadelphia Business Journal Most Admired CEO honoree. Dea holds a PharmD from the University of Rhode Island. He completed his dissertation at Brown University, earned a Master of Public Health from Johns Hopkins University, and served as a post-doc health outcomes research Fellow at Thomas Jefferson University.   11:06 “The concept of co-pay accumulators wasn't just a … PBM thought, but it also came from their customers, whether it was health plans or employer groups.” 15:50 “[This is] literally a math problem based on, ‘Do I spend it now? Do I spend it later?'” 17:20 What reason do employers and payers have for doing this? 21:13 “This is another mechanism for payers to push down additional cost to both the patient and now the pharma company.” 22:24 EP241 with Vinay Patel. 22:59 “I don't think accumulators are really forcing Pharma to be more competitive.” 25:06 How co-pay maximizers are different from co-pay accumulators. 28:09 Who doesn't like co-pay accumulators and maximizers? 30:01 How patient advocacy groups are a different model. 32:10 What is the biggest challenge facing employers right now?   You can learn more at ascellahealth.com.   Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #copay   Recent past interviews: Click a guest's name for their latest RHV episode! Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356)

Thanks, shurx, for this review on iTunes entitled “Prepare to Learn.” Shurx wrote: “[RHV] provides key insight from experts that you won't find anywhere else. It paints the picture of how our healthcare is tangled, and who benefits because of it. Whether it's drug pricing, PBM shenanigans, hospital billing, or market trends that are challenging the status quo, this podcast is worth your time. I've shared many of the episodes with my pharmacy colleagues who have replied, ‘I didn't know that's how it worked.' Now they do thanks to Stacey and her team.” I wanted to kick off this particular show with this review because today we are again digging into the business of hospital care in this country. That's actually how Sanat Dixit, MD, MBA, FACS, put it on LinkedIn recently. He said some of the hospitals these days aren't in the healthcare business; they're in the hospital care business. And when I say some hospitals, I mean some people in decision-making roles at some hospitals. There was an opinion piece in the New York Times the other day by Eric Reinhart, and here's my highlight from his essay. He writes, “But the burnout rhetoric misses the larger issue in this case: What's burning out health care workers is less the grueling conditions we practice under, and more our dwindling faith in the systems for which we work.” Relentless Health Value is here so that our Relentless Tribe has the information that you need to influence what goes on in some of the boardrooms where some of these decisions are being made. With that, let's move on. You know why my guest, Brennan Bilberry, got into his current line of work battling hospital chain anticompetitive practices? He got into it because this behavior, which is normalized in healthcare, would never be tolerated in any other sector of the economy. No one would get away with it because these anticompetitive practices are, hey, anticompetitive. They spell the death of functioning markets. We kick off our conversation, Brennan and I, going through the typical hospital system consolidation playbook and how anticompetitive practices are kinda part of the typical gig here. It's quite clever, by the way, for hospital system executives to think this way. I mean, it's illicit and, some would say, unethical but clever if your main metric is revenue maximization. Anticompetitive contract terms are, after all, a flywheel. You consolidate to get enough market power to effectively force everyone to sign your anticompetitive contracts. And then step two: After that, you break out your anticompetitive contract terms spatula and you scrape out any remaining competition from your area. Which leads you to step three: Rub your hands together and raise prices and donate to politicians so legislation becomes even less likely. And then step four: Continue to raise your prices. Don't you love it when a plan comes together? In this healthcare podcast with Brennan Bilberry, we talk about four contract terms that any self-respecting anticompetitive hospital contract should include and how each of them restricts competition unfairly and causes higher prices for communities, taxpayers, patients, employers … basically everybody, including people who work at the health system, who wind up needing medical care. In a nutshell, here's the four anticompetitive contract terms that we dig into in this episode: All-or-nothing contracting, wherein a hospital system says if you want us in your network, you must include every single facility that we have in your network and at the monopoly-level prices we demand, even in areas that might be competitive. There is a reason why a hospital system might be all hachi machi to buy a rando not super profitable hospital in a rural area. The payer must include that hospital in their network then because of network adequacy or whatever. And then from then on, all of their care settings are now in network—even the lower-quality ones—and all of them at the highest prices. And there's no price negotiation that's possible after that. Anti-steering and anti-tiering clauses: This means that a payer/ASO (administrative services organization)/TPA (third-party administrator)/plan sponsor cannot steer members to lower-cost or higher-quality hospitals, nor can it offer benefit designs that have tiers (ie, lower co-pays if a member goes to specified high-value hospitals). So, any chance of using consumerism or navigation as a way to get members to better places is just eviscerated by this little move. Pricing gag clauses: It's when contract terms prohibit an ASO/TPA from telling its plan sponsor customers or members what the price of services are before (or sometimes even after) the service is rendered, claiming it's important to not let employers or patients know these costs because revealing actual prices will [checks notes] cause hospital prices to go up. I'm speechlessly mystified by this logic, but OK … I only have a bachelor's in economics. Contract terms that restrict other providers in the market: So, a dominant hospital uses admitting privileges or referrals or other leverage to effectively control other providers in the market, including providers who are ostensibly independent. So, while the market may look dynamic, it is really not. Some links to interesting articles and posts and other episodes related to this topic: Definitely listen to the shows with Mike Thompson (EP389) and also the one with Chris Skisak and Gloria Sachdev (EP390). We talk about market dynamics and hospital legislation in these two shows, which are, frankly, the best ways to get rid of hospital systems' ability to hold their communities and other local providers hostage with some of this strong arming. Here's a link to an article I was thinking about while recording this show about Daran Gaus's hypothesis for how mergers will impact hospital prices. And here's a link to an article about how commercial prices for outpatient visits were 26% higher for patients receiving care at a health system than those visiting non-system physicians and hospitals. Another episode I mentioned when Brennan and I discussed the consequences of some of these anticompetitive contract terms is the one with Cora Opsahl (EP373). I also reference the episode with Dale Folwell, treasurer in North Carolina (EP249). One last link is to the conversation I had with Dr. Scott Conard (EP391), where the local hospital bought a local ACO (accountable care organization) physician organization and the community paid an additional $100 million to the hospital the following year. My guest in this healthcare podcast as aforementioned is Brennan Bilberry, who is a founding partner over at Fairmark Partners, which is a law firm litigating some of these antitrust lawsuits against some of these hospital chains. You can learn more at fairmarklaw.com.  Brennan Bilberry is a founding partner of Fairmark Partners, LLP, a law firm focused on fair competition issues, especially in the healthcare industry. Fairmark has filed numerous antitrust cases against dominant hospital systems, seeking to tackle anticompetitive practices that lead to higher prices for businesses, consumers, and unions. Prior to founding Fairmark, Brennan worked as a policy consultant and political operative whose work included overseeing environmental public policy campaigns in numerous countries, providing international political intelligence for US investors, advising political campaigns around the world, and designing consumer and legal advertising. Brennan also worked on numerous US political campaigns, including serving as communications director for Terry McAuliffe's 2013 successful campaign for Virginia governor, serving as deputy executive director of the 2012 pro-Obama Super PAC Priorities USA, and developing research and policy communications for the House Democrats. Brennan is a native of Montana and South Dakota and has lived in Washington, DC, for the past 15 years.   06:16 What happens after a hospital consolidates? 07:23 What does an anticompetitive system look like when a hospital consolidates? 10:13 Tricia Schildhouse on LinkedIn. 10:35 What are some anticompetitive “tricks” that hospitals employ? 12:37 The Sutter case in northern California. 14:50 What can you do if you're forced to engage in an all-or-nothing contract with a hospital system? 18:31 The Atrium case in North Carolina. 19:36 EP373 with Cora Opsahl. 21:33 What are price gag clauses? 23:08 How are legacy gag clauses designed to prevent scrutiny in litigation? 24:04 EP249 with Dale Folwell. 26:08 How do hospital restrictions on other providers create an anticompetitive environment? 27:23 EP391 with Scott Conard, MD. 29:48 EP389 with Mike Thompson or EP390 with Gloria Sachdev and Chris Skisak.   You can learn more at fairmarklaw.com.   @brbilberry discusses #hospital #anticompetitive practices on our #healthcarepodcast. #healthcare #podcast #hospitals #hospitalsystems #anticompetitivepractices Recent past interviews: Click a guest's name for their latest RHV episode! Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, 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  

You would think that hospitals with the most money would offer the most charity care—trickle down and all of that. If my health system is big and I have lots of money and profitable commercial patients, I can stuff more dollar bills into the charitable donation balance sheet bucket, right? Except, in general, it's a fairly solid no on that. Let's talk about some of my takeaways from the conversation that I had with Vikas Saini, MD, and Judith Garber from the Lown Institute. During the conversation, there's also mention of a powerhouse of a New York Times article. So, let's circle up on but a few of the more interesting (according to me) reasons why some rich hospitals fail to offer the level of charity care that you might think they could or should: #1: Chasing commercial contracts because they are very profitable means building in areas where there are frankly not a whole lot of poor people. You see hospital chains doing this all of the time and saying at the 2023 JPM (J.P. Morgan) conference that they intend to do more of it, opening up in a fancy suburb with no affordable housing. When this happens, there is just less opportunity to offer charity care. The need for financial aid in that ZIP code is just less. #2: The Ambulatory Surgical Center (ASC) movement, which is weird to say because, in other respects, I'm a big fan. There are a lot of services and surgeries moving out of the hospital into ambulatory surgical centers or just the outpatient setting, and this is going on for a bunch of reasons, including Medicare and employers being very on board with this to save facility fees. But here's a consequence: Surgeons and other docs are now not in the hospital. So, indigent patient shows up in the emergency room and needs an emergency surgery or some intervention. But wait … those physicians and their teams are no longer in the hospital. And now the hospital doesn't have the “capability or the capacity” to serve that patient. I heard from a surgeon the other day, and when he's on call at his hospital, he's getting patients shipped to him on the regular from hospitals in other states. Now, about this “oh, so sorry … we can't possibly help you so we're gonna stick you in an ambulance and take you to another state” plan of action. I called up emergency room expert Al Lewis. He told me that if this “ship 'em out” is being done routinely as a pattern by hospitals who have an ER, you could call it evidence of an EMTALA (Emergency Medical Treatment and Labor Act) violation on several levels. You can't have an emergency room and then routinely not be able to handle emergencies, especially when the emergencies you can't handle always seem to be of a certain kind and for a certain kind of patient. Speaking of violations, one more that reduces the need and level of charity care is canoodling with ambulance companies to take the poor people to some other hospital and the rich people to your hospital, which was allegedly transpiring in New Jersey, based on a recent lawsuit. #3: [play some foreboding music here] This last one is the big kahuna underlying reason why some very rich hospitals may not offer the level of charity care which you'd think they would. This was superbly summed up by Tricia Schildhouse on LinkedIn the other day. She knew a physician leader who would go around saying, “Non-profit and for-profit is a tax position, not a philosophy.” Bottom line, this whole thing boils down to what has been normalized as OK behavior at some of these rich hospitals. You have people in decision-making roles taking full advantage of their so-called tax position to jack up their revenues—revenues which they have no interest in frittering away on charitable causes. Why would they do that when they can use the money to, I don't know, stand up a venture fund or make Wall Street investments? Don Berwick's latest article in JAMA is entitled “The Existential Threat of Greed in US Health Care.” And, yeah … exactly. Back to that New York Times article that we talk about in this healthcare podcast, here's what it says about a hospital in Washington State. It says: “The executives, led by [the hospital's CFO] at the time, devised … a program called Rev-Up. “Rev-Up provided [the hospital's] employees with a detailed playbook for wringing money out of patients—even those who were supposed to receive free care because of their low incomes.” All of this being said, there are hospitals out there who are, in fact, living up to their social contract and serving their communities well with very constrained resources. You also have hospitals just in general working within some really whack payment models that we have in this country, which easily could be a root cause precipitating this suboptimal-ness. Dr. Saini and Judith Garber mention three direct solves for hospital charity shortfalls and also the larger context of the issue. So, there's, of course, better reporting and better auditing, which is pretty nonexistent in any kind of standardized way right now. I also really liked one of the solutions that Dr. Saini mentions on the show: Maybe instead of all the hospitals doing their own charity care thing, they all should pool their money regionally and then put a community board in charge of distributing it. That way, if there is a hospital in an area where the charity care is really needed, even if the rich hospital nearby doesn't have a facility there, they can help fund this care that their larger community really needs—including, by the way, public health needs, which is currently a big underfunded problem. As mentioned earlier, I am speaking with Vikas Saini, MD, and Judith Garber. Dr. Saini is president of the Lown Institute. Judith Garber is a senior policy analyst there. They've studied hospitals from a number of dimensions, not just charity care.   You can learn more at lowninstitute.org and lownhospitalsindex.org.    Vikas Saini, MD, is president of the Lown Institute. He is a clinical cardiologist trained by Dr. Bernard Lown at Harvard, where he has taught and done research. Dr. Saini leads the Institute's signature project, the Lown Institute Hospitals Index, the first ranking to measure hospital social responsibility. The Index, first launched in July 2020, evaluates hospitals on equity, value, and outcomes and includes never-before-used metrics such as avoiding overuse, pay equity, and racial inclusivity. In his role at the Lown Institute since 2012, Dr. Saini led the development of the Right Care series of papers published by The Lancet in 2017, convened six national conferences featuring world-renowned leaders in healthcare, and guided other Lown Institute projects such as the “Shkreli Awards.” Dr. Saini also serves as co-chair of the Right Care Alliance, a grassroots network of clinicians, patient activists, and community leaders organizing to put patients, not profits, at the heart of healthcare. Prior to the Lown Institute, Dr. Saini was in private practice in cardiology for over 15 years on Cape Cod, where he also founded a primary care physician network participating in global payment contracts. He also co-founded Aspect Medical Systems, the pioneer in noninvasive consciousness monitoring in the operating room with the BIS device. Dr. Saini is an expert on the optimal medical management of cardiologic conditions, medical overuse, hospital performance and evaluation, and health equity. He has spoken and presented research at professional meetings around the world and has been quoted in numerous print media, on radio, and on television.  Judith Garber is a senior policy analyst at the Lown Institute. She joined the Lown team in 2016, after receiving her Master of Public Policy degree from the Heller School of Social Policy. Her research interests include hospital community benefit policy, overuse and value-based care, and racial health disparities. She has authored several white papers, journal articles, op-eds, and other publications on these topics. Judith previously worked at the Aspen Institute Financial Security Program, the Midas Collaborative, and Pearson Education. She has a bachelor's degree in American studies and political science from Rutgers University.   06:50 Why does America need socially responsible hospitals? 08:23 What standards are hospitals beholden to with their charitable spending? 08:47 “It's the honor system, essentially.”—Dr. Saini 11:38 What is fair share spending? 13:43 Which hospitals are paying their fair share? 15:05 Why do hospitals that are financially more strapped tend to give back to their communities more? 17:25 Why is it hard for hospitals with the most privately insured patients to do the most for their community? 18:56 “These outcomes … are the outcomes of the [current system].”—Dr. Saini 21:23 “A key problem here is [that] systems have gotten so big.”—Dr. Saini 22:30 What's the solution to fixing the problem with hospital charity care? 23:52 EP374 with Dave Chase. 29:21 What would be the level of acceptance with changing the system as it stands with hospitals?   You can learn more at lowninstitute.org and lownhospitalsindex.org.   @DrVikasSaini and @JudiTheGarber of @lowninstitute discuss #hospitalcharitycare on our #healthcarepodcast. #healthcare #podcast #hospitals Recent past interviews: Click a guest's name for their latest RHV episode! David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, 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  

Andréa calls Dr. Vikas Saini, President of the LOWN Institute to discuss their Hospital Index which measures a hospital's social responsibility, examining how hospitals rank in terms of health outcomes, value and equity. The index is comprised of 53 different metrics, Dr. Saini explains how they collect and analyze their data. This podcast is sponsored by Embold Health.

Dr Emily Cleveland Manchanda joins Ethics Talk to discuss her article, coauthored with Dr Karthik Sivashanker, Steffie Kinglake, Emily Laflamme, Dr Vikas Saini, and Dr Aletha Maybank: “Training to Build Antiracist, Equitable Health Care Systems”  Recorded November 9, 2022.  Read the full article at JournalofEthics.org.

In this healthcare podcast, I have Merrill Goozner on the show talking about his prognostications for the future of healthcare in this country and how, realistically, it could be engineered so that the healthcare industry rightsizes itself relative to our GDP. Merrill offers three glide paths to this end. Okay … so, let's break this down some. First, Merrill talks about the full impact of huge numbers of patients/people in this country who are scared to seek medical attention. They are afraid to play the game at the end when the bill comes in the mail and they open it up having no idea what it is going to be. It's a magical mystery guessing game of luck and chance where losers go bankrupt. This is not a victimless situation we have going on here in this country. All these deaths of despair and life expectancy going down … this is unprecedented. So now, we're level-set on the stakes. Interestingly, Merrill plots out the aspiration for healthcare spending in exactly the same way that David Muhlestein, PhD, JD, did in episode 364. The goal, according to both of them, isn't to reduce healthcare spending per se. That would be nie near impossible to pull off in the real world, but we could work on holding healthcare cost increases below the rate of GDP growth. Optimal might be healthcare costing, say, 13% of GDP like it does in Switzerland instead of upwards of 20% ($1 out of $5) getting stuffed in the pockets of a healthcare entity or their shareholders. Fifty percent of that, by the way, is being paid for by the government, the other 50% largely coming out of the wages of employees either directly or indirectly. Okay … so, what is the lightning-in-the-bottle moment where we clip in for this journey toward rightsizing healthcare prices? Merrill says it's a combo of patients and employers and taxpayers crying uncle at the same time that technology and new competitors move in on the supply side and start to chip away at older incumbents like hospitals, especially hospitals who have broken their social contract with their communities—and there I'm paraphrasing some terminology Vikas Saini, MD, uses in an upcoming episode on hospitals and their embarrassing levels of charity care. So, it's harnessing forces on the demand side of the equation and on the payment side of the equation, coupled with goings-on on the supply side. With all of this going on, Merrill says that, in this crucible of transformation, we could get better care for lower costs. To accomplish that, he says step 1 is for the team for healthcare costs going down—employers taxpayers, government policy makers—gang up, create a value alliance, and work together. These allies then tell the healthcare industry, “Look, gang … ixnay on the growth rates you've been accustomed to in the past. Period. You are going to need to deal with that, so get used to it.” That is kind of where all of this starts. Merrill mentions three glide paths that will help up get from here to there, and he names the three: Accountable care—essentially putting providers at risk, giving them budgets that they are responsible to work within Paying for value. We have PCPs who deliver a lot of value. We should pay 'em more. We should also put docs on salary like they do at Mayo and some of these other leading Centers of Excellence. All-payer pricing, which we do get into. They have this now in Maryland. It's basically when everybody pays the same price for the same service. Merrill says this all kind of rolls up into removing the incentives that reward low-value care. That can be really expensive. I'm paraphrasing here. I'm sure for many of you, Merrill Goozner needs no introduction. He's been the editor in chief of Modern Healthcare. He wrote a book on the drug industry. He was a reporter for many years before that and also did public interest work. Thank you to Hugh Sims, MD, MBA, for his support and insight! You can learn more at GoozNews. You can also read his book on the drug industry, The $800 Million Pill. Merrill Goozner served as editor in chief of Modern Healthcare from 2012 to 2017 and, as editor emeritus, continued to write the magazine's weekly column until April 2021. In October 2020, he launched GoozNews.substack.com, where he continues to write about healthcare, the environment, and other subjects. Prior to joining Modern Healthcare, his journalism career spanned nearly 40 years as an editor, writer and journalism educator. In 2004, he authored The $800 Million Pill: The Truth Behind the Cost of New Drugs. He previously served as a foreign, national, and chief economics correspondent for the Chicago Tribune (1987-2000) and a professor of journalism at New York University (2000-2003). He has contributed to numerous lay press and scientific publications over the course of his career, ranging from the New York Times to the Journal of the National Cancer Institute. He earned his master's degree in journalism from Columbia University in 1982 and his bachelor's degree in history from the University of Cincinnati in 1975. The University of Cincinnati named him a Distinguished Alumni in 2008 and inducted him into its Journalism Hall of Fame in 2016. 06:24 How is the rise of the high-deductible plan affecting the nation's health? 07:20 What is one of the big issues not being discussed in America today? 08:33 What kind of tipping point is in store for hospitals in this decade? 09:01 What two trends are we going to see in healthcare in the coming decade? 10:50 What are the ways in which the changes in healthcare go well, and what pitfalls do we need to look out for? 11:14 “[This] is about what is sustainable and what is not sustainable.” 12:35 “Healthcare is misnamed. It's sick care.” 13:12 Why do we need to talk more about who gets sick in this country? 13:51 “Pricing is part of the problem, but volume is the other part [of the problem].” 15:40 “The world is gonna change, you're gonna change, and we're gonna provide you a glide path … because this is what we need as a society.” 17:20 What should be the overall goal for healthcare spend? 18:45 EP364 with David Muhlestein, PhD, JD. 19:40 Why do we need to address physician pay? 25:31 Why does the single pricing system create equality? 30:11 EP363 with David Scheinker, PhD. 30:34 EP370 with Erik Davis and Autumn Yongchu. 30:55 What are the three glide paths for the future of healthcare? You can learn more at GoozNews. You can also read his book on the drug industry, The $800 Million Pill.   @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast How is the rise of the high-deductible plan affecting the nation's health? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What is one of the big issues not being discussed in America today? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What kind of tipping point is in store for hospitals in this decade? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What two trends are we going to see in healthcare in the coming decade? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What are the ways in which the changes in healthcare go well, and what pitfalls do we need to look out for? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “[This] is about what is sustainable and what is not sustainable.” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “Healthcare is misnamed. It's sick care.” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast Why do we need to talk more about who gets sick in this country? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “Pricing is part of the problem, but volume is the other part [of the problem].” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast “The world is gonna change, you're gonna change, and we're gonna provide you a glide path … because this is what we need as a society.” @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast What should be the overall goal for healthcare spend? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast Why do we need to address physician pay? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast Why does the single pricing system create equality? @_GoozNews discusses the future of #healthcare on our #healthcarepodcast. #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34)  

Dr. Vikas Saini is the president of the Lown Institute. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. E.J. Rourke. Ten Years of Choosing Wisely to Reduce Low-Value Care. N Engl J Med 2022;386:1293-1295.

Listen Now Listeners of this podcast are aware the US suffers from extreme wealth and income inequality. (E.g., see my...

Sohinee Day Pal talks to Vikas SainiVikas Saini, an Actor and writer and currently writing a web series show in Hindi. After spending 3 years in the industry, he has done 5 + TVCs adverts. Played 5-6 Characters in Serials and web series, Mirzapur- 2

Season 1 | Episode 30 | September 8, 2021In this week's episode, Dr. Trey Dobson hosts Vikas Saini, MD, the president of the Lown Institute. They will discuss the Lown Hospitals index, launched in July 2020, which evaluates hospitals on equity, value, and outcomes, and includes never-before-used metrics such as avoiding overuse, pay equity, and racial inclusivity. Dr. Saini is a clinical cardiologist trained by Dr. Bernard Lown at The Brigham and Women's Hospital and Harvard University, where he has taught and done research. Dr. Saini leads the Institute's signature project, the Lown Institute Hospitals Index, the first ranking to measure hospital social responsibility. In his role at the Lown Institute, Dr. Saini led the development of the Right Care series of papers published by The Lancet in 2017; convened six national conferences annually featuring world-renowned leaders in health care; and guided other Lown Institute projects such as the “Shkreli Awards.” Dr. Saini is also co-chair of the Right Care Alliance, a grassroots network of clinicians, patient activists, and community leaders organizing to put patients, not profits, at the heart of health care. He has practiced cardiology with the Lown Cardiovascular Group at the Brigham and Women's Hospital, and, before joining the Lown Institute,  was in private practice in community cardiology for 15 years on Cape Cod. There he also founded Cape Physicians LLC, a primary care network managing global care with financial risk. Early in his career, he was scientific co-founder of Aspect Medical Systems, the pioneer and continued market leader in consciousness monitoring in the operating room using the BIS monitor. Underwriter: Mack Molding

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

"It's rare for anyone to try and tally the precise cost of unnecessary care. But when they do, the estimates are staggering. The Washington Health Alliance, a nonprofit dedicated to making care safe and affordable, analyzed insurance claims from 1.3 million patients who received one of 47 tests or services that are considered overused or unnecessary. What they found should make patients and doctors rethink that next referral. In a single year, more than 600,000 patients underwent a treatment they didn't need, costing an estimated $282 million. More than a third of the money spent on the tests went to unnecessary care, their study found. Unnecessary medical care has 'become so normalized that I don't think people in the system see it,' Dr. Vikas Saini told me. Saini is president of The Lown Institute, a Boston think tank focused on making health care more effective, affordable and just. Lown researchers have shown how overtreatment happens across the spectrum of medical care. Doctors may push for Caesarean sections for their own convenience, not so moms and babies can be healthy. Breast cancer, prostate cancer and thyroid cancer get over-diagnosed, leading to harmful and costly treatment. Around a third of colonoscopies are unnecessary, research has shown. That's not just wasting our money. It's also putting us at risk of harm." Marshall Allen is a journalist and author of Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. He shares his story and discusses his KevinMD article, "How to avoid treatment you don't need." (https://www.kevinmd.com/blog/2021/06/how-to-avoid-treatment-you-dont-need.html)

In May, the Lown Institute published a ranking of which hospitals deliver the greatest amount of “low value” care. In this episode president of the nonpartisan think tank, Dr. Vikas Saini discusses the methodology used in constructing that measure.

Analytics is not just a one time thing, it has to be treated as something you will use in a continuous cycle that will improve your business processes and performance. Let's dig deeper. Vikas Saini is a Technology Product Leader at Willis Towers Watson with specific expertise in HR Technology, Analytics and Big Data platforms. His core expertise is in delivering consumer grade analytics and big data products with a career that spans across startups to fortune 500 organizations.Let's dive right into Vikas' expertise and learn about building your data analytics capabilities as it relates to technology, how to get started and what to avoid.[00:01 - 04:34] Opening SegmentDino and I welcome and learn more about Vikas Saini Today's topic - Building Your Data Analytics (Technology) Capabilities[04:45 - 14:44] Getting Started with Your Overall Analytic StrategyUnderstanding the needs of the corporate strategy and the capabilities of usersBuilding a fact/data driven culture - getting startedGetting passed the ‘give me everything' effect[14:45 - 21:26] Build vs. Buy Decision for Technology 3 high level criteria to follow Factoring in the technology and the content [21:27 - 27:51] Navigating Potential Challenges; What Could Go Wrong?The data is only as good as the source - ensure qualitySeeking to improve the user experienceDon't be afraid to change directions - adoption and evolution [27:52 - 30:45] Closing SegmentSummary of our conversation and final pointsFinal WordsSupport the show (https://www.buymeacoffee.com/hrdatalabs)

Decades of poor outcomes in terms of cost, quality, and access have not created societal commitment to confronting the issue of low-value care in hospitals. Despite medical errors serving as the #3 cause of death, unpaid hospital bills leading as the #1 reason for personal bankruptcy in our country, vast disparities in care prevalent across racial and sociodemographic lines, and a general sense of pricing opaqueness, we have not yet seen a community-led movement towards hospital accountability for health equity, quality of care, and avoidance of low-value care.   If hospitals are to equitably deliver the high-quality care that is essential to improving community health, the time is now. Assessing how well hospitals are serving all of their patients in their communities is a key first step in improving their quality of care. The Lown Institute, a think tank generating ideas for a just and caring system for health, has developed a tool to answer the question, “Are hospitals providing high-value care, achieving excellent patient outcomes, and meeting their obligation to advance health equity in their communities?”   Today we are joined Vikas Saini & Shannon Brownlee of the Lown Institute to discuss The Lown Institute Hospitals Index, a novel way of evaluating and ranking hospitals in order to help them better serve their patients and communities and to hold them accountable to addressing social determinants of health. This unique hospital ranking system is breaking new ground as we move forward in the race to value.   Episode Bookmarks: 02:00 Despite decades of dreadful outcomes, society has yet to confront the issue of hospitals providing low-value care 04:30 The legacy of Dr. Bernard Lown, as a pioneering cardiologist, humanitarian, and early advocate of value-based care 08:20 Dr. Lown's philosophy of value-based care and the subtle distinction between doing as little “to” patients, but doing as much as possible “for” them 11:15 A new hospital ranking tool is needed in value-based care -- one that factors in civic leadership and racial equity 12:50 The Lown institute Hospitals Index is the first ranking system that actually measures overuse and unnecessary care 13:20 Economic tradeoffs matter when you look at racial equity 14:05 In ranking hospitals, the value of the care is as important as clinical outcomes. 15:05 Good hospitals are vital to healthy communities, but how you define and measure “good” matters. 15:30 The Civic Leadership component of the Hospital Index which accounts for spending on charity care, pay equity, and racial inclusivity 19:00 Variation in social and civic leadership metrics with academic medical centers, particularly inclusivity and pay equity 20:20 How Black Lives Matter has forced hospitals to reexamine their culture and commitment to health equity 21:45 Neighboring hospitals with drastically different racial inclusivity scores and the impact of residential segregation 25:00 Segregated (“separate and unequal”) hospitals with disproportionate impacts in COVID outcomes for those in low-income communities 26:30 The way we have organized and funded the hospital sector will not meet population health needs for communities 27:30 The need for regional coordination, changes in payment mechanisms, and global budgeting for health care transformation. 29:00 The Big Business of Healthcare and why “Health care is too important to leave to the Healthcare sector.” 30:00 Having a hospital system based on cooperation in population health versus having individual healthcare businesses competing against each other for volume 31:00 The disappointing, yet predictable, inequitable distribution model for COVID-19 vaccines 36:00 Low-value care is a significant portion of waste; estimates of spending on low-value care range from $100 billion to $700 billion each year! 39:00 Vikas discusses how his clinical training with Dr.

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Vikas Saini discusses a new Lancet Series, which aims to improve global health care through an emphasis on reducing overuse and underuse of medical treatment.