Relentless Health Value

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

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

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

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

In this healthcare podcast, I'm talking with Brian Klepper. If you haven't heard of him, Brian's a longtime healthcare analyst and former CEO of the National Business Coalition on Health. This interview takes off like a shot, as most of my conversations with Brian Klepper do. We're talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the '90s. This is a great comparator to really get a handle on what's going on today. During the heyday of HMOs (back in the '90s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn't an accident that it was really hard to get an appointment with a PCP. On the other hand, it also wasn't an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody's happy then, right? Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend … Oh right, everybody's happy except the patient who can't get care and the PCP who can't do their job. By the way, for more information on why the '90s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the "why" really actually took me by surprise. But back to primary care … Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we're not really counting urgent cares or what amounts to urgent cares in that mix—meaning, not counting a lot of the retail clinics because they don't really manage patient care like you'd hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can't manage a chronic condition in 15 minutes. So, like I said, there's three kinds of PCPs that are around today; and let's call the first kind the OPCP, the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn't really what their payer mix is. It's that they're not taking on much risk or any risk of real consequence. Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered. Third, we have what Brian calls industrialized primary care—or some people call it advanced primary care, or APC—but I'd probably call it something different. I'd call it "taking risk for the full continuum of care" primary care. Maybe I wouldn't even call it primary care at all because this third category really is starting to color outside of the lines of primary care. This third iteration requires many things to accomplish. It requires an unimpeachable relationship with the patient; you cannot be successful with this otherwise. It requires great virtual/digital capabilities. It also requires data—data to help ensure that care gaps are filled but also to make sure that patients are referred to high-quality, high-value specialists downstream who will actually create outcomes. It also includes optimizing specialty pharmaceutical usage, for example. Brian gets into this and how a state employee health plan is on track to save $1.3 billion in this fashion. Brian believes that this third iteration of primary care—this APC industrialized primary care—is the third leg of a three-legged stool that is needed to transform healthcare. If you must know, the second leg is identification and the use of high-performing specialty services; and the third is value-based reimbursement environment. Most of the second half of this conversation with Brian is about why there's just a flurry of investment into various forms of these advanced or just maybe even regular primary care models and how they might evolve moving forward. I ask Brian about Carbon Health and their recent claim that they can do primary care with about 25% to 30% EBITA, even at Medicare FFS rates. So, there's that. One last thing: Next week, we'll be posting an "Ask an Expert" with Brian Klepper, where he gives the backstory about how the RUC—that AMA committee—basically killed primary care. So, come back for that show after you're done with this one. It's a plot full of intrigue, that's for sure. You can learn more by emailing Brian at [email protected]. Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Ad

In this episode, host Stacey Richter speaks with Sunita Desai, PhD, a health economist and assistant professor at NYU Grossman School of Medicine, about the real-world impact of price transparency in healthcare. They break down the intended progression from transparency to consumerism to lower costs and higher quality care—and why, in practice, that progression often stalls. Sunita shares key research on the barriers consumers face when trying to act on price information, and they discuss what it will take to make consumerism an effective force in healthcare. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episode/ep334 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 06:23 Why is everyone so interested in price transparency right now? 07:30 How does price transparency enable consumerism? 08:05 What are the two aspects to consumerism in order to enable it in health care? 11:01 Does access to price transparency tools lower costs and spending? 15:19 Why is there such low utilization of price transparency tools? 16:13 What's the first barrier to using price transparency tools? 17:10 Why bypassing the physician at the point of care limits the use of price transparency tools. 17:53 EP284 with Carm Huntress.23:20 EP308 with Mark Fendrick, MD.23:31 How does reducing spending with high-deductible health plans negatively affect high-value health care? 25:23 "There is not a strong correlation between prices of providers and quality." 28:48 How does a reduction in physician choices undermine price transparency? 29:30 "We owe that information to patients … it's useful for patients to know what out-of-pocket costs they should expect."

In this episode, host Stacey Richter engages with a panel of experts—including Jeff Hogan, Darrell Moon, Dr. Grace Terrell, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy—to discuss the practical implementation of care plans in real-world settings. The conversation delves into the challenges and successes of integrating care plans into healthcare practices, offering insights into effective strategies and common pitfalls. Listeners will gain valuable perspectives on enhancing patient outcomes through the thoughtful application of care plans. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episode/ep331 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 02:10 Jeff Hogan (EP309) talks about the consequences of when there's a disconnect between what the patient thinks is happening and what is actually happening in a care plan.03:48 EP315 with Bob Matthews. 03:58 Merrill Goozner's perspective on successful population health.04:55 Why did Darrell Moon (EP305) give up being a hospital administrator because of care plans? 08:02 "It's a myth that population medicine … and precision medicine are incompatible or opposites."—Dr. Grace Terrell (EP319) 11:28 Dr. Rich Klasco (EP321) explains "noncognitive" medicine and why it bogs physicians down.14:45 What is at the core of appropriateness for care? 16:33 "You start to bring that data to the physician, and it really does open their eyes."—Nicole Bradberry (EP324) 16:51 Nicole Bradberry and Kelly Conroy (EP324) discuss how to really change the way physicians work.

In most other industries, it's the customer who consumes the services and engages with the purveyor of services. In health care, not so much. Legacy health care has evolved to honor the insurance carrier as the customer or, in some cases, the fancy surgeon or other driver of revenue as the customer. Listen to the podcast with Marshall Allen for more on that front, but yeah. And here we are. Health care should be designed so that patients get the best outcomes at a financially not-toxic price point. Otherwise, what are we doing here besides putting profit over patients? In this health care podcast, the conversation is about PCVS, otherwise known as creating a "patient-centered value system," otherwise known as building a new OS, or operating system, for health care—one that is built around the patient and their experience. The general idea here is to rationalize the patient journey from start to finish: to create a longitudinal flow that guides a patient from here to where they need to be with a minimum of being told you need a follow-up appointment but having no idea with whom or how that's supposed to happen and when, or getting discharged with no instructions, etc. So, PCVS … let's talk about this, how this works, real quick before we dive in with Dr. DiGioia. In a nutshell, the first step is to really, really carefully trace the patient journey from beginning—really the very, very beginning of the experience, which might start in the parking lot or with the first digital interaction or at the PCP referral—to the very last interaction, which might be after discharge from the SNF (skilled nursing facility) after their last follow-up appointment. It's figuring out what matters to the patient at each step in that journey and then documenting that flow map. Then the next step is to compare the current patient journey, the current state, to what the team decides is the ideal patient journey. Then the last task, which may be obvious, is to implement—for implementation teams to devise and implement action plans to get from here to there. Here's an interesting point to ponder: We often talk about fragmentation and interoperability, and when I said these words, your brain immediately snapped to technology fragmentation and interoperability. But bear this in mind: The patient is the only commonality between all the settings of care that are using all those varied technologies. When you rationalize the patient journey, you also, to some extent, create the foundation to integrate technology. Why a PCVS process, you might ask, if you're in charge of the P&L and regard patient centeredness as a nice to have if there's extra cash lying around? Here's why: If you're going to successfully roll out a prospective bundle, for example, to employers, you better have gone through a PCVS process. Other things, too, but being intimately aware of the patient journey and where patients fall through the cracks or get disgruntled can easily spell the difference between bundle success and failure. This is probably also true for really almost any sort of risk-based/capitation arrangement. It's probably also true for great customer satisfaction scores. It's probably also going to become increasingly true when competing against some of these virtual-first operations that may have been built from the ground up to be sticky and engaging for patients, as well as guide them through a longitudinal journey. For more on the WIIFM (the "what's in it for me?") if you are a provider organization and are thinking about patient-centered care, listen to one of our most popular episodes over here at Relentless Health Value—the one with Joe Selby, MD, from PCORI—on this topic. In this health care podcast, I'm talking with Tony DiGioia, MD, about PCVS (patient-centered value systems). Dr. DiGioia is a practicing orthopedic surgeon at the Bone and Joint Center over at UPMC Magee-Womens Hospital and also the medical director of the UPMC Innovation Center. Dr. DiGioia wrote a book aptly titled The Patient Centered Value System. One thing I thought of as I listened to this conversation again in preparation for releasing the episode: Dr. Shantanu Nundy has written that on the front lines of health care, clinicians and other frontline workers know what to do for their patients. They know what's the matter and what matters to the patient and, really, what they need. Dr. Nundy talks about how, to efficiently transform health care, one thing that we need to do is "decentralize" control or shift power in terms of decision-making authority and resources back to the front lines and to patients. The point that I'm making is that the PCVS might be the OS that health care needs for "decentralization" to happen at a system level and in a way that everyone works together toward a common, aligned goal—as opposed to clinicians and patients all doing their own thing, making their own assessments about what is needed at any given moment at potentially cross-purposes to one

In this episode, host Stacey Richter interviews Al Lewis, founder and "quizmeister-in-chief" of Quizzify, about the misleading tactics wellness and point-solution vendors use to inflate their cost savings claims. They explore statistical tricks like regression to the mean, flawed participant comparisons, trend inflation, and overstated engagement metrics. Al also shares advice for employers on spotting these deceptive practices and ensuring their brokers or benefit consultants are acting in their best interests. For more details, check out the Validation Institute's PDF linked in the show notes. Links below. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episode/ep331 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 04:49 Are brokers going to have to become more transparent about where their money is coming from? 07:33 Are carriers transparent? 08:09 What's the goal of the Validation Institute? 08:55 "You either get a true statement put up or learn what you have to do in order to get a true statement put up." 11:18 How is Regression to the Mean (RTM) used in a flawed way? 16:32 "If you do wellness for employees instead of to employees, the people who want the wellness will be able to access it." 21:13 What is plausibility testing? 23:17 What about actuaries and validation? 23:40 "That's one of the reasons the Validation Institute exists, is because actuaries are easily corrupted." 25:18 What is a prime example of population health economics? 26:20 What does it mean to overstate engagement? 27:15 "How often did you use this and was it useful?" 28:55 "Are you validated by the Validation Institute, and if not, why not?"

In this health care podcast, I'm interviewing John Marchica, who is the CEO at Darwin Research Group. Starting last year in the middle of the worst of the COVID pandemic, Darwin Research Group conducted a study about what was going on at health systems or integrated delivery networks (IDNs), and they've updated it every quarter since then. The goal was to try to stay on top of the effects of COVID-19 on care management and the business of care delivery. I loved having this opportunity to quiz John about what health systems are saying about how they are doing and what they are doing, both strategically and reactively, coming out of the pandemic and in response to the pandemic. Now this is a half-hour conversation about an extensive research report, so we're kind of aggregating all of the health systems in one big bucket. Said another way, we're obviously not going to play the deep cuts here. No worries—the insights that John lays out are fascinating and give an insider's look into what's going on at these really powerful institutions. By the way, when I say powerful institutions, I just was looking at some stats the other day. Something like 50% of all prescriptions these days run through IDNs (that was in 2020). And also in 2020, aggregate IDN market size was $1 trillion. And by 2027, their anticipated combined revenues may exceed $2 trillion. That's double. (I know, that was some quick math by me. You're welcome.) We'll see, though, what the recent Executive Order yields—the one to look into the market power that some of these consolidated IDNs wield. Regardless of who you are, it is tough to deny the mountain of evidence showing that IDN health system consolidation considerably jacks up prices that patients, employers, and taxpayers pay in any geography where consolidated IDNs, otherwise known as monopolies, have destroyed all competition. Probably the most striking takeaway I had from this conversation was how much there is to read between the lines. At the end of the day, IDNs are, and are run, like businesses; and regardless of whether they have a nonprofit on the door or not, that is still true. Before I get into this, let me just clearly say that my heart goes out to the frontline workers—doctors, nurses, everybody else—and all they have done and continue to do for us, and I mean that with three underlines. While I really admire and support some of the rural and urban truly safety net hospitals who are trying to cobble together positive net revenue against all odds, I am far less sympathetic to some of the huge institutions who will engineer an "it's good for patients, honestly" cover story for any and all endeavors which all seem to have one thing in common: their profitability. Like, nobody mentioned 340B revenue opportunities or how much money there is in specialty pharmacy when explaining the rationale for standing up specialty pharmacies within some health systems' walls. Maybe it goes without saying. Here's my conversation with John Marchica, CEO of Darwin Research Group and host of the Health Care Rounds podcast, by the way. You should check that out. You can learn more at darwinresearch.com or by emailing John at [email protected]. You can also listen to the podcast Health Care Rounds wherever you listen to podcasts. John Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He's a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and MA in public policy from the University of Chicago, and completed his PhD coursework at The Dartmouth Institute. He is a faculty associate in the WP Carey School of Business and the College of Health Solutions at Arizona State University and is an active member of the American College of Healthcare Executives. 03:50 What were John's top three health system findings during COVID? 05:24 What is priority for integrated delivery network health systems right now? 08:57 Why do health systems have a renewed focus in primary care? 10:07 How did infusion centers manage throughout the pandemic? 13:58 "It's not just in cancer, people not getting screened and being diagnosed; it's in other areas as well." 14:17 Which of these telemedicine changes are permanent? 19:39 "A visit is a visit … so why would you reimburse at a lower rate?" 19:57 "Telemedicine … is, by its nature, more efficient … and they should be able to figure out how to make money." 27:17 What are health system plans that own their specialty pharmacy groups doing right now? 29:57 What does Darwin Research Group focus on? You can learn more at darwinresearch.com or by emailing John at jm@da

In a recent article in STAT news, TJ Parker, the VP of pharmacy at Amazon and the founder of PillPack, explained that Amazon's plan to stand out in the pharmacy space is simple: "Better selection, better convenience, and better prices." He added, "It really is the Amazon playbook." Better selection, better convenience, better price. The playbook of arguably one of the most successful companies ever, Amazon has decimated and bankrupted anybody standing in its way toward total market dominance. This same better selection, better convenience, better price trio—maybe with "better selection" inferred to mean "getting the right care to the right patient at the right time"—is the vision of many of the virtual-first health care providers starting to pop up. And when I say "pop up," I mean that in Q1 of this year, according to data from Rock Health, $6.7 billion was invested in digital health companies. In this health care podcast, we're talking about the proliferation of these "virtual-first" health care solutions. Before we begin, though, let me just clarify that in our conversation, virtual first doesn't mean virtual only. Most of the time, actually, virtual first means that the connective tissue of the operation is virtual/digitized. In other words, we're not just talking about some random mobile app here. There are likely human providers involved, and the goal is to offer patients not only a sticky engaging entry point and journey but then also a continuous longitudinal care experience. The patient journey should be clear, and the virtual-first solution is making sure that the patient isn't getting lost somewhere in their journey from diagnosis to better outcomes. Here's my main point: The big contrast between these newer virtual-first solutions and traditional health care enterprises is that humans involved in these virtual-first solutions are connected to each other and to their patients with technology designed for that purpose—as opposed to software and systems designed to maximize billing, which, sadly, many software tools and systems used in legacy health care were. The promise of these virtual-first solutions is to fill care gaps for patients who are currently having issues. It sometimes takes 10 years for people to get properly diagnosed. Care for chronic conditions is also abysmal in this country. Now, this all being said, much of the promise of these virtual-first, also called point solutions when someone is not a fan, has yet to be realized. Tune in to my interview with Al Lewis next week for more on that front. One area of concern is that if you have a point solution for MSK (musculoskeletal) care and a point solution for diabetes and a point solution for mental health, you wind up with silos. PCPs have complained that they don't know what's going on with some of these solutions, and it makes it harder to manage patients. Here's my inadequate response to these two criticisms: Well, how many silos currently exist in the health care system? When a specialist gets ahold of a patient, do the specialists talk to one another much less the PCP if we're talking about an average here? Sometimes patients have multiple PCPs even, who, I'm not exactly sure if they hold regular discussions. So, if the status quo is the benchmark to beat, then at least with some of these virtual-first silos, you have the patient getting longitudinal care within that silo. That's not the case with many specialists who, at best, manage one episodic or a series of episodic visits. On the other hand, consider that $6.7 billion of investment. Some PE company there is looking for 4x on their investment, so $6.7 billion of PE investment means that they expect to get $28 billion out of health care spend, meaning $28 billion paid for by patients, employers, or taxpayers. On the other other hand, $28 billion is a drop in the bucket compared to the almost $3 trillion that this country spends annually on health care. I talk about all this and more with Joe Connolly in this health care podcast. Joe was originally in medical devices and has created his share of digital health solutions. Currently, Joe serves as CEO and founder of Visana, a virtual-first solution for women's health. You can learn more at visanahealth.com or by emailing Joe directly at [email protected]. Joe Connolly is the founder and CEO of Visana Health, a virtual-first women's specialty care clinic focused on high-cost chronic gynecologic conditions like endometriosis. Visana works with payers and self-funded employers to improve access to best-practice women's health care. Joe also writes a popular blog consisting of long-form, in-depth analyses on the burgeoning virtual-first care industry. Prior to Visana, Joe led digital health and strategy efforts at Boston Scientific, a large medical device company. 05:01 What does it mean to be virtual first? 05:50 "It's meeting people where they are and where they want care to be delivered. It does not mean virtual only." 07:01 Ho

"Scientists Announce Successful Experiment to Bankrupt Mouse That Can't Afford Cancer Drug." That's a recent headline from The Onion, which is, by the way, a funny satire newspaper, if you haven't heard of it. You could swap out "Cancer Drug" in that headline with "a Trip to the ER"—or pretty much any aspect of health care in this country. No matter what health care service you stick in there as the potential cause for a mouse's bankruptcy, it's a pretty LOL headline, right? But the reason why it became a headline is because obviously it's based on a truth that resonates with your regular citizens in this country. Think about that. A critical mass of people around here believe that health care will bankrupt you. This is one of those sociological signals that has implications to health care leaders. Here's another signal with implications. In this health care podcast, I'm interviewing the incomparable Marshall Allen. That's not the signal. His book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, a book with that title being on the New York Times best seller list, is the signal. Marshall's book is an instruction manual for patients on how to fight back against unfair and/or egregiously inaccurate bills. This interview with Marshall Allen is different from others that you may be hearing. Marshall wrote a book to motivate patients, a critical mass of patients, to get empowered relative to their health care bills. Because listeners of this show are health care executives, I wanted this interview to be relevant to you. What does this book mean for you? Doug Aldeen told me one time, unless something has a direct impact on the CEO or leadership team at a health system or insurance company, they're just bored. Let me sum up this interview in one sentence: This is not boring. If you want to skip to the exact examples of "not boring," you can skip ahead to about the 30-minute mark. We go through the ways that health systems can and probably will be hurt by the financial toxicity that they create. Here's the three-ish ways that Marshall and I talk about: Doctors who no longer trust their employers (ie, the health systems they work for) leave and then you have to recruit new doctors—#problematicandexpensiveonanumberoflevels, but I don't need to tell you that. Reputational damage. When the slogan on the door becomes a joke, that's a problem. Employers and taxpayers reading best-selling books like this one and Marty Makary's (which also is or was just recently on the best seller list) and learning how to not be basically passive suckers anymore. You can find Marshall's book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, anywhere that books are sold. Marshall Allen investigates why we pay so much for health care in the United States and get so little in return. He is the author of the new book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. He is also the founder of Allen Health Academy, which produces a curriculum of short on-demand videos to equip and empower employees to navigate the health care system. Marshall has investigated the health care industry for 15 years, including a decade at ProPublica. He has also spent a decade as an educator at the Craig Newmark Graduate School of Journalism at The City University of New York. His work has been honored with many journalism awards, including some of the top business reporting honors, the Harvard Kennedy School's Goldsmith Prize for Investigative Reporting, and twice as a finalist for the Pulitzer Prize. Before he was in journalism, Marshall spent 5 years in full-time ministry, including 3 years in Nairobi, Kenya. He has a master's degree in theology. 03:35 What's the point of view that Marshall is coming from with his investigative reporting? 04:06 "How does this affect the people who are paying for it and the people who are undergoing the care?" 04:58 "There's a lot of good people working within this very messed up system." 05:12 Why are patients considered outsiders in the health care system? 05:55 "What's happened in health care is that the stakeholders treat each other more as the customer." 07:54 What is upcoding? 11:27 "These are schemes that have been created within the industry to increase revenue." 11:56 "This system is not set up for the benefit of the patient." 12:22 "On the financial side, the industry is actually oppressing the American people." 12:39 Can a critical mass of patients force health systems to become more accountable? 16:02 "We have been expected to pay whatever aggregate sum is thrown at us." 17:09 Why have patients been so passive toward this crooked health care system so far? 18:04 "They're violating the trust of the American people when they don't treat us fairly." 19:28 "It's totally legal to do that, [but] is it ethical?" 20:11 What's the difference between making a profit and profiteering? 21:43 "It's hard to argue against your own pa

If I had a nickel for every guest on this show who went on to achieve wild success … TJ Parker from PillPack three years before they were bought by Amazon. Anyway, let me introduce this show with a clip from the recent podcast (EP325) with Dr. Mai Pham. We were talking about the rampant and very open secret of excessive upcoding in Medicare Advantage (MA) that is costing American taxpayers a fortune and is very not correlated with actual spend. Here we go with Dr. Mai Pham: Stacey: Do you have any thoughts relative to how you ensure that these MA plans that are becoming vast are still accountable to not game the system? How do you plug loopholes in a way that doesn't invite additional and more nefarious gaming? Dr. Pham: My fantasy has always been that CMS can develop, or somebody can develop, a black box machine learning–driven, risk-adjustment algorithm that no one can see into—not even the payer. It would very much level the playing field, assuming that it was developed correctly, appropriately, and you used unbiased data; but that's the kind of system and extreme solution that I think starts to sound almost necessary given the state of things and the rate of acceleration in upcoding. So, people may not have noticed that CMS had put out a request for — I think it was a challenge grant, maybe? And they recently announced a couple of winners. They were asking for artificial intelligence–driven approaches to predicting health outcomes, which I believe is just the first shadow approach, the first step that you take in thinking about artificial intelligence–driven risk adjustment. I also want the audience to understand, it's not like we're talking about replacing a really superlative gold standard, right? The majority of the most commonly used risk-adjustment approaches today produce a correlation with actual spend of only like 0.2. This is the best we can do? This is how we're deciding how we're going to spend a trillion dollars each year? Surely, we can do better. And, by the way, the winner of that CMS AI contest was ClosedLoop.ai; and Andrew Eye from ClosedLoop.ai was on the show. Cue Encore Episode here! In the original version of this show, there was a whole prelude about whether AI is or is not anything beyond an overused marketing pitch; but I think, in the time-space continuum, we're beyond that conversation now. Don't get me wrong, everybody still has AI in their cloud analytics platforms. And some of them are still, as they say, programmed in PowerPoint (that was a joke); but real deals are emerging from the fray. As mentioned, in this health care podcast I talk with Andrew Eye about AI. (He was born for this job.) Andrew is CEO over at ClosedLoop.ai. ClosedLoop.ai beat out over 300 rivals with their system that forecasts adverse health events and then plops warnings even in the EHR with action steps for clinicians to avoid the calamity in the making. You can imagine many things that CMS might be contemplating using this tool for, including as a control for false upcoding and all of the financial toxicity that goes along with that. By the way, keep in mind all the top-performing Medicare Advantage plans are using today, right now, some form of advanced analytics and artificial intelligence to risk stratify their populations and predict which members will, without intervention, become high cost in the near term. Others are using AI right now to do the kind of predictive analytics that you need to excel at population health. I get to ask Andrew some of the hard questions that have been bothering me about all the AI hype, and he set me straight a couple of times. Love it when that happens. You can learn more at closedloop.ai or by following Andrew (@andreweye) on Twitter. Andrew Eye's executive and entrepreneurial experience spans over 20 years in business to consumer and business to business for start-ups and Fortune 500 companies. Andrew founded and sold three technology companies and today is the CEO and founder of ClosedLoop.ai. In 2012, Andrew cofounded the mobile software company Boxer. Boxer developed mobile productivity software for individuals and large corporations. Boxer's flagship email product was downloaded by millions of users and received significant industry praise for its exceptional user interface, including a 2015 Webby Nomination as one of the top 5 productivity applications in the world. Boxer was purchased by VMWare (one of the top 10 largest software companies in the world) in 2015. Prior to Boxer, Andrew cofounded the cybersecurity firm Ciphent in 2007. Ciphent grew to nearly 100 employees with 1000 customers by 2010 before being acquired by Accuvant (now Optiv). With a three-year growth rate of 8900%, Ciphent was recognized by Inc. magazine as the 16th fastest-growing private company in the United States. During his tenure as SVP of services at Accuvant, Andrew oversaw a $50-million, 200-person organization and was responsible for doubling revenues in 18 months. Andrew also s

You can subscribe to this show two ways. One way is through the iTunes podcast app or your podcast app of choice. That's a cool way to subscribe because then the show just kind of turns up in your podcast app each week and you can decide to listen to it on the fly. The other way is to subscribe on our Web site. This is more like a newsletter subscription. If you subscribe this way, you get an email each week that transcribes the show introduction, plus includes timed show notes. Many people subscribe both ways, just saying, because each way has different benefits that are pretty complementary. If you subscribe to the newsletter, you only get the newsletter. We are frankly way too busy doing other things to send out other emails. Also, you can easily unsubscribe at any time. I saw a post the other day in Twitter. Someone wrote, "So much can be done to improve community and share lessons to improve outcomes. The trick is making money without selling patient data to Pharma." Here's my question for you, and I'm legit asking: I have seen many use cases that benefit patients and that are incredibly worthwhile. But no one is willing to pay for them. That's the first point this Tweet I just read infers. And I've seen it time and time again: gaps in care no one is willing to fill. If you're speaking about very specific patient populations in very specific therapeutic categories, like some rare diseases, you're not going to find basically anyone besides Pharma who has the bandwidth, the money, the expertise, and the reach to fill that gap. If you contemplate this further, and I have, Pharma might be the only entity who, if they do it, the price of health care doesn't immediately go up. Hear me out here because I'm wading into controversial waters, so let me make my point before you jump me in a dark alley. If Pharma does something and it comes out of their existing marketing budget or their R&D budget or some other existing budget, them spending money on filling a patient gap versus them spending money on some TV ad is not going to impact the price of the drug either way. If the price of the drug is already too high, the price of the drug is still too high. That's going to be true regardless. Why not let Pharma pay the freight for making sure their own patient populations get the best care possible? This show is posted on LinkedIn and Twitter. Let me know what your thoughts are. I'm very interested. In this health care podcast, I am really pleased to be speaking with Naomi Fried, PhD. Dr. Fried has had and continues to have a storied career. Each of her roles has always circled around innovation. She's been the chief innovation officer at Boston Children's, where she built their first digital health accelerator. She was recruited by Biogen after that to be their VP of innovation and external partnerships. She founded a consulting practice focused on innovation, and her latest endeavor, which she talks about later on in this show, is PharmStars, which is, in my own words, a sort of 10-week crash course/accelerator for digital health start-ups looking to work with Pharma—and for Pharma looking to work with digital health start-ups. You can learn more about PharmStars at pharmstars.com. Naomi Fried, PhD, is the founder and CEO of PharmStars, the first and only pharma-focused accelerator for digital health start-ups, dedicated to driving digital health adoption to improve patient outcomes. PharmStars understands and addresses the challenges that Pharma and start-ups face when seeking to collaborate. Its PharmaU™ program supports its digital health start-ups and pharma members seeking to "bridge the gap," leading to greater success and faster adoption of "beyond the molecule" solutions for patients. PharmStars provides education and mentoring to digital health start-ups seeking engagement with pharma and biotech firms. Its pharma members are committed to working with its graduating start-ups. Applications for participation in the first cohort are due July 21, 2021. Dr. Fried is also the co-founder and managing partner of Ambit Health Ventures, an early-stage venture capital fund focused on digital health investments. Previously, she was the CEO of the consulting firm Health Innovation Strategies, VP of innovation and external partnerships at Biogen, the first chief innovation officer at Boston Children's Hospital, and the first VP of innovation and advanced technology at Kaiser Permanente. She advises and serves on the boards of digital health start-ups. 03:42 What does the pharma–start-up gap look like? 05:49 Why is it hard to navigate Big Pharma when trying to partner with start-ups? 09:53 "A lot of what contributes to that pharma–start-up gap is a lack of understanding." 10:05 What's the best way to navigate the pharma–start-up partnership? 10:55 "There's not a clear path as to who should be engaged from the pharma side, because the value proposition wasn't well articulated." 12:27 "Even if … the product is better, if

Here's the context, friends: As you may have noticed over the past few episodes, we have been digging into value-based care here at Relentless Health Value corporate work-from-home headquarters. Many lessons have been learned, and it's important that we sit back and think hard every now and then about how we are going to use these learnings to improve. While this show tackles the Hospital Readmissions Reduction Program (HRRP)—and wow, I was glued to my seat during this interview—the show is really about more than that, which I'll get into in 30 seconds. But let's start here: HRRP was originally part of the Affordable Care Act in 2010. In 2012, HRRP began imposing penalties on hospitals with higher-than-expected 30-day readmission rates for three conditions: heart failure, myocardial infarction, and pneumonia. Spoiler alert: More recently, CABG, THA/TKA, and COPD were added to the list. So basically, if a patient is in the hospital for any of these six things and then is readmitted to the hospital for any reason within 30 days, penalties can happen. Today's guest is Rishi Wadhera, MD, MPP. Dr. Wadhera authored a retrospective analysis in the BMJ about the HRRP, which we will talk about in this health care podcast. His findings are fascinating and relevant on a number of levels. Dr. Wadhera is a cardiologist at Beth Israel Deaconess Medical Center. He also has a master's in public policy at the Harvard Kennedy School of Government and also a master's in public health from the University of Cambridge. Dr. Wadhera works on policy at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. But here's the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this health care podcast and which my nerd heart could not love more: Goodhart's Law. This law is the root of so very many problems. Goodhart's Law is this (which I learned from Dr. Wadhera): "When a measure becomes a target, it ceases to be a good measure." In other words, when we set a goal, people will try to take a shortcut to the goal, regardless of the consequences. And sometimes the consequences, paradoxically, are to do worse at the goal. For example, teaching to the test may not actually lead to students who deeply understand a subject. Here's another example, and Rebecca Etz, PhD, talks about this in EP295: If you want PCPs to do an amazing job managing diabetes, for example, the best measures are ones that quantify the doctor's relationship with the patient and the amount of trust between them. The second you start using their panel's average A1C as the performance metric, A1Cs at best don't improve. Why? Bean counters and admins and maybe even goal-oriented clinicians themselves will go right to the end goal, inadvertently skipping a whole bunch of (it turns out) rate-critical steps. It doesn't go well. It's like salespeople who try to close before they build a relationship. Time to goal counterintuitively is slower, and performance is poorer. Anyone building value-based care or quality programs might really want to include Goodhart's Law in their thinking. And anyone trying to achieve value-based care success, improve quality, form collaborations, or make sales might want to remember that old proverb, "Sometimes the shortest way home is the long way around." You can learn more at Dr. Rishi's Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site. Rishi K. Wadhera, MD, MPP, MPhil, is an assistant professor of medicine at Harvard Medical School, a cardiologist at Beth Israel Deaconess Medical Center (BIDMC), and the associate program director of the cardiovascular medicine fellowship at BIDMC. He is also health policy and equity researcher at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. Dr. Wadhera received his MD from the Mayo Clinic School of Medicine as well as an MPhil in public health as a Gates Cambridge Scholar from the University of Cambridge. He completed his internal medicine residency and cardiovascular medicine fellowship at Brigham and Women's Hospital in Boston. During this time, he also received a master's in public policy (MPP) at the Harvard Kennedy School of Government, with a focus on health policy. Dr. Wadhera's research spans questions related to health care access, quality, and disparities, as well as understanding how local, state, and national policy initiatives impact care delivery, health equity, and outcomes. Dr. Wadhera has published more than 80 articles to date, and he receives research support from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health (NIH). 03:10 What was the Hospital Readmissions Reduction Program intended to do? 05:05 Why did the Centers for Medicare & Medicaid (CMS) think some readmissions were preventable? 05:46 "The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge plannin

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

Recently, the University of Pennsylvania Leonard Davis Institute of Health Economics, or LDI, put out a white paper called "The Future of Value-Based Payment: A Road Map to 2030." Spoiler alert: Next week's show is with Dr. Mai Pham, an author of that paper; and it'll be a great show—so, tune back in next week. But, in the meantime, that paper made some really interesting points about ACOs (accountable care organizations). For example, they say that the average ACO shows a net savings of I wanted to ask somebody who had attained great success with the ACO model what they thought about this average, rather, unimpressive average. And you know what? I am so pleased to say that today we have not one but two such superstars. Today's show features Nicole Bradberry and Kelly Conroy. Nicole Bradberry spent 16 years on the payer side. She was instrumental in a lot of the quality and affordability programs, which led to her founding the Florida Association of ACOs, which she leads in her role as CEO. Also on the program today, we have Kelly Conroy. Kelly helped start the very successful Palm Beach ACO and was the executive director there for a number of years. She's also a co-founder with Nicole and founding board member at the Florida Association of ACOs, as well as a director of Pinnacle Healthcare Consulting. So, in this conversation, we jump right into the ACO deep end, so let me just review a few bullet points about ACOs to get us all level set here. The flavor of ACO we'll talk about in this health care podcast is the MSSP ACOs, the Medicare Shared Savings ACOs. The deal is this: We are not talking right now about Medicare Advantage patients. We are talking about Medicare FFS (fee-for-service) patients. Medicare fee-for-service patients get attributed to one of the many MSSP ACOs by where the patient gets their plurality of services over the past three years. So, rough translation of that: If you're the doctor this FFS patient saw the most in the past three years, you get dibs on that patient. They're attributed to the MSSP ACO that you are in. A financial benchmark is then created for each of these attributed patients (ie, how much has the patient cost over the past three years). Then, if, while the patient is part of your ACO, if that patient costs less than that benchmark, the ACO group gets a percentage of those savings (ie, that's where the term shared savings comes in). This percentage the ACO gets can vary depending on the ACO model and how much upside/downside risk that ACO group is taking. Like in many things, the more risk, the bigger the upside. Here's an important note: In an ACO model, docs still get paid FFS as per usual. It's not like every single patient a doctor might see is attributed to them in this ACO model. So, any given doctor could have some Medicare patients that are Medicare Advantage patients, and maybe there's some kind of alternative contract there. They might have regular FFS Medicare patients and those who maybe are attributed to somebody else's ACO. And then they have the patients that are attributed to them where they are now responsible for the upstream and downstream costs as I just mentioned and can get a piece of that savings action—or cut a check back to CMS should things not go so well in the upstream/downstream costs department. There's another implication here if you think about it: Patients don't necessarily know what's going on during this whole thing. It's not like Medicare Advantage, where the patient has to actively sign up somewhere. So, patient engagement at these ACOs is a big deal. If the patient suddenly starts going somewhere else, especially a somewhere else that costs the big bucks, the ACO where that patient is attributed is now on the hook. Likely, we'll put out an "Ask an Expert" with today's guests Nicole Bradberry and Kelly Conroy where we dig into some of this background a little bit deeper. So, stay tuned for that, but we should be ready to dive into today's show with that. You can learn more at flaacos.com, valueh.com, and Pinnacle Healthcare Consulting. You can also connect with Nicole and Kelly on LinkedIn. Nicole Bradberry is the founder and chief of growth and innovation officer for MIND 24-7. MIND 24-7 runs mental health crisis centers with a focus on immediate access, quality care, and the understanding that mental health and substance abuse drive significant health cost. She is also the founder of ValueH Network, which aggregates high-performing value-based care network providers in order to enable the best performance in new innovate contracts. In addition, she is currently the chief executive officer and chairman of the board of the Florida Association of ACOs (FLAACOs). FLAACOs is the premier professional organization for accountable care organizations (ACOs) throughout Florida which provides education and collaboration in the fee for value health care space. Nicole spent 16 years leading operations and information technology programs for U

This episode seemed particularly relevant right now because it gives insight into how large self-insured employers are prioritizing their efforts to disrupt health care revenue streams that do not provide adequate health outcomes for dollars spent. This episode's conversation is with Lee Lewis. This is an encore episode. The original was recorded when Lee was the newly minted chief strategy officer at the Health Transformation Alliance, otherwise known as HTA. The HTA is a group of 50 major corporations that have come together in an alliance to do one thing: fix our broken health care system. Anybody who knows Lee knows he knows a lot about how to improve health and health care benefits for large employers. The most amazing thing I always find about improving health and health care benefits is that it's like having your cake and eating it, too. On one hand, both employer and employee save money. On the other hand, employees get better care and spend less time away from work struggling to navigate the health care jungle all by themselves. Lee's playbook consists of three chapters which we get into here. The first chapter covers the "how" of health benefits, including what Lee calls the "administrative superstructure." The second chapter in Lee's playbook is the "what," which usually comprises drug spend and then, on the medical side, how care is delivered for specific clinical conditions like musculoskeletal, cardiometabolic, etc. There are a few conditions that tend to rack up the most costs categorically. The last chapter in Lee's playbook is the "who," meaning where employees are steered for care, especially in those high-cost areas. You can learn more by visiting htahealth.com and by connecting with Lee on LinkedIn. Lee Lewis serves as chief strategy officer and GM medical solutions for the Health Transformation Alliance. He leads efforts across over 50 large and jumbo employers and six million employees to save lives and save millions of dollars through improved health delivery, outcomes, and experience. Key initiatives in this role include new models of health benefits administration, curated provider steerage, and improved clinical delivery and outcomes.

One way to spot a flash point is to notice when people are using different words to describe the same concept. Throughput is one example of this. On one side of the table, you have those who grasp that if a provider organization is concerned about patient outcomes, with few exceptions, building relationships with said patients is essential. It's not entirely clear to anyone anywhere how you manage to build relationships and trust without spending a certain amount of time with patients. These "we need time with patients" people will bring up the Quadruple Aim issues that arise from rigid 7-minute appointments or even 50-minute appointments really. On the other side of the table, you have those who have built practice fiscal models on the backbone of however-many-minute appointments. They use different terminology for this whole concept, however. They call it throughput. How many patients can a physician manage to squeeze into a day? Some of these folks will tell you that throughput success is "more is more." In other words, throughput is one of those things that you can never have too much of. Let me back up for a sec and mention the mission of this show. It is to connect health care leaders together by helping everyone understand each other well enough to communicate effectively, which is rate critical numero uno for any collaboration. You can't collaborate if parties don't really grasp what anyone else is actually saying when they communicate their WIIFMs (their "what's in it for me?") or their organizational imperatives. If we consider that the health care industry can only transform when multiple stakeholders collaborate, these little "language discrepancies" actually can have macro implications. In this respect, this throughput example—not in all cases but at a minimum—it's an exemplar illustration and certainly something to contemplate. Consider people arguing against 7-minute appointments without mentioning the word throughput. They're probably not going to even reach the headspace of those who just spent the past two decades in meetings to increase throughput. It's like two ships passing in the night. You could be sitting there right now pooh-poohing what I'm saying, but I've sat in enough meetings where people talk around each other using different terminology, think they've agreed on some collaboration or compromise or solution, except nothing happens because everyone got to walk out without addressing the elephant in the room. It sounds something like this: DOCTOR OR NURSE: We need you to enable patients to have quality time with their doctors and the rest of the care team. SOMEBODY ELSE: We need to get rid of inefficiencies, which means driving maximum throughput. ANOTHER PERSON: OK, let's compromise. Doctors should have quality time while maximizing throughput. Don't laugh. I've heard "action items" like this often enough, and so have you if you think about it. That's why I originally started this podcast—because I can also guarantee you if this is the action item, no action will actually take place. The only way this conversation is going to net any change is if people around that table head-on confront that quality time with patients means less throughput. And how much less are we going to agree on and/or how are we going to creatively change the practice model so throughput is an archaic term (ie, asynchronous stuff, etc)? I say all this to say that this throughput business also leaks into the technology space in ways that we should probably think about. Increasing throughput, after all, is one of the key ways to increase FFS (fee-for-service) revenue. FFS is all about the need for speed. The faster you can smack a billing code on a patient visit, the more patient visits you can pack into a day, the more billing revenue you can rack up. To some extent, throughput is code word for an addiction to FFS. You can always tell a tech vendor who is used to selling in an FFS environment because the second slide of their pitch deck is always one of two things: either how much faster the tool will get patients in and out of a doctor's line of sight or what the billing code is for the tool (but that's a whole different topic). I just described the second slide in an FFS-centric technology vendor deck. The first slide in those "use our AI thingamajig to revolutionize your throughput" decks is always some mission statement about improving patient care. And this is where not everybody using the same language creates immense wiggle room for profit over patients under cover of mismatched terminology. To add one point of context, when I say throughput here or increasing throughput, nobody is talking about making the front desk more efficient, minimizing faxing things around, or streamlining prior auths or duplications in the workflow (ie, fixing things that are in desperate need of a fix). What we're talking about in this health care podcast are tools like the one I saw the other day. This biz dev person of th

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

If you listen to this show on the regular, you probably have a pretty good bead on a couple of things I've been really into lately. One of them is high-value care versus low-value care. These are terms that are really easy to throw around. You also can get pretty much everybody to agree with a plan to deliver only high-value care and quit it with the low-value care … in theory. But the wheels fall right off the bus when it comes to actually doing this. IRL (in real life), what constitutes high-value care and what is low-value care exactly and specifically? This answer is the crucible for value-based care of almost any flavor. How are you supposed to do value-based care successfully when it remains an open question, "What is care that is of value?" Here's the good news, though. There is a bounty of unmistakably, inarguably low-value things. We can start there. Now, these low-value things may be situational in some respects, so you'll need to listen to my interview with Dr. Mark Fendrick (EP308) for the scoop on that nuance. But there are definitely some things which are incontrovertibly low value. Here's some more good news. There's a few ways to ferret out low-value things, and one of them is to look at data on practice patterns across a specialty. You can index the data nationally or regionally or even within the same practice. Here's an example: Let's just say, on average, a dermatologist does 1.74 cuts or surgical slices for Mohs surgery, where they often get paid by the cut, by the way. However, you can find some physicians who are outliers—derms who have two standard deviations above that average. The good news is that a lot of the times, all you have to do is show the doctors the data. Show them that they're an outlier and they'll alter their practice patterns. So, one way to figure out what the standard of care should be is by looking at physicians' actual experience and practices. That seems very fair. Marty Makary, Will Bruhn, and others from the team at Hopkins get a lot of credit for their pioneering work in this area. Other ways include assessing pubs and the guidelines that societies put out. I'm also sure that, more and more, it will also involve combing through real-world evidence. In this health care podcast, I speak with Rich Klasco, MD, who is chief medical officer at Motive Medical Intelligence; and we talk about the challenges and opportunities and solutions when it comes to identifying high- versus low-value care. Dr. Klasco has an interesting construct for this. We also talk about how patients, providers, and payers might have different points of view, incentives, and capacities really to distinguish the high from the low. You can learn more at motivemi.com. For more information and the case study, please visit motivepw.com/resources. Rich Klasco, MD, FACEP, has focused throughout his career on rendering evidence-based medicine operational—that is, making the right thing the easy thing to do. He has pursued this goal in academia, in industry, in policy, and in the press. In addition to publishing extensively in both peer-reviewed journals such as JAMA and lay publications such as The New York Times, Dr. Klasco has taught at leading academic medical centers, including Harvard, Stanford, Mayo, and the University of California, San Francisco; served on the executive committee of Brigham and Women's Hospital Center for Patient Safety Research and Practice; testified before the United States Congress on evidence-based practices; and won CMS approval for an officially designated compendium of evidence-based oncologic drug information. Dr. Klasco previously served as chief medical officer and editor-in-chief for the Thomson Reuters group of health care companies, where he had editorial responsibility for companies including Micromedex, the Physicians' Desk Reference (PDR), and the United States Pharmacopoeia (USP) Drug Information. For the past 15 years, Dr. Klasco has served as chief medical officer for Motive Medical Intelligence, where he provides clinical leadership for the development and deployment of solutions that quantitative assess physician performance for payers, providers, and patients, and integrate scientific knowledge into workflow systems where it can be accessed and applied in real-time. Dr. Klasco received his medical degree from Harvard Medical School. He completed his internship and residency in internal medicine at Brigham and Women's Hospital, and he completed his residency in emergency medicine at the Denver Health Residency in Emergency Medicine, where he served as chief resident. 03:31 How do you define high-value care? 04:40 How do we define what isn't appropriate care? 05:26 Why aren't patients good at recognizing high-value care? 07:02 "He was in the 'more is more' school of medicine, which is always wrong." 11:54 Are payers good at identifying high-value care? 13:41 Why are payers so adept at understanding what high-value care really is? 15:53 "It's not just cost

When I was talking with Dr. David Carmouche from Ochsner in EP316 about the importance of collaboration amongst anybody trying to actually pull off value-based care, we took a little detour, which I wound up cutting out, into the potential and challenges for health systems to collaborate and do value-based contracts with pharmaceutical manufacturers. It's a really interesting sidebar, though, that I wanted to share with you—especially on the heels of the recent interview with Troy Larsgard from Johns Hopkins (EP318) on how Pharma can better meet the needs of their health system customers. Here's an interesting point that Dr. Carmouche makes in the sidebar that I thought was worth highlighting. Chalk this up as one of the challenges when trying to create some kind of risk-share agreement with a pharma company to get the manufacturer to put their money where their mouth is when they say that downstream costs will be saved or complications avoided or better outcomes attained. The challenge comes in assembling enough patients to make it worth everyone's while. As we're considering the assemblage of patients, we have to first consider who's paying for the drugs. It's a payer, usually, who contracts with a PBM (pharmacy benefit manager). So, any given health system is going to have to have enough patients not only on that one particular payer in its payer mix but also on that one payer with a plan design that uses that one PBM. As I consider this, I still have questions. Dr. Carmouche is executive vice president of value-based care and network operations at Ochsner. You can learn more by visiting Dr. Carmouche's LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs. David Carmouche, MD, views health care from three distinct perspectives: as a physician provider, an executive for an insurance company and as a leader in a health system. Specifically, he built a large, multidisciplinary internal medicine and preventive cardiology practice in Louisiana; served as the chief medical officer for Blue Cross Blue Shield of Louisiana; and currently has a triad of responsibilities with Ochsner Health, the largest nonprofit academic health care system in the Gulf South. He was recently promoted to serve as executive vice president of value-based care and network operations in addition to his duties as president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network. He is known as an expert in value-based care. He led one of the top 25 performing accountable care organizations in the United States, managing billions in care spend and generating millions in year-over-year shared savings. Dr. Carmouche earned a bachelor's degree from Tulane University and a medical degree from Louisiana State University School of Medicine in New Orleans. He completed his residency in internal medicine at the University of Alabama at Birmingham. 01:57 Why has creating collaboration across Pharma been difficult? 03:10 "Is it better over an episode of care to add a more expensive drug … or would we be better served using less expensive drugs?" 03:51 Why has it been difficult for health systems to execute agreements directly with pharma companies? 04:36 "The question is really just whether or not there's enough value that's created to make it worth our while." You can learn more by visiting Dr. Carmouche's LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs. @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why has creating collaboration across Pharma been difficult? @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma "Is it better over an episode of care to add a more expensive drug … or would we be better served using less expensive drugs?" @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why has it been difficult for health systems to execute agreements directly with pharma companies? @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma "The question is really just whether or not there's enough value that's created to make it worth our while." @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma

If you want to hear what my mom and dad, both Medicare Advantage patients in their late 70s, have to say about telehealth (or teleconferencing, as my dad puts it), you'll have to listen to the episode. They are not and have never been health care professionals, but they fully get that the question "What's better—telehealth or in-person care?" asked like it's some kind of winner-takes-all cage fight doesn't serve anybody's needs. And by anybody, I mean clinicians or the patient. And by patient, I mean even Medicare Advantage patients in their late 70s. In this health care podcast, I'm speaking with Christian Milaster from Ingenium. Christian worked at Mayo for 12 years before starting his consulting firm specializing in many aspects of telehealth. He has a great newsletter, by the way. I've appreciated subscribing to it. It's called Telehealth Tuesday. I would recommend it. Christian says telehealth is a clinical tool. That's why there's no answer to the question of whether in-person is better than virtual. It's like asking, "What's better—an x-ray, a CT scan, or an MRI?" Or like, "What's better—a daily blood pressure test at home or one super fancy EKG a year?" I guess telehealth could also be considered maybe a setting of care. Christian probably wouldn't agree with me. Either way, few people sit around pitting Exam Room 6 against the one on the fourth floor with the extra-wide doorway. So, let's not even talk about this. We're over it. The relevant question to be asking about telehealth would be "What's the best clinical workflow, patient journey, clinical pathway for X kind of patient or for this patient?" The tools that we choose to use or the care setting we choose should be a function of the best care plan for the patient. You figure out the care plan first. It's just like you figure out what surgery someone needs, and then you stock the OR. It would be super weird to do it the other way around. You know, neurosurgeon walks into OR. "Hey, what's this knee replacement doing here?" You get my drift. What's the why, you might be asking, if I'm a provider and I'm kinda like the urologist that my father fired the other day? And I'm thinking I'm just going to require all of my patients to come into my office all the time because that's the way I've always done it and I kinda like it. Well, let me refer you to the article written by Jane Sarasohn-Kahn the other day entitled "Virtual Health Tech Enables the Continuum of Health From Hospital to Home." This article is great and talks about a bunch of things, but here's a quote I particularly liked: "[The demand for telehealth] will impact every segment of care delivery and sponsor, including small to mid-sized physician practices, employers, behavioral/mental health, public/government-sponsored health [plans], and the pharma and life science industry." She is talking about demand post-pandemic, by the way. Let me put a finer point on this. You know who is most likely, besides my father, to fire a doctor who doesn't know how to incorporate telehealth into his or her treatment pathway? Yes, exactly—educated working-aged people. People with commercial insurance. The people that health systems and doctors are always trying to attract because … favorable payer mix. So, there's that. One more thing before I turn the floor over to the interview with Christian Milaster: I just wanted to call out something that matters, especially right now. I recently saw a post by Joe Kvedar on LinkedIn about how digital inclusion is actually a social determinant of health. The post referenced an article by Jill Castek and Cynthia Sieck, amongst others. The point of it was that sometimes people have spoken about telehealth being the solution to rural health issues (eg, access issues) or people who have to work three jobs or those who have transportation issues. The problem is that it's exactly these people who may not have internet access or maybe have less digital literacy. So, exactly the people that, at least originally, telehealth was supposed to serve are exactly the people that are having trouble taking advantage of it. You can learn more at ingeniumdigitalhealth.com and connect with Christian on LinkedIn. Christian Milaster optimizes telehealth services for health systems and physician practices. He serves as a digital health and telehealth advisor to start-ups and established digital health companies. Christian is a master builder of digital health and telehealth programs and is the founder and president of Ingenium Digital Health Advisors, a boutique consultancy focused on enabling the effective delivery of extraordinary care through workflow optimization and the judicious use of technology. Born, raised, and educated as an engineer in Germany, Christian started his career at IBM Global Services before joining the Mayo Clinic in Minnesota, where he worked for 12 years in various roles before launching Ingenium in 2012. 06:53 What's the biggest mistake provider organizations a

I'll tell you what I wanted to figure out: How does care improve in SNF (skilled nursing) or assisted living facilities? My starting point in contemplating a possible path toward this goal was advanced primary care. There is so much talk and evidence these days about advanced primary team-based care and how much patients like it, the low-value care it could potentially prevent downstream, and the patient outcomes it can create. But in general, these advanced primary care models are talked about for patients in the community, not really for the intensely vulnerable populations inside facilities. So, where do these worlds collide if they do, in fact, collide? In this health care podcast, I'm speaking with Grace Terrell, MD. Dr. Terrell is a practicing general internist. She is also chief executive officer of Eventus WholeHealth, which is a company that is focused on medical care for medically vulnerable adults, specifically those who live in skilled nursing facilities, assisted living facilities, or reside at home and cannot make it into clinics or otherwise get care. Dr. Terrell and her team at Eventus have done some really powerful work bringing this kind of advanced primary care model, whole-person integrated primary care, into long-term care facilities; and she shares some of the promising results of doing so during our conversation. But for more, go to links in the show notes. One point that Dr. Terrell made, which I found really interesting—maybe not in a good way—is that in an FFS (fee-for-service) world, there is really zero financial incentive beyond consumerism to improve care. Skilled nursing facilities get paid a set of Medicaid/Medicare rates, and that's it, whether the facility is awesome or it kind of sucks. In this conversation, we also get caught up on the latest goings-on in the post-acute and assisted living parts of our industry, which, of course, were decimated by COVID pretty much bashing it from all directions. Add to the challenges of 2020 the general truth that SNF and assisted living care for years has been chronically underfunded and highly regulated in ways that aren't super productive of better care in many cases. Bottom line: There's a lot of work that needs to be done so that all of us have the best chance of great holistic medical care when we're older. And we shouldn't forget the lessons that we've learned in the community to make that happen. You can learn more at eventuswholehealth.com and follow Dr. Terrell on Twitter. Grace E. Terrell, MD, MMM, is CEO of Eventus WholeHealth, a company focused on integrated value-based behavioral medicine and primary care in the long-term care space. She is a national thought leader in health care innovation and delivery system reform and a serial entrepreneur in population health outcomes driven through patient care model design, clinical and information integration, and value-based payment models. She is the former CEO of Cornerstone Health Care, one of the first medical groups to make the "move to value" by lowering the cost of care and improving its quality for the sickest, most vulnerable patients; the founding CEO of CHESS, a population health management company; and the former CEO of Envision Genomics, a company focused on the integration of precision medicine technology into population health frameworks for patients with rare and undiagnosed diseases. Dr. Terrell currently serves on the US Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee and the board of the AMGA (American Medical Group Association), is a founding member of the Oliver Wyman Health Innovation Center, and is the coauthor of Value-Based Healthcare and Payment Models. 04:09 "The industry itself is in a real pickle." 04:49 What are the fiscal opportunities that a SNF might have in a value-based care model? 09:34 What's the basic principle that needs to be true to provide the best care possible in a SNF environment? 11:05 How does whole-person care work? 15:51 "It does require integrative care; it does require somebody … to be steering the ship." 18:53 "This population doesn't necessarily do well with the typical medications that are prescribed … by a specialist." 20:49 "Most of us in health care … don't have the opportunity to build something from the ground up. You have to work in the system that you're in." 23:10 "More and more people are thinking about integrative models of care." 27:50 "Integrated care is very much based on … access to information, access to communication capabilities, the ability to know what the patient wants, … and the skills to actually provide them good care." 29:27 "Once you get past critical thinking and get into … creative thinking, you'll find that there's just a ton of folks out there who want to be with you, who want to create with you." You can learn more at eventuswholehealth.com and follow Dr. Terrell on Twitter. @gracet22 discusses #healthoutcomes of #skillednursing and #assistedlivin

I heard someone say the other day, "Practicing medicine without pharmaceuticals is like running to the ten-yard line, putting down the ball, and walking off the field." So, it's pretty imperative that providers and Pharma know how to work together to get the best outcomes for patients. In this context and in this podcast, when I say "get the best outcomes for patients," I kinda mean it. There's a sweet spot in the middle of "won't let those [expletive goes here] pharma reps in the building" and blatant conflicts of interest. I wanted to find out from someone who would know what a great collaborative relationship with a pharma company looks like for a large health system from their point of view. How do two, in general, gigantic bureaucratic organizations find ways to help each other help patients? No one would disagree that finding the best collaborative strategy with a health system is going to depend a lot on how that health system rolls in general. One aspect of how they roll is to take a look at their so-called level of control. This means how centralized decision-making is. For example, on the far one end of the control or lack thereof spectrum, you'll have your more controlled systems of care. These systems have centralized decision-making. Most of them will tell you that this centralization signals a bunch of things like, for example, a commitment to total care of patients. More control can mean that patients can have confidence if they walk in, there's a system of care that is standardized across all the sites of care and any drugs prescribed, for example, not only have been FDA approved but also vetted at the health system level. They've gone through some rigorous evidence-based decision-making. In this health care podcast, I'm talking with Troy Larsgard, who is the category manager of pharmaceuticals at Johns Hopkins Medicine. He held a similar role at Intermountain for a number of years also. As part of his role, Troy has sat on and sits on P&T (Pharmacy and Therapeutic) committees as a nonvoting member. Basically, Troy is the guy that drug companies want to meet with. Here's a point that Troy Larsgard makes during our conversation that I found really enlightening. And I guess this could pertain to either a more open or closed health system. It would just happen at a differing scale. Some suppliers, pharma companies, have a "boots on the ground" strategy for large health systems—lots of representatives running around who don't necessarily have a strategic framework to coordinate their efforts. From a health system perspective, this is what Troy considers not a strategic approach. As Troy says, all things being equal, he likes to work with companies who meet him where he's at and who understand the needs of his organization. In this conversation, I paid particular note to the ways that pharma companies who are really good at crafting their collaborative strategic approach get a leg up over competitors who cling to a more transactional, maybe legacy, pharma approach. Point of note: While this whole conversation is technically about pharma company collaborations, everything that we talk about in this episode is almost wholesale applicable to others looking to work with health systems, like medical device manufacturers, purveyors of digital health technologies, etc. You can connect with Troy on LinkedIn. Troy Larsgard is a health care professional specializing in pharmacy supply chain. After working six years at Intermountain Healthcare in Salt Lake City, Utah, he joined The Johns Hopkins Health System Corporation in Baltimore, Maryland, in January 2020. One of his most rewarding career experiences is taking an active role with key stakeholders in planning for and operationalizing the COVID-19 vaccine at Johns Hopkins. After thousands of meetings, proposals, and presentations from pharmaceutical companies, he is convinced there are better ways suppliers can work strategically with large health systems. He welcomes forward-thinking ideas and engagements to move beyond the transactional and create strategic alliances and value-added opportunities. He has put this philosophy to practice helping to remove barriers and working together with suppliers to make industry changes. 04:16 What's the rationale behind trimming the supplier list for pharmacists? 05:35 What's the difference between a strategic model and a tactical model? 06:49 "A lot of effort goes into developing drugs and bringing them to market, but sometimes the thought of how to interact with the health system beyond that isn't always thought out." 09:06 "I think there's opportunity to be more seamless." 10:48 "Those who inform early, often, and are transparent … save much more face." 11:04 What do account managers need to know about health systems and vice versa for them to work together? 14:15 How do drugs on formulary fall into these pharma/health system collaborations? 16:46 How do physicians know when a drug is on formulary? 19:32 Are down

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 inflati

I don't know what I thought we were going to talk about during my interview with David Carmouche, MD; but I'm glad it turned out exactly as it did. Lately, we've had a number of guests on Relentless Health Value talking from the point of view of the employer: what a self-insured employer wants and needs from the large, and small, providers in their network. In this episode, we're flipping the script and talking about what a large provider organization wants and needs from the commercial side of its payer mix. If value-based care or risk shares are to be a thing, we can't have, as Troy Larsgard has put it, all risk and no share. In this health care podcast, I had the honor and pleasure of speaking with Dr. David Carmouche. Dr. Carmouche started out as a physician in a multi-specialty group. He practiced there for about 15 years before leaving to become chief medical officer at BCBS (Blue Cross Blue Shield) of Louisiana. Five years ago, Dr. Carmouche transitioned to Ochsner Health, where he is currently executive vice president of value-based care and network operations. At Ochsner, Dr. Carmouche helps lead the value-based care agenda—that's everything from managing strategic partnerships with payers, as well as managing risk in value-based contracts for Ochsner and affiliated network partners across their ACO (accountable care organization) and CIN (clinically integrated network). Highlighting one point that Dr. Carmouche makes early in our chat, there's four things that have to come together for meaningful value creation for providers: (1) willingness of providers and provider leadership to think and do things different than they have historically; (2) they have to be able to affect payment for those things; (3) they have to have data and be able to access it; and then (4) some control over steering patients. This kind of sets the stage, actually, for our fast dive, in this conversation, right into employer and commercial collaborations. Three of the four things on that list—affecting payment, data, steering patients—are right in the wheelhouse of forward-thinking employers, or commercial payers/TPAs (third-party administrators) trying hard to compete for or serve employers. Just a quick heads-up here: Coming soon, we're going to release a second episode with Dr. Carmouche giving some great advice for the leadership of provider organizations who are trying to figure out their transition away from FFS (fee for service) to a more risk-based, value-based model. One quick point that I thought was also relevant to the show here: It was super interesting to me how quickly Dr. Carmouche got from "transition to value" to "knows how to collaborate with other organizations." Here's the pretty obvious inference: You can't transition to value if you don't know how to play well with others to co-create value and share the rewards of such an endeavor. There might be a broader lesson in here for whoever you are in the health care ecosystem. And I'm looking at you, pharmacy, Pharma, tech, societies, BUCAs, etc. Thanks so much to Brian Klepper for the introduction to Dr. Carmouche. You can learn more by visiting Dr. Carmouche's LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs. David Carmouche, MD, views health care from three distinct perspectives: as a physician provider, an executive for an insurance company and as a leader in a health system. Specifically, he built a large, multidisciplinary internal medicine and preventive cardiology practice in Louisiana; served as the chief medical officer for Blue Cross Blue Shield of Louisiana; and currently has a triad of responsibilities with Ochsner Health, the largest nonprofit academic health care system in the Gulf South. He was recently promoted to serve as executive vice president of value-based care and network operations in addition to his duties as president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network. He is known as an expert in value-based care. He led one of the top 25 performing accountable care organizations in the United States, managing billions in care spend and generating millions in year-over-year shared savings. Dr. Carmouche earned a bachelor's degree from Tulane University and a medical degree from Louisiana State University School of Medicine in New Orleans. He completed his residency in internal medicine at the University of Alabama at Birmingham. 04:15 Who needs to be working together to create value-based success? 04:31 "I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers." 04:45 What four things have to come together for meaningful value? 06:02 "We're focusing specifically on payer employers today. We think that's where there's the biggest opportunity." 07:23 What's the overarching reason for health systems to want to grow their commercial market share? 14:00 Is the competition moving

Medicine is complex. It's getting more complex. We double what we know in medicine every 73 days. There's 800,000 journal articles published every year. It is impossible for any human to keep up. It's just impossible. There's a lot of talk about amazing technology to help humans manage the 26,000 variables in heart failure treatment or what have you. And, yeah, I'm a huge fan of technology doing what technology is good at doing. But here's a point to ponder: Just like meds don't work if the patient doesn't take them, technology kinda doesn't work unless it's part of a bigger framework. Who in the practice uses it or deploys it? Who checks the dashboard and follows up with patients and how do they follow up with patients? This is all process. Of course, there's good processes and not-so-good processes. But a value of process as a construct is you can incrementally improve a process. You can't incrementally improve everybody doing different things at different times. Nobody seems to talk about this in the "cool" circles, but any quality expert will tell you that complexity can only be mastered with process. Said another way (and this is inarguable), if anyone is trying to improve the quality of care delivered in any provider organization or any organization really—regardless of whether that organization is a solo practitioner or employs thousands of clinicians—the only way to improve the quality of care across time and the entire patient population is to standardize care at some level (ie, you have to have processes or care plans or pathways or whatever you want to call them). If you don't, the quality of care will always regress to the mean. The average of care will always be the top of the bell curve. You'll always hover around 65% of whatever measure. Why will you never be better than average if everybody is doing whatever they decide to do solely based on their own individual experience at that moment in time? Because you'll always have your great doctors (the 95 percenters) and your not-so-great doctors (the 45 percenters). So, if you want to level up, you have to deploy care standards that push up the poor performers. But those great performers? Consider this: Probably those great performers have a process. Otherwise, they wouldn't be consistently great, whether they realize it or not. Furthermore, great consistent performance generally happens with a team-based approach. That's more and more indisputable. And the second you have a team, you need a playbook—otherwise known as a book of processes. This is one of those boring aspects of delivering great care that gets lost in the hype of cool technology. Everybody's an individual, but every individual is a human—and there are some basic truths and precepts and research for what good care includes and constitutes at different points in care journeys and for differing diagnoses. In this health care podcast, I'm talking with Bob Matthews, president and CEO of MediSync. He's also VP for quality and care redesign for PriMed Physicians. Our conversation spirals in a few different directions, but the central theme is this: How and why does a provider organization level up care? And speaking of leveling up care, we talk about the business reasons to do so right now for organizations who base their decision making on their financials, which many in the health care space do. And once a provider organization has decided that they're going to produce better outcomes across their whole patient population, what are the major constructs necessary to pull it off? Process is a long tentpole in that big tent. So is culture. So is technology. So are the right incentives in quality measures. An upcoming Relentless Health Value episode with Grace Terrell, MD, also digs into this topic, so stay tuned. You can learn more at medisync.com. Bob Matthews is president and CEO of MediSync. Bob has led multiple medical groups over 20 years. He is Black Belt trained in the Six Sigma quality methods. The MediSync team creates sophisticated processes and AI technologies to enable physicians to achieve best-in-the-nation clinical outcomes, especially in chronic disease management. 04:47 How do you address concerns about chronic care costs? 06:15 What are the disjunctures in the health system? 07:01 "Very few organizations today know how to do a great job in managing [chronic care]." 09:58 "Some medical group organizations … put the pressure on, but they don't offer much help." 10:09 "There's something inherently difficult about the work, or we wouldn't have this problem." 10:44 What is the increasing pressure on practices to manage chronic conditions? 11:51 "We just simply cannot afford to get the outcomes we need with the system we have." 13:37 "The pressure to improve outcomes is just really now starting to heat up." 14:00 What things need to be focused on to improve outcomes? 17:32 "The only thing you get rewarded for is speed." 19:20 "Just because you start the journey doesn't mean th

Have you never heard of the Nuka System of Care? If that's the case, it is an award-winning and really remarkable health system in Alaska. In this 5-minute "An Expert Explains," Dr. Douglas Eby, medical director over at Nuka, gets directly to the point. A key component to making sure that the people/customers in your plan get the best care is to make sure that they have access to a team of providers who know them well enough to have earned their patient consumers' trust. Both the trust and the access part of that last sentence are important. Both are needed in spades to reduce downstream costs. The access part might be a little counterintuitive and has a disclaimer or two that Dr. Eby articulates. But, yup, when you restrict access, what winds up happening is that people demand more when they finally get seen. They want their money's worth, so to speak, and will nab any lab diagnostic or expensive follow-up they can get while they're there, since they may never have the opportunity or the money or the time to arrange being seen again—or at least how it might feel to them at the time. Circling around to trust, listening to Dr. Eby talk, it makes me even more frustrated by providers who regard shared decision making endeavors or building trust with patients as a waste of time unless they're getting paid for it directly somehow. If a patient isn't going to do anything you tell them to do because they don't trust you, and if they have to do what you tell them to do to get the outcomes that they probably should be getting, then it's a bigger contemplation for providers and provider organizations than whether there's a billing code for that—for provider organizations trying to create the best patient outcomes for their patients, that is. If you're an employer and you recognize the criticality of access and trust, select your network accordingly would be my advice. Douglas Eby, MD, MPH, CPE, is the physician executive/VP of medical services at the Southcentral Foundation Nuka System of Care. This "An Expert Explains" sums up Dr. Eby's advice for employers, but if you haven't listened to it yet, when you're done with this "mini-sode," you might want to go back to the main episode I just did with Dr. Eby that gets into the how to provide effective health care from the provider organization clinician and kind of community standpoint. You can learn more at southcentralfoundation.com. Douglas K. Eby, MD, MPH, CPE, is vice president of medical services for Southcentral Foundation's Malcolm Baldrige Award–winning Nuka System of Care. Doug is a physician executive who has done extensive work with the Institute for Healthcare Improvement and other organizations around the Triple Aim, accountable care organizations (ACOs), patient-centered medical homes, whole system transformation, workforce, cultural competency, health disparities, and other topics. His speaking and consulting include work across the US, Canada, and portions of Europe and the South Pacific. Doug has spent more than 20 years working in support of Alaska Native leadership as they created a very innovative integrated system of care that has significantly improved health outcomes. Doug received his medical degree from the University of Cincinnati in Ohio and his master's in public health degree from the University of Hawaii. 03:19 "The employer is the total-cost provider." 03:23 "The people who don't like us are people who are trying to make profits … extremely high use of high-end medicine." 03:47 "Health care, for chronic disease management, should be provided when, where, and how the person on the receiving side wants and needs it." 07:05 "People think demand is driven by … paranoia … but when you replace all of that by trust … that's a massive replacement for all of that other stuff." You can learn more at southcentralfoundation.com. @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth "The employer is the total-cost provider." @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth "The people who don't like us are people who are trying to make profits … extremely high use of high-end medicine." @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth "Health care, for chronic disease management, should be provided when, where, and how the person on the receiving side wants and needs it." @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth "People think demand is driven by … paranoia … but when you replace all of that by trust … that's a massive replacement for all of that other stuff." @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth

This episode is for anyone as curious as I have been about pharmaceutical supply chain goings-on in long-term care facilities like skilled nursing facilities, otherwise known as SNFs. There are a lot of players in the mix: You have your PBMs. You have your wholesale pharmacies. You have your LTC (meaning long-term care) pharmacies. You have the facilities themselves. You also have Medicare Part A and Medicare Part D and, in some cases, Medicare Advantage. Let me just lay some groundwork here before we dive headfirst into the confoundingly messy middle. If we're talking about patients who have been in a SNF for services not covered by Part A—maybe because the patient needs help with basic activities of living—then their drugs are covered by Part D (Med D) or maybe their Medicare Advantage plan. The point I'm making is that it's not a global payment at that point in the SNF. The patient's Part D drug coverage is gonna be the same as if that patient were outpatient. They may have deductibles and coinsurance just like an outpatient. In this health care podcast, I speak with Sheldon Weiss, MD, who I pretty much interrogate about the who, what, and when of the various parties involved in getting a drug into a long-term care facility. Dr. Weiss is a great guy to ask because he is a practicing physician and operating efficiencies consultant and a previous COO of an LTC pharmacy. Now, let me editorialize a moment: At its core, the model of having a consultant pharmacist working with a medical director and a director of nursing at a long-term facility is a really interesting one. I just saw another article (this one in Health Affairs) the other day that came out proving yet again that provider teams outperform solo providers in managing chronic diseases. In theory, having a team including a pharmacist should definitely level up care. But there are confounders when it comes to the care of older Americans in facilities. One of them is that physicians—and I say this as an unfair broad stroke—sometimes don't listen to the advice of consultant pharmacists because they're just a pharmacist and not an MD. I've heard this go down myself and not just with pharmacists. In fact, in my recent interview with Dr. Douglas Eby from the Nuka System of Care, he said the same thing about doctors and behavioral health specialists. At the beginning, the docs are, like, "Oh, we don't need behavioral health specialists. That's what we do very well, thank you very much." It didn't take them long to revise that opinion, but it's really common pooh-poohing that I hear repeatedly. And so, for possibly this reason and others, we have a situation where one of the main reasons why patients wind up in the ER from SNFs is that they have adverse drug events. Now, this being said, patient care in SNFs is a hard row to hoe because patients and SNFs are often highly complex and under the care of, in some cases, 10 or more specialists, all prescribing drugs without any knowledge of what other specialists are prescribing. Will the medical director of a facility want to take on the responsibility of contradicting a cardiologist or a pulmonologist or an oncologist and unprescribe some med? It takes a certain amount of fortitude and willingness to take on that risk. Keep in mind one point to ponder, however: Most people "aging in place" at home right now are not going to have anybody at all looking over their shoulder and even partially coordinating care reconciling meds. You can learn more by connecting with Dr. Weiss on LinkedIn. Sheldon Weiss, MD, practiced OB/GYN for over 30 years and has a master's degree in health care management from the Harvard School of Public Health. He was the chief strategy officer for Indiana University Health system for 5 years and was the chief operating officer of a long-term care pharmacy for 2 years. He now does consulting for operational efficiencies in the health care space and has founded a start-up company focused on developing a health care record interoperability solution. 04:19 What's the role of a wholesale pharmacy in a SNF? 04:48 What's the connection between a wholesale pharmacy, a long-term care pharmacy, and a retail pharmacy? 07:00 Why does a SNF need two players? Why can't a long-term pharmacy also take on the role of the wholesale pharmacy? 09:43 Why don't long-term care pharmacies negotiate directly with PBMs? 10:02 "The key for … getting the best prices for medications is on volume." 10:11 Who are these wholesale pharmacies negotiating the best prices? 11:19 "The goal of driving health care costs down by helping out the residents is a good model." 13:43 "Ultimately the resident gets the same quality of medication, but yet it's at a much more reasonable price." 14:35 How does overmedication happen in the long-term care pharmacy model? 15:19 "The lower the amount of medicines, the less the chances of someone to become overmedicated." 17:50 "I would think that most of the time it's subtractive." 19:00 "The i

Let's talk about one aspect of health care that's not talked about possibly often enough: big national health care players siphoning money out of local communities—potentially a lot of money depending on where you are and considering that health care is inching toward about 20% of the GDP. But besides the money leaving the community, another downside of large national players is that sometimes problems—even kind of seemingly simple problems—can be totally intractable and unsolvable because there's just so much diversity of need and intricacies if you're trying to come up with a broad-stroke solution that works for everybody across the land. On the other hand, by thinking and acting locally, these same problems can be solved. Besides, at a local scale, community and relationships within the community can become powerful forces for good. In this context, I was super thrilled to have had the chance to interview Dan Strause from Hometown Pharmacy and Drew Leatherberry from Avergent about a collaboration model they put together pairing up local PCP teams hired by self-insured employers with their local hometown pharmacy. Together, they're similar to a team-based advanced primary care model that also has a level of navigation built in. Considering that patients visit their local pharmacy something like 35-ish times a year, it's the expertise right in front of your face to help manage patients with chronic conditions. Add to this equation a pharmacist's education and a local pharmacy's position as a member of the community. Local pharmacies who are patient first and entrepreneurial could be a great way to keep health care local and solve for the needs of their communities at the same time. This episode is the first-ever simulcast between Health Rosetta and the Relentless Health Value podcast. It was recorded live at the recent Health Rosetta Summit. Thanks much to the Health Rosetta team, including Dave Chase, for inviting me and Relentless Health Value to be a part of the summit. In this episode, the CPESN Pharmacy Network comes up. Should you wish to learn more about the CPESN Pharmacy Network, listen to the Relentless Health Value interview 129 with Troy Trygstad. You can learn more at hometownrxpharmacy.com and avergent.com. Dan Strause is a partner at Hometown Pharmacy of Wisconsin, a group of 70+ independent pharmacies focused on personalized patient care. Hometown Pharmacy educates and empowers patients and communities to make informed decisions about their health. Drew Leatherberry is founder of Avergent, a Wisconsin-based benefits advisement firm serving employers around the country, guiding them to 20% to 40% cost savings on top of next-gen benefits and patient experiences. He has spent over a decade leading employers to restore health care to sustainable levels for their team members. 05:02 What has Avergent's collaborative care model accomplished? 06:07 How did Drew and Dan connect? 07:08 "We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care."—Drew 07:31 Why would a pharmacy make it their goal to get their patients off their medications? 08:20 "Prescription medicine is the most expensive, most dangerous form of a plant."—Dan 08:39 "We believe we can help people by giving up prescription medicines."—Dan 08:45 Is a pharmacy equipped to create a personal relationship with their patients? 12:50 "It's a spin on traditional navigator-advocate-type roles."—Drew 16:15 What does helping the patient look like through this partnership program? 19:18 "We're really unifying the patient health record … and then … cross-referencing all those different data points … on a micro level [and] a macro level."—Drew 20:53 "Everyone is onboarded into the collaborative care model."—Drew 21:05 How does this collaborative care model cross the spectrum? 22:13 "Pharmacists are one of the unique professions that doesn't get paid for time and knowledge [but rather] because of the product they dispense."—Dan 23:06 "We can see the day where … patients will get a prescription from mail order but still need us."—Dan 25:46 "We would love to get paid to keep you healthy."—Dan 27:15 Why are pharmacists wanting to get patients off prescriptions, and how are they involved? 27:36 "In some cases, we are misapplying expertise that's sitting right in front of our face that can help us deliver a better patient outcome."—Drew You can learn more at hometownrxpharmacy.com and avergent.com. Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma "We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care." Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma Why would a pharmacy make it

This episode is a master class in raising health outcomes at lower costs from an award-winning health care system in … Alaska?! Who knew? In fact, I learned about the work of the Southcentral Foundation and the Nuka System of Care only because I happen to listen to Swedish health care podcasts and heard about them on one of those shows. Color me surprised when the interview suddenly switched to English and the guest was from Alaska. Here's the short version of what's happening with the Nuka System of Care, which serves Alaska Native and American Indian people. They have gone as close to the Triple Aim as I've seen in this country. Health outcomes are superior at costs about half the average. Patients—or, as they call them, customer owners—are happy. So are clinicians. How this was achieved (spoiler alert here) was not through incrementally trying to jigger the earlier and pretty much failing model of health care delivery that had been going on in Alaska for Alaska Natives at that time. No can do! The Nuka System of Care was rebuilt pretty much from the ground up to be, for reals, patient- and community-centric and to be relationship based, not transactional. Behavioral health is a built-in, not dangling off the back bumper. It's also about assembling a multidisciplinary primary care team, one in which each clinician on the team really can work at the top level of their license. In this health care podcast, I had the honor and pleasure of speaking with Douglas Eby, MD, MPH, CPE. Dr. Eby is the physician executive/vice president of medical services, Southcentral Foundation Nuka System of Care. This episode is sort of two parts. There is the main episode, which you're listening to now, that gets into the how to provide effective health care from the provider organization, clinician, and community standpoint. In a few days, we'll release "An Expert Explains" episode, where Dr. Eby specifically goes over the lessons a self-insured employer might take away from all of this. If you are intrigued by what you hear in this episode, Dr. Eby will also be speaking on July 14, 2021, at the Aspirational Healthcare Conference, which will be virtual. Go to aspirationalhealthcare.com for more info. Yours truly will be there as well on July 15, and I'm very much looking forward to it. For those of you into more immediate gratification, some of the themes that Dr. Eby covers in this health care podcast are expanded on in my interview with Greg Makoul (EP203) about listening to patients and Darrell Moon, who is the founder of the Aspirational Healthcare Conference. You can hear in EP305 talking about the 1% year over year most expensive claimants and the best way to help them and help your cost management at the same time. You can learn more at southcentralfoundation.com. Douglas K. Eby, MD, MPH, CPE, is vice president of medical services for Southcentral Foundation's Malcolm Baldrige Award–winning Nuka System of Care. Doug is a physician executive who has done extensive work with the Institute for Healthcare Improvement and other organizations around the Triple Aim, accountable care organizations (ACOs), patient-centered medical homes, whole system transformation, workforce, cultural competency, health disparities, and other topics. His speaking and consulting include work across the US, Canada, and portions of Europe and the South Pacific. Doug has spent more than 20 years working in support of Alaska Native leadership as they created a very innovative integrated system of care that has significantly improved health outcomes. Doug received his medical degree from the University of Cincinnati in Ohio and his master's in public health degree from the University of Hawaii. 03:52 What's the what and where of the Nuka System of Care? 04:49 What does the word Nuka mean? 05:25 "It's all built around this idea that we're raising … the ability for people to take control of their own health issues, and then we are just advisors … on that journey." 06:39 "The reason why people do pay attention to us is … the proof in the pudding." 09:09 What did the Southcentral Foundation do to create an ideal health system? 11:09 "It's access, it's relationship, it's partnering, it's being known … it's getting at the whole family and the whole person." 12:02 "There's two huge problems with modern medicine all across the world. One is how money is handled … [and the other] is this blind acceptance of the medical model." 14:14 "For 20 years, we've established a base of companionship and relationship." 16:06 What does advanced primary care look like? 19:25 How does this new style of chronic management work, and why does it get better results than Centers of Excellence and other health system models? 23:25 "We refer out to specialists 65% less often than we used to." 24:17 "It's a ballet; it's continual … all day, every day." 25:33 How big are the patient panels in this system? 28:49 "I would say that 95% of what we do here is directly translatable to any

This episode might be about local providers getting disintermediated not by virtual front doors like I discussed with Jeff Hogan in EP309 but by entities providing virtual continuous care at home. Predictivae and proactive, the idea is to help reduce acute events requiring on-premises care. But if someone does wind up needing ramped-up care, they can get it hospital at home or SNF (skilled nursing facility) at home instead of them going anywhere. So, there's a baseline level of home monitoring followed by periods where care is stepped up. The point is, everything is going down at home with the care coming to the person at the care level that they need, so it ramps up or down depending on what they're going through or need at the time. I'm talking in this health care podcast with Sumit Nagpal, CEO and founder over at Cherish Health. We talk about the goings-on in the whole aging in place or, as he calls it, living in place vertical. A couple of takeaways from our conversation I think are notable: First of all, who is going to drive first change here isn't going to be, for example, hospital systems at scale suddenly deciding to work against their own perverse incentives to keep heads out of beds. Our first movers here—the ones who will push assisted living at home or SNF at home or CCRC at home or whatever you want to call it at home—is going to be consumers and their families who either can't afford to or don't want to send Grandma to an assisted living institution. So, this is how it's gonna go down: Families across the country install technology to keep Grandma safe at home. A natural ally here, if you think about it, is Big Retail, by the way. Why wouldn't Big Retail and Big Tech sell these solutions to grandmas' families like they sell televisions today? But the second that grandmas everywhere have monitoring software in their homes is the second that FFS-dependent hospitals and other providers have a problem on their hands—a business problem, that is. And assisted living facilities and SNFs working a similar model are in the same boat. Here's why. Actionable population heath data is now available, and once that data is available and looked at predictively and proactively, grandmas are not going to go to the ER like they once were for two reasons: (1) Proactive and predictive technology in the home will reduce acute events and (2) because if and when Grandma does have an acute event, she's not calling an ambulance. The technology is notifying someone. Maybe it's notifying the Medicare Advantage plan that Grandma's on, who has realized the power of all this at-home stuff. And the Medicare Advantage plan maybe just hooked up with a forward-thinking hospital that built an ER at home service or a hospital at home service. Or maybe there's some national technology player who is providing similar services. Sumit Nagpal and I talk through how this might look and also the essential factors for the health care industry to eventually adopt an at-home model. You can learn more at cherishhealth.com. Sumit Kumar Nagpal is the CEO and founder of Cherish Health, a consumer electronics company that develops advanced sensors and artificial intelligence combined with medical evidence and human touch. Cherish Health solutions improve the lives and enable the supported self-care of people aging or living with health challenges—our grandparents, parents, children, many of us. Sumit is a serial entrepreneur and has cofounded and grown five digital health companies over the past two and a half decades that have tackled progressively bolder challenges facing our health care economies. He serves on important industry boards, including HIMSS and Health eVillages. Prior to founding Cherish Health, Sumit was global lead for digital health strategy at Accenture. He is sought after for his expertise and unstoppable energy as an entrepreneur, change agent, strategist, and technology architect. 03:55 What does "health care is coming home" truly mean? 07:35 "It's not like we're cheese and we're aging in place. We're living. We're living our lives." 07:51 "Give us the ability to live where we want for as long as we want as safely as possible." 10:31 "The challenge with wearables beyond the initial cost is … you have to remember to wear them." 10:53 "The tech itself is not unreliable, but we as human beings are unreliable." 13:34 "The conversation typically begins with privacy and goes into other kinds of risks." 15:50 "Our health care economy is fundamentally misaligned." 17:57 "The incentives … today don't really enable this kind of proactive, preventive engagement." 23:30 How do we solve this cost problem at scale? 23:44 How do you align incentives for those that will care to solve these problems? 26:47 "I don't think that we're going to have mass, large-scale change in health care moving home until people are starting to adopt … these kinds of services in their homes." You can learn more at cherishhealth.com. @sumitknagpal of @WeCheri

In this health care podcast, Ge Bai explains GoodRx's business model and how PBMs and pharmacies fit in to that business model. Here's the short version: GoodRx takes advantage of the dysfunction in the pharmacy supply chain. And while they help patients save money, their master plan only works because pharmacies would be charging cash pay patients too much in most circumstances. Why, you might ask? Well, one reason is the big PBMs have contracts with pharmacies that stipulate the PBM must get the best prices. So, any patient wandering in off the street without a PBM card is going to always pay more than the rate a PBM can get for its patients. So, a pharmacy's list price will always be more than the PBM price. I'll let my guest in this episode, Ge Bai, explain this better and get into a few details; but that's kind of the general level set there. Ge Bai, PhD, CPA, is an associate professor of accounting at Johns Hopkins Carey Business School and associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. This "An Expert Explains" goes very nicely with EP306, in which Ge Bai and I talk about Amazon's pharmacy and pharmacy model. So, you might want to check out that episode if you have not listened to it yet. You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. Ge Bai, PhD, CPA, is an associate professor of accounting at the Johns Hopkins Carey Business School and associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on health care pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies. 01:53 What's the difference between GoodRx and Amazon Pharmacy? 02:17 "GoodRx pharmacy makes money from one fact, and one fact alone." 03:43 "On the surface, it looks like the patients are paying cash without any middleman; but in reality, the patients are paying cash by using a network created by a PBM." 04:52 "GoodRx contracts with a network of PBMs." 06:06 Where does the pharmacy fit in this deal? You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What's the difference between GoodRx and Amazon Pharmacy? @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma "GoodRx pharmacy makes money from one fact and one fact alone." @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma "On the surface, it looks like the patients are paying cash without any middleman; but in reality, the patients are paying cash by using a network created by a PBM." @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Where does the pharmacy fit in this deal? @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma

The Shkreli Awards have been published each year, for the past five years and counting, by the Lown Institute. The Shkreli Awards are a much-anticipated top 10 list of the worst examples of profiteering and dysfunction in health care. This year's list, celebrating the most excellently egregious profiteering in 2020, are unique in the sense that everybody on this list this year—every one of them—decided, deliberately, that a pandemic might be a super opportunistic global stroke of luck to exploit fear and anguish to line their own pockets. The list is named for Martin Shkreli, the price-hiking "pharma bro" that is easy to point to as a model of pure, unadulterated health care profiteering. Here's the point: Just because you can be clever and shifty enough to make a whole lot of money in health care doesn't mean you should. Every dollar anyone earns without adding commensurate value back is just one more nail in the financially toxic coffin that patients and employers face in this country—and taxpayers. The Lown Institute is a nonpartisan think tank advocating bold ideas for a just and caring system for health. Their work is centered around four main topics: low-value or unnecessary care, accountability, health equity, and the human connection. In this health care podcast, I am looking so forward to speaking with Vikas Saini, MD, and Shannon Brownlee from the Lown Institute about this year's Shkreli Award winners. (I wish I had a soundtrack of audience clapping. I'd cue it right now.) There are 10 winners, and we talk about most of them in this episode. You can learn more by connecting with Dr. Saini (@DrVikasSaini) and Shannon (@ShannonBrownlee) on Twitter. Vikas Saini, MD, is president of the Lown Institute. He is a clinical cardiologist trained by Dr. Bernard Lown at Harvard, where he has taught and done research. He has also been an entrepreneur as scientific cofounder of Aspect Medical Systems, the pioneer in noninvasive consciousness monitoring in the operating room with the BIS device. He was in private practice in cardiology for over 15 years on Cape Cod, where he also founded a primary care physician network participating in global payment contracts. Dr. Saini is board certified in cardiovascular disease, internal medicine, and nuclear cardiology. He has served on the faculty of Harvard Medical School and the Harvard School of Public Health, where he initiated the first course focused on policy translation for cardiovascular disease prevention. Shannon Brownlee is senior vice president of the Lown Institute. She and Lown Institute President Dr. Vikas Saini are cofounders of the Right Care Alliance, a network of activist patients, clinicians, and community leaders devoted to organizing a broad-based movement for a radically better health care system. Before joining the Lown Institute, Brownlee served as acting director of the health policy program at the New America Foundation. As a senior fellow at New America, she published the groundbreaking book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, which was named the best economics book of 2007 by the New York Times.

This episode is a tale of what happens when some employers decide to open up a few virtual front doors and when these virtual front doors lead only to referrals to providers who are willing to be accountable and offer financial predictability. That's what these employers want, after all. They want accountability and financial predictability. Many employers now have access to all claims databases and other data like the RAND 3.0 report. Therefore, employers can and are using this information in a big way to steer their plan member populations. Given these goings-on, some slower-moving providers could easily find themselves on the outside looking in. So, who are those providers who are or will be getting shut out of referral flows? They're definitely FFS-centric, but they could be a large health system, an urgent care center, or a hospital-owned PCP. In this health care podcast, I speak with Jeff Hogan, the northeast regional manager for Rogers Benefit Group and also president of Upside Health Advisors. We talk in this episode not about what might be theoretically possible but about what is happening right now. You can learn more at [email protected] and connect with Jeff on LinkedIn. Jeffrey Hogan is the northeast regional manager for Rogers Benefit Group, a national benefits marketing and consulting firm. Jeff has been with Rogers Benefit Group for 30 years. Additionally, Jeff operates a consulting firm, Upside Health Advisors, where he provides expert witness services on health care–related litigation, is a consultant to payers and large provider groups for product development and launch, and is a resource to employers desirous of implementing strategies to manage their health spend. Jeff is focused on health care payment reform, health policy, care coordination, value-based health care, health care quality, and precision medicine. Jeff regularly appears on national forums focused on moving to value-based health care and is actively working to promote health care–related transparency measures in the market. He serves as the group's liaison to the National Alliance of Healthcare Purchaser Coalitions. Jeff is the regional leader for The Leapfrog Group. He is also one of the coordinators of Connecticut's Moving to Value Alliance. 01:43 What are self-insured employers doing right now to impact referral flows? 03:29 Are any virtual tech companies moving in on the local provider space? 07:46 "What we're trying to do … is to help the member have the best outcome." 10:32 "It's a continuum, if you will." 10:44 "There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence]." 11:13 "What is value for employers coming out of COVID? Accountability and predictability." 13:40 What are second-order effects? 14:29 "People like and want better access." 14:46 "Fee-for-service providers fear the informed health care consumer." 22:19 "Many of the brick-and-mortar providers are realizing that they have to up their game." 24:52 "Things will change." 25:07 "People not only want convenience, but they want safety, they want data." 26:11 "We are at an inflection point … After 35 years in the business, I really finally feel like we've broken through." 27:31 "This requires people to really think; it requires employers to actually know what their biggest problems are." 29:53 "We can't go back to the fragmentation of fee for service." 30:25 "Data is critical." You can learn more at [email protected] and connect with Jeff on LinkedIn. Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth What are self-insured employers doing right now to impact referral flows? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth Are any virtual tech companies moving in on the local provider space? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth "What we're trying to do … is to help the member have the best outcome." Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth "There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence]" Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth "What is value for employers coming out of COVID? Accountability and predictability." Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth "People like and want better access." Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth "Fee-for-serv

And here I thought I knew a lot about value-based care. In this health care podcast, I am speaking with Mark Fendrick, MD, who is the director over at the University of Michigan Center for Value-Based Insurance Design. This conversation is for those of you who already know pretty much about value-based care concepts. If you do not, I'd go back and listen to, say, Encore! EP206, with Ashok Subramanian, before this one. Dr. Fendrick talks in this health care podcast about what it takes for value-based care to happen in the real world. No kidding, it's about making sure that reimbursement is aligned with good things (no great surprise there). Everybody is always talking about properly aligning provider incentives. And, although often discussed, it really matters. But two light bulb moments I had in this conversation with Dr. Fendrick: Here we are at the beginning of the year. How many doctors and nurses, inspired to do the right thing, have told their patients with diabetes, say, to go get an eye exam to check for diabetic retinopathy? No one would disagree that this is definitely a good idea. Diabetic retinopathy causes blindness. But here's the reality of that conversation. Doc says, "Go get an eye exam." And patient says, "I can't. My deductible is huge, and I can't afford it." So, the patient doesn't get the follow-up care and winds up in the hospital or blind. And the doctor gets dinged on his or her quality scores. Suboptimal outcomes all around, I'd say. This also happens on the pharmacy side of the equation, but I think a lot of us are a little bit more familiar with that scenario—like type 1 diabetics who can't afford to pick up their insulin because of a Medicare Part D or commercial deductible that they haven't met yet. I just never really connected the dots back to the provider getting black marks because their patient has a benefit design that's not aligned with the quality measures. In a majority of benefit designs, consumer price sharing is based not on the value of the service but on how expensive the service just happens to be. Wow! Think about that. So, we're trying to get our plan members to be consumers and use the power of their wallets to make good health care choices. And what we're really doing is driving them toward cheap things or no care and discouraging them from indulging—and I say that sarcastically—in expensive things. But the expensive things might be the high-value care, and the relatively cheap things might be crap that's fully unnecessary or harmful and, over a whole population, adds up to a lot of zeros. Health care is not like a consumer market where the expensive things are usually a better version of the cheap things. For all you economists out there, you don't want the demand curve to be elastic when what's cheap and what's expensive has no correlation to quality or necessity. Nobody should be super flabbergasted when a $35 cure-all supplement peddled on YouTube makes some random influencer a millionaire. That's how supply and demand works. Much to ponder in this episode. You can learn more at vbidcenter.org. There's also a great newsletter you can sign up for there. A. Mark Fendrick, MD, is a professor of internal medicine in the School of Medicine and a professor of health management and policy in the School of Public Health at the University of Michigan. Dr. Fendrick received a bachelor's degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School. He completed his residency in internal medicine at the University of Pennsylvania, where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Fendrick conceptualized and coined the term Value-Based Insurance Design (V-BID) and currently directs the V-BID Center at the University of Michigan (vbidcenter.org), the leading advocate for development, implementation, and evaluation of innovative health benefit plans. His research focuses on how clinician payment and consumer engagement initiatives impact access to care, quality of care, and health care costs. Dr. Fendrick has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design. His perspective and understanding of clinical and economic issues have fostered collaborations with numerous government agencies, health plans, professional societies, and health care companies. Dr. Fendrick is an elected member of the National Academy of Medicine (formerly IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the US Senate Committee on Health, Education, Labor and Pensions; the US House of Representatives Ways and Means Subcommittee on Health; and the US Senate Committee on Armed Services Subcommittee on Personnel. 03:53 Is back surgery high-value care? 04:46 If care is patient to patient, how is high-value care decided upon? 05:36 "Flintstones delivery

In this health care podcast, I speak with Loren Adler, who is the associate director of USC-Brookings Schaeffer Initiative for Health Policy and has a particular focus on surprise billing. I wanted to talk to Loren about the surprise billing legislation that is going into effect on 1/1/22. I will let Loren explain, but, in short, this legislation removes the patient from the mix. If a provider decides to send a surprise bill, the patient will just pay the co-pay or coinsurance they normally would have if the provider had been in network. Then, it's up to the provider who sent the bill and the insurer to duke it out on the back end. What this back end duking out consists of is the provider sending their big surprise bill to the insurer. The insurer may reply, with regrets, "Hey, we're only gonna pay you … whatever … a fraction of the big bill." The provider may at that point say, "Fine … whatever. I'll take it." Or the provider may say, "No can do. I'll see you in arbitration." This arbitration that then happens is a style called baseball arbitration, and Loren gets into the "why" there. Also, a provider cannot trigger an arbitration more than once every 90 days for the same service. So, there's a wrinkle that will slow the roll of any provider with a plan to clog up the system by arbitrating every claim. I quiz Loren mercilessly about exactly what the provisions of this legislation are and the winners and the losers. But we also talk a lot about potential ramifications. For example, making surprise bills illegal will potentially accelerate bundled payments, if you think about it, because one of the reasons why bundles have stalled is because various parties who enjoy surprise billing refuse to be a part of the bundle—and then the whole thing just flies off the track. Also, premiums will go down approximately 1%, they say, for self-insured employer plans. And Loren and I get into the "why" of that—or, more accurately, Loren gets into the "why" of that. In listening to this recording, I realized we do sort of pick on anesthesiologists a bit here. So, apologies to those anesthesiologists who have been billing fairly this whole time, which is definitely the majority. You can learn more at brookings.edu. Loren Adler is associate director of the USC-Brookings Schaeffer Initiative for Health Policy. His research focuses on a range of topics in health care economics and policy, including provider payment and consolidation, insurance markets, Medicare, the Affordable Care Act, prescription drugs, and COVID-19 testing. Previously, he served as research director for the Committee for a Responsible Federal Budget and as a senior economic policy analyst for the Bipartisan Policy Center. Adler holds a bachelor's degree in mathematical economics from Wesleyan University and a master's degree in applied economics from Johns Hopkins University. 03:04 What is this surprise billing legislation? 04:27 What happens when a patient is sent a huge bill from the provider? 06:15 What is "the going rate"? 09:44 "If you weren't leveraging surprise billing beforehand, this law has no effect on you." 11:14 Will this legislation push the industry toward one hospital bill? 12:20 What will providers have to do if they don't like what insurance wants to pay them? 15:26 What is benchmark pricing? 17:37 "Fundamentally … it's really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other." 18:19 Is this surprise billing legislation a compromise? 19:48 "Arbitration really isn't meant to adjudicate every single claim." 20:11 "The idea is really to kind of push the facility … to negotiate and figure this all out." 20:50 Are hospitals being impacted by this bill? 24:56 What happens to providers who decide to send surprise bills anyway? 26:09 What are the implications of this legislation for self-insured employers? 28:48 Why have ground ambulances been left out of this surprise billing legislation? 32:23 "At the end of the day, I think this is a net positive for consumers and should be considered a win." You can learn more at brookings.edu. @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is this surprise billing legislation? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth "If you weren't leveraging surprise billing beforehand, this law has no effect on you." @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Will this legislation push the industry toward one hospital bill? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What will providers have to do if they don't like what insurance wants to pay them? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is be

Here's a trigger warning: This show gets pretty deep into some of the nether regions of PBM (pharmacy benefit manager) contractual terms with pharmacies. If you are not, I'm gonna say, pretty familiar with PBM goings-on, I'd suggest you listen to EP241 with Vinay Patel first or skip the first third of this show. In this health care podcast, I am speaking with Ge Bai about Amazon's pharmacy business. Ge Bai, PhD, CPA, is an associate professor of accounting at Johns Hopkins Carey School of Business. She is also associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. Ge trained as an accounting researcher who originally started looking into chargemasters for her dissertation. From there, she started checking out health care pricing and contracting issues. Who knew chargemasters were like a gateway drug into health care? I ask Ge questions such as, "Why the heck does Amazon need a PBM for cash pay patients?" and "What's this Amazon Pharmacy model that some self-insured employers are talking about?" And then we get into rebates and the impact that Amazon will have on rebates. Right up front, I want to just say flat out, I learned a mind-blowing detail from Ge. There's a contracting term that PBMs put in their contracts with pharmacies. Basically, a pharmacy cannot sell a drug to a cash pay patient for an amount that is less than the price a PBM pays the pharmacy for the drug or the pharmacy charges the PBM for the drug—I guess it depends how you perceive that relationship. So, the pharmacy's list price paid by cash pay patients can't be less than the contracted price that it has with any third-party payer. The PBMs will always have to get the better price than cash pay patients. There's one exception, though: unless the cash pay patient wanders in with a coupon (like a GoodRx coupon, for example). There are a whole lot of implications to this if you start to think about it. Spoiler alert: There will be an "Ask an Expert" with Ge Bai coming out after the show, where Ge and I get deeply into GoodRx's business model. So, stay tuned for that if you are interested. You might be subscribed to the show on iTunes, but I'd also encourage you to sign up for our newsletter on relentlesshealthvalue.com. Every week, you get a transcript of the introduction to the show that's coming out that week, so you can prioritize your listening accordingly. You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. Ge Bai, PhD, CPA, is an associate professor of accounting at the Johns Hopkins Carey Business School and associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on health care pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies. 03:27 Why is Amazon in the pharmacy space a big deal? 04:03 "I view Amazon Pharmacy as a combination of GoodRx and mail-order pharmacy." 05:07 What's the difference between Amazon and other pharmacies? 06:14 Why does the third-party payer health care system keep Amazon from cutting out the PBM? 07:49 "We don't have insurance companies, we don't have PBMs." 09:21 "Who's really using prescription drugs? The majority is Medicare patients." 11:46 Is Amazon doing anything innovative in the pharmacy space? 12:37 What options do self-insured employers have now with Amazon? 14:42 Why employees and employers might choose to use Amazon Pharmacy over other mail-order pharmacies. 21:27 Will Amazon affect pharmacy rebates? 25:28 "Fundamentally, employers want to have more power in the whole process." 27:41 What should you be doing as a self-insured employer? 28:58 "If we do not put out effort to make the private market work, then the next option would be single payer." You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why is Amazon in the pharmacy space a big deal? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma "I view Amazon Pharmacy as a combination of GoodRx and mail-order pharmacy." @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What's the difference between Amazon and other pharmacies? @GeBaiDC discusses the Amazon Phar

My guest in this health care podcast is Darrell Moon, who is the CEO over at Orriant. I was super intrigued by some of the work that Darrell and his team are doing regarding high-cost claimants. Said a different and probably better way, certain people in need of care were identified because they were costing so much. Year after year after year, these individuals—I call them hyper-users during this episode, but it's possible I made that term up myself—these hyper-users were getting all kinds of expensive health care, while at the same time, they were not getting any better. So, Darrell and his team realized that something was afoot here, and it turned out to be a combination of maybe loneliness, maybe low self-esteem and low self-efficacy. And no matter how many times you go to the cardiologist or the rheumatologist or the pulmonologist, none of those things will be cured. In fact, when someone's identity becomes their myriad of health issues, they have a sort of perverse incentive, if you think about it, not to follow any of their doctor's recommendations to take meds or make lifestyle changes. So, while their underlying condition—low self-esteem, low self-efficacy—remains untreated, their physical health tends to actually get worse, not better, despite all the medical attention. What's necessary to help this type of patient is the best that behavioral science has to offer. A nuance I found really interesting and important in the work that Darrell is doing is that it's pretty easy to identify a hyper-user from someone with a horrid chronic condition simply requiring a lot of care. The hyper-users will respond and appreciate the extra attention that a behavioral health coach/program has to offer. In contrast, those with other ailments will just merely get annoyed—usually on the quick—so they exclude themselves from the program. Sidebar: My guest Darrell Moon is organizing an Aspirational Healthcare Conference for July 14 and 15, 2021. In that virtual meeting, the intent will be to highlight Southcentral Foundation's Nuka System of Care in Alaska and other similar health care models that achieve much better health care outcomes at half the cost. So, check that out if you are so inclined. Thanks so much also to Lee Lewis from the HTA (Health Transformation Alliance) for the introduction to Darrell and Orriant. You can learn more at orriant.com. Darrell Moon founded Orriant in 1996 to change the dynamics of health care and give employers some control over the ever-increasing costs of the health care benefits they offer their employees. Darrell believed that engaging individuals in the management of their own health was a key that had to be inserted back into the economic equation of health care. Darrell received both his bachelor's degree in finance and his master's degree in healthcare administration from Brigham Young University. As the CEO, COO, or CFO, Darrell managed medical and psychiatric hospitals throughout the country for over 10 years prior to creating Orriant. He also has more than a decade of experience managing insurance and managed care products. Darrell is a Forbes leadership contributor. 03:11 What do CEOs want out of the health care system? 04:52 Is it a good strategy to focus on high-cost claimants? 07:04 Who are the people year over year that wind up in the high-cost claimant pool? 07:50 "Really, you have to get to the crux of the problem, which is … they've become a victim … to the health care system." 08:16 Who are these "hyper-users" and how do we define them? 11:35 "Getting that person to have a regular relationship with someone isn't the hard part; the hard part is then helping them to build their self-esteem." 13:20 "That's the key to building self-esteem—is helping people accomplish what's most important to them." 14:57 Why helping a patient not to view themselves as a victim helps them manage their care better. 17:45 "It's often less the training and the right personality of the person." 18:54 Do health outcomes correlate with the self-esteem of the patient? 19:28 "If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience." 21:21 "They're the customer/owner of their own health." 24:23 "How do you help not just the 1% but everybody [in health care]?" 27:16 "The ideal environment is to have a massively powerful primary care team." 27:47 "Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right." 29:34 "It's not about just when [people] reach out … but [getting] people to reach out early." You can learn more at orriant.com. Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth What do CEOs want out of the health care system? Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is it a good strategy to f

I had a vision for this inbetweenisode. I wanted to highlight the wisdom of our amazing guests this year. I really wanted to find some theme that might be a key to our health care transformation. To achieve maximum suspense, here's the very short story of how I got from "Is there a common thread of wisdom throughout all the RHV episodes this year?" to "Why, yes, there is … and it's a good one!" So, let's start our journey of discovery with this. Here's a fact: If you talk to patients, they will often tell you that they receive poor care or their needs are not met—when they fall between different providers, or their payer and their provider and their PBM (pharmacy benefit manager) are singing off of different sheets of music. For more information, go to aventriahealth.com. When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specHumana recently came out with their Value-based Care Report. The subhead is Physician Progress and Patient Outcomes. It's a very fancy report with a lot of pages and graphics, and this impressive format definitely caught the attention of some of our industry. I read one blog post really keying in on one sort of depressing aspect of the report, namely, that Humana's value-based care (VBC) program saved a rounding error of 0.4% over their non-VBC program. I wanted to get an expert's take on this report and the reaction to the report and could think of no better person than Steve Blumberg, who has worked in value-based care delivery on the provider and on the payer side. Steve Blumberg, MBA, is the VP of practice transformation for GuideWell Health, a subsidiary of GuideWell. This Humana report, if you'd like to see it for yourself, can be found at digital.humana.com/VBCReport. You can learn more at guidewell.com. Steven Blumberg serves as vice president, practice transformation, for GuideWell Health. In this role, he is responsible for developing and implementing strategies for the further establishment of a high-quality, economically effective clinical system across Florida. He also provides guidance on value-based care and population health models. Prior to joining GuideWell in June 2019, Blumberg served as vice president for value-based care at Baptist Health South Florida, where he led the strategy and implementation for Baptist's population health and value-based care efforts. Prior to that, he was senior vice president and executive director of AtlantiCare Health Solutions, the New Jersey division of the Geisinger Health System, where he was responsib

In this health care podcast, I speak with Steve Blumberg, VP of practice transformation for GuideWell Health, a subsidiary of GuideWell. How's this for an interesting career trajectory? Steve spent the last decade working on population health and value-based care delivery ... on the provider side. Recently, he transferred over to the payer side, working for GuideWell Health, which is the health services arm of GuideWell, which is part of a family of companies including Florida Blue. So, a payer, in other words. I wanted to find out a bunch of things from Steve, but the main one is this: How do—if they, in fact, do—payviders improve care for patients? Or what does it take for an organizational structure to drive Triple Aim results? Going into this conversation, here is what I was thinking about: Payviders have access to longitudinal data (potentially) that siloed entities will certainly not. They also have a goal to keep care affordable in a really real way, especially if the patient/member/client is on the ACA (Affordable Care Act) marketplace and shopping for premiums. My big concern with payviders, though, is whether they're an "HMO in drag," as they say. On the other hand, payers and providers, in the most cynical sense, have wildly divergent goals. Search #medtwitter any day of the week—you will find a galaxy of tweets wherein doctors complain about payers—to just get a tiny sense of those wildly divergent goals. Do separate payers working with separate providers offer a kind of check and balance? A historical knock on this hypothesis is the inarguably crappy outcomes for chronic conditions that US patients have the privilege of paying comparatively ridiculous sums for. I couldn't tell you whether those crappy outcomes are a result of the separateness of payers and providers or some other factor, but so it is. Here's the short version of one of Steve's main points: It's not about control. It's about connection. It's about being able to connect with patients over their continuum of care. It's also about how consumers and employers are increasingly trading out choice and broad networks for an assurance of quality. You can learn more at guidewell.com. Steven Blumberg serves as vice president, practice transformation, for GuideWell Health. In this role, he is responsible for developing and implementing strategies for the further establishment of a high-quality, economically effective clinical system across Florida. He also provides guidance on value-based care and population health models. Prior to joining GuideWell in June 2019, Blumberg served as vice president for value-based care at Baptist Health South Florida, where he led the strategy and implementation for Baptist's population health and value-based care efforts. Prior to that, he was senior vice president and executive director of AtlantiCare Health Solutions, the New Jersey division of the Geisinger Health System, where he was responsible for population health, the organization's provider physician group, and home care and hospice continuum services. Earlier in his career, he was chief planning and business development officer at UHealth–The University of Miami Health System. Blumberg also held leadership roles at UF Health–Shands Healthcare and Baptist Health Jacksonville. Blumberg has been active in community and professional organizations, including serving on the boards of the Ronald McDonald House, Community Hospice, and the Northeast Florida Health Planning Council. He has also served nationally on the Premier Population Health Steering Group and on the National Institute of Standards and Technology's Baldrige Board of Examiners. Blumberg holds a bachelor's degree in business administration and marketing from the University of Florida and a Master of Business Administration from Florida State University. He is a fellow of the American College of Healthcare Executives. 03:30 How does thinking like a payer change the way you build out a primary care provider practice? 04:37 "When I was on the provider side, I definitely worried about the total cost of care … but making the products affordable was … someone else's concern." 09:12 How would you define practice transformation? 13:29 "We're curating networks." 16:56 "If they come to the market, they'll be hard to ignore." 17:38 How integrated is the physicians network? 18:35 "Control isn't the right word … it is the connection with the patient … that's where we think the most effective primary care takes place." 18:59 Where does attempting team-based care fall apart the most? 21:25 Are employers trading out for an assurance of quality? You can learn more at guidewell.com. Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth How does thinking like a payer change the way you build out a primary care provider practice? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healt

Alex Azar, who is the current Health and Human Services (HHS) secretary (until January 21 anyway), came out with a reboot of the proposal that effectively halts the practice of pharma manufacturers paying rebates to Part D plans. This reboot is supposed to go into effect on 1/1/2022. But this podcast is less about this may-or-may-not-actually-happen rule and is more about the actual impact of removing drug rebates within this unintuitively constructed health care system of ours. Should rebates go away, it's actually a big deal that fundamentally could upend the heretofore-not-transparent messy middle of drug pricing. I'll let Chris Sloan, associate principal over at Avalere Health, explain. Spoiler alert: The impact of killing pharma rebates to plans and PBMs (pharmacy benefit managers)? Bottom line, everybody's insurance premiums go up in the current model when rebates go away. A few episodes from now, I'm talking with Ge Bai about why this is a suboptimal and not forgone conclusion. But this is what we've got going on right now. So, look for EP306 coming up for more on that. You can learn more at avalere.com. Chris Sloan, associate principal at Avalere, advises a number of clients—including pharmaceutical manufacturers, health plans, providers, and patient groups—on key policy issues facing the health care industry. Chris's economic analyses of key policy proposals and issues, including drug pricing and the repeal and replace efforts around the Affordable Care Act, have been featured in a wide range of publications, including the Wall Street Journal, the New York Times, the Washington Post, Politico, Axios, and Vox.

In November 2020, there was an Executive Order entitled "Lowering Prices for Patients by Eliminating Kickbacks to Middlemen." And we had HHS (US Department of Health and Human Services) Secretary Alex Azar and the HHS Office of Inspector General finalizing a regulation to eliminate the current system of drug rebates in Med D (Medicare Part D). And what they were trying to do is create incentives to reduce out-of-pocket spending on prescription drugs by delivering discounts directly at the pharmacy counter to patients. Those discounts delivered at the pharmacy counter? Not insignificant. In 2019, Part D rebates totaled $39.8 billion. The new rule stipulates that federal spending can't be increased as a result of this action. But in summary, it's pretty much a reboot of the same ruling from earlier last year. Here's a couple of points: The rule is only for Medicare (Med D)—Medicaid and commercial aren't included—but … there's a but, and we get into that in this episode. Also, the start date for this ruling is 1/1/22 if it continues to stand in the new administration, which is a big if. What was at stake the first time this rule was drawn up by HHS and is likely still at stake is the implementation flowchart. Who exactly is involved in adjudicating these "potential discounts for patients at the pharmacy counter"? Since any middleman who gets themselves involved in anything takes a buck, there is a massive land grab, if you think about it, that if any middleman can grab a buck, this could be a lot of money. So, the first time this HHS proposal was presented in 2019, I talked to AJ Loiacono, who's the CEO over at Capital Rx. I have to say I was a little over-cocky relative to how well I really understood the hidden machinations behind pharmacy Rxs being adjudicated, and AJ does an amazing job explaining it. This is incredibly relevant as we contemplate potentially who gets a piece of the action moving forward. But regardless of, in some respects, what happens with this HHS rule, I found it interesting and valuable to understand what exactly happens in the dark messy middle, maybe underbelly, of a pharmacy adjudication. You can learn more at cap-rx.com. Anthony J. "AJ" Loiacono is a serial entrepreneur with over 20 years of experience in pharmacy benefits and software development. As the CEO of Capital Rx, a pharmacy benefit manager (PBM) that is bringing transparency and fair pricing into an otherwise opaque industry, his mission is to change the way prescriptions are priced and administered to create enduring social change. AJ spent his career studying the pharmaceutical supply chain and producing engineering solutions that have continually redefined the pharmacy benefit industry. At its core, Capital Rx is a technology-first company that has received multiple awards for the innovations that have propelled the company to record growth (Accenture Health Technology Champion, AMCP Gold Ribbon, EHIR Innovation Award, NYC Digital 100, etc).

I had a vision for this inbetweenisode. I wanted to highlight the wisdom of our amazing guests this year. I really wanted to find some theme that might be a key to our health care transformation. To achieve maximum suspense, here's the very short story of how I got from "Is there a common thread of wisdom throughout all the RHV episodes this year?" to "Why, yes, there is … and it's a good one!" So, let's start our journey of discovery with this. Here's a fact: If you talk to patients, they will often tell you that they receive poor care or their needs are not met—when they fall between different providers, or their payer and their provider and their PBM (pharmacy benefit manager) are singing off of different sheets of music. For more information, go to aventriahealth.com. When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specializes in helping pharmaceutical, employer, pharmacy, and health system clients improve patient outcomes by creating and leveraging collaborations with other health care organizations. For more than 20 years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders and, most of all, the patient. For more information, go to aventriahealth.com. Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week's #healthcarepodcast. #podcast #digitalhealth

You know back in the olden days when a foot of measurement was actually the measure of your own foot? So, I might measure something and it's, like, 19 feet. And then you measure the same exact thing and it's 38 feet because you have tiny feet. This is the analogy that kept running through my mind as I was talking with Anna Kaltenboeck in this health care podcast about QALYs to measure the value of drugs. In this metaphor, QALYs are the ruler so that 1 foot of drug value is the same for everybody and all drugs. It's very civilized as a concept if you think about it. QALY stands for quality-adjusted life year. The goal of a QALY is to figure out how much any given drug is worth to a society so that we, as a society, have a benchmark to evaluate the price of pharmaceutical products. QALYs are an apples to apples or a foot to foot way to compare the value of drugs for we the people. I mean, is this drug amazing and we should all pay a lot for it? Or is the drug more expensive than the current standard of treatment and it doesn't confer any added benefit to patients? It'd be good to know that as a patient and as a payer and, frankly, as a pharma company. QALYs offer a framework for levelheaded discussions. It's complicated. I'm gonna take the risk of oversimplifying, but here's how I'd explain the three parts in a QALY measurement, which combines measure pharmaceutical value. The first part is, if relevant, how much additional survival can be expected with this drug? So, if it's an oncology drug, for example, how much longer will the patient live? The second part of a QALY is, how does the drug make the patient feel? So, in an ideal world, survival is long and the patient feels super great. So, some economists and scientists get together and they do some math and they come up with the sum of these first two factors. Then the third part of a QALY calculation is the cold hard cash. How much is society willing to pay for this improvement in survival, in quality of life? This last part will depend based on the society (ie, the country) and also the condition. We're willing to pay a lot for a drug that helps blind people see. We might be not so willing to pay a whole lot for a drug that lowers blood pressure marginally, for example. My guest in this health care podcast is Anna Kaltenboeck. She is a health economist and program director for the Drug Pricing Lab at Memorial Sloan Kettering. She knows a lot about QALYs. One last thing: ICER is the Institute for Clinical and Economic Review. It is an independent and nonprofit organization who creates a lot of these QALY assessments. Whether they succeed or not is something that is sometimes questioned, but the team over at ICER prides themselves in not working for Pharma and not working for payers in an effort to be as impartial as possible. You can learn more at drugpricinglab.org. Anna Kaltenboeck is the senior health economist and program director for the Center for Health Policy and Outcomes and the Drug Pricing Lab at Memorial Sloan Kettering Cancer Center (MSKCC). She focuses on the development and application of reimbursement methods for prescription drugs that reduce distortionary incentives in the supply chain and encourage pricing of treatments based on their value. Her work centers on developing an unbiased evidence base that characterizes the effect of federal policies on coverage and reimbursement decisions for branded specialty drugs and cell and gene therapies and identifying opportunities for policy changes that encourage affordability and access while maintaining incentives for innovation. Her current research interests include global comparisons of reimbursement policy and supply chain regulation, game theory in innovation decisions, and the effect of market concentration on pricing decisions. Ms. Kaltenboeck's research and policy work is informed by her experience as a consultant for pharmaceutical clients. Prior to joining MSKCC, Ms. Kaltenboeck spent 10 years working for Analysis Group and IMS Consulting Group, where she conducted health economics and outcomes research and developed pricing and market access strategies for pharmaceutical and diagnostic products. She has published numerous articles in peer-reviewed journals and other press, including JAMA and Morning Consult, and speaks frequently on the topics of value-based pricing, economics of the supply chain, and reimbursement models. Ms. Kaltenboeck holds bachelor's and master's degrees in economics from Tufts University. 3:56 What is a QALY? 05:28 "You don't get marks; it's the treatment that gets the marks." 09:13 What is willingness to pay? 10:52 "What we pay for drugs should be reflected in societal preference." 12:29 Does Pharma fear the QALY? 15:38 "At the end of the day, the ideal here is simply to be able to quantify 'This is what we're going to pay for this additional benefit that we're going to provide for patients.'" 17:09 "When you meet that price, patients should be getting access

Sometimes when I overhear a conversation/argument about telehealth, it occurs to me that there's a lot of fighting words about some things and very, very little about other things which I'd regard as equally, or maybe even more, important. Some of the sparring tends to jump immediately to tactics and UX (user experience), absent of strategy and CX (customer experience). In my experience, you can't talk about a user interface until you talk about the overall customer experience and journey and what your goal is. So, here's what I mean: Let's take urgent care as an analog. Say a patient goes to urgent care with symptoms consistent of allergic asthma. The NP (nurse practitioner) gives the patient strict instructions to take an antihistamine and Flonase and Flovent. She tells the patient to be sure to make a follow-up with their PCP (primary care provider) to evaluate how it's going. If the patient doesn't make a follow-up visit, do we suggest it's because the live in-person visit should have been telehealth? Or if the patient is nonadherent and winds up in the hospital with a full-blown asthma attack, do we suggest that live in-person visits diminish adherence? Let me respectfully suggest that it'd be a solid no on that. This is exactly why, whenever I listen to a diatribe about how telehealth did not work out for a patient, I find it interesting to ask a couple of questions. The question that I tend to ask when someone starts talking about some telehealth fail is "How did it fail?" How did it not work out? And the answer to this question tends to be similar to the above allergic asthma example: that the patient needed lab work or imaging or a follow-up visit, and that couldn't be done via telehealth. There was no resolution to the patient concern, in other words. Okay … so, first of all, most practices don't have immediate on-premises lab work or imaging, so the patient would have had to have gone somewhere else to get it anyway. But even if they did, as far as I know, you can't have a follow-up visit at the same time that you have the first visit. Not to be cheeky, but that's why they call it a follow-up visit. Then the next logical question is, if the patient doesn't show up for a follow-up, if the patient were in person, what's the greater likelihood that they would have gone for the lab test and/or come back for the follow-up? This is when you start to realize that the setting of care (ie, virtual or in person) may be a little bit less important than the agency of the provider involved. And it may be a little less important than the structure of the organization sitting around that patient encounter. Said another way, strategically, what are we doing here? What are we trying to accomplish? What's our road map to get the patient from where they are now to wherever that goal is? A patient visit is a tactic. It's one point in time. And that's true regardless of whether it's a remote visit or an in-person one, synchronous or asynchronous. A patient visit or interaction is not a care pathway. It is rarely, if ever, a magic bullet one and done. But that doesn't stop us from thinking about patient encounters, one encounter at a time, which may be exactly why we wound up with a fragmented health care system that doesn't work very well. But I digress. So, from what I can see, some of the flaws that some people attribute to telehealth might be more properly construed as flaws to the ecosystem in which the telehealth is being deployed. For example, how much agency or data or infrastructure does the provider behind the camera have to see where the patient is in their treatment journey and make sure that they get to that next milestone? Because in cases where the doctor behind the camera or the telephone or the text message has agency and the telehealth visit is part of a defined patient journey, telehealth results are strikingly comparable to not telehealth results, if not better. If we're contemplating a patient journey or a treatment journey, writ large, the site of care at any moment in time is a secondary or tertiary factor—certainly not a primary one. Here's what I want to know about telehealth. How do you best use it, not as a point solution but as part of a larger whole? How do you optimize a telehealth encounter so it pulls its weight in helping patients get a resolution to their chief complaint or manage their chronic conditions? Christian Milaster has written about this in his Telehealth Tuesday newsletter, which is great, by the way. Christian wrote that the delivery of care, when viewed through the eyes of a systems engineer (which he is), becomes a quite simple four-step process. These are the four steps that Christian says. He says, the first step is assessment, which leads to a diagnosis, which is step two. Step three is the development of a treatment plan. And then step four is the implementation of that treatment plan. Amongst other sidebars, I talk about these four steps in this health care podcast

There's lots going on these days with transparency. Three cost transparency rules, as a matter of fact, just came out of CMS, for example. These rules demand that hospitals and payers make available cost information so patients can shop and employers can also shop. That last part there, about employers and/or payers being able to shop … that might wind up actually being the part of these transparency rules that has the most impact. It all goes back to kind of a first-principle assumption that many made—including me, by the way—which is turning out to be arguable. It's the great hope for consumerism through high-deductible health plans. The thought originally was that by pushing the burden onto patients/employees to find high-quality care at a fair price, we assumed that health care delivery would level up. We assumed that prices would come down, driven by the weight of consumer demands. But anybody seeking to validate this hypothesis would be pretty hard pressed to claim any sort of broad-stroke success beyond cost shifting by brute force. The vast majority of patients don't have medical degrees. This is why they went to a doctor to begin with. So, it's unsurprising to learn that providers wield a lot of influence. If a doctor tells a patient to go here for an MRI or there for surgery, patients have a tendency to go, without questioning. So, logically, if we want to create a high-value health care system and high-value health care—high quality at a fair price—we need to contemplate the recommendations that providers are making. These recommendations especially matter because a patient's entry point into the health system—where they go first—can make all the difference. This is also a particularly relevant point these days with all the discussion about digital front doors. Earlier, I spoke with Ashok Subramanian, CEO and founder over at Centivo. Centivo is a novel self-funded health plan centered around robust primary care. And I thought this episode had particular relevance given what is going on in the health care industry today. You can learn more at centivo.com. Ashok Subramanian founded Centivo in 2017 after observing the inefficiency in the health care system and the pain that has resulted for employers and employees.

Three transparency rules have come out of CMS in the past months. My guest in this health care podcast, Jeff Leibach, calls these three rules three steps on a ladder. They build on each other. The first rule was announced last year, and it was for hospitals to post their chargemasters. You could consider this a baseline step. It's not really all that useful in practice as many discovered. The next step on the ladder (which is coming out on 1/1/21): Providers (hospitals) for all services have to post a machine-readable file—all of their negotiated rates for all service categories. They also have to post a shoppable service file and/or some kind of patient estimator tool so patients can estimate the cost of the most shopped services. Then there's the payer rule. This is more comprehensive than the provider rule, and the payers have some extra time—actually, they have an extra year (till 1/1/22). But basically, payers have to comply at a higher level. They have to allow price shopping across all sites of care. My guest in this health care podcast, Jeff Leibach, is a director with Guidehouse in the Healthcare Practice. He focuses on how health care services are priced and paid for, working with a lot of payers and providers. Thus, he is the perfect person to discuss these transparency rules with because of his deep knowledge of payers and provider contracting and also how pricing impacts patients, employers, and stakeholders across the industry. Jeff and I get into these three transparency rules and their likely impact and also kind of their philosophical underpinnings. We also talk about what might happen with them under a Biden administration. After our conversation, I started to think about these transparency rules in the broader context of what's going on in the health care marketplace. There's kind of a constellation of market factors, and these market factors increasingly seem to be necessitating hospitals and ambulatory practices to really differentiate themselves in ways that employers and patients/consumers care about. I mean, these CMS transparency rules for payers and hospitals are but one thing that is going on. But these rules ultimately mean that it's easier for patients and employers to price shop. It also makes it easier for employers to narrow their networks and exclude providers. Consider this impact and then think about how that fits with the ONC TEFCA (Office of the National Coordinator for Health Information Technology Trusted Exchange Framework and Common Agreement) rule. So, that ONC TEFCA rule means that it's gonna be a less effective tactic to prevent network leakage by hoarding patient data. So, if patient data is portable, patients can seek out the best care provider without the friction of some kind of PHI (protected health information) transfer. Okay … so now prices are available because of the transparency rule, and patients can walk more easily because of the TEFCA rule. So, these two together could be a forceful combination. We also have the rise of consumerism. I just saw a study the other day kind of validating that consumers are voting with their feet if a provider does not meet the quality of care, the supportive patient experience that they believe could be found elsewhere. And add to that the at-risk PCPs (primary care providers) cropping up in various concentrations across the country. But then also, you've got payers buying PCPs. And what that means is that you get these PCPs who control the referral flow, and they're taking an active interest in the downstream costs and population outcomes of specialists in their referral networks. So, you've got specialists who maybe lack processes to minimize inappropriate care or who do not deliver consistently high patient experiences and outcomes. They could easily get excluded from those referral flows. So, you take all these things together—the transparency, the ONC TEFCA rule, consumerism, and the disruption of certain referral flows—and, if you ask me, I think all of this together means that providers who are more commodity and less brand may need to consider ramping up their Triple Aim endeavors. You can contact Jeff at [email protected]. You can also connect with him on LinkedIn and Twitter. Jeff Leibach, MBA, is a director with Guidehouse's Healthcare Practice. Over the last decade, Jeff's main area of expertise has been in developing and implementing managed care solutions for payers and providers. These solutions include development of several analytic solutions, alignment of clinical and financial models, and negotiation training and preparation. Jeff has significant experience building and leading teams to deliver complex analytical tools to quantify opportunities into business strategies for clients. Jeff currently leads Navigant's Strategic Pricing and Revenue Rebalancing Solutions for Navigant. Prior to his consulting career, Jeff led national nonprofit Camp Kesem, a summer camp for children affected by a par

Wow! It's episode 300. That's a milestone. Because of you, we've grown to be one of the largest podcasts for health care executives—so, thank you to every one of you who has recommended the show to your friends and colleagues, which is really the highest compliment. Thanks also to all the listeners of this show who have written reviews, LinkedIn posts, and sent emails. The team over here at Relentless Health Value really appreciates your kind words. They're super motivating. The emails we love to get are the ones where one of you talks about a success story, like an example where you've taken something you heard and made it actionable—how you helped patients get better care to lower cost or how you were able to collaborate with fellow stakeholders in a meaningful way. That's really why we're here and why it's so motivating to hear stories like this, which brings me to a really important point. We're in this together. All of you health care decision maker/stakeholder types out there, you who can directly effect change, it's really you who deserve the biggest round of applause, if I do say so. We appreciate the opportunity to kick off the activity or the decision making, but it's you all who pick up the ball and run with it. And for that, we—as both professionals and patients—thank you. Moving on to today's episode 300, my guest in this health care podcast, Bruce Rector, MD, is an expert on drug affordability; and he has extensively studied how to make sure we get the right drugs developed by considering innovation incentives among other things. He's done a lot of work with Doctors for America and the Center for American Progress. He also teaches medical students, pharmaceutical policy, and has worked with drug companies on drug development promotion. So, I felt like that was a pretty rounded perspective of the issues that I wanted to get into here. Let me tell you why I started to think about this. Any one of those stories where somebody dies of an infection that was resistant to antibiotics, they're always ghastly tales that seem so unnecessary. And every time I hear one of them, I wonder why pharma companies aren't in the antibiotic business. Clearly, there's a need. Well, it turns out antibiotics are a great case study of what happens when drug companies don't have the incentive to develop drugs that are a huge need to society—which brings me to the big hairy challenge I'm talking with Bruce Rector about in this podcast. How do you ensure that pharmaceutical manufacturers are fairly incented and compensated to develop the drugs that are of the most value to society? Orphan drugs, by the way, are a great example of what happens when incentives are put in place to develop drugs. At last count, half the drugs developed in the past decades have been for rare diseases—because of the 1983 Orphan Drug Act that made it quite profitable to develop for rare diseases. So, in this health care podcast, we dig in to two—arguably three—categories of incentives that are typically offered or available to pharma companies in this country today and which are, frankly, used in that Orphan Drug Act. The first two are push incentives, and then there's pull incentives. Push incentives are when the government, generally, offers incentives to reduce industries' costs during the R&D (Research & Development) stages, like they give grants or tax credits for clinical research—things like this. Pull incentives, on the other hand, are ways to guarantee demand after the drug is developed or to help the pharma company make more money on the drug, for example, by extending patent exclusivity—like if you, Pharma, develop this drug, we'll promise to buy millions of doses right up front and/or we'll bar any generics for two extra years so you get the two extra years of revenue. (You might be thinking about what's going on with COVID right now. Just sayin'.) So, we have push incentives, we've got pull incentives, and then this last one, which is more of a market condition than really anything paid up front or deliberately engineered on the back end. It's that drugs aren't like new desk chairs or some other product that, if the price goes too high, your employer just doesn't buy it. If someone is suffering from a deadly disease and there's one drug for it with no competition, there's nothing and nobody in the US marketplace that really has the power to hinder the pharma company from basically charging whatever they want for it. Dr. Vincent Rajkumar talks about this in EP296 if you want to go back and listen to that one for more info. But wait … there's more I talk with Dr. Rector about in this health care podcast. He brings up two different ways to contemplate paying for drugs. First is the fire extinguisher model, which is really applicable to antibiotics—and we talk about a couple of things I had never thought about relative to antibiotics. And then secondly, we have the subscription model—definitely food for thought for any of you innovativ