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Relentless Health Value™

Author: Stacey Richter

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American Healthcare Entrepreneurs and Execs you might want to know. Talking.

Relentless Health Value is a weekly interview podcast hosted by Stacey Richter, a healthcare entrepreneur celebrating fifteen years in the business side of healthcare.

This show is for leaders in pharma, devices, payers, providers, patient advocacy and healthcare business. It's for health industry innovators, entrepreneurs or wantrepreneurs or intrapreneurs.

Relentless Healthcare Value is the show for you if you want to connect with others trying to manage the triple play: to provide healthcare value while being personally and professionally fulfilled.
509 Episodes
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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 #medicalindustrialcom
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
Let’s get a fast bead on what’s going on with drug pricing reform, shall we? Every time I wade into these waters, my head about explodes. So, I very much appreciate the opportunity to quiz Josh LaRosa from the always-well-informed Wynne Health Group. Here’s the goings-on in a nutshell: There’s goings-on. This infrastructure bill that’s in all the news all over the place right about now? You know what the plan is to fund all those bridges? Yeah, well, part of it is for Medicare to save money on drugs and then apply the savings to cover the costs of all those roads and train tunnels. There are three major potential ways that the federal government might conceive of collecting these drug savings: (1) They could try to get others to pick up some of the Medicare Part D costs—others meaning private payers and pharma manufacturers. (2) Also, they can limit how much manufacturers could raise prices via this “inflation rebate” proposal. Interestingly, this “you can’t raise prices more than the rate of inflation or else you have to rebate the difference” legislation is also being bandied about for Medicare Part B (as in boy) drugs. And those Part B drugs? Those are frequently the really expensive ones (ie, the oncology meds that are infused). And then the third way (3) to save some shekel that might wind up in the infrastructure bill is permitting HHS (the Department of Health and Human Services) to negotiate for drug prices. This last one is always a hot potato, but the winds might be changing some. On the Executive Branch front, we also may have a reboot of the Most Favored Nation rule, but I’ll let Josh explain that one. In fact, I’ll let Josh explain the brouhaha on all of these possibilities. For more information on any of this, read the article that Josh LaRosa and his Wynne Health Group colleagues wrote for The Commonwealth Fund blog recently.  You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.  Josh LaRosa, MPP, is a policy director at Wynne Health Group, focusing primarily on regulatory affairs with a focus on the US Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS). His interests lie in delivery reform and innovations in payment and care delivery models. Josh also supports the firm’s Public Option Institute, which studies the emergence of public option programs at the state level. Prior to Wynne Health Group, Josh consulted for the CMS Innovation Center, where he worked to implement, monitor, and spread learning garnered from the center’s high-profile demonstration projects, most recently including the national primary care redesign effort, Comprehensive Primary Care Plus (CPC+). Josh holds a Master of Public Policy from the University of Virginia’s Frank Batten School of Leadership and Public Policy. He also completed his undergraduate studies at the University of Virginia, graduating cum laude with a BA in political philosophy, policy, and law. 02:56 Where are we on drug pricing reform in legislation? 05:06 What things have the greatest potential for consideration on drug pricing reform legislation? 06:07 How is the Part D benefit design and reform shaping up? 07:55 Who is one of the largest offenders of high federal spending? 09:15 Who is going to pay in the reform of the catastrophic pricing phase? 12:04 What are inflation rebates? 15:36 “The interesting part of the inflation rebates … is that it not only … had these inflation rebates as applying to … Medicare Part D drugs but also Medicare Part B … drugs.” 16:20 How likely is this reform? 18:43 What’s happening on the regulatory and administrative side of drug pricing? 24:23 When will we start to see what the White House intends to do about drug reform pricing? You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.  @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Where are we on drug pricing reform in legislation? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What things have the greatest potential for consideration on drug pricing reform legislation? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma How is the Part D benefit design and reform shaping up? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Who is one of the largest offenders of high federal spending? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Who is going to pay in the reform of the catastrophic pricing phase? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What are inflation rebates? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma How likely is this latest drug pricing reform? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What’s happening on the regulatory and administrative side of drug pricing? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma
Over the holiday season here, we’re running some of our favorite episodes from years past. This one is with Mike Schneider, who actually has taken another role since this show was recorded. Other than that, the information that Mike shares during this episode from 2020 is all good. So, let’s do this thing. Disclaimer before we get started here: This show is probably a 300-level class in pharmaceutical/PBM relations. If you are tuning in for the first time and you aren’t pretty familiar with the role of PBMs, I would go back and listen to, say, episode 241 with Vinay Patel or episode 166 with Tim Thomas from Crystal Clear Rx. OK, now that that’s out of the way, if you’re still with me, this episode is like a ride on a roller coaster. I talk with Mike Schneider. And we get into, you know, kinda deeply, the what and the why behind the “Big Three” traditional PBMs deciding that now might be a fantastic time to set up GPOs. PBMs are pharmacy benefit managers—there’s three huge ones. GPO stands for group purchasing organization. Traditionally, these GPOs have purchased drugs and supplies for hospitals and other providers at, according to their marketing materials, volume discounts. So, the unfolding story here, in a nutshell, is that ESI (Express Scripts) set up a GPO called Ascent in Switzerland. Optum has had an Ireland operation going in full swing for a while. And now we have CVS Caremark setting up a GPO called Zinc. These GPOs are not like normal GPOs working with hospitals, but instead, these GPOs are the entity which is now going to negotiate with pharma companies. In the past, it was the PBM that was negotiating with the pharma company to get rebates. Now it’s this GPO entity. “But wait,” you may say. “Wasn’t there an executive order the other day requiring PBMs to, for example, pass through all of the rebates that they’re collecting to patients?” Indeed, there was. And that rule doesn’t say anything about GPOs having to do the same, especially GPOs in, let’s just say, Switzerland. It’s a tangled web we weave. You can learn more by connecting with Mike on LinkedIn.  Mike Schneider is an experienced healthcare executive with over 20 years of experience in the pharmaceutical manufacturer, pharmacy benefit manager, and payer side of healthcare. He previously spent 9 years at CVS Caremark, where he was a director of industry relations with responsibility for trade strategy development, rebate negotiations, and contract execution for CVS Caremark’s own Medicare Part D plans and that of its clients. He held a similar position at Universal American (UA) before it was acquired by CVS Health, where he also negotiated UA’s commercial business. Mike has held various sales and market access roles with pharmaceutical manufacturers with increasing responsibility. Before entering healthcare, Mike began his career as a researcher at the Procter & Gamble Company in Cincinnati, where he worked on hair care product formulation development focusing on the key markets of China and Japan, and then moved on to work in drug development. Mike holds a BS degree from the University of Illinois and an MBA from the University of Akron. 02:48 What does a GPO add to a PBM? 05:23 Rebates vs driving more revenue. 10:39 PBMs vs safe harbors. 12:25 The net impact on the commercial side. 14:07 PBMs vs pharmaceutical manufacturers. 14:54 How the “Big Three” PBMs compete with each other, and how employers would choose between them. 15:56 What the net-net is here. 18:06 How PBMs are shifting their models. 20:42 How GPOs may be making things even less transparent. 21:31 “The PBM world as a whole is not very transparent.” 25:00 “One of the biggest beneficiaries of this whole rebate [system] is the government.” 25:46 “The question is, ‘Who’s paying those costs?’” 26:02 EP216 with Chris Sloan.27:00 A better way to move money from Pharma to employers and plan sponsors. 28:04 “Put your money where your mouth is.” You can learn more by connecting with Mike on LinkedIn.  Check out our newest #healthcarepodcast with Mike Schneider as he discusses #PBMs and #GPOs. #healthcare #podcast #digitalhealth #healthcarefinance #pharma What does a GPO add to a PBM? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma Rebates vs driving more revenue. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs safe harbors. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma What is the net impact on the commercial side? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs pharmaceutical manufacturers. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How do the “Big Three” PBMs compete with each other? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How do #employers choose between the “Big Three” PBMs? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma What’s the net-net here? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How are PBMs shifting their revenue models? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How are GPOs making things even less transparent? Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “The PBM world as a whole is not very transparent.” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “One of the biggest beneficiaries of this whole rebate [system] is the government.” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “The question is, ‘Who’s paying those costs?’” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma A better way to move money from Pharma to employers and plan sponsors. Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “Put your money where your mouth is.” Mike Schneider discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma Recent past interviews: Click a guest’s name for their latest RHV episode! Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis
There is a transparency zeitgeist kicking off right about now. In June was the biggie, the one where health systems now have to divulge their contracted rates with insurance carriers starting January 1, 2021. But this zeitgeist is flowing into drug prices as well. Surescripts just released their real-time prescription price transparency tool. This price transparency tool allows detailed cost and alternative drug information to be seen in real-time. Surescripts, by the way, is owned by several large PBMs (pharmacy benefit managers). Can the prescriber see how much drugs will cost the patient as they are writing the prescription? The answer is yes if that prescriber is using a tool to display the prices in their EHR (electronic health record) or e-prescribing system. That is pretty cool and could save a whole lot of rigamarole and time for both the prescriber and the patient who doesn’t now have to go the whole way over to the pharmacy to figure out the drug price is unaffordable. I just want to bring up one point to be aware of: Surescripts is, as aforementioned, owned by some PBMs. PBMs are not exactly non-profits. They do a great job for their shareholders collecting middle-man dollars from pharma and pharmacies and patients alike. The copay amount a patient pays is a decision that is made, in many cases, by a PBM. So, showing the PBM-set patient price at the point of care to doctors increases PBM leverage in conversations with at least pharma. You see what I mean? Maybe that’s good if the PBM actually takes the dollars it shakes out of pharma and gives it to employers or the patients, the government or pays pharmacies they don’t own fairly. Maybe it’s bad if the PBM uses its additional leverage to, I don’t know, start its own GPO (group purchasing organization). In Switzerland. Wait, what?! Yeah, that happened. All I’m saying is, this is a tangled web we weave with implications for pharma, pharma's PBM negotiations, pharmacies and patients as patients and also patients as members of plans. Here’s a really important point that I need to make. Nobody in the health care industry is conflict free. Not PBMs, not IDNs (integrated delivery networks), not you, not me. I love transparency and I love sparing doctors and clinicians administrative burden. If I were a provider organization, I would definitely use this tool. But here’s what I need to say… in addition to transparency showing the copay of a drug and the best pharmacy to get it at, these systems also make transparent the underlying levers of the system itself if you look at them in a kind of pattern-wise way. So, if I’m a doctor and I find it weird that the lowest price is always at the pharmacy owned by a PBM, for example. Yeah, it’s up to you to start asking questions. My hope is that everyone sticks with the spirit of the endeavor and gets to the heart and the potential of transparency and chooses the path that benefits the patient the most. To that end, I am speaking in this health care podcast with Carm Huntress, who is the CEO and cofounder of RxRevu. We talk a lot today about how showing prescribers how much drugs cost can really help patients avoid financial toxicity and/or a whole lot of running around getting prescriptions changed to drugs that are on-formulary. You can learn more at RXrevu.com. You can also connect with Carm Huntress on Twitter at @carmhuntress. Carm Huntress is CEO and cofounder of RxRevu. As CEO, Carm has successfully taken prescription decision support from a concept to a reality for physicians, payers, health systems, and patients. At the core of this work is to transform the value of health care through better prescribing decisions. At a national level, Carm has played a key role in supporting interoperability and patient access to data through the development of the Fast Healthcare Interoperability Resources (FHIR) standards and other projects with the Office of the National Coordinator (ONC). 04:25 The protracted way doctors prescribe drugs right now. 06:15 “What is the macro thing we want to have happen here?" 08:10 Where we are today. 08:38 Value-based contracts. 10:10 Who is hurt by higher-cost alternatives. 12:50 The number one thing doctors get out of drug cost transparency. 13:20 The second thing doctors get out of drug cost transparency: patient satisfaction. 13:55 The downside to drug cost transparency. 14:40 “We gotta back up and just say, ‘What do we want?’” 16:30 How real-world evidence is going to affect drug pricing and rationalization. 17:43 “They’re waking up to the new world.” 20:20 How copays play into this. 20:45 “What’s the total cost, what’s the patient cost, and what are the alternatives?” 22:00 The history of formulary and benefit. 26:41 The problem with specialty drugs. 29:30 “Can we just start with first principles here?” 29:40 “We don’t really think about socio-economic factors.” 29:43 “What can you really pay?” 31:00 Why do IDNs care about drug pricing transparency? You can learn more at RXrevu.com. You can also connect with Carm Huntress on Twitter at @carmhuntress. Check out our newest #healthcarepodcast with @carmhuntress of @RxRevu as he discusses patient cost for prescription drugs to the point of care. #digitalhealthcare #healthcare #podcast #digitalhealth The protracted way doctors prescribe drugs right now. @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth “What the macro thing we want to have happen here?” @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth Value-based contracts. @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth Who is hurt by higher-cost alternatives? @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth The number one thing doctors get out of drug cost transparency. @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare  #healthcare #podcast #digitalhealth Patient satisfaction with drug cost transparency. @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth Is there a downside to drug cost transparency? @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth “We gotta back up and just say, ‘What do we want?’.” @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth How is real-world evidence going to affect drug pricing and rationalization? @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast  #digitalhealthcare #healthcare #podcast #digitalhealth “They’re waking up to the new world.” @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth How will copays play into drug cost transparency? @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth “What’s the total cost, what’s the patient cost, and what are the alternatives?” @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast  #digitalhealthcare #healthcare #podcast #digitalhealth “Can we just start with first principles here?” @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth “We don’t really think about socio-economic factors.” @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth Why do IDNs care about drug pricing transparency? @carmhuntress of @RxRevu discusses patient cost for prescription drugs to the point of care. #healthcarepodcast #digitalhealthcare #healthcare #podcast #digitalhealth
The Society for Integrative Oncology recently completed a systematic evaluation of peer-reviewed randomized clinical trials for patients with breast cancer. The researchers assigned letter grades to therapies based on the strength of the evidence. Meditation got an A; it had the strongest evidence supporting its use. Music therapy, yoga, and massage received a B grade. Hypnosis got a C. By the way, the letter grade varied depending on the symptoms that were involved. You can go on the website of the Society for Integrative Oncology if you want to look up the trial itself. So, here’s my question: Are insurance carriers paying for music therapy, meditation, and yoga? How about cooking classes? Some are, generally if it’s part of the services provided by the cancer center. It’s striking, though, that every single insurance carrier will pay for the downstream costs of unfettered anxiety, stress, poor nutrition … you get the idea—things that an integrative oncology focus would aim to attenuate. Do employers know about integrative oncology? I think I’d rather have an employee on a cocktail of music therapy and yoga than a cocktail of pretty much anything else. I’m thinking about this because if these therapies are not covered benefits, then I’m going to doubt that the middle-of-the-bell-curve employees or patients can afford them. Who’s going to “splurge” on meditation classes when GoFundMe has a whole section to help people pay for their traditional cancer care? Today I speak with Glenn Sabin, an integrative oncology consultant at FON Consulting. Glenn is a nationally recognized thought leader with a reputation for successfully positioning integrative health organizations for sustainable growth. You can learn more at fonconsulting.com and glennsabin.com. Glenn Sabin is director of FON Consulting, a leading strategy and business development consultancy specializing in the integrative health and medicine sector. FON’s clients span from medical practices, hospitals, and health systems to nutraceutical, pharmaceutical, and media companies. Glenn brings economic and moral clarity to the misnomer that health creation and promotion cannot align with profitability.  Glenn is participating in and advising Harvard’s Department of Biomedical Informatics on its People-Powered Medicine NEER Study, an initiative investigating exceptional responders. He was the recipient of American College of Nutrition’s 2017 Communications and Media Award. In 2016 Glenn published his popular memoir, n of 1. Through FON, Glenn also released the freely available 92-page publication The Rise of Integrative Health and Medicine.  02:36 What is integrative oncology? 04:43 “What’s the quality of life that’s being led here?”—Stacey 05:13 Patient vs host. 06:41 Evidence around the core tenets of lifestyle medicine. 07:19 What the American Society of Clinical Oncology (ASCO) pathways look like. 08:30 The Society for Integrative Oncology. 11:41 Integrative medicine programs and centers within health systems. 13:24 “It happens at the point of diagnosis.” 15:11 The referral process for integrative medicine. 16:10 Integrative medicine and value-based care. 19:04 “Prevention largely via lifestyle choices.” 19:20 Pivoting to engaging around information that’s attractive to millennials. 22:19 “The evidence is there to support these sensible recommendations.” 24:07 Glenn’s advice to administrators: really take a look at integrative health and integrative medicine.  You can learn more at fonconsulting.com and glennsabin.com. What is #integrativeoncology? @GlennSabin discusses on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  “What’s the quality of life that’s being led here?” @GlennSabin and our host Stacey discuss on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  #Patient or host? @GlennSabin discusses on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  What are the core tenets of #lifestylemedicine? @GlennSabin explains on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  What exactly is the society for #integrativeoncology? @GlennSabin discusses on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  “It happens at the point of diagnosis.” @GlennSabin discusses #integrativemedicine programs and centers within #healthsystems on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  What does the referral process for #integrativemedicine look like? @GlennSabin explains on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  How do #integrativemedicine and #valuebasedcare go together? @GlennSabin discusses on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  “Prevention largely via lifestyle choices.” @GlennSabin discusses on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  “The evidence is there to support these sensible recommendations.” @GlennSabin discusses on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg  #integrativehealth and #integrativemedicine: why should you care? @GlennSabin discusses on our #podcast this week. #healthcare #healthcarepodcast #digitalhealth #healthtech #hcmkg 
It turns out, patient-centric care that produces outcomes patients care about is usually less expensive than care that is not. The Patient-Centered Outcomes Research Institute (PCORI), an independent nonprofit, nongovernmental organization in Washington, DC, was authorized by Congress in 2010. PCORI was established to fund research that can help patients make better-informed decisions, guided by clinicians, payers, and others. In other words, help nudge health care into a patient-centric place, for the good of everyone involved in a quadruple aim sort of way. Since December 2012, PCORI has funded hundreds of studies that compare health care options to learn which work best, given patients’ circumstances and preferences. Today I speak with Dr. Joe Selby, executive director of PCORI. You can learn more at PCORI.org.   Joe V. Selby, MD, MPH, is the executive director of the Patient-Centered Outcomes Research Institute (PCORI). A family physician, clinical epidemiologist, and health services researcher, Dr. Selby has more than 35 years of experience in patient care, research, and administration. He is responsible for identifying strategic issues and opportunities for PCORI and implementing and administering programs authorized by the PCORI Board of Governors. Dr. Selby joined PCORI from Kaiser Permanente Northern California, where he was director of the division of research for 13 years and oversaw a department of more than 50 investigators and 500 research staff members working on more than 250 ongoing studies. He was with Kaiser Permanente for 27 years. An accomplished researcher, Dr. Selby has authored more than 200 peer-reviewed articles and continues to conduct research, primarily in the areas of diabetes outcomes and quality improvement. His publications cover a spectrum of topics, including effectiveness studies of colorectal cancer screening strategies; treatment effectiveness, population management, and disparities in diabetes mellitus; primary care delivery; and quality measurement. Dr. Selby was elected to membership in the Institute of Medicine in 2009 and was a member of the Agency for Healthcare Research and Quality study section for Health Care Quality and Effectiveness from 1999 to 2003. A native of Fulton, Missouri, Dr. Selby received his MD from Northwestern University and his MPH from the University of California–Berkeley. He was a commissioned officer in the Public Health Service Corps from 1976 to 1983 and received the Commissioned Officer’s Award in 1981.  01:34 Can payers afford to make health care patient-centric? 01:57 “If you make care more patient-centric … you actually see decreases in utilization.” 02:30 Shared decision making. 05:57 “What gets in the way of implementing good evidence?” 06:05 A study involving community health workers. 07:24 Default care and back surgery. 10:28 “There’s just a lot of habits like that in clinical care that aren’t backed up by evidence and can be undone with good evidence.” 11:36 “Where would you push the randomization?” 12:07 “We are trying to conduct practical research that really helps clinicians and patients make decisions differently.” 12:34 How Dr. Selby figures out what the patients want and what outcomes to focus on. 13:00 Looking for evidence gaps. 14:47 What PCORnet is and what they’re doing. 16:28 “To do really good quality research, you have to be able to link the data from health systems ... to data from claims.” 17:46 “We’re asking questions that matter to them, to their bottom line, and to their patients.” 18:07 What the main goal of PCORnet is—what or where? 19:59 Giving and getting data as a health system. 21:33 Studies that have come from PCORI’s queries. 25:02 “It’s very important that the systems … appreciate that PCORnet is active in their midst.” 25:41 “It’s hopefully a culture-changer, driving toward more collaboration and toward … finding common ground between people who are asking purely clinical questions and people who are asking the more practical questions.” 26:01 What frustrates Dr. Selby the most. 28:12 Turn the Ship Around!—a book about short-term evaluation and short-term results vs long-term change. You can learn more at PCORI.org.  
For a full transcript of this episode, click here. Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO who reports to a board of directors or these shareholders? Well, this show is for you. And it’s about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that with Mark Cuban (EP418) also. So, this show isn’t really about health benefits; it’s about the business that these health benefits have become and how, if the CEO or CFO of an employer is not intimately involved in the financial layer wrapping around health benefits, then the company is getting really taken advantage of by those entities who are intimately familiar with the financial layer surrounding those healthcare benefits. And the employees of that company also are getting equally taken advantage of. This is not a case where paying more or less results in better or worse employee health or healthcare. It is a case where not minding the shop in the C-suite means that financial actors just take more of the pie and nobody wins but them. Employer loses; employee loses. Andreas Mang, my guest today, kicks off this interview talking about the conversation that will go down between himself and any CEO whose company gets bought by Blackstone. So, if you’re a CEO and you’re aspiring for this to happen, yeah … heads up. But he says it’s kind of an unnatural act to dig into anything that smells like health benefits or health insurance. Some may not even realize that this whole financial layer has developed that sits above the healthcare benefits themselves. And they also may not think that there’s anything that’s possible that can be done. As far as both of these points are concerned, Andreas Mang gives a list of, as he calls them, easy things a C-suite can do to save 10% while improving employee satisfaction and health. Saving 10% or more, this can be a really big number. A lot of this is just enforcing purchasing discipline that is being used elsewhere. Here’s Andreas’s list recapped: 1. Have CFO engagement throughout the year. (We talked about that with Mark Cuban also.) 2. Be self-insured once you have reached a certain size. (Andreas gets into this in more detail during the show itself.) 3. Be very, very careful who you hire as your broker or benefits consultant. There are five things that need to be true: ·      They have the experience to do the job. ·      Flat-fee model compensation ·      No product pushing ·      Fees at risk (30% or more) ·      Simple termination provisions 4. Do carrier/ASO/TPA RFPs once every three years or thereabouts. 5. Do dependent eligibility audits. (Cora Opsahl talked a lot about this also in an episode [EP372] last summer.) 6. Leverage pharmacy coalitions and stop-loss collectives. (In the show itself, Andreas offers some warnings because some of these coalitions and collectives are great and some are not.) But bottom line, just keep in mind, as Mark Cuban said two weeks ago (EP418), those that are taking your money, your company’s money, are advantaged when you are confused. Where there’s mystery, there’s margin. If you can’t convince ’em, confuse ’em and all that. This is a business strategy. Healthcare should not be this complicated. But yet, it has become so; and anyone who doesn’t realize that is letting themselves and their employees really get taken advantage of. Unknown unknowns are not benign. As I have said several times already, Andreas Mang is my guest today. He is a partner at Blackstone, the private equity and alternative asset manager. His job is helping portfolio companies manage their US healthcare benefits for their employees.   You can learn more at Blackstone and by connecting with Andreas on LinkedIn.     Andreas Mang is senior managing director, portfolio operations, and chief executive officer of Equity Healthcare, where he is involved in managing medical benefits spend across the Blackstone portfolio. Andreas brings 20 years of healthcare experience to Equity Healthcare, having held various roles in healthcare finance, operations, and strategy. Prior to joining Blackstone, Andreas was the vice president responsible for national provider network operations at CareCentrix, a PE-backed, leading home health benefit-management company. At Blue Cross Blue Shield of Massachusetts, he held a variety of roles, including a leadership role identifying and implementing administrative cost savings opportunities throughout the organization and ultimately designing a new corporate business model. In addition, he held roles as the manager of strategic financial planning at Harvard Pilgrim Health Care and was a senior consultant with Deloitte Consulting’s Strategy and Operations group in Boston. Andreas has a bachelor’s degree in healthcare management and policy from the University of New Hampshire and an MBA from the University of Rochester’s Simon School of Business Administration. He currently serves on the board of DECA Dental.   04:19 Why Andreas starts every conversation with the question, “How’s your healthcare company?” 07:04 Why is it important, as a self-insured employer, to treat your business as a small healthcare company? 08:42 Why is it unnatural for companies to be providing health insurance? 10:13 What can be achieved when there is alignment between employers and insurers? 12:07 What things can a company do to reduce spend by 10%? 13:40 Why is it better to have CFO engagement in the benefits plan throughout the year? 15:51 Why does self-insurance save 5% to 9% for companies automatically? 17:41 “The funding isn’t a healthcare thing; it’s a CFO thing.” 17:54 Why is it vital to have a reliable, trustworthy broker? 24:38 When is the last time your company has RFP’d their health plan? 27:06 Why does changing a health plan feel scary but is necessary? 27:58 What is a dependent eligibility audit? 30:48 Why are employers better together? 34:02 How do employers truly get a flat-fee model with brokers?   You can learn more at Blackstone and by connecting with Andreas on LinkedIn.   Andreas Mang of @blackstone discusses the financialization of #healthcarebenefits in our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest’s name for their latest RHV episode! Karen Root (Encore! EP381), Mark Cuban and Ferrin Williams, Dan Mendelson (Encore! EP385), Josh Berlin, Dr Adam Brown, Rob Andrews, Justina Lehman, Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl
Why did I decide to encore this show about being customer-centric and transforming or innovating at a very large organization? Well, two main reasons. First reason can be neatly summed up by this recent Tweet from Rik Renard, which I have edited slightly to suit my own purposes. Here’s the Tweet: “The Achilles’ heel for most healthcare [innovators] is overlooking the role of change management. The deal isn’t sealed until the whole team is raving. Adoption doesn’t [automatically follow innovative thoughts no matter how good they are or how much it cost to build or buy anything]. Take change mgmt seriously.” This is relevant to pharma companies, to big provider organizations, to SaaS vendors, to payers … pretty much anyone. So, yeah. This show … still relevant. But also there’s a #2 reason for this encore. It’s coming at ya smack in the middle of an ongoing series for boards of directors, CEOs, and CFOs of self-insured employers. As discussed last week in the show with Mark Cuban and Ferrin Williams, PharmD, MBA (EP418), healthcare has become financialized. There is a whole financial layer sitting in between health benefits and the employer, and dealing with that requires customer centricity, transformation, and innovation at the employer level—a little change management, if you will. And with that, here is your encore. I was at the PanAgora Pharma Customer Experience (CX) Summit. Let me tell you one of my big takeaways. Many at pharma companies who are trying to convince their organizations of the need to be provider- and/or patient-centric are having a tough go of it. Heard that coming from every direction. Seems there are quite a few pharma organizations out there who are not actually customer/patient-centric. Say it isn’t so. Turns out, they continue to be pretty darn brand-centric whether or not anyone besides the CX team and the most successful KAMs (key account managers) realize this hard truth. This matters because, from a provider organization, physician, or patient standpoint, it’s not what’s written on the walls … it’s what goes on in the halls. It’s what a company actually does in their interactions with the rest of the healthcare ecosystem that matters and that builds their reputation. You see this lack of customer centricity and, et cetera et cetera, there are certainly other things going on here; but you see the lack of customer centricity manifesting, right? You see the pharma reps that get kicked out of hospital systems because the perception is they add little if any value and “waste doctors’ time; all they do is shove detail aids in our faces.” Heard that recently. Look, this doesn’t just pertain to Pharma; this is a message for the whole industry. But there is certainly a way to do well by doing good, and how that starts is helping provider organizations and patients improve patient outcomes as the primary goal. Being innovative to that end. It’s about supporting the best-practice standard of care and bringing resources to bear that are truly helpful. That is how more of the right patients can get the right treatment/drug at the right time or take their meds as per the A1A clinical guideline. It’s probably also the way to sustainable business success. I’ve said it here a thousand times: People trying to do the right thing by patients all need to work together. If there’s a party in the mix that nobody else wants to deal with because they are deemed not a team player or they don’t listen … yeah, that’s what I call a competitive disadvantage, beyond just squandering their ability to achieve their mission statement and improve patient care and lives, that is. Today’s conversation is with Karen Root, who was a speaker at the aforementioned PanAgora conference. In this healthcare podcast, we are talking about how to make transformation and innovation actionable at a large organization—maybe a pharma company but pretty much any large organization with lots of people, lots of human beings with different motivations and goals. As we all know, for every early adopter, there are (it feels like) five laggards who will fight you tooth and nail because they do not want to transform. They like being brand-centric, and it’s been working out fine … well, up until this year, at least. Karen Root is currently director of experience strategy at Boehringer Ingelheim, which is a pharma company. For many years prior to her current role, she was an enterprise head of brand and culture at WL Gore & Associates. What we talk about in this show is how to break down the historical “brand is king” mentality so that people want to follow with the awareness, courage, and determination to do so. Everything that we talk about in this episode can also be applied to pretty much any organizational transformation or the rollout of any innovation or new capability. Here’s the key things that Karen talks about which are essential for an organization to transform, maybe (again) in a way that is customer-centric and/or to roll out new innovations or capabilities: 1. Leaders must communicate a compelling vision that also includes a realistic assessment of what it’s gonna take to reach that vision and offer hope and the promise that the hard work and inevitable problems will all be worth it. 2. Systems thinking—a consideration of the systems and the people who will need to be a part of the transformation, thinking through what is likely to go wrong and proactively planning for it 3. Identify the right entry point. This should be a micro-journey or a quick win so that the team can score a victory and get through the messy middle that exists in any transformation or rollout. Triple points if you can find a micro-moment that has some emotionality connected to it from your customers’ perspective or patient perspective. If you can fix a so-called moment that matters, it really matters. Consider starting by looking into call center logs, finding a common complaint, and fixing it. Do it this way and it’s harder for anybody to complain that the status quo is so super amazing and tell you to talk to the hand. 4. Determine how you are going to measure what your quick win accomplished, as well as your whole larger transformational effort. 5. Ensure you have a full story arc here that shows the before and the after that clearly articulates that the before (the status quo) is problematic and that we have to, with urgency, get to the after. 6. Never forget that we’re working with human beings here and not, as they say, rational economic actors. One heads-up: In the conversation with Karen today, we talk a lot about the so-called J curve. As Karen says (and you can look this up), whenever you introduce a new anything into an organization, at some point, there’s gonna be a mess-up. And when something messes up, the whole team will spiral into a so-called “trough of disillusionment” or a “trough of despair,” sometimes it’s called. This is the rock-bottom hook of that J in the J curve. The thing is, if a leader’s vision isn’t sufficient or their will to continue isn’t sufficient, then the organization quits at this low point instead of working through it and coming out in a better place on the other side of the J. And you know what happens then. From that point forward until eternity, everybody who brings up implementing an innovation or a transformation will definitely hear the lecture about the time we tried that and how it failed miserably. So, the J curve … Check it out. Don’t underestimate it. One very last thing: If you are working for a large organization (like Fortune 500 large) and you have succeeded in moving a transformation forward (like being actually patient-centric or customer-centric, for example), hit me up. I would certainly love to hear your thoughts on how you did it and why you think you were successful and the impact that you had.   You can learn more by connecting with Karen on LinkedIn.     Karen Root, MBA, CCXP, is a strategy, innovation, operations, and marketing executive with more than two decades of experience in healthcare, including medical devices, biopharma, and pharmaceuticals. Her background spans more broadly to include computer software, publishing, and consumer package goods. She has driven transformation and growth as a senior executive for companies ranging from start-ups to Fortune 100 multinational organizations. Driving transformative capabilities include digital marketing for Sanofi Pasteur and marketing at start-up for their subsidiary, VaxServe. Karen then led the medical division in customer experience at WL Gore & Associates, later leaving the organization as enterprise leader of brand and culture. She is currently leading customer experience in the United States for Boehringer Ingelheim. Karen has been adding innovative experience design in the metaverse to her arsenal of knowledge. Certified in blockchain technology, cryptocurrency, non-fungible tokens (NFTs), and as a metaverse expert, she has a patent pending in smart contracts and is exploring integrating NFTs and meta-realities into the healthcare space. Karen is the author of Spectrum Thinking and Signature Experience: The Intersection of Brand Promise and Customer Experience for Competitive Advantage. Her next book, Ready Worker One, was co-written with her daughter, Kayla Root, and is expected to be published in early 2024. It pulls from gaming and behavioral science, along with DAO structure (decentralized, autonomous organizations). Karen was recognized by Forbes in 2022 as one of the Top 10 Healthcare Entrepreneurs to Watch.   08:51 What skills does leading a large company in customer centricity require? 10:36 What needs to be included in a vision for customer-centric change? 11:01 “In transformation, we have to adjust the approach to that vision. We have to break it down into a couple of key steps.” 11:39 What is the J curve? 12:26 “Disruption is going to happen; it’s just how do we minimize its impact.” 14:00 Why is hope so important for s
CEOs and CFOs … hey, this show is for you. Let’s start here: What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion? These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There’s one vital first step. That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits. Why can’t much happen without you, CEOs and CFOs? Here’s the IRL: In 2023, the healthcare industry has been financialized. There is a whole financial layer in between your company and its healthcare benefits. And unless the C-suite is involved here and bringing their financial acumen and organizational willpower to the equation, your company and your employees are currently paying hundreds of thousands, maybe millions, of dollars too much and doing so within a business model that deeply exacerbates inequities. There are people out there who are very strategically taking wild advantage of a situation where CEOs/CFOs fear anything to do with healthcare in the title and don’t do their normal level of due diligence. You think it’s an accident that this whole space got so “complicated”? HR needs your help. Bottom line, if you are a CEO or CFO and you do not know everything that Mark Cuban and Ferrin Williams talk about on the pod today … wow, are you getting shellacked. Mark Cuban uses a different word. Healthcare benefits are, after all, for most companies the second biggest line-item expense after payroll. But don’t despair here, because all of this information is really and truly actionable. Others out there are cutting zeros off of their spend and actually doing it in ways that are a total win for employees as well. My guest today, Mark Cuban, is a CEO, after all; and when he looked into it, it took him T-minus ten minutes to figure out just the order of magnitude that his “trusted” benefits consultants and PBM (pharmacy benefit manager) and ASOs (administrative services only) and others were extracting from his business. He pushed back. So can you. But just another reason to dig into that financial layer wrapping around your employee health benefits right now, you might get sued by your employees. Below is an ad currently being sent around on LinkedIn by class action attorneys recruiting employee plan members to sue their employers for ERISA (Employee Retirement Income Security Act of 1974) violations. It’s the same attorneys, by the way, from those 401(k) class action lawsuits. I’ve talked to a few CEOs and CFOs who are scrambling to get ahead of that. You might want to consider doing so as well. Now, for my HR professional listeners, considering that some of what Mark Cuban says in the pod that follows is indeed a little spicy, let me just recognize that the struggle is real. There are multiple competing priorities out there in the real world, for sure. And bottom line, because of those multiple competing priorities out there in the real world, it’s really vital that everybody work together up and down the organization in alignment. Lauren Vela talks a lot about these realities here in episode 406. This is a longer show than normal, but it’s also like a show and a half. Mark Cuban talks not only about his work with Mark Cuban Cost Plus Drugs, which is a company that buys drugs direct from manufacturers and sells them for cost plus 15%, a dispensing fee, and shipping. It’s kind of crazy how so often that price is cheaper, sometimes considerably cheaper, than the price that plan members would have paid using their insurance—and the price that the plan is currently paying the PBM. Most Relentless Health Value Tribe members (ie, regular listeners of this show) will already know all that, but what is also fascinating that Mark talks about is what he’s doing with his own businesses and the Mavericks on other fronts, like dealing with hospital prices. In this show, we also talk the language of indie pharmacies, fee-only benefits consultants, TPAs (third-party administrators), PBMs, and providers doing direct contracting. There are, in fact, entities out there trying to do the right thing; and Mark acknowledges that. Ferrin Williams, PharmD, MBA, who is also my guest today, is chief pharmacy officer at Scripta and an expert in pharmacy benefits. She adds some great points and some context to this conversation. Scripta is partnering with Mark Cuban Cost Plus Drugs. Scripta has a neat Med Mapper tool and also services to help employees find the lowest costs for their prescriptions. If you are a self-insured employer, for sure, check out Scripta. Here are links to other shows that you should listen to now if you are inspired to take action. I would recommend the shows with Paul Holmes (EP397); Dan Mendelson (Encore! EP385); Andreas Mang (upcoming); Rob Andrews (EP415); Cora Opsahl (EP372); Lauren Vela (EP406); Peter Hayes (EP346); Gloria Sachdev, PharmD, and Chris Skisak, PhD (EP390); and Mike Thompson (EP389). Also Mark Cuban mentions in this show the beverage distributor L&F Distributors. Thanks to Ge Bai, Andreas Mang, Lauren Vela, Andrew Gordon, Andrew Williams, Cora Opsahl, Kevin Lyons, Pat Counihan, David Dierk, Connor Dierk, John Herrick, Helen Pfister, Kristin Begley, AJ Loiacono, and Joey Dizenhouse for your help preparing for this interview. For a full transcript of this episode, click here.   You can learn more at Mark Cuban Cost Plus Drug Company and Scripta Insights. You can also connect with Scripta and Ferrin on LinkedIn.     Mark Cuban has been a natural businessman since the age of 12. Selling garbage bags door to door, the seed was planted early on for what would eventually become long-term success. After graduating from Indiana University—where he briefly owned the most popular bar in town—Mark moved to Dallas. After a dispute with an employer who wanted him to clean instead of closing an important sale, Mark created MicroSolutions, a computer consulting service. He went on to later sell MicroSolutions in 1990 to CompuServe. In 1995, Mark and longtime friend Todd Wagner came up with an internet-based solution to not being able to listen to Hoosiers basketball games out in Texas. That solution was Broadcast.com—streaming audio over the internet. In just four short years, Broadcast.com (then Audionet) would be sold to Yahoo! Since his acquisition of the Dallas Mavericks in 2000, Mark has overseen the Mavs competing in the NBA Finals for the first time in franchise history in 2006—and becoming NBA World Champions in 2011. Mark first appeared as a “Shark” on the ABC show Shark Tank in 2011, becoming the first ever to live Tweet a TV show. He has been a star on the hit show ever since and is an investor in an ever-growing portfolio of small businesses. Mark is the best-selling author of How to Win at the Sport of Business. He holds multiple patents, including a virtual reality solution for vestibular-induced dizziness and a method for counting objects on the ground from a drone. He is the executive producer of movies that have been nominated for seven Academy Awards: Good Night and Good Luck and Enron: The Smartest Guys in the Room. Mark established Sharesleuth, a research and investigation Web site to uncover fraud in financial markets, and endowed the Electronic Frontier Foundation’s Mark Cuban Chair to Eliminate Stupid Patents, an effort to fight patent trolls. Mark gives back to the communities that promoted his success through the Mark Cuban Foundation. The Foundation’s AI Bootcamps Initiative hosts free Introduction to AI Bootcamps for low-income high schoolers, starting in Dallas. Mark also saved and annually funds the Dallas Saint Patrick’s Day Parade, the largest parade in Dallas and a city institution. In January 2022, he started Mark Cuban Cost Plus Drug Company as an effort to disrupt the drug industry and to help end ridiculous drug prices because every American should have access to safe, affordable medicines. Ferrin Williams, PharmD, MBA, is chief pharmacy officer of Scripta. With 15+ years’ experience in the pharmacy industry, Ferrin brings a unique perspective to Scripta that spans the retail pharmacy, pharmacy benefit manager (PBM), and broker/consulting sectors. Her expertise ranges from pharmacy operations and services to innovative clinical programs, pharmacy audit, alternative payer funding, and specialty drugs. As chief pharmacy officer, Ferrin leads the company’s clinical strategies organization responsible for devising innovative cost-containment strategies for prescription drugs, ensuring Scripta clients, members, and their providers are provided with best-in-class clinical insights and tools. Ferrin earned her bachelor’s, Doctor of Pharmacy, and MBA degrees from the University of Oklahoma.   05:41 What was Mark Cuban’s own journey as a self-insured employer with Cost Plus Drug Company? 06:56 What did Mark find when he decided to go through and look through his company’s benefit program? 08:23 “When you think it through, you start to realize that money is being spent primarily by your sickest employees.” —Mark 09:13 How do you get CEOs and CFOs of self-insured employers to realize that their sickest employees are the ones subsidizing their checks? 12:10 What is the role of insurance in healthcare? 13:42 “If you can’t convince them, confuse them and hide it.” —Mark 14:35 The reality behind getting a rebate check. 15:32 Why are rebates going away, and why isn’t that changing PBM earnings? 18:17 How do you get CEOs and CFOs to dig into their benefits plan? 20:13 Does morally abhorrent move the needle? 20:47 “What we’re trying to do is just simplify the [healthcare] industry.” —Mark 23:33 What’s been changing in consumer behavior? 24:18 “Transparency is a huge pa
There are two big reasons why I decided to encore this show with Dan Mendelson from Morgan Health at this exact moment in time. 1. It’s a great show (one of our most popular shows in the last year, actually) with lots of keen insights for self-insured employers—and by self-insured employers, I mean HR folks, of course, but also CEOs and CFOs. That was foreshadowing for my second reason. 2. It’s gonna be an employer CEO/CFO triple play here on Relentless Health Value. Next week on the pod, my guest is Mark Cuban, along with Ferrin Williams from Scripta. And Mark Cuban, spoiler alert, has his own message for CEOs and CFOs of self-insured employers. Then the week after that, we hear from Andreas Mang from Blackstone who shares, among other things, what happens when some company gets bought by Blackstone and that CEO shows up for a meeting with Andreas and that CEO happens to know nothing about their vast, inefficient, and wildly wasteful healthcare spend. And with that, here is your encore. For a physician practice to transform itself from an FFS (fee-for-service) machine cranking out volume but not necessarily health or care, the office has to have a high enough percentage of their patients in value-based arrangements to make it actually feasible to transform. It is only when they hit a tipping point of enough patients in risk-based contracts that they can afford to be accountable for their results. At that point, yeah, everybody wins—doctors, patients, actually the entire community wins because when a local practice transforms, all of their patients tend to benefit at some level from the new processes and procedures and standardizations and pop health systems that get put in place. So, let’s move forward with this with all haste, shall we? Why aren’t we? What’s the problem here? Well, there are lots of problems, don’t get me wrong. But a big one is self-insured employers on the whole are not offering any sort of accountable care arrangements to the providers in their community. This is 150 million patient lives we’re talking about here—a huge chunk of many providers’ patient panels. Self-insured employers have a really big opportunity to level up the care in their whole community due to the spillover effect when a provider practice transforms itself because it has enough patients to do so. But these employers are stuck. They are paralyzed. They are doing the same thing this year that they’ve done last year, and therefore their whole community is equally stuck in a smorgasbord of suboptimal FFS goings-on. So, offering accountable care contracts is one thing (a very big consequential thing) that is also one of the five things self-insured employers can do to improve employee health that I talk about in this healthcare podcast with Dan Mendelson. Dan Mendelson, my guest today, also wrote a Forbes article listing out these five things. Here are all five things that Dan mentions in one handy list: 1. Expand availability of accountable care models to improve the care experience, quality, and affordability at a local level. For a deep dive on this, listen to the show with Dave Chase (EP374). 2. Invest in the data access needed to assess health outcomes. For a deep dive on this, listen to the show with Cora Opsahl (EP372). 3. Align employees’ health benefits with pop health outcomes. For a deep dive on this, listen to the show with Mark Fendrick, MD (Encore! EP308). 4. Prioritize care models that can meet employees wherever they are. For a deep dive on the DEI (diversity, equity, and inclusion) aspect of this, listen to the show with Monica Lypson, MD, MHPE (EP322). 5. Make care navigation a central part of the benefits package and experience. My guest today, Dan Mendelson, is CEO of Morgan Health at JPMorgan Chase. He previously founded Avalere Health. Before that, Dan served as associate director for health at the Office of Management and Budget. Besides exploring the why and the what for each of the five things employers should do right now, I also wanted to find out from Dan what’s going on at Morgan Health and how they are looking to help self-insured employers who want to do these five things actually do them.   You can learn more at the Morgan Health Web site.     Dan Mendelson is the chief executive officer of Morgan Health at JPMorgan Chase & Co. He oversees a business unit at JPMorgan Chase focused on accelerating the delivery of new care models that improve the quality, equity, and affordability of employer-sponsored healthcare. Mendelson was previously founder and CEO of Avalere Health, a healthcare advisory company based in Washington, DC. He also served as operating partner at Welsh Carson, a private equity firm. Before founding Avalere, Mendelson served as associate director for health at the Office of Management and Budget in the Clinton White House. Mendelson currently serves on the boards of Vera Whole Health and Champions Oncology (CSBR). He is also an adjunct professor at the Georgetown University McDonough School of Business. He previously served on the boards of Coventry Healthcare, HMS Holdings, Pharmerica, Partners in Primary Care, Centrexion, and Audacious Inquiry. Mendelson holds a Bachelor of Arts degree from Oberlin College and a Master of Public Policy (MPP) from the Kennedy School of Government at Harvard University.   05:01 Why did Dan direct his article about health benefits at CEOs? 06:03 What does an accountable care model mean to a self-insured employer? 07:58 “This alignment of value will never work … if the 150 million Americans … getting their health insurance through their employer are not also aligned in the same way.” 11:28 “We’re offering them a higher level of service.” 11:40 “Everything that we do is intended to be scalable and not just for us.” 12:09 “We have an obligation to do better for our employees.” 14:52 “Employers need to understand, the only way to get outstanding care is locally.” 17:28 Encore! EP206 with Ashok Subramanian and EP358 with Wayne Jenkins, MD. 18:18 Why is getting quantitative metric data important? 18:50 Encore! EP308 with Mark Fendrick, MD. 20:58 “This is a much broader vision of accountable care than … primary care.” 22:48 “Until everything is aligned, the employer is just not going to be providing an optimal product.” 23:39 “There are substantial issues with … health equity, and employers are paying for the care of 150 million Americans in this country.” 25:23 Is digital health access important for creating meaningful relationships between patients and providers? 29:50 What is the myth that employers need to tackle? 30:18 Why is care navigation important for employees? 31:44 EP334 with Sunita Desai, PhD.   You can learn more at the Morgan Health Web site.   @dnmendelson of @JPMorgan discusses #selfinsuredemployers on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Josh Berlin, Dr Adam Brown, Rob Andrews, Justina Lehman, Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7)  
Yeah, it’s a fact that the vast majority of past and present provider and payer relationships are not exactly collaborative. They may better be described as fairly adversarial, actually—especially when viewed through the lens of provider organizations trying really hard to find a payment model that will enable them to do better by their patients and deliver better outcomes. We’ve had Justina Lehman (EP414), Ali Ucar (EP362), Dan O’Neill (EP359) talking about this from the provider organization standpoint. We also had Dan Serrano (EP410) and Will Shrank, MD (EP413) corroborating here. But after each of these earlier episodes, many comments and conversations ensued about said potential (or not) payer/provider collaborations. And there was a theme of many of these online exchanges. The theme was wondering if we’d all get laughed at for even talking about these rare and elusive Shangri-la scenarios. Like expending words and energy thinking about payers and providers working together was as crazy as being seen earnestly discussing, I don’t know, whether mermaids know about pants or something. And that’s why I wanted to get Josh Berlin on the podcast today: to talk about the why, the what, and the how of collaboration. I wanted to know if there really is a solid why here for the why collaborate, especially from a payer point of view. And when I say payer, I mean a payer kind of payer like a Blue Cross, United, Cigna, Aetna plan kind of payer. And I’m calling that out because payers are intermediaries in all cases except for their fully insured members. Except for that one book of business, entities actually taking the risk are taxpayers or self-insured employers. So, saving money on its face is not a super compelling value proposition. Listen to the show with David Contorno (EP339) for the why there. As we talk about in the interview that follows, though, what might be compelling is predictable spend, possibly—or even more compelling could be a competitive differentiation for that payer that leads to higher market share. Payer/provider collaborations can also lead to a more resilient market foothold that can stand up to threats from upstart competitors or big tech and big retail swooping in looking for a tasty slice of this $3 trillion industry. There’s also the potential for a higher profit margin. And, oh, one additional reason to collaborate if you’re a payer that we don’t get into super heavily but I’d be remiss to not mention is the whole Star Ratings thing for Medicare Advantage plans, because stars equal big money. But a payer is not gonna get that Star Rating shekel if providers aren’t delivering high enough quality care. Also, of course, we have HEDIS (Healthcare Effectiveness Data and Information Set) and other quality measures that have financial value ascribed to them. In the conversation that follows, Josh talks about different types of collaborations. Collaboration is a really very vague term, so what exactly is this collaboration, what does it entail, and how do you do it? Josh told me that there are five kinds of collaboration, and here they are in order of their depth of entanglement, I guess you could call it. 1. Sharing data back and forth 2. Use that data to identify areas of need and then do something programmatic together, like create clinical pathways or work on one very specific type of quality program. 3. A joint venture (JV)—you JV and work together on some sort of narrow network kind of product 4. Become capital partners in some way. 5. Having a risk-bearing kind of relationship—the provider gets a piece of the premium dollar So, that’s the five types of collaboration. But here’s the things you’ve got to tick through, that you have to really go through and make sure you’ve got all these things before you start. Otherwise, it’ll be a monumental waste of time. 1. Complementary capabilities that enable scalability 2. A desire for sustainability in a market, and both have common goals and objectives and an agreed-upon time horizon 3. Both parties need to be pretty flexible. Rigid products have a shelf life. You’ve got to be willing to advance with market dynamics flexibly—know how to iterate around whatever it is you’re doing. 4. Excel at collaboration. If you’re going to collaborate, you have to know how to collaborate. And that’s a cultural thing. 5. Compatible risk profiles—this means not just “taking risk” but knowing how to do it in a way that will work and navigating around things that could cause trouble when moving from fee for service to a more capitated way of going about things. Josh talks about some of them. Just to loop back around on #4 there, because … yeah, to collaborate, you need to collaborate. I call Josh out on this one, and he reiterates that … yeah, nothing to take for granted here. It might seem obvious, but it’s so frequently an internal unknown unknown—at a lot of payers especially. I mean, if I’m a provider organization and you force me to only communicate with you through snail mail (ie, postage stamp, letter box, the whole nine), I don’t know, I’d kind of get the vibe that I’m being enthusiastically ignored, which I just cannot square with a collaborative spirit of any kind. Josh Berlin is a founding partner of Rule of Three, which is a consulting firm. Rule of Three has clients that are physician practices, hospitals, health systems on the traditional side; and they also work with nontraditional organizations like Walmart Health and Wellness. They also work with payers, like regional blues and employer plans.   You can learn more at Rule of Three and by connecting with them on LinkedIn.   Josh M. Berlin, JD, is CEO of Rule of Three, LLC, with more than 25 years of experience, most of which has been in healthcare advisory in service to his clients. Most recently, he has served as principal and co-practice leader of Citrin Cooperman’s Healthcare Practice and managing partner for IBM Watson Health’s Strategic Advisory Practice, leading a unique group of consultants in each instance to serve clients across the full healthcare ecosystem (providers, payers, employers, governments, advocacy, etc). Prior to those roles, Josh served as a principal in the healthcare consulting practice at Dixon Hughes Goodman (now FORVIS), helping to lead their strategy consulting business, and served as a leader in all versions of KPMG (KPMG Consulting/BearingPoint and KPMG). Currently, he serves on the Boards of the Validation Institute, Population Health Management journal, and HealthTrackRx. Josh’s expertise spans both the consulting and healthcare industries. Some of his clients have included the Hospital Corporation of America, the Department of Health and Human Services (including the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services), various pediatric health systems, the National Association for Healthcare Quality, Nebraska Medicine, Penn Medicine, the Ochsner Health System/Network, the BJC Collaborative, and The Leapfrog Group, as well as a variety of other healthcare organizations. Josh has developed long-standing client relationships at all levels of organizations, notably including some of the most prestigious C-suite executives in healthcare today.   06:06 Why should payers want to collaborate with providers? 09:46 “Collaboration … is bilateral. … Both sides, plan and provider, should be equally as interactive with the individual populations they work with.” 12:37 What are the must-haves for collaboration between providers and payers? 13:10 What are the five different types of collaboration? 16:03 What are the five characteristics you want to be focused on in partnership? 21:35 EP359 with Dan O’Neill. 22:16 In order to collaborate, do you have to be collaborative? 26:11 Ochsner as a great example of collaboration. 27:46 Episodes with David Carmouche, MD, and Eric Gallagher. 28:51 A collaboration failure in Haven.   You can learn more at Rule of Three and by connecting with them on LinkedIn.   Josh M. Berlin of Rule of Three, LLC, discusses #payer and #provider #collaboration on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #healthcare   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Adam Brown, Rob Andrews, Justina Lehman, Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6)  
Now, I’m being pretty careful here because med schools are super sensitive about their curriculums. And I am sensitive to the fact there’s much to teach in four years. So, throwing no shade here, what do I know from the Krebs cycle? Choices of what to teach are tough. With that disclaimer, in this healthcare podcast I am speaking with Adam Brown MD, MBA, about an article he wrote entitled “Dear Medical Schools, Educate Students on the Business of Medicine—Without it, you are doing your students a disservice.” Let me give you Dr. Brown’s list for the “why teach the business of medicine.” He says: 1. The role of physicians in medicine has changed, and we dig into this in the episode. 2. There’s an expectation mismatch. Docs are investing 10 years and, on average, $200K to $300K in real dollars to get that MD or DO. You don’t want those new physicians quitting on the quick because the reality is so different from what they thought it would be. Not being up front about the business of medicine is like hiding the reality of the situation instead of preparing them. 3. If you don’t understand the business of medicine, you do not know how to advocate for yourself or the profession or even patients in a way that is compelling to the current set of decision-makers. As maybe a corroboration here, may I just report that I probably have gotten (conservatively) 100, 150 emails and LinkedIn notes from physicians who say basically some version of the same thing: Thanks so much for Relentless Health Value. I wish I would have learned even the basics of what you cover in med school. If I had, I would have been able to help myself and help myself help patients far better. 4. Docs are the ones with the prescription pads. Docs are just functionally the gang who are driving costs that patients and employers and taxpayers ultimately incur. Not knowing the how much or just the whole story here can inadvertently contribute to clinical morbidity, because patients who fear they cannot afford care do not follow doctors’ orders. We should get real about that. Or if they do follow doctors’ orders and go into debt … I mean, there’s just study after study in oncology and otherwise that shows patients who cannot afford their care have worse outcomes. We cannot hide from this any longer. 5. The last reason is that there’s lots of things that docs can do besides just be at the bedside. Not giving insight into these alternative paths seems unfortunate for any doc who maybe wants to mix it up some because they’re feeling burned out or in a different season of their life looking for something more aligned with where they are as a person. So, now let’s think about this whole question from the standpoint of the system itself—from the standpoint of doing better by patients. Why is it important to teach docs the business of medicine? Let’s start here. When physicians do not understand the business of medicine, it’s harder for docs to get into boardrooms and have their voices heard. Not teaching the business of medicine in med school might be one reason why there is such a shockingly small percentage of doctors on the boards of directors at major nonprofit hospitals (listen to the show with Suhas Gondi, MD, MBA [EP404]) and why there’s so little “dyad leadership” in the ranks of both clinical and payer organizations, etc. And even fewer nurses are in organizational decision-making roles, by the way, despite nurses actually being the most trusted profession—even more trusted than doctors by 14 percentage points, according to Gallup. One way to interpret this lack of docs and other clinicians in the boardroom is simple cause and effect. Doctors are losing control and ownership—and I mean this in literal terms—of the organizations that run the business of medicine, which controls the medicine of medicine. Chad Erickson wrote a comment about this on LinkedIn that I thought was great. He wrote, “Opportunities for physicians to really control or even impact the 86% of healthcare outside of their practice are being reduced every year. We expect doctors to make the decisions and be accountable for patients and outcomes, yet we are taking away their ability to do so.” And going one level deeper here on how not having enough docs in admin roles becomes a snowball rolling downhill kind of downward spiral, I’m gonna quote Jeremy Granger, MD, FAAP. He wrote, “When you are a physician administrator, it can be very strange. There is tremendous pressure from administrators to think and act like one of them and give insight into how to best coerce physician behavior to align with administrator-determined goals without necessarily involving the physician with setting those goals. When you advocate instead with your physician hat, you can find yourself ostracized from that administrator clique. You realize that they view physicians as knaves and you as the Judas goat. You either pick a side or, if you’re lucky, you land with a team that has physician leaders equipped with equal power as administrators.” So, you see what happens. Doc gets an admin role and either chucks their stethoscope and their patient-first mindset out the window to fit in, or they quit. And then we never get to any sort of critical mass of clinicians in leadership roles that would reset the organizational ethos. So, here we are. Too few mission-driven and business-savvy docs in boardrooms mean patients get the kind of care they’re currently getting and at the prices we’re all currently paying. From the standpoint of doing better by patients, I hear story after story about some doc who was under the impression that, I don’t know, working with a private equity firm to do a roll-up of all the specialty practices in a local market was pretty cool and a totally victimless strategy. Or the surprisingly high number of docs prescribing drugs on that most wasteful spending list. There’s one on that list, for example, that costs taxpayers or an employer $2000 when that drug consists of basically two $15 over-the-counter meds mashed together—and yet there’s the impression that the $2000 drug is a better financial choice because there’s a co-pay card and the patient out of pocket might conceivably be less … until it isn’t, of course, because it’s not like that additional $1970 in cost suddenly becomes free. Or what happens when a clinician is told to order largely unnecessary MRIs because workers’ comp covers everything and no one cares—so this kind of thing continues to just happen … all this stuff. It takes a broader understanding to get the why and create the intrinsic motivation and necessary insight and right language and arguments to make things better. But all of this is about patients. If I’m talking to margin-driven people sitting around the conference room table with their calculators, are there any organizational consequences, meaning financial consequences, to not making sure doctors understand business and have a seat at the table? Here’s two (there’s probably more): 1. Staff turnover. If that’s a concern for any organization now, and if moral injury is cited as a reason for that turnover (which it often is), moral injury doesn’t happen when organizational demands are aligned with clinician values. 2. Successful value-based care isn’t gonna happen if docs don’t understand the business of medicine. Listen to the show with Eric Gallagher (EP405) or the one with Amy Scanlan, MD (EP402) or Larry Bauer (EP409). There’s like 10 guests who essentially say the same thing. Docs who are in the dark about how the world actually works IRL cannot be an aligned force helping move past the FFS (fee-for-service) status quo and the whole business model that underpins that. Adam Brown, MD, MBA, my guest today, is a practicing emergency physician, board-certified ER doc. He recently founded ABIG Health, working with healthcare companies on communication strategies and advising investment firms. He’s also a professor of practice at the University of North Carolina, Chapel Hill. Mentioned in this episode is a Tweet by Brendan Keeler. Also, Dr. Denver Sallee’s very inspirational predictive scheduling work. I’ll leave the last word on this to Michael R. O’Brien, MD: “You don’t overcome the corrupting influence of money in medicine by ignoring its existence. … To slay the dollar-eyed dragon, we must be able to see like the dollar-eyed dragon.”   You can learn more at ABIG Health and by reading Dr. Brown’s bimonthly column.     Adam Brown, MD, MBA, is a board-certified emergency physician, entrepreneur, and accomplished healthcare executive whose professional journey traverses clinical practice to strategic leadership. Having risen through the ranks at Envision Healthcare, Dr. Brown’s tenure there culminated in his role as president of emergency medicine, where he spearheaded the COVID-19 response and clinical communications. His impactful leadership led to his appointment as chief impact officer in 2021. In 2022, Dr. Brown left Envision and established ABIG Health, a healthcare strategic advisory firm. Additionally, he took on the mantle of professor at the University of North Carolina, Chapel Hill, Kenan-Flagler School of Business (his alma mater), teaching healthcare operations and strategy to MBA students. He is the advisory board co-chair at the Center for the Business of Health and on the business school Board of Advisors. A frequent media presence, Dr. Brown has been featured on CBS, Yahoo Finance, BBC, and local Washington, DC, outlets, speaking on various healthcare issues. His column, “Prescriptions for a Broken System” in MedPage Today, showcases his commitment to meaningful change in healthcare. His passion for empowering informed health decisions shines through his roles as a communicator, leader, and strategist. A recognized thought leader, his ability to connect, envision, and lead underscores his impact on shaping healthcare.   08:49 What does it mean to teach the business of medicine? 11:04 The four Ps th
I just want to stop here and have a gratitude moment. I wanted to thank the Pittsburgh Business Group on Health for inviting me to do the keynote at their annual symposium. It was a big honor. But in doing so, I had the opportunity to play clips from both the podcast and also from people who helped out and gave me a custom clip special for the occasion. So, thanks to Matt Ohrt; Jodilyn Owen; Justina Lehman (who provided a clinical pathway example); Andreas Mang; Larry Bauer; Rob Andrews (my guest in this episode); Nicole Bradberry; Amy Scanlan, MD; Rebecca Etz, PhD; David Muhlestein, PhD, JD; Lisa Trumble; and Doug Eby, MD, MPH, CPE. If you’d like a copy of that presentation, which is all about care gaps and the impact of care gaps especially as it might relate to self-insured employers, click here to request it. I also again want to thank Havarti Risk Services and Keith Passwater for a super nice donation to support the show, as well as Employees First. Please support these organizations who have supported us and help us keep the lights on over here. I am so looking forward to the show today. It is with Rob Andrews, who is the CEO of the Health Transformation Alliance (HTA), which is a group made up of jumbo employers. I had wanted to get Rob on the show ever since I heard him say at the thINc360 conference in DC earlier this summer, “Morally abhorrent doesn’t move the needle. What moves the needle is financial implications.” This interview was my chance to ask Rob Andrews, what are these financial implications of which you speak that move needles? Financial implications to whom? What kinds of financial implications are we talking about? And when that needle moves, what happens? In the show that follows, Rob says that when you improve the health of employees and dependents and actually just the health of the community, you as an employer improve your financials directly and also indirectly, which Rob talks about relative to maternal health outcomes as his exemplar because, as a case study, it’s undeniably superb. It’s really interesting how employers in a geography wind up footing indirectly a rather shockingly large bill for babies and uninsured or underinsured moms or moms on Medicaid avoidably going to the ICU and the NICU, which the hospitals tally up as hundreds of thousands of dollars in billed charges. The term million-dollar baby is a term, after all. Listen to the episode that follows for more on these indirect costs and how they happen, but let me focus on the direct bucks out of pocket right now because … yeah, study after study shows that, for self-insured employers, if you pay for the right things and you steer to the right providers in the right care settings known to actually improve health, a self-insured employer and the member do a whole lot better than if the employer kind of laissez-faire pays for any manner of things provided by anybody who can manage to submit a billing code—even if that billing code comes with a too-good-to-be-true discount. Rob talks about how the HTA has data to suggest that if you, as a self-insured employer, lean in on paying for the right things, readmissions go down 29%. Total cost of care is 15% lower. Drugs cost 25% less. So, none of this is theoretical, as we talk about how employers can create a win-win—better health, lower costs. There are jumbo employers in the HTA right now who are doing this. I love how Will Shrank, MD, has put it; and I’m paraphrasing, but it’s a point that keeps getting reiterated in episode after episode here on Relentless Health Value: There’s a difference between paying for what you want and just negotiating allegedly cheaper prices. Buying things is not a strategy. And that is true no matter what price you think you’re paying. Also not a strategy is buying things and then cost shifting to plan members, by the way. I love how Josh Butler uses a grocery analogy to describe but one possible flashpoint. Strategy, on the other hand, means addressing root causes. It’s a considered plan of action to achieve an optimized ambition. Here is the strategic stepwise that Rob offers on this: 1. Discern the difference between rumor and data. Get your data and get it objectively analyzed by an objective third party, self-insured employers. Similar to what Justina Lehman was talking about last week (EP414), then you have what you need to figure out the delta between the worst performers and the best performers on a risk-adjusted basis. 2. Now that you know what normal is and what good looks like, gang up and negotiate contracts that hold intermediaries accountable for outcomes and with performance guarantees. Address root causes and the excess and wasteful spend, in other words. Listen to the show with Dr. Will Shrank (EP413) for more on wasteful spend. 3. Be transparent with consumers/employers about relative quality. Educate them. You may also want to reward members who go to see those high-quality docs and/or make it expensive for them to go to the worst performers. There are lots of win-win case studies here on how well this works. Rob Andrews and I talk a bunch, as aforementioned, using maternal outcomes as a case study for lots of the points made; and this was done for several reasons. One is that, for some employers, maternity is a large chunk of their healthcare spend; so avoidably bad outcomes for moms and babies here is not only scandalous, as Rob Andrews puts it, in a country as wealthy as ours but also really costly—and many times avoidably so. Keeping even one mom and/or one baby out of the ICU or NICU can save hundreds of thousands of dollars. I said this already, and it’s a brutal number worth repeating. But the good news is that there are really cost-effective pathways that actually work to keep moms and babies out of the most expensive care settings money can buy. Jodilyn Owen (on an episode coming up in about three weeks) talks about one of them in detail: how her maternal health clinic, which serves ZIP codes with, let’s just say, a lot of social determinants of health going on, moms in her clinic have a lower rate of NICU admissions than even the fancy ZIP codes nearby. So, this can be done. Purchasers of healthcare just have to demand that it happens and pay for it to happen. Rob Andrews talks about this, and he also talks about why it is quite unlikely that payer or provider organizations themselves are gonna pick up this torch and make this happen unilaterally of their own volition. Now, he offers some nuance, and you should listen to that nuance.   You can learn more by emailing Rob at randrews@htahealth.com.   Robert E. Andrews is the chief executive officer (CEO) of the Health Transformation Alliance (HTA), an original author of the Affordable Care Act, and a former member of Congress. As CEO of the HTA, Robert oversees the strategic direction of approximately 60+ major corporations that have come together in an alliance to do one thing: fix our broken healthcare system. Formed by four founding members in September 2015, the HTA member companies collectively are responsible for more than 8 million employees, dependents, and retirees with an annual healthcare spend of $30+ billion. Through Robert’s leadership, the HTA has launched value-driven solutions specifically designed to improve patient care and economic value through world-class data and analytics, pathbreaking pharmaceutical solutions, high-quality medical networks, and robust consumer engagement initiatives. To date, the cooperative has saved its member companies well over $2 billion in healthcare costs. Robert’s leadership has been equally important in the HTA developing programs addressing racial and ethnic disparities in healthcare, mental health issues, and safe return-to-work programs following the pandemic. Robert served as a member of the United States House of Representatives for nearly 24 years. Upon his departure from Congress, President Barack Obama praised Robert’s service as “an original author of the Affordable Care Act … and a vital partner in its passage and implementation.”   07:29 How did Rob get to his current role? 09:11 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this. 10:36 Why economic consequences move the needle, and why sometimes they don’t. 12:36 Why the best way to address costs isn’t to re-shift costs but to address them directly. 14:34 Why compensation that isn’t dependent on outcomes is a problem. 18:09 “Strategy’s not what people say; it’s what they do.” 21:40 How do you operationalize saving money with better outcomes? 29:46 How do employers turn conflict into collaboration? 31:41 What is the win-win-win structure among employers, payers, and providers in Rob’s eyes? 34:13 To whom should the task of risk adjustment fall? 38:03 “Better contracts do improve outcomes.”   You can learn more by emailing Rob at randrews@htahealth.com.   Rob Andrews of HTA Health discusses how employers can save money and get better #healthcareoutcomes on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #healthcare   Recent past interviews: Click a guest’s name for their latest RHV episode! Justina Lehman, Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4)
Here’s why I think this interview with Justina Lehman is different. We get into the actual whys and how-tos of trying to be specialists, like an OB/GYN or an orthopedic practice that offers coordinated care … AND gets paid to do so. There’s so many conversations that transpire at the 50,000-foot level. This one is far closer to the ground. And if you want an even deeper dive on this topic, go back and listen to the episode with Steve Schutzer, MD (EP294). There are so many who put financial growth and doing “value-based” coordinating care kinds of things at a counterpoint. Like, “Oh, boy … we need to make some money this quarter, so let’s put all the VBC [value-based care] stuff on the back burner.” The point that Justina Lehman makes, both implicitly and also explicitly, is that doing the right things for patients, things we know are going to improve patient outcomes … doing these right things can also be a growth strategy. And I don’t just mean offering access and convenience. I mean also doing things that defragment care and coordinating it—things that will truly drive better chronic disease outcomes. This is what we talk about exactly and specifically in this healthcare podcast: How do practices work alone or band together into a kind of “value alliance,” I’ll call it, to both improve patient care AND make money? Alright, so here’s the absolute simplest possible business upside that taking really good care of patients can achieve: higher patient volumes at the practice. Patients, who I guess could be called consumers in this example, want to go to such a practice. The practice is differentiated. Your marketing has to be good for that to happen, but yeah … turns out patients really like nonfragmented care with a physician, a nurse navigator, and the rest of their clinical team who patients know, like, and trust. Also, turns out clinicians, ones who are purpose driven, like to work at places where they can be part of a team providing great care. So, you wind up with growth—you got your demand from patients who want to come to your practice; you got supply of clinicians who want to work there. Who would have thought? So, as long as practice leadership is also purpose driven, this can all be very opportunistic. But there’s also some risk exposure for those who don’t consider models like this. Will Shrank, MD, said on the pod last week (EP413) that any specialists who aren’t figuring out how to work with capitated primary care docs are gonna have some referral problems coming up here. And how do you work with capitated, advanced primary care docs? You demonstrate you have better patient outcomes. You cannot do that unless you do all the things that Justina Lehman talks about in this healthcare podcast. So, there’s risk in not doing some of this stuff. I’m gonna summarize the process that Justina uses to level up care and also get paid for it. 1. Assemble a committee of purpose-driven, committed physicians who want to improve care. Committee should self-select. No one should be there who doesn’t want to be there. 2. Define the situation analysis. What is care as usual? And then, what’s ideal care? And then, determine what the delta is between where we are now and where we want to go. 3. Design ideal care and the plan for how you’re gonna get from where you are now to where you want to be. What does ideal care look like? I actually gave the keynote at the PBGH (Pittsburgh Business Group on Health) symposium a few weeks ago, and I showed a slide that Justina Lehman had put together showing the ideal care pathway for a patient with gestational diabetes. If you weren’t there, here’s the aha: Ideal care includes multiple physicians. It includes working with payers and PBMs (pharmacy benefit managers) and how you’re gonna do that. There’s also gonna be a nurse navigator involved. It includes standardizing certain care flows and choices and making sure that patients have the right information so that they can get to the right care settings at the right time. The exam room, as Justina Lehman says, is but the start of the patient journey; it’s not the beginning, middle, and end of it. 4. Align the model to possible financials. First of all, consider two potential payers: self-insured employers … you could offer a bundle if you see a lot of any self-insured employer’s members. You also could go to a regular payer kind of payer. There’s gonna be two kinds of payers: engaged payers and not engaged payers. If there’s an engaged payer who is actually trying to figure out how to work with providers in their network, then there’s four potential opportunities with such an engaged payer: (1) You could start talking about prospective bundle payments. (2) Less attractive, you could start talking about retrospective payments based on savings. (3) There could be quality incentives that are a percentage of FFS (fee-for-service) withhold, or a quality incentive that is in addition to FFS payments. (4) There could be specialty quality programs that are PMPM (per member per month). If you’re dealing with a not engaged payer, then one potential move is to gang up with others in the area, create some sort of value alliance, and see if you can inspire the payer to become more engaged. You also could try to align your care pathway to what is possible to get paid for within an FFS model. Scott Conard, MD, in an earlier episode (EP391), talks a little bit about that. He’s talking from a PCP standpoint, though. 5. Measure results. 6. Prepare the story/value prop for payers. 7. Get more docs on board. Create the meaningful stories that inspire additional doctors to want to become a part of this beyond your initial gang. 8. Manage and maintain success; continue to evolve. Big takeaways for me: It’s really important to engage payers and get them at the table early. Will Shrank, MD, in another point of alignment from last week’s show to this week’s, Dr. Shrank also was talking about this same thing. He said, historically payers and providers have had a pretty adversarial relationship … but it can be really hard for a provider to migrate to a value-based arrangement without the payer to provide data and, to some degree, shelter for providers who are along the transition to value journey. Besides the show with Dr. Steve Schutzer and Dr. Scott Conard that I mentioned earlier, I’m gonna leave you with two other interesting “for further reading or listening” references. One is a LinkedIn post from Benjamin Schwartz, MD, MBA, that also includes some pretty great comments and back and forth. In sum, Dr. Schwartz wrote, “We need to uncouple value from the payment model and focus on outcomes tied to diagnoses.” I also thought a Radio Advisory show was thought provoking. This was with Rae Woods, Erik Johnson, and Daniel Kuzmanovich. The gist of it is, at one point, Rae Woods says, “If I think about the very fragile financial state that a lot of these leaders are in, they’re telling me, ‘I’ve got to pull back on my value-based care objective for 2024, maybe even 2025, because I just have to focus on my margin right now.’ But what I’m hearing you say is that’s actually not the right mindset to have.”   You can learn more by connecting with Justina on LinkedIn.   Justina Lehman, CNP, DNP, founder and president of Revolution Health, is a proven visionary leader at the forefront of transforming healthcare and fueling people’s passion for high-value care. With over a decade of leadership experience, she has devoted herself to urging forward a revolution in healthcare. She stands as a staunch advocate for physicians and clinicians eager to join the movement toward high-value care. In an evolving healthcare landscape, Justina serves as a guiding force, reigniting the passion of physicians and clinicians and accelerating them toward a future of high-value care that is transparent, accessible, and transformative for all.   07:35 What has Justina been up to, and why is it relevant to this conversation? 08:23 What is high-value care, and how do we figure out what it is in reality? 08:59 EP412 with Robert Pearl, MD, on the art and science of medicine. 10:08 “What is the clinical design of … high-value care?” 10:21 Care as usual vs ideal care. 11:11 Summer Shorts 8 with Larry Bauer. 12:23 How does Justina figure out what the benchmark is for high-value care? 12:36 Meeting patients where they are at, not where we want them to be. 17:42 EP402 with Amy Scanlan, MD. 18:28 “What is the story as a group to the payer? What is the story as a group to the self-funded employer?” 19:19 How do you align business operations and the financials? 20:16 What are the four avenues for getting paid for high-value care? 21:58 What are highly engaged payers most intrigued by in high-value care? 24:11 What are the different ways a practice can get compensated? 28:52 Are there programs that have advanced without payers leading the way? 29:37 What’s the “hook” for payers? 31:12 What’s a winning message to payers and employers? 33:04 Summer Shorts 4 with Eric Gallagher. 34:13 “Not everyone needs to participate.” 38:24 Can a program be successful even if a physician is a passive participant in the program?   You can learn more by connecting with Justina on LinkedIn. Justina Lehman discusses delivering better care and getting paid for it on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Will Shrank, Dr Carly Eckert (Encore! EP361), Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano  
My conversation today is with Will Shrank, MD. Dr. Shrank led the evaluation group at CMMI (Center for Medicare and Medicaid Innovation). He has spent time in the private sector, first at CVS Health and UPMC (University of Pittsburgh Medical Center) as chief medical officer of the health plan in Pittsburgh, and then as the chief medical officer for Humana. Now he is a venture partner at Andreessen Horowitz and doing some consulting for CMMI. We start out this conversation talking about waste in healthcare. In fact, Dr. Shrank was on a team who did a study about waste in the US healthcare system. (The article is, unfortunately, firewalled.) In that study, it says estimates suggest we have upwards of a trillion dollars of waste a year. There’s two main groupings of said waste, turns out. The first is in administrative failures. There’s three subcategories here: fraud, waste, and abuse; administrative complexity; and pricing failures. Then there’s the clinical failures side of the waste house. There’s three subcategories here as well, and they are failures in care coordination, failure in care delivery, and then low-value care. Dr. Shrank digs in a bit on each of these in the interview that follows, but I have to say, I go in fast for the now what. Great that we know where the waste is coming from, because gotta know the problems to solve for them. But really, what’s the best way to solve for this waste? You know me by now, so I, of course, point out immediately that someone’s waste is someone else’s profit. So, that’s a wrinkle. And it’s a really rough wrinkle, because now you have groups lobbying to basically protect the waste. As just one example, what are pricing failures, after all, if not someone else’s margin? Major spoiler alert here, but Dr. Shrank says one sort of broad-stroke solution is aligning incentives with higher-quality care, paying for the longitudinal patient journey, and paying for outcomes. If you do this, then at least the clinical failures side of the equation could improve. The implication here is that if the incentive is to be accountable for value—which is, you know, numerator quality denominator cost—then the supply chain has an incentive to reduce its own waste because effectively, at that point, it’s coming out of their pocket as opposed to somebody else’s. Will this resetting of the financial model happen overnight? That was a rhetorical question that we all know the answer to. Commercial payers are slow to change, and all but the best employers have been (historically, at least) busy making extremely lateral moves and going nowhere fast. Few seem super inclined to reward and pay for what they care about rather than just negotiating a price. I sort of say this to Dr. Shrank, and he says, yeah, true enough. I’m paraphrasing with a lot of creative license right now, but he says, let’s reset our expectations with reality. We’ve actually come a pretty long way, baby, in not a particularly long time if you consider the whole value-based thing really only started not that long ago, relatively speaking. So, there will be problems to overcome and bumps in the road. We should expect that, and we haven’t had the time to work them all out yet. I think a couple of other interesting insights for me, one was a little sidebar we go off on about the power that PCPs might find themselves wielding if they can gang up and harness it. And this is kind of starting. We’ll see if it goes anywhere. I recently heard a story about a bunch of employed PCPs who went to their health system bosses and asked to stand up an APCP (advanced primary care practice) able to coordinate care, etc, do all the things that at this juncture we know are the right things to do for patients. Now they got shot down—bam!—with the backhands from above. I hope those engaged and activated PCPs quit and start up their own thing. Maybe they will. PCPs getting together here could be a way to solve for waste if they can gang up and harness it. And that’s actionable if you happen to be a PCP or are looking to continue to employ them moving forward. The potential rising power of PCPs might cause some health systems to rethink some of the choices they are making (ie, the choice to employ PCPs as RVU [relative value unit] referral machines). PCPs, better than anyone, can see the harm inflicted by the business model that forces a drive-by PCP level of care. Moral injury is at an all-time high, and in addition, I just saw that study recently that showed to do all the administrative work of a PCP these days, it would take longer than 24 hours in a day. If you’re a self-insured employer, I’d also kind of take note of this because it also could be actionable for you. Someone who would know told me recently that if enough employers demanded some value-based accountability, some advanced primary care going on, even a dominant consolidated health system would listen. So there seems to be some alignment here between employers and PCPs if these groups can come together and collaborate. In sum, we have a waste problem in this country. Aligning incentives might be one way to curb that waste. Can I just share with you some of the reviews that we got on iTunes recently? They make my heart so warm. I just want to acknowledge these individuals who took the time to write reviews. Here’s the first one. It’s from Jspeaks1987. He wrote, “[RHV is] my weekly go-to for smart takes on VBC [value-based care]. I have recommended this podcast to literally hundreds of people (including onstage at our recent customer success summit). Anyone who cares about the sustainability of our healthcare system owes it to themselves to give [Relentless Health Value] a permanent spot on their playlist. Always smart, often provocative, scrupulously fair [I like that … scrupulously fair], it’s well worth the listen.” Thank you so much, Jspeaks1987. Here’s another one. And this is from happygilmore80. I know who you are, happygilmore. “RHV is an amazing podcast and sorely needed in the healthcare community. I tell everyone about it. … I’m a recent listener and have learned so much from [episode] 399 and 400 [which are the manifestos]. Episode 410 was packed with knowledge, 407 was great, etc. Let’s start a hundred RHV communities across the US where we implement small experiments so change is grassroots and ubiquitous. Then the status quo will concede.” And yeah, for sure with that. If anyone is interested in creating a meetup or something in your local area, reach out. I’ll try to hook you up with others in the Relentless Tribe. Here’s a third one, and this is by Miriam. Thank you so much for this, Miriam. Miriam says, “I scoured the podcast world to find a healthcare industry podcast that offers intelligent, relevant, clear information and dialogue. I found it. Stacey and RHV cover the US healthcare industry across all sectors while managing to go deep within those sectors. Most importantly, [RHV] highlights how all of those sectors interact, supposedly with the patient at the center, while performing as businesses that are really driven by capitalism.” Miriam says she never misses an episode. To the three of you, thank you so much. It’s actually reviews like this that keep me and the team going over here.   You can learn more by connecting with Dr. Shrank on LinkedIn.     William H. Shrank, MD, MSHS, is serving as venture partner, bio and health, at Andreessen Horowitz. Previously, Dr. Shrank served as chief medical officer for Humana, where his responsibilities included implementing Humana’s integrated care delivery strategy, with an emphasis on advancing the company’s clinical capabilities and core objective of improving the health outcomes of its members. Dr. Shrank previously held the position of chief medical and corporate affairs officer, during which time he oversaw government affairs. From 2016 to 2019, Dr. Shrank served as chief medical officer, insurance services division, at the University of Pittsburgh Medical Center. Previously, Dr. Shrank served as senior vice president, chief scientific officer, and chief medical officer of provider innovation at CVS Health. Prior to joining CVS Health, he served as director of the Research and Rapid-Cycle Evaluation Group for the Center for Medicare and Medicaid Innovation. Dr. Shrank began his career as a practicing physician with Brigham and Women’s Hospital in Boston and as an assistant professor at Harvard Medical School. He has published more than 270 papers on improving the quality of prescribing and the use of chronic medications. Dr. Shrank received his MD from Cornell University Medical College. He completed his residency in internal medicine at Georgetown University and his fellowship in health policy research at the University of California, Los Angeles. He also earned a master of science in health services from the University of California, Los Angeles, and a bachelor’s degree from Brown University.   05:56 Can we cut healthcare waste while improving patient care? 06:35 What does “healthcare waste” consist of? 06:48 What are the six categories of “healthcare waste”? 09:25 EP363 with David Scheinker, PhD. 09:39 How much money does Dr. Shrank estimate is wasted each year in healthcare? 12:11 Where is that healthcare waste going, and why does it happen? 19:09 Uncaring by Robert Pearl, MD. 20:20 “We’ve built a backbone of extraordinary waste on a fee-for-service chassis.” 21:18 EP409 with Larry Bauer, MSW, MEd. 23:26 EP359 with Dan O’Neill. 25:04 Dr. Shrank’s warning to providers out there. 29:04 Summer Shorts 2 with Scott Conard, MD. 30:43 Why there might be a generational shift among younger providers looking to work with different models.   You can learn more by connecting with Dr. Shrank on LinkedIn.   @WillShrank discusses #healthcarewaste, #vbc, and #PCPs on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Carly Eckert (En
Just taking a moment here to thank our Relentless Tribe for really getting yourselves involved in the work that I had originally kicked off to improve the outcomes for CKD (chronic kidney disease) patients in this country. With the momentum that we have so far, this Relentless Tribe of ours, we are really (for reals) going to produce measurable improvements for patients with CKD—so many of you, not just talking but actually out there, actively doing what you need to do so that patients do better, and it’s making a difference. I have talked to doctors, other clinicians, administrators, IPAs, other provider organizations big and small, payers, societies, a great data company, a number of you who are consultants. It’s crazy what we have been able to build so far, and we’ve been doing this for less than a year. The Relentless Tribe … let me tell you, we move mountains. We get patients properly diagnosed. We get them into appropriate treatment plans. What restores my faith in these rough times, we have encountered one PCP, one clinician after another; and the second that we show them the “as per the guidelines” way to accurately diagnose and stage chronic kidney disease (which is not just using eGFR for those clinicians who might be listening), yeah, that’s it! These are great doctors, and they switch it up. They switch up what they are doing, and that makes my heart warm. These are doctors across the board, from ones in independent practices to ones maybe employed by academic medical centers. And once they have the right information, they use it. And it’s a wonderful thing, and I cannot thank everybody who has contributed enough. We are making real differences in patients’ lives. If what I am doing speaks to you in any way, please hit me up, because we’re cooking with gas and I could not be prouder of this community of change agents that we have built here. You’re amazing. You know what needs to be done, and you’re not afraid to do it. Now, back to our regularly scheduled programming. In this healthcare podcast, I am talking with Secretary David Shulkin, MD, and Erin Mistry. Here’s the first reason why I was interested in taking this interview after their public relations firm contacted me. We were at the thINc360 conference in DC earlier this summer, and I heard them talking about patients on dialysis dying from infections, which … didn’t realize how common that was and it seemed like a nice adjacency to our ongoing CKD work. I also thought this might be an opportunity to learn a little bit more about what’s going on with hospital-acquired infections and infection control. Superbugs are hella scary, but one thing I’m just gonna point out—and, small sidebar here, but listen to the show with Bruce Rector, MD (EP300) for more on this—in recent times, I don’t think there has been a pharma company who has managed to launch an antibiotic and achieve commercial success. So, what can easily wind up happening under the current payment model is that instead of just using the new antibiotic to treat resistant cases, there’s this perverse incentive to push for the drug’s use more broadly because more prescriptions, more money. But when the new antibiotic is used more broadly, that actually reduces its effectiveness against those resistant infections that it is here to treat. Okay … back to bloodstream infections now, which is the topic of the conversation today. If a patient has a central line infection and then gets sepsis, their chances of readmission within 30 days is almost 99%. This is not a little cohort. It’s not small potatoes we’re talking about here either. As Secretary Shulkin says during this interview that follows, if you’re gonna make a preventative care economic case study, do it on hospital-acquired infections and, most particularly, those with central lines that lead to sepsis. Even with very short time horizons, you can make that case. So, that was two reasons for this interview. The third: I’ve been extremely intrigued by how and why decisions get made in hospitals for whether or not to buy and use potentially expensive new innovative things—specifically, innovative new things which are used during inpatient goings-on paid for with a DRG. DRG stands for Diagnostic Related Group. Medicare (and others a lot of times) pays hospitals a flat sum to care for a patient coming in with heart failure or sepsis or needing dialysis, regardless of what services are actually delivered. There are something like 13,000 diagnoses and 5000 procedures that Medicare pays for with a DRG lump sum payment. It’s up to the hospitals to make sure they buy low and sell high. So, you can see where this is going. A hospital can’t go tell Medicare, “Hey, we just got some fancy new equipment or a better IV drug, so now we’re gonna charge more.” The DRG is what the DRG is, and if the hospital chooses to spend more on the cost of goods, then the hospital makes less money. This is kind of along the same lines as Marty Makary, MD, MPH, talks about in his book Unaccountable. The purchasing department or some administrator somewhere is making decisions about what monitors to put in the ORs, and they pick the cheap ones that don’t have the color contrast that the surgeons need to do a good job. But the monitors are cheaper, and the hospital can’t pass on the costs. So, from a strictly purchasing perspective, it seems like fiscally solid purchasing, even if doctors are not on board with the decisions and patients have worse outcomes. Seems like somebody over at CMS figured this out, and to solve for the “purchasers or administrators or whomever who are not willing to lose money by using new stuff,” Medicare introduced this extra payment opportunity, which we’ll get into in the interview today. But the short version is this: Biotech companies, device companies, others who are innovators can apply to get Medicare to pay a so-called NTAP to healthcare delivery organizations who use the new product. NTAP stands for new technology add-on payment. Again, these are additional Medicare payments in the inpatient setting that may be available to those who use certain qualifying new technologies as part of services rendered that are normally part of a DRG. Here’s my assessment of the tension between hospitals and plan sponsors because, yeah, when hospitals get paid more for something, that is coming out of somebody’s wallet. If we assume that we’re talking about an innovation that actually produces better patient outcomes, I don’t know how anyone can say there’s a right answer here. If the innovation is expensive, you’re gonna have payers worried about the money, and fair enough. I can easily hear them saying something like, “We’re already paying however much to the hospital, and now there’s an additional charge that’s allowed on top of the DRG?” On the other hand, if I’m a patient, yeah, it would kinda suck to not get the innovation that’s gonna save my life or whatever because the payers insist on paying no more than the DRG and the hospital won’t pay out of their own pocket. Really enjoyed my conversation today with Secretary David Schulkin. Secretary Shulkin spent his career running healthcare systems, mostly in the Northeast. A number of years ago, he entered the Obama administration to run the VA (Veterans Affairs) healthcare system. In the Trump administration, Dr. Shulkin was in the Cabinet as the Secretary of the Department of Veterans Affairs. Secretary Shulkin now has a consulting firm and is working with CorMedix. Erin Mistry, my second guest today, spent her career in health systems and then in biopharma. She now works for CorMedix. My sincere thanks for helping validate a couple of facts in this intro to Scott Haas, Autumn Yongchu, and Erik Davis from USI. For more on the topic of hospitals getting paid to administer drugs through a patient’s medical benefit, listen to the show with Autumn Yongchu and Erik Davis (EP370). They cover the ways hospitals sometimes can figure out how to charge plan sponsors and patients 6x the cost of the drug. Acronym alert! CVC, which comes up a couple of times in the interview that follows, stands for central venous catheter, which is something that many dialysis patients have. Second Acronym Alert! QIDP stands for Qualified Infectious Disease Product. A QIDP qualifies for a special NTAP incentive specifically for infectious disease products. So again, just recapping what an NTAP is. It’s a new technology add-on payment, and it’s paid for by CMS, who has studied the new technology thing and determined that they actually want hospitals to be using it. So, they’re willing to pay more than the DRG if a hospital uses this thing, because they recognize if they don’t pay more, then the hospital won’t eat the cost. And just because of all the focus on infectious disease right now, these qualified infectious disease products have some prioritized status over at CMS relative to getting the NTAP designation. Oh, hey, some unexpected news. This interview is unavailable at this time. One of these days we may be able to make it available, and if so, this will be announced in our weekly email. So please subscribe by going over to our website at RelentlessHealthValue.com.   You can learn more by connecting with Secretary Shulkin, Erin, and CorMedix on LinkedIn.     Honorable David J. Shulkin, MD, was the ninth Secretary of the US Department of Veterans Affairs (VA), having been appointed by President Trump. Secretary Shulkin previously served as Under Secretary for Health, having been appointed by President Obama and confirmed twice unanimously by the US Senate. As Secretary, Dr. Shulkin represented the 21 million American veterans and was responsible for the nation’s largest integrated healthcare system, with over 1200 sites of care serving over 9 million veterans. Prior to coming to VA, Secretary Shulkin was a widely respected healthcare executive, having served as chief executive of leading hospitals and health systems,
I decided to encore this episode with Carly Eckert, MD, PhD(c), MPH, because I keep finding myself quoting Dr. Eckert in conversations, even a year later. First off, if you’re not familiar, a care gap is what happens when there is a bad transition of care. Patient has no idea what their discharge instructions actually mean, so they wind up back in the hospital. Patient didn’t pick up their prescription, so they wind up in the hospital or back in the hospital. Patient still has uncontrolled hypertension long after being diagnosed with uncontrolled hypertension or uncontrolled diabetes. It’s crazy how many patients keep going to their doctor and being told they have high blood pressure or high blood sugar and their care plans are not adjusted. Or they don’t take their meds due to cost or a lack of trust or whatever other reason. Or care gaps exist because the patients don’t go to their doctor in the first place. So, they settle right into a care gap that no doctor can fix because down there in the bottom of that care gap, there’s no medical professionals. So, a year later and the year after that, their blood sugar or their blood pressure is still high. These are patients in care gaps. I mean, consider that heart failure … I heard it called the “a little too late disease” by William Bestermann, MD, the other day. You don’t just spontaneously develop heart failure, after all. If you have uncontrolled hypertension and/or uncontrolled diabetes for too long, you will get heart failure and you’ll also probably get chronic kidney disease. Chronic kidney disease, by the way, is often the cause of most heart failure readmissions, so think about the entire impact of heart failure and most kidney disease when you think about the cost of care gaps. This is what we talk about today. And with that, here’s your encore. In this healthcare podcast, I’m speaking with Carly Eckert, MD. It’s kinda funny, actually. I originally wanted to get Dr. Eckert on the show to talk about care gaps and how to close them, but this show did not wind up going how I thought it was going to go because Carly Eckert is a physician by training who got really interested in the upstream causes of what she was seeing in clinical practice. Despite my best efforts, she refused to be lured into my closing care gaps conversation. So, instead, this conversation is about the construct of care gaps and thinking about them in context. Closing care gaps is a model of care and maybe not a particularly great one, relatively speaking. In fact, here’s another name for the model of care called closing care gaps: care gap whack-a-mole. Care gap pops up … we whack it. Care gap pops up … we try to close it. Another care gap pops up … we try to close it. Another care gap … you get the idea. Carly Eckert has worked in epidemiology and public health and also clinical informatics for health systems and payers. I recorded this show with Dr. Eckert prior to EP359 with Dan O’Neill. In that interview, which you should go back and listen to when you have a sec, Dan O’Neill cleared up a couple of things that I struggled with during this interview. Here’s the big one that I could not figure out: Why with the whack-a-mole? Why do we still insist as a nation on waiting for someone to show up in clinic to retroactively and reactively address a missed preventative care opportunity? Why don’t so many more provider organizations create pop health programs that consider the whole person proactively? Why don’t they take the time to operationalize whole-person care in a meaningful way? Ah, yes … to the surprise of exactly no one, it’s all about the Benjamins. As Dan O’Neill put it, if all a provider organization is doing is slapping a sheet on a doc’s desk every morning with a list of care gaps for all the patients that he/she will see that day, it’s highly likely that incentives, or penalties to do anything else, are very weak. It’s a sign that, from a paying for value perspective, we’re not paying enough for value that it’s worth it or maybe even feasible for any provider organization to take the time and capital expense to switch up their business model in any meaningful way. So, the provider gets a little bump or a little knock if they don’t meet some quality standard. Okay, great … so then they’ll minimally tweak their workflow and have doctors within their 7- to 15-minute visit suss out and try to close care gaps. I don’t want to say this is entirely negative. It’s known that when provider organizations do close care gaps, patient outcomes do tend to get better—so, not arguing that. But there’s opportunities that get left on the table with all this reactiveness. Bottom line: You insurers, you purchasers of healthcare, pay for value, for real. But you provider organizations, if you don’t fix this stuff yourself, you’re gonna get doctors and other clinicians (as we’re seeing) burning out and quitting because there’s only so much you can jam into a 7- or 15-minute visit, number one. But number two, doing population health reactively like this is suboptimal—and everybody knows it. So, what winds up happening is dedicated doctors and nurses desperately want to do the right thing but simply do not have the time. And they watch patient after patient suffer for it. That sucks. So, fix it. At the end of the day, it’s probably cheaper than having to recruit all new doctors and hire traveling nurses when all of the current staff quits due to burnout and/or moral injury.   You can learn more by connecting with Dr. Eckert on LinkedIn and following her on X (Twitter).     Carly Eckert, MD, PhD(c), MPH, is a physician and technologist with dual board certifications in preventive medicine and clinical informatics. With nearly a decade of experience, Dr. Eckert has led multidisciplinary teams encompassing clinical, product development, and data science domains within healthcare start-ups. Her areas of expertise include AI governance, ethical considerations, and bias mitigation, along with a deep understanding of healthcare data and its appropriate use. Dr. Eckert also educates fellow physicians and healthcare professionals on the practical and applied facets of AI solutions, as well as how to foster effective communication with technical teams. In her current professional role, Dr. Eckert is embarking on collaborations with various partners to assess and accelerate the transformative influence of data and technology on care delivery. The overarching goal of this work is to enhance the healthcare experience for broad and varied populations, with exciting new developments on the horizon.   05:31 What is the true goal in making population health successful? 05:58 How does the clinical pathway need to manifest in population health? 06:29 How do we get a nonfragmented state of care? 06:54 What is the best model of care? 08:37 “Identifying and addressing care gaps is an important element of population health.” 11:30 Closing care gaps vs creating a nonfragmented system of care. 15:38 “I think you have to take small steps with people.” 16:45 “There’s a lot of power in peer support.” 17:18 Why should provider organizations connect with peer groups? 19:05 “The key is that it’s not going to be the same for everybody.” 23:09 Why is diversity of the workforce key to closing care gaps? 23:33 EP322 with Monica Lypson, MD, MHPE. 23:37 EP347 with Ian Tong, MD. 28:36 Where can providers improve transparency to help close care gaps?   You can learn more by connecting with Dr. Eckert on LinkedIn and following her on X (Twitter).   @carlymeckert discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3)  
One of the questions I often get asked is this (actually, it’s more of a comment usually than a question): Someone says, “Seems like this whole transformative primary care thing is pretty much just, let’s go back to the old country doctor. Let’s just have a single doctor out there taking care of patients like a Norman Rockwell painting.” To which I reply (and I’m channeling many experts, including my guest Robert Pearl, MD, when I do), “Yeah … except no.” In the golden olden days of the “ye olde country doctor,” there was a lot of art in medicine and a lot less science. If someone got cancer or even heart disease, what was required, fairly exclusively, was comfort and compassion. Now, first and foremost so there’s no confusion, am I dismissing the importance of bedside manner and of providing comfort and compassion? Hell no. Would rather have that any day of the week than deal with a “drive-by PCP” or “drive-by specialist” with the throughput of a freeway who has no idea what I may befall the second I step out of his or her exam room. But in the olden days, medicine was fundamentally art with a lot less science … because there wasn’t much science. For the most part, we didn’t have data. Or MRIs. This was before the whole pharma industry for the most part. We had weird heroin-infused tinctures, but we didn’t have oncology meds or biomarkers or even statins for Pete’s sake. Consider all the new diabetes meds and biologics and artificial joints and sub-subspecialists who have, through data and advanced analytics by looking at patients across the country, proven out some best practices that might be fairly unintuitive—or disproven some conventional wisdom. It’s a different and much more complicated world today, and what’s required now is a healthy appreciation for not only the art of medicine but also the science. And science inherently means that, yeah, there are standards of care to be adhered to. That’s what science means. There are rules and better ways to do things as proven by looking at the data and not relying primarily on personal recollections of what may or may not have worked in the past. Listen to the shows with Bob Matthews (EP315) or Alex Akers (EP154) for more on this topic, but this all leads me to the interview with Dr. Robert Pearl in this healthcare podcast where we get into some concepts that he covers in his new book, Uncaring. In this episode, we’re talking about some how-tos for being a leader of doctors, going about that against the backdrop of this evolving art and science of medicine dynamic, and the impact of this evolving art and science dynamic on physician culture and self-esteem. Because (spoiler alert) if a doc is following evidence-based guidelines, not relying solely on their own personal experience, does that make said doc feel like they are being devalued and that they are but a cog in the wheel and practicing so-called “cookie cutter” medicine? So many nuances, so little time. But, yeah, there’s a lot going on which, at its core, is this tension that can play out in some big bad ways. I asked Dr Pearl for some advice for today’s healthcare leaders, and he did not disappoint. He suggested using a model that he calls the A to G model, and, in short, you’ve got to have: A: an aspirational vision B: behaviors C: context D: data E: engagement (throughout the organization and also with the patient) F: faculty G: governance You’ll have to listen to the episode for the why and how of each of these. My guest today, as aforementioned, is Dr. Robert Pearl. I am sure that most of our Relentless Tribe who are listening to the show today already know Dr. Pearl, but in short, he was the CEO of Kaiser Permanente for 18 years. Now he hosts a podcast called Fixing Healthcare. He teaches at the Stanford Graduate School of Medicine and Business. He writes articles for Forbes and elsewhere. He’s also an author. He wrote a great book called Mistreated, and now there’s a new one called Uncaring. I would recommend both. Also mentioned in this episode is Zeev Neuwirth, MD.   You can learn more at robertpearlmd.com.   Robert Pearl, MD, is the former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group, and former president of the Mid-Atlantic Permanente Medical Group (2009-2017). In these roles, he led over 10,000 physicians and 38,000 staff and was responsible for the nationally recognized medical care of 5 million Kaiser Permanente members on the west and east coasts. Named one of Modern Healthcare’s 50 most influential physician leaders, Dr. Pearl is an advocate for the power of integrated, prepaid, technologically advanced, and physician-led healthcare delivery. He serves as a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business, where he teaches courses on strategy and leadership and lectures on information technology and healthcare policy. He is the author of Mistreated: Why We Think We’re Getting Good Health Care—And Why We’re Usually Wrong, a Washington Post bestseller that offers a roadmap for transforming American healthcare. All proceeds from the book go to Doctors Without Borders. His most recent book, Uncaring: How the Culture of Medicine Kills Doctors and Patients, was published May 2021. Dr. Pearl hosts the popular podcasts Fixing Healthcare and Medicine: The Truth (formerly Coronavirus: The Truth). He publishes a newsletter with over 13,000 subscribers called Monthly Musings on American Healthcare and is a regular contributor to Forbes. He has been featured on CBS This Morning, CNBC, and NPR, and in TIME, USA Today, and Bloomberg News. He has published more than 100 articles in medical journals and contributed to numerous books. A frequent keynote speaker at healthcare and medical technology conferences, Dr. Pearl has addressed the Commonwealth Club, the World Healthcare Congress, the Institute for Healthcare Improvement’s National Quality Forum, and the National Committee for Quality Improvement (NCQA). Board certified in plastic and reconstructive surgery, Dr. Pearl received his medical degree from the Yale University School of Medicine, followed by a residency in plastic and reconstructive surgery at Stanford University. From 2012 to 2017, Dr. Pearl served as chairman of the Council of Accountable Physician Practices (CAPP), which includes the nation’s largest and best multispecialty medical groups, and participated in the Bipartisan Congressional Task Force on Delivery System Reform and Health IT in Washington, DC.   04:50 What is the idea of the art of medicine? 09:29 EP407 with Vivek Garg, MD, MBA. 09:32 Why has the intrinsic motivation of doctors plummeted? 09:48 Patient perspective versus doctor subjective response. 12:36 Why is there a fundamental change in what doctors and medical professionals can take pride in? 14:38 What did change management look like in the past? 15:24 “What does a patient really want? They’d like not to have a stroke, a heart attack … in the first place.” 20:23 “How do leaders achieve evolution?” 23:57 “Incentives always work … the problem in medicine is, they rarely work the way you planned.” 24:20 What’s the way to make change happen, and why doesn’t it involve financial incentives? 28:10 What do leaders in organizations today consistently underestimate? 29:11 What are the three parts of leadership? 29:25 What is the hardest part about leadership? 31:31 Dr. Pearl’s two books, Mistreated and Uncaring.   You can learn more at robertpearlmd.com.   @RobertPearlMD discusses art vs science and leadership in #medicine on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2)  
During the recording of episode 409, where Larry Bauer was explaining some really cool and innovative bright spots in the healthcare industry created by physicians, we somehow got off on a tangent about an article in JAMA from 2010—and I was all in. Unfortunately, going all in on a topic that has nothing to do with the actual topic of the currently in progress podcast means one thing; and you probably know by now what that one thing is. Yep … summer short. So, let me unveil for you our last summer short of 2023. In this healthcare podcast, we’re gonna talk about doctors and the societal perception of them as being a knight, a knave, or a pawn. All of this is from a JAMA article that is entitled, surprisingly enough, “Societal Perceptions of Physicians: Knights, Knaves, or Pawns?” and it’s by Sachin Jain, MD, MBA, and Christine Cassel, MD, and is unfortunately firewalled (but I’ve linked to it anyway). To get us started here, this is the first sentence of that JAMA article: “The British economist Julian Le Grand suggested that public policy is grounded in a conception of humans as ‘knights,’ ‘knaves,’ or ‘pawns.’ Human beings are motivated by virtue (knights) or rigid self-interest (knaves) or are passive victims of their circumstances (pawns).” And, yeah, that plays out. Why can’t physicians own hospitals? Well, in somebody’s eyes, docs got a knave rap. How’d that happen? I don’t know. I can make some guesses. Even if it’s a small percentage of docs doing knave-y money grabs or power-hungry things, there is spillover. We societal humans, after all, like black and white, not gray. So, everybody gets painted with the same brush in the same color, and policy gets created to control the lowest common denominators. I loved this conversation with Larry Bauer that follows because it explains a lot of sequelae, if you will, that I couldn’t quite put my finger on the root cause of. So, in the brief but fast-moving clip of the conversation that follows, Larry Bauer and I chat about docs as knaves or knights. But we don’t get around to pawns, so I did just want to chuck in my two cents here about this third category. I also will say that since I’ve got these three new classifications, I find myself using it to predict actions—to some effect, I might add. I was chatting with someone recently, and I said something about doing well by doing good and he replied, “Well, how about this? You can do the good, and I’ll focus on doing well by doing well.” Okay … so, that’s a predictive layup. The harder ones are where people with a lot of press training and social capital do talks about doing good and being knightly, but then you listen to the minutes of their board meetings and, wow, are they focused on revenue maximization … at the expense of patients and their fellow doctors. This happens more often than I would like to see, but then again, I would like to see this happen never. As I mentioned about eight sentences ago, the category we don’t talk about in this conversation with Larry Bauer that follows—which has also occupied a chunk of my mind space lately—are pawns. As with all of these categories, it’s not just docs who fall into them but everybody else, too. Pawns are super interesting. You might be way ahead of me here and have been thinking about this for years because, on its face, this is obvious. But sometimes there’s truth hiding in plain sight, so I’m not embarrassed to keep talking about this in case it helps you connect the same dots I’ve recently started to connect. I will state at the outset here that those who I would chuck in the pawn category do not listen to this podcast (neither do knaves). They do not like this show at all. This show forces a level of self-reflection and awareness and, to some degree, accountability about the net net of some of the goings-on that those who don’t want to hear it don’t like at all. I was reading an article the other day about the “tragedy of organizational decision-making.” Kind of like the tragedy of the commons if you’re familiar with that terminology, but don’t worry about it at all if you’re not. The tragedy of organizational decision-making is that everybody in companies, especially big ones, is making lots of decisions. Tens of thousands of decisions happen in any given company on any given day, but so few then feel accountable or responsible or are even keeping track of the downstream and ultimate impact or consequences of any of the combined actions. It’s this big machine, and you’ll hear some people say that they are but a cog “just doing my job” with no sight line into patient or member or community or societal impact. Without this context or accountability or ownership, it is so easy to make decisions that take to the extremes what should be a nuanced plan of action. And then we get what we’ve currently got. Look, anybody who is part of a larger organization has to toe the party line to some extent; but there’s a difference between making informed choices and seeking ways to deliver a net positive for those we ultimately serve and doing things without contemplation. This is one thing that I love about the Relentless Tribe: just how much contemplation happens. I am still working this out in my own head. I would welcome your feedback and thoughts, but from what I’ve seen so far, what pervades some of this pawn-like thinking might be—and I empathize with this a lot—it could be a feeling of powerlessness. Why bother being a knight, because nothing I do really matters anyway? Sometimes people just throw hands in air and, yeah, a familiar feeling even amongst those of us who try to think things through and have manifestos. So, I get it. But whereas this feeling of powerlessness causes some of us, meaning you and me, to double down on reflection, it may cause others to just quit trying altogether because they think they have a snowball’s chance in hell of influencing absolutely anything. If it helps you in conversations that you might be having at some point with someone who may be feeling powerless, here’s a quote I memorized: “Great things are done by a series of small things brought together.” That was Vincent Van Gogh who said that. You also have Malcolm Gladwell from his book The Tipping Point, which talked about how many people have to be doing something to reach a tipping point: 12%. That’s doable. If basically 1 out of 10-ish people in any organization becomes a knight, the minority becomes the majority. Or here’s another quote that has some problems admittedly, but it makes a good point if you don’t cognate on it too hard: “If you think you are too small to make an impact, try going to bed with a mosquito in the room.” That was Anita Roddick. Anyway, I hope that’s inspirational or helpful to you in some way.   You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com. Larry wrote a “Bright Spot” report; check it out here.   Laurence Mahoney Bauer, MSW, MEd, served as chief executive officer of the Family Medicine Education Consortium, Inc., from 1994 to October 2021. The FMEC is a not-for-profit corporation designed to promote collaboration among the academic family medicine and primary care communities in the northeast region of the United States. He has also served as director of network development for the Center for Innovation in Family and Community Health in Dayton, Ohio, from January 2006. He is an associate clinical professor in the Wright State University School of Medicine, Department of Family Medicine, in Dayton. Previously, he served at The Ohio State University School of Medicine, Department of Family Medicine, for 4 years as director of organization and faculty development. He served as director of faculty development and behavioral science in the Department of Family and Community Medicine at the Pennsylvania State University School of Medicine in Hershey, Pennsylvania, for 13 years. Presently, he is an active consultant committed to the creation of a primary care–driven system in the United States. He lives in Hershey. He enjoys pickleball, basketball, and gardening.   07:36 Are physicians knaves or knights? 10:05 “Most of the people … that [I’ve met], I would actually put under the cap of knights.” 10:21 “By and large, the healing community is quite ubiquitous.” 10:38 What is more important than accountability in the healing community? 13:42 Why is it important to recognize our own biases in how we view physicians and the medical community? 18:10 EP266 with Matt Anderson, MD, MBA. 18:16 Is it “the suits” versus “the scrubs”? 19:08 Why is it important to get doctors on committees and get policymakers on the ground?   You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com. Larry wrote a “Bright Spot” report; check it out here.   Larry Bauer of @FMEC_ discusses the perception of #doctors and #providers in society on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1)
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