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

Relentless Health Value

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

INBW30: A Hot Take on Healthcare Stakeholders Not Collaborating

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

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

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

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

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

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

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

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

In most other industries, it’s the customer who consumes the services and engages with the purveyor of services. In health care, not so much. Legacy health care has evolved to honor the insurance carrier as the customer or, in some cases, the fancy surgeon or other driver of revenue as the customer. Listen to the podcast with Marshall Allen for more on that front, but yeah. And here we are.  Health care should be designed so that patients get the best outcomes at a financially not-toxic price point. Otherwise, what are we doing here besides putting profit over patients? In this health care podcast, the conversation is about PCVS, otherwise known as creating a “patient-centered value system,” otherwise known as building a new OS, or operating system, for health care—one that is built around the patient and their experience. The general idea here is to rationalize the patient journey from start to finish: to create a longitudinal flow that guides a patient from here to where they need to be with a minimum of being told you need a follow-up appointment but having no idea with whom or how that’s supposed to happen and when, or getting discharged with no instructions, etc. So, PCVS … let’s talk about this, how this works, real quick before we dive in with Dr. DiGioia. In a nutshell, the first step is to really, really carefully trace the patient journey from beginning—really the very, very beginning of the experience, which might start in the parking lot or with the first digital interaction or at the PCP referral—to the very last interaction, which might be after discharge from the SNF (skilled nursing facility) after their last follow-up appointment. It’s figuring out what matters to the patient at each step in that journey and then documenting that flow map. Then the next step is to compare the current patient journey, the current state, to what the team decides is the ideal patient journey. Then the last task, which may be obvious, is to implement—for implementation teams to devise and implement action plans to get from here to there. Here’s an interesting point to ponder: We often talk about fragmentation and interoperability, and when I said these words, your brain immediately snapped to technology fragmentation and interoperability. But bear this in mind: The patient is the only commonality between all the settings of care that are using all those varied technologies. When you rationalize the patient journey, you also, to some extent, create the foundation to integrate technology. Why a PCVS process, you might ask, if you’re in charge of the P&L and regard patient centeredness as a nice to have if there’s extra cash lying around? Here’s why: If you’re going to successfully roll out a prospective bundle, for example, to employers, you better have gone through a PCVS process. Other things, too, but being intimately aware of the patient journey and where patients fall through the cracks or get disgruntled can easily spell the difference between bundle success and failure. This is probably also true for really almost any sort of risk-based/capitation arrangement. It’s probably also true for great customer satisfaction scores. It’s probably also going to become increasingly true when competing against some of these virtual-first operations that may have been built from the ground up to be sticky and engaging for patients, as well as guide them through a longitudinal journey. For more on the WIIFM (the “what’s in it for me?”) if you are a provider organization and are thinking about patient-centered care, listen to one of our most popular episodes over here at Relentless Health Value—the one with Joe Selby, MD, from PCORI—on this topic. In this health care podcast, I’m talking with Tony DiGioia, MD, about PCVS (patient-centered value systems). Dr. DiGioia is a practicing orthopedic surgeon at the Bone and Joint Center over at UPMC Magee-Womens Hospital and also the medical director of the UPMC Innovation Center. Dr. DiGioia wrote a book aptly titled The Patient Centered Value System.  One thing I thought of as I listened to this conversation again in preparation for releasing the episode: Dr. Shantanu Nundy has written that on the front lines of health care, clinicians and other frontline workers know what to do for their patients. They know what’s the matter and what matters to the patient and, really, what they need. Dr. Nundy talks about how, to efficiently transform health care, one thing that we need to do is “decentralize” control or shift power in terms of decision-making authority and resources back to the front lines and to patients. The point that I’m making is that the PCVS might be the OS that health care needs for “decentralization” to happen at a system level and in a way that everyone works together toward a common, aligned goal—as opposed to clinicians and patients all doing their own thing, making their own assessments about what is needed at any given moment at potentially cross-purposes to one another, re-creating all kinds of wheels that are going all kinds of different directions. You can learn more at discoverdrd.com and goshadow.org. Anthony (Tony) DiGioia, MD, is an entrepreneur, engineer, and practicing orthopedic surgeon, and a pioneer in care delivery transformation. “Dr. D” developed the Patient Centered Value System (PCVS), a personalized, replicable approach to care that improves clinical outcomes and experiences while reducing costs. His book, The Patient Centered Value System: Transforming Healthcare Through Co-Design, helps you understand what matters most to patients, map the current state of care in your organization, identify what can be improved, and build teams that co-design sustainable change. Using “What Matters to You?” surveys and shadowing to keep patients and families at the core of care, the PCVS serves as the care delivery model for Dr. D’s current award-winning practice at the Bone and Joint Center at UPMC Magee-Womens Hospital.  Dr. D most recently used the PCVS to develop the Center for Bone and Joint Health, flipping the script of routine health care visits by putting patients in the driver’s seat. In this relationship-based program, patients team up with providers to engage in their own care and personalize a plan based on their needs and priorities. But the PCVS is not just for orthopedics. It is increasingly being adopted nationally and internationally and has been applied to over 65 clinical conditions. Dr. D is medical director of the Magee Bone and Joint Center as well as the UPMC Innovation Center and a Fellow of the American Academy of Orthopaedic Surgeons and the American College of Surgeons. He is a faculty member for the Institute of Healthcare Improvement and an adjunct faculty member in the Department of Biomedical Engineering and the Robotics Institute at Carnegie Mellon University. Dr. D founded the not-for-profit AMD3 Foundation, which leads the Operation Walk Pittsburgh medical mission effort. 06:19 What is the Patient-Centered Value System, and why should it be the operating system for all health systems moving forward? 07:47 “It’s the infrastructure to allow us to redesign care delivery.” 09:00 “These artificial silos that we have in health care have to be crossed and broken down.” 10:03 “The patient is the common denominator. We have to follow the patient.” 10:33 Why does the disjointed patient experience affect a patient’s trust in their care delivery? 12:00 What are the steps to creating a patient-centric system? 12:30 “The challenge is to view all care through the eyes of patients and families.” 13:19 “Our end users are patients and families. Period.” 16:36 What’s the difference between asking patients, “What is the matter with you?” and “What matters to you?” 19:56 How are nonclinician staff included in a patient-centric value system? 25:40 “We can give them the tools, wherever they’re coming from.” 29:33 “The bottom line is, these are engagement tools and technologies that we do need to start looking at to help redesign care delivery.” You can learn more at discoverdrd.com and goshadow.org. @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity What is the Patient-Centered Value System, and why should it be the operating system for all health systems moving forward? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “It’s the infrastructure to allow us to redesign care delivery.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “These artificial silos that we have in health care have to be crossed and broken down.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “The patient is the common denominator. We have to follow the patient.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity Why does the disjointed patient experience affect a patient’s trust in their care delivery? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity What are the steps to creating a patient-centric system? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “The challenge is to view all care through the eyes of patients and families.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “Our end users are patients and families. Period.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity What’s the difference between asking patients, “What is the matter with you?” and “What matters to you?” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity How are nonclinician staff included in a patient-centric value system? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “We can give them the tools, wherever they’re coming from.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “The bottom line is, these are engagement tools and technologies that we do need to start looking at to help redesign care delivery.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity

EP332: A New OS for Provider Organizations—The Patient-Centered Value System (PCVS), With Tony DiGioia, MD

My guest in this health care podcast, Al Lewis, was telling me before we hit record that employer customers are vastly worse at evaluating wellness and point-solution vendors today than they ever have been in the past. Let’s break this down. One aspect leading up to the “worse than ever” is the proliferation of point-solutions lately and all the PE (private equity) dollars flowing into the health care space. You pick up any rock and you’ll find 25 health care startups underneath it. A second aspect is this: and this is not going to be a newsflash for many, but employers really trust their brokers and their EBCs (employee benefit consultants) to put together a good benefit package on their behalf. If an EBC says, “buy it,” employers click their heels and buy it a lot of times. And with that great power comes great... opportunity. We see an uptick in brokers and employee benefit consultants, enjoying themselves a little arbitrage-ish money grab by taking money from these startups/vendors under a variety of umbrellas while at the same time they call the employers their customers. This is especially profitable and also slimy when done under the cover of darkness because, as with so many aspects of health care, these backroom deals often happen without the employer customer knowing that there’s a vig involved in the recommendation process. Al Lewis says he works in the “Integrity Segment” of the market. He is well known for outing vendors for basically lies they tell in their marketing. The thing is though, if a vendor comes to Al and asks questions about how to do it right, Al is always happy to help. He has said that he wants people to learn and if you’re asking questions, it means you’re interested in learning. Al has been on the show before, actually multiple times, but one full episode was episode 245, and we dig into wellness that’s done “to” employees, not “for” them in that episode. So, check that out after you listen to this one, if you want more Al. Al also founded the Validation Institute and he’s also CEO over at Quizzify. On the show in this health care podcast, Al explains the six major logical fallacies, computational flaws, tricks, if you will, that wellness vendors or point-solution vendors may deploy to inflate their “proven cost savings.” The six “watch outs” I’d guess I say for employers are: Regression to the mean Participants vs nonparticipants or matched controls or propensity scoring The trend inflation trick Plausibility testing Actuaries and validation Overstating engagement These six things are all of the different logical fallacies some vendors employ in order to overstate their results or outcomes. The Validation Institute has a PDF write up of each of these flaws which you can find in the show notes. Bottom line? Buyer Beware. And, also, get a broker or an EBC who you know for a fact they’re working for you if you’re an employer because they’ve committed in writing to not taking payola from the vendors that they’re recommending to you. One footnote is that if you haven’t listened to episode 329 with Joe Connolly you might want to go back and do so. Joe gets into the trend of some services who could, potentially, start taking on risk. Said another way, if services like these create their own bundles of point solutions and take on the risk of offering said bundle to employers, that could be nice. You can learn more at the Validation Institute. You can connect with Al by emailing al@quizzify.com, visiting the website at quizzify.com, on LinkedIn, or on Twitter at @quizzify and @whynobodybeliev.  Al Lewis wears multiple hats, both professionally and also to cover his bald spot. Hat #1: Employee Health Literacy. He is the founder and “quizmeister-in-chief” of Quizzify, whose mission is to help companies teach their employees to utilize health care services appropriately, using a format best described as “Jeopardy meets Choosing Wisely meets Comedy Central.” Quizzify is the only vendor authorized to display the Harvard Medical School “Veritas” shield and has received excellent reviews from users. Quizzify is also well known for its surprise billing “Prevent Consent” solution, which was recently featured in the New York Times. It can be taped to an insurance card, used as a stand-alone card, or downloaded into your Apple Wallet. Starting in 2022, use of this language prevents forced arbitration under the Surprise Billing Act and instead allows payment of 2x Medicare for non-elective care.  His quiz-specific background includes authorship of the best-selling Newsweek Presents the Ultimate Trivia Game, which Games magazine lauded as having the best questions of any trivia game; hosting two quiz shows on Boston network affiliates; and appearing on Jeopardy. Hat #2: Outcomes Measurement. As an author, his critically acclaimed category best-selling book on outcomes measurement, Why Nobody Believes the Numbers, chronicling and exposing the innumeracy of the health management field, was named digital health book of the year in Forbes. Cracking Health Costs, written in conjunction with Walmart alum Tom Emerick, was also a trade best seller. He was the cofounder of the World Health Care Congress’s Validation Institute. His expertise in outcomes measurement got him named one of the unsung heroes changing health care forever.  He graduated Phi Beta Kappa with honors from Harvard, where he taught economics as well. He also graduated from Harvard Law School, albeit with no honors that time—other than winning their annual trivia contest, of course. 04:49 Are brokers going to have to become more transparent about where their money is coming from? 07:33 Are carriers transparent? 08:09 What’s the goal of the Validation Institute? 08:55 “You either get a true statement put up or learn what you have to do in order to get a true statement put up.” 11:18 How is Regression to the Mean (RTM) used in a flawed way? 16:32 “If you do wellness for employees instead of to employees, the people who want the wellness will be able to access it.” 21:13 What is plausibility testing? 23:17 What about actuaries and validation? 23:40 “That’s one of the reasons the Validation Institute exists, is because actuaries are easily corrupted.” 25:18 What is a prime example of population health economics? 26:20 What does it mean to overstate engagement? 27:15 “How often did you use this and was it useful?” 28:55 “Are you validated by the Validation Institute, and if not, why not?” You can learn more at the Validation Institute. You can connect with Al by emailing al@quizzify.com, visiting the website at quizzify.com, on LinkedIn, or on Twitter at @quizzify and @whynobodybeliev.  @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth Are brokers going to have to become more transparent about where their money is coming from? @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth Are carriers transparent? @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth What’s the goal of the Validation Institute? @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth “You either get a true statement put up or learn what you have to do in order to get a true statement put up.” @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth How is Regression to the Mean (RTM) used in a flawed way? @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth “If you do wellness for employees instead of to employees, the people who want the wellness will be able to access it.” @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth What is plausibility testing? @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth What about actuaries and validation? @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth “That’s one of the reasons the Validation Institute exists, is because actuaries are easily corrupted.” @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth What is a prime example of population health economics? @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth “How often did you use this and was it useful?” @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth “Are you validated by the Validation Institute, and if not, why not?” @whynobodybeliev of @quizzify discusses #wellnessvendors and #pointsolutionvendors on our #healthcarepodcast. #healthcare #podcast #employerhealthcare #digitalhealth

EP331: Employers Buyer Beware! Six Tricks Wellness and Point-solution Vendors Use to Overstate Their Results, With Al Lewis, Cofounder and CEO of Quizzify

Relentless Health Value is the podcast for business leaders working in payer/insurance carrier and provider organizations, as well as for pharmaceutical, medical device, patient advocacy, and other health care organizations. Health care–oriented venture capitalists (VCs) and digital health entrepreneurs also regularly engage with our show. Finally, we have a growing contingent of employer CFOs and benefits professionals who tune in. The podcast mission is to help transform health care by fostering collaboration and breaking down silos. Our panel of expert guests connects you with other health care leaders trying to achieve the quadruple aim of improving population health and patient and provider experience, while managing costs effectively. Relentless Health Value is one of the oldest and largest podcasts dedicated to health care industry decision makers trying to do the right thing.

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Relentless Health Value

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