Relentless Health Value

If you are a forward-thinking specialist right now, alarm bells may be going off, given COVID and/or the prospect of another COVID-style pandemic. Also, all of the capitated and advanced PCP (primary care provider) practices popping up. Also, virtual care models. FFS is a cushy status quo revenue model until it isn't. One underappreciated point might be that FFS is not only a revenue/payment model. It's also a business model. And as a business model, FFS very much drives how practices structure themselves to realize that FFS revenue. Consider that to earn a fee for a service, someone (a human person) has to physically do the service. So, all FFS-style businesses have an inherent incentive to add labor and not use technology in any way that actually reduces the amount of billable human hours involved in providing care to patients. But if that top-line revenue line goes down—wow!—you'll find yourself as many did with way too many employees. An FFS business model has zero flexibility when it comes to revenue that isn't consistently going up or, at a minimum, a flat line. If revenue plummets and payroll is big—big so as to power a way higher revenue number than is possible for whatever reason—you have a major financial problem on the quick. That is what I talk about in this health care podcast with Alan Kaplan, MD, MBA. Dr. Kaplan is assistant professor of urology at Georgetown University, and he is a practicing urologist. He recently cowrote a paper with Dan O'Neill in the publication NEJM Catalyst Innovations in Care Delivery. The article discusses COVID-19 and health care's "productivity shock," as they call it. Dan O'Neill, by the way, was on the show. Also, he was on EP287 and part of EP292. But in the article that Dr. Kaplan and Dan O'Neill wrote, they give some advice to specialists and hospitals who are looking to evolve with the changing marketplace. Spoiler alert: Conceptually, it's a shock to move from a place where, every year, you can count on your billings going up and up and move to a model instead that assumes that this is not the case. So, yeah, there's a little talk for sure about the joys and challenges of transitioning to value or a value-based payment model. But that's only the very first consideration. It's also about reconsidering the operating model and the strategic use of digital technologies. We talk about all of the above in this health care podcast. Quick sidebar: My interview with Dr. Steve Schutzer (EP294) might be a good follow-on for a very actionable work plan for specialists to implement some of the advice that Dr. Kaplan gives in this podcast. You can learn more by contacting Dr. Kaplan via LinkedIn. Alan L. Kaplan, MD, MBA, is a practicing surgeon, innovator, and health services researcher. After finishing his urology residency, a health care administration fellowship, and an MBA, all at UCLA, Alan helped build a multispecialty medical group in a highly underserved area of South Los Angeles. Alan is currently an assistant professor of urology at Georgetown University; an attending physician at the Washington, DC, VA Medical Center; and a physician advisor at IDEO, a human-centered design firm. Alan's work over the past 10 years has centered on value-based care redesign, aiming to transition to a more just, equitable, and sustainable health care system for all Americans. 03:51 Who are we actually discussing when we use the term specialist? 05:58 How does the PCP taking on more risk affect the specialists' path to value-based care (VBC)? 09:42 "Technology leads to … a reduction in labor burden … but in health care, that really hasn't been the case." 11:36 "Technology … in health care … has never really been about making the bottom line more efficient. It's been about expanding the top line." 13:39 What do specialists need to be considering if they want to stay relevant in the next 5 years? 14:27 EP292 with Brian Klepper, PhD. 16:53 Is there a future where specialists can transition from FFS to VBC while skipping the messy middle of a transition? 18:37 "The way we always did things is not the way that we have to always do things in the future." 25:20 "When all is said and done, the relationship between [PCPs] and the specialists that they refer … those relationships are really, really important." 26:14 EP219 with Arshad Rahim, MD, MBA, FACP. 28:13 What's going to be a big driver for providers to become more independent in the next 5 to 10 years? You can learn more by contacting Dr. Kaplan via LinkedIn. @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models in this week's #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #ffs Who are we actually discussing when we use the term "specialist"? @ALKaplan_MD of @DCVAMC discusses #valuebasedcare and #feeforservice models. #healthcarepodcast #healthcare #podcast #digitalhealth #vbc #ffs How does the PCP taking on more risk affect the specialists' path to value-based care? @ALKaplan_MD of @DCVAMC discusse

I was really vexed the other day when I read on Twitter—First rule of thumb: Stay away from Twitter—but I read on Twitter someone bashing telehealth because, for many older Americans, going to the doctor is the only thing on their social calendar. Ummm, OK. So, we celebrate the idea of paying a cardiologist or a nephrologist or an orthopedic surgeon or some other specialist how much in FFS (fee-for-service) payments to be a paid friend for 7 minutes? So, we're going to expect these expensive specialists to provide mental and behavioral health support when they have no particular mental health training, and, at the same time, we're going to weirdly slam telehealth for not enabling this obviously failing and expensive model to continue. And I'll tell you how I know it's failing: We have an epidemic of loneliness in this country. So maybe, instead of this serpentine logic, we should instead actually directly address the epidemic of loneliness. Maybe we should directly address mental health and behavioral health. Another oddity with this whole telehealth bash is how fast telepsychiatry services are taking off with COVID and how much, in general, people like it. Granted. Not sure about the elderly cohort who want to go see their doctor for the outing aspect of it, but if we're talking in generalities here, telehealth/telepsychiatry has been a boon for patients able to access behavioral health and mental health services. In this health care podcast, I speak with Don Fowls, MD. Dr. Fowls is president of Don Fowls and Associates, based in Scottsdale, Arizona. He's also past president of the Arizona Psychiatric Society. Dr. Fowls talks to us today about the importance of considering behavioral health when committing to value-based payment models or the management of populations. But we bookend the topic by me taking the opportunity to quiz Dr. Fowls on the impact of telehealth on behavioral and mental health. Two big points of emphasis are integrated data and the vitalness of industry stakeholder collaborations. Just to clarify some terms before we dive in here: Mental health is a subset of behavioral health. If we're talking about managing populations of patients, managing both is essential. Mental health typically, people say, has to do with substance abuse and people's thoughts and feelings. Behavioral health, meanwhile, has more to do with the specific actions people take and how they respond in various scenarios. Obviously, both are impacted by social determinants of health in a big way. And, as more and more evidence comes out, it becomes more important to integrate mental and behavioral health services within almost any site of care—or any site of care looking to improve patient outcomes and possibly succeed in a value-based world. You can learn more on Dr. Fowls's LinkedIn page. Don Fowls, MD, is a nationally known psychiatrist and health care consultant who works with organizations across the country to develop solutions for the many challenges they face today, including integration; value-based reimbursement; managing complex, special populations; and strategic partnerships. Dr. Fowls has helped several national and regional health plans and health systems integrate behavioral and physical health and develop value-based payment models to support this. Dr. Fowls previously served as chief medical officer and executive vice president of business development for ValueOptions and its parent company FHC Health Systems for 11 years. He also worked at Schaller Anderson Inc. as executive vice president, business development, and president and CEO of its behavioral health subsidiary. In Arizona, he recently served as chief medical officer for Mercy Maricopa Integrated Care as well as the behavioral health advisor to the Practice Innovation Institute in Phoenix, one of the CMS Transforming Clinical Practice Initiative grant awardees to transform the practices of health care providers. As part of this process, he co-led the Behavioral Health Affinity Group nationally. Dr. Fowls is chairman of the board of Copa Health, an Arizona-based community provider of services for behavioral health and intellectual and developmental disorders. Dr. Fowls is also past president of the Arizona Psychiatric Society and a fellow in the American Psychiatric Association. 03:27 Is telehealth here to stay? 06:16 "Now there's coverage in these medical clinics that there never was before." 07:38 "It's really trying to align the payment with the outcomes and services provided." 08:51 What does good look like? 12:06 "It's getting … plan and provider focused on achieving an outcome." 16:43 Do you really see outcomes change after implementing value-based payments? 17:40 "What are we really trying to achieve with this population? It's really four things. And these become … the pillars for outcomes." 23:29 "Right now, there's still way too much 'more is better.'" 24:16 "Well, that's great, but how did they do when they left? That's what you reall

Here's something I never really understood: how physicians and nurses more often than not get to be responsible for the entire patient journey, including, start to finish, patient satisfaction. But if you just take one look at any random poorly rated physician's reviews, they're usually littered with complaints about the front desk in the practice. Negative reviews, of course, are not limited to front desk diatribes; but there's often a lot of front desk commentary in them. It has always seemed to me to be a common and strange phenomenon in health care provider practices where the front desk is like a totally separate little fiefdom with a different mission statement and goals from the health care providers in the same exact office. Isn't that odd when you think about it? I mean, first, the front desk is literally physically separated from everybody else. No matter which direction you approach from, there's at a minimum a half-wall barrier surrounding them. Sometimes, in directions most likely to receive an attack, I suppose, there's been added a big glass barrier. Liliana Petrova pointed this out in EP236 of the Relentless Health Value podcast, and it was really the first time that I had thought about it at all and also thought about the implicit message this sends not only to patients but also to clinicians. That whole physicality of the setup, it just screams, "We over here have nothing to do with the mission or vision of anyone else in this place. We have our own thing going on over here, and to do it, we need to be protected from you all and all of your chicanery and untoward goings-on, you doctors and nurses and patients!" I was really inspired the first time I heard Jerry Durham from The Client Experience Company talking. His message, as I understood it, was that a practice really on board with helping patients achieve the best patient outcomes and, nothing for nothing, erode clinician burnout includes the front desk in their thinking. Jerry has said that there's four phases in the patient life cycle, as he calls it, which is sort of a synonym for the patient journey: Marketing The moment that a patient/person engages with the clinic or office Provider interactions The post course of care So, all of these phases—all four of them—are critical to both patient outcomes and experience but also, really, to business success. So, you kind of almost have to do well by doing good. The front desk is mostly responsible for that phase two: what happens when that person/patient engages with your office or clinic. In this health care podcast, as mentioned, I'm talking with Jerry Durham. He's a former physical therapist and practice owner who has worked with a whole lot of PT (physical therapy) practices and also other MSK (musculoskeletal) specialties among other clients. His message transcends the specialty, however. In this health care podcast, we get into a lot of aspects in terms of how a front desk can work for or against patient experience and outcomes. One of them is how a front desk can help secure a patient's relationship with a practice. Trust follows from a relationship. Lately, maybe even earlier than lately, study after study is coming out—including some that Rebecca Etz, PhD, talks about in EP295—which shows that, without a relationship and trust, patient outcomes are meh at best. (You can always count on me for scientific terminology.) But a lack of trust is a big hairy factor behind disparities in outcomes among different ethnic groups, for example, as one point to ponder. You can learn more at clientexperiencecompany.com or by emailing Jerry at [email protected]. Jerry Durham is a physical therapist with over 25 years of experience and 20+ years of business ownership. Jerry's singular passion is leveraging the entire practice team toward improved patient outcomes while boosting the practice bottom line. Jerry has spent significant time on the front line, answering patient calls and learning why patients think and act the way they do when interacting with the front desk. Jerry now leads The Client Experience Company, focused on improving both client outcomes and practice profitability through the leveraging of the patient life cycle by the front desk. 04:31 What is the patient life cycle? 05:33 What are the milestones of the patient life cycle? When does it start? 08:51 "This isn't a business solution; this is a patient-driven solution." 09:08 "What is best for the patient is best for business." 12:45 "The takeaway there is that your team members are all driving toward the same goal." 13:54 How does the front desk impact health outcomes? 16:00 What is the objective of a front desk to reduce provider burden? 20:38 "There's actually three roles at the front desk." 29:57 EP228 with Julie Rish, PhD, from the Cleveland Clinic. You can learn more at clientexperiencecompany.com or by emailing Jerry at [email protected]. @Jerry_DurhamPT discusses #patienttrust and #healthoutcomes in this week's

My guest in this health care podcast is Vincent Rajkumar, MD. Dr. Rajkumar is a professor of medicine at Mayo Clinic, Rochester. He's also a practicing hematologist at the Mayo Clinic with a focus on multiple myeloma. Dr. Rajkumar does research and conducts clinical trials. He's a well-known thought leader in questions about the cost of drugs in this country versus other countries. So, let me tell you what happened with this episode: I mentioned to a few people I would be speaking with Dr. Rajkumar, and every single person I mentioned it to sent me questions to ask him. So, that happened. I wound up with way too many questions; thus, I spent my Thursday evening organizing said questions into some semblance of a logical order. In this health care podcast, we talk about telehealth in oncology. We talk about standardizing treatment pathways in oncology amidst the growing complexity of said treatments and how this could potentially help community oncologists and generalists. We wrap things up with Dr. Rajkumar's insights on the high price of oncology and other drugs. You can learn more by reading Dr. Rajkumar's papers about the high cost of insulin, the high cost of prescription drugs, and cost-effective therapy of multiple myeloma. You can also watch his presentation on the high cost of prescription drugs. S. Vincent Rajkumar, MD, is the editor in chief of Blood Cancer Journal and the Edward W. and Betty Knight Scripps Professor of Medicine, Mayo Clinic, Rochester, Minnesota. His academic career was profiled by The Lancet (November 26, 2011). He is co-chair of the International Myeloma Working Group (IMWG) and chair of the Eastern Cooperative Oncology Group (ECOG) myeloma committee. He also serves as the associate editor for Mayo Clinic Proceedings, Leukemia, and European Journal of Hematology. Dr. Rajkumar has received several awards, including the Giants of Cancer Care Award (2019) from OncLive and the Robert A. Kyle Lifetime Achievement Award, an honor given by the International Myeloma Foundation (IMF). He has also received the Relentless for a Cure Award from the Leukemia and Lymphoma Society (2010), the John Ultmann Lecture and Award (2011), and the Janet Davison Rowley Patient Impact Research Award from Cures Within Reach Foundation (2015). He was named Mayo Clinic Distinguished Investigator in 2018. He serves on the board of directors for the IMF and is a member of the National Institutes of Health's Multiple Myeloma Steering Committee. Dr. Rajkumar has over 600 publications, including over 350 peer-reviewed original research papers and over 200 reviews and book chapters. 01:45 What is the perspective on telehealth and its impact on oncology? 03:50 "Cancer has become extraordinarily complex." 05:32 Is it possible to still have community oncologists in the advent of technology? 08:39 What's the viability for flat-fee reimbursement in oncology? 14:31 "The pathways should be designed and developed by people who don't have a financial stake [or] conflict." 18:34 "Part of the problem for physicians is, you want to deliver the best care." 21:23 "There are no allies in this fight for lower prescription drug costs." 23:18 "This is not like a television or a car where you can say you can live without it." 24:33 "It's absolutely not a free market." 25:35 "Each drug is a monopoly." 30:22 "When you do value-based pricing, you're not putting a price on anybody's life. You're only putting a price on what [a] drug is worth." You can learn more by reading Dr. Rajkumar's papers about the high cost of insulin, the high cost of prescription drugs, and cost-effective therapy of multiple myeloma. You can also watch his presentation on the high cost of prescription drugs. @VincentRK of @MayoMyeloma discusses #oncology #FAQs on this week's #healthcarepodcast. #healthcare #digitalhealth #healthtech What is the perspective on telehealth and its impact on oncology? @VincentRK of @MayoMyeloma discusses #oncology #FAQs on this week's #healthcarepodcast. #healthcare #digitalhealth #healthtech "Cancer has become extraordinarily complex." @VincentRK of @MayoMyeloma discusses #oncology #FAQs on this week's #healthcarepodcast. #healthcare #digitalhealth #healthtech Is it possible to still have community oncologists in the advent of technology? @VincentRK of @MayoMyeloma discusses #oncology #FAQs on this week's #healthcarepodcast. #healthcare #digitalhealth #healthtech "The pathways should be designed and developed by people who don't have a financial stake [or] conflict." @VincentRK of @MayoMyeloma discusses #oncology #FAQs on this week's #healthcarepodcast. #healthcare #digitalhealth #healthtech "Part of the problem for physicians is, you want to deliver the best care." @VincentRK of @MayoMyeloma discusses #oncology #FAQs on this week's #healthcarepodcast. #healthcare #digitalhealth #healthtech "There are no allies in this fight for lower prescription drug costs." @VincentRK of @MayoMyeloma discusses #oncology #FAQs on this week's #h

PCPs (primary care providers) are really important to population health. Primary care is the foundation of any well-functioning health system, I am sure many listening to this podcast know well. For the Triple Aim to happen, patients really need access to robust primary care. This has been affirmed by almost anyone who looks into it. And yet, in this country, our system sort of anemically supports our primary care colleagues. As a general statement, poking and prodding and procedures are compensated at a far higher rate than anything requiring cognitive services. What a PCP or a pediatrician mainly does all day is really cognitive. It's listening and thinking and counseling and coordinating. But here is maybe an underappreciated point: If we're going to measure PCP performance, then we need the right measures to measure that performance. You might be doing this measurement as a basis for incentives or maybe for continuous improvement programs. Either way, if you don't have the right measures, then maybe great primary care is under-rewarded or your continuous improvement process is counterproductive—you're incenting the wrong things, you get the wrong activity. And to add to that, PCPs (ie, practices) can spend upwards of $40,000 a year of uncompensated time trying to add and subtract and tote up the difference in all these varied and potentially inapplicable measurement standards coming at them from all manner of directions. My guest in this health care podcast is Rebecca Etz, PhD. Dr. Etz and the team over at The Larry A. Green Center have worked hard to create a set of 11 performance measures for primary care. These measures went through the wringer as far as their creation and validation. These 11 measures take into account what patients want, what primary care clinicians (including pediatricians, nurse practitioners, and others) think is most important and possible to provide, and what payers want to pay for. These 11 measures are aligned across the three stakeholders, and they are actionable. Neither of these descriptors is anything to take for granted. Rebecca Etz, PhD, is associate professor of family medicine and codirector of The Larry A. Green Center, which is in Richmond, Virginia, at the Virginia Commonwealth University. You can learn more at green-center.org. Rebecca S. Etz, PhD, is an associate professor of family medicine and population health at Virginia Commonwealth University (VCU) and codirector of The Larry A. Green Center—Advancing Primary Health Care for the Public Good. Dr. Etz has deep expertise in qualitative research methods and design, primary care measures, practice transformation, and engaging stakeholders. Her career has been dedicated to learning the heart and soul of primary care through three main lines of inquiry: (1) bridging the gap between the business of medicine and the lived experience of the human condition, (2) making visible the principles and mechanisms upon which the unique strength of primary care is based, and (3) exposing the unintended, often damaging consequences of policy and transformation efforts applied to primary care but not informed by primary care concepts. As a member of the VCU Department of Family Medicine and Population Health and previous codirector of the ACORN practice-based research network, Dr. Etz has been the principal investigator of several federal and foundation grants, contracts, and pilots, all directed toward making the pursuit of health a humane experience. Recent research activities have included studies in primary care measures, behavioral health, simulation modeling, care team models, and adaptive use of health technologies. Dr. Etz currently leads the fielding of a weekly survey regarding the response to and impact of COVID-19 on US primary care practices. She also serves on the National Academies of Medicine consensus study, "Implementing High-Quality Primary Care." 03:41 Why is primary care one of the "best-kept secrets" of better health outcomes? 08:38 "Measures are a form of communication." 08:51 "If the way that you are assessed does not actually match up with the work you do or what you find to be important, it's pretty demoralizing." 11:41 "It is the outcome of health care, but it is not the same thing as quality." 16:31 "It creates a financial incentive to hit a target by any means necessary." 18:06 "We incentivize people to have good outcomes, and what that means is that electronic medical records are no longer simply databases that tell us what the health of the population is. They are databases that tell us what is the optimal picture that a clinician is able to paint of their patients." 21:07 "Primary care is a relational field." 22:14 "How does this relate to cost and utilization?" 26:43 "I think we all know that fee for service is death." 27:11 How has the measure of PCPs in the time of COVID held up? 27:32 What measure performs worse in the time of COVID? 28:17 "Primary care is the place that everybody goes." 31:1

Lately, several of the Relentless Health Value episodes have focused on digital health companies and their disruptive potential on referral flows of traditional provider organizations. We also talked about other goings-on with the potential to encroach on hospital systems and independent docs alike. For example, we've got Walmart getting, in a big way, into the health clinic business. We've got VillageMD and Walgreens teaming up. We've got mergers in the on-site clinic space. There's just a lot of action. But let's talk about what Dan O'Neill called "physician entrepreneurship" in EP287. Dan said that now is a fantastic time for entrepreneurial physicians to reinvent the practice model. This is true because many, including Dr. Matt Anderson in EP292, have said that it's not an entirely safe bet if you're a doc right now to hope that all the practice changes initiated by COVID (like telehealth, etc) go away like a bad hangover the second this pandemic gets stuffed back into Pandora's box. So, there's risk mitigation strategies at play here, but there's also a great opportunity for those who figure out how to legitimately improve patient outcomes in a way that consumers and patients love and that employers can easily contract for. Here's the bottom line: Some, not all, of these new-fangled deliverers of health care have great marketing and maybe a great Net Promoter Score; but effectiveness is less than well validated. Don't get me wrong. There's a whole lot of providers who aren't sure what kind of results they deliver and who aren't exactly delivering amazing and sticky customer experiences. So, we certainly can't forget that, as Bob Matthews has said, in the land of the blind, the one-eyed man is king. But what about a physician practice known in a local community that works together to create a Center of Excellence? Now, that's interesting in this land of the blind. You get all the history and the advantage of being the "default care provider." But you also are well poised for a post-COVID future, even in the face of all this disruptive activity. In this health care podcast, I speak with Steve Schutzer, MD. Dr. Schutzer is a physician executive for the orthopedic service line at Trinity Health of New England and medical director of Connecticut Joint Replacement. Dr. Schutzer knows a lot about setting up a COE, otherwise known as a Center of Excellence. He knows a lot about how to be a physician entrepreneur, and he knows how to compete in emerging market conditions. You can contact Dr. Schutzer at [email protected]. Steven F. Schutzer, MD, graduated with honors from Union College and the University of Virginia School of Medicine. Following a surgical internship at the University of Rochester, he served as lieutenant in the Medical Corps of the United States Navy. After his tour of duty, Dr. Schutzer did his general surgical training at the University of Rochester and then completed his orthopedic residency at the University of Connecticut. He was then a fellow in adult hip and reconstructive surgery at the Massachusetts General Hospital, after which he entered practice with Orthopedic Associates of Hartford. He is currently on the staff of Saint Francis Hospital in Hartford, Connecticut. Dr. Schutzer is a founding member and medical director of the Connecticut Joint Replacement Institute (CJRI), a Center of Excellence at Saint Francis. He is also president of the management company overseeing the Institute, the Connecticut Joint Replacement Surgeons, LLC, as well as physician executive for the orthopedic service line at Trinity Health of New England. In 2014, Dr. Schutzer and two colleagues, Ms. Steph Kelly and Ms. Maureen Geary, launched a consulting company, Novel Healthcare Solutions, whose mission is to establish effective and trusting business relationships between physicians and hospital partners—and then create orthopedic Centers of Excellence. 03:22 Why would competitive physician groups gang together? 07:32 "Even if you never … bundle, going through the implementation process … will yield incredible unrecognized value." 08:49 "It demands an end-to-end care redesign process." 10:10 "The value of a COE is really unquestionable." 10:18 "For every dollar saved [in a COE], two-thirds was in the quality side, and one-third was in the price point." 13:08 Slide deck discussing the definition of a COE and its seven building blocks.14:05 "I'm talking about business relationships between the physicians … these are the most fundamental [relationships]." 15:23 "It is all about trust." 15:48 What is the most central issue as to why a COE does well or fails? 16:25 "It's not just data. It has to be actionable data because physicians naturally don't trust data." 21:54 "Employers are definitely taking note to patient-reported outcomes." 22:37 What is the seventh element that is necessary for a COE, and what is fundamental to that element? 23:27 Where will fee-for-service doctors be in 2 to 3 years? 24:45 "T

Let's cut to the chase here for our conversation about co-pay cards offered by pharma companies versus co-pay accumulators and co-pay maximizers deployed by health plans. This whole war of the co-pays started back in the day when PBMs (pharmacy benefit managers) began to shake down Pharma for higher discounts. The prize that PBMs offered Pharma was lower co-pays for patients. It's a well-known fact that the higher the patient out of pocket, the lower the market share of the drug—the old supply-and-demand curve at work. So, the PBMs and health plans kind of had an ace up their sleeve because they control how much the patient pays out of pocket. And so, they use that ace to pull in higher discounts from Pharma. "You'll make it up in volume," they told Pharma. "We'll make sure you get lots of patients by putting your drug on a lower formulary tier and giving patients who take your drug the lowest possible co-pays." At a certain point, pharma companies started to get mad about their dwindling net prices. And they're pretty smart. So, Pharma came up with a workaround to PBMs holding them hostage for lower net prices. Pharma decided to hand out co-pay discount cards. Then, they don't have to pay the PBM. They can finesse lower patient co-pays all by themselves. Except now, the PBM sees this and they raise. Enter co-pay accumulators and co-pay maximizers. For this part of the extravaganza of game theory at its finest, I'll let Dea Belazi, PharmD, MPH, explain. Dea is the president and CEO over at AscellaHealth. He's a pharmacist by training who has worked for Pharma, then at a health plan, then spent lots of time in the PBM space. Now he's working to create a different kind of pharmacy benefit at AscellaHealth. He has seen this tangled web from pretty much every angle. One thing to point out here before we begin: In the olden days, this whole war of who has leverage over who transpired in the context of small molecule drugs in competitive markets. So, like, Lipitor versus Crestor versus simvastatin—and they all cost, like, $100 a month. If the health plan made it untenable to get one of those drugs, they usually made another one in the same class financially attractive. So, the patient had options, and the stakes were a lot lower. Now this same war is being fought on the specialty side of the house, where drugs cost thousands or tens of thousands of dollars a month and the patient may have but one option. So, if it's made financially toxic for a patient to get that one drug, then the patient has to choose between their family's health and dipping into their 401(k). In these cases, Pharma can be, sort of authentically (and the "sort of" is an important qualifier), a hero who steps in and helps patients who are basically functionally uninsured because they can't afford the co-pays and deductibles to actually use the insurance they're paying handsome premiums to have. Pharma can step in and help via co-pay discount cards or through patient assistance programs to help those with lower incomes. But let me point out an obvious but rarely-mentioned-in-the-same-sentence connection. If the patient cost share is really high, there are at a minimum two parties responsible for that: the insurance company, who set the patient cost share and may have created functionally uninsured members in the process, and the pharma company, who may have set the price of the drug untenably high, maybe way over what the value of the product was. Neither is an innocent bystander, and the patient, sadly, is caught in the middle of this war. You can learn more at ascellahealth.com. Dea Belazi, PharmD, MPH, has more than 20 years of experience in the health care industry, mostly developing and managing pharmacy benefit management companies. He is currently the president and CEO of AscellaHealth, a national specialty pharmacy benefit manager (SPBM™) serving commercial, Medicare, and Medicaid segments. He was part of the development of PerformRx, a PBM owned by Keystone First Health Plan, as well as another, FutureScripts, an Independence Blue Cross company that was sold to Catamaran a few years ago. Dea holds a PharmD from the University of Rhode Island and completed his dissertational work at Brown University. He later completed a Master of Public Health from Johns Hopkins University and a post-doc health outcomes research fellowship at Thomas Jefferson University. He is a reviewer for multiple medical journals and sits on multiple boards. 05:03 "The concept of co-pay accumulators wasn't just a … PBM thought, but it also came from their customers, whether it was health plans or employer groups." 10:00 "[This is] literally a math problem based on, 'Do I spend it now? Do I spend it later?'" 11:31 What reason do employers and payers have for doing this? 15:26 "This is another mechanism for payers to push down additional cost to both the patient and now the pharma company." 19:57 EP241 with Vinay Patel. 20:33 "I don't think accumulators are really fo

Welcome to Episode 292, Part 2. This is the second part of a two-part episode, but, in a way, you can listen to whichever part you want first. So, if you wound up here first, no worries. Just go back when you have a sec and listen to Part 1. There's some good stuff there you don't want to miss, including some background information that might be good to have. This episode, as well as the last one, is about Teladoc buying Livongo. I am going to call the combined organization T&L because I heart acronyms as much as you do. Here's the thing with T&L: They are not alone in their quest to disrupt the traditional health care delivery market. You also have Aetna making a plan design that advantages CVS clinics. You got Humana doing the home health thing. You got Walmart and Oak Street hooking up in Texas and risk contracting with managed Medicaid and Medicare Advantage. You have employers across the country direct contracting with Centers of Excellence and buy in perspective bundles. Also, speaking of employers, on the on-site clinic space, Premise Health just recently acquired CareHere. These two organizations will reach 11 million eligible lives at 2200 customers in 300 markets. All this being said, let me make a fairly obvious point: Increasingly, the competition is going to be about outcomes—or perceived outcomes. Competition is going to be around the value delivered (ie, quality divided by cost). This I like. To me, it's a tragedy that the health care industry can get away with charging prices no one would consider fair and delivering subpar health care let alone health. I want some of these organizations that do a really nice job coordinating care and which patients really appreciate to do well by doing good. And I love that some of the payers out there—some of the employers and even some of the Medicare Advantage and other health plans—recognize the value that these organizations can deliver. But let's consider the implications of this—notably, here's one: Few, probably even the very best, for example, endocrinology practices or maybe even cardiology practices, have a bead on how well they ultimately attenuate downstream medical costs. They might not even know, outside of what they are required to report for quality incentives, how well they are consistently creating better patient outcomes. Livongo does—or at least claims they do—and lots of employers and plans buy the results they're selling to the tune of something like $300 million in sales this year. Here's what I don't like: What is shaking out is a turf war, and the weapon of choice may or may not be authentically better patient outcomes. Some of the weaponry here is built on a marketing "chassis." The one who has the best marketing shall triumph. People judge books by their covers, and that's a cliché for a reason. You can read Al Lewis's blog post on Livongo, where he dug into their purported results. Then listen with your left ear to some of the chatter on the street about how Livongo is more of an employee retention tool than, you know, a clinical tool. I don't kn0w where these rumors started, but I keep hearing that because the Livongo NPS (Net Promoter Score) is high and employees, including executives, think it's pretty cool as a service, that maybe, given this, that it's okay if many of the Livongo charts and graphs don't have labels on their Y axes. And it kind of, you know, makes sense if you actually sit there and stare at them as I have done. All this I just said? Background noise. The games have begun, and the winners will be those who consumers/patients love. It'll be the ones who know how to market to employers or Medicare Advantage plans. It'll be the ones who can succeed in risk-based models. There you go. There are your three success factors. In this health care podcast, I speak with Matt Anderson, MD, MBA. Matt sees the ecosystem through the eyes of an innovation leader at a health system. And my finale interview of our two-part series here is Brian Klepper, PhD, principal over at Worksite Health Advisors. Brian will speak from the POV (point of view) of employers. You can learn more at bannerhealth.com and drmatthewanderson.com and connect with Dr. Anderson on Twitter at @DrAnderson19 and on LinkedIn. You can also learn more at careandcost.com, by emailing [email protected], and by visiting validationinstitute.com. Matthew Anderson, MD, MBA, has a passion for finding unique solutions to difficult problems in health care. He focuses on creating environments that allow patients and physicians to have frictionless experiences. Through insights gained in private practice, leading physician groups, and embedding himself in the health care innovation landscape, he can empower those looking to improve the health of communities and the well-being of those that dedicated their lives to providing care. He has been a business owner, medical director, and chief medical officer and now leads clinical innovation projects for Banner Health and

This is episode 1 of a two-part show about the potential impact of the Teladoc acquisition of Livongo. To get started here, in deference to the fact that we're all in the health care industry, let's agree on an acronym, shall we—because I can't keep saying Teladoc-Livongo. So, I'm going to go with T&L heretofore that will refer to the Teladoc acquisition of Livongo. What is the general merged T&L pitch? Here it is (I looked at their investor deck): T&L is going to use technology to transform the experience of living with a chronic condition and provide a differentiated consumer experience. The merger will also create a consumer-first, data-driven digital health experience that puts the consumer in charge. T&L will also translate deep consumer data to improve member outcomes and cost savings. Here's why I think that whole slide is the tip of a disruptive iceberg. First of all, we're in the middle of a land grab for patients. For my full land grab observational analysis, you can read the show notes of the Labor Day 2020 encore episode with Dr. Joe Selby or listen to it. But consider these intertwined points from the T&L investor deck: 80% of large employers believe virtual care will significantly impact the delivery of health care in the future—80%! Also, implementing more virtual care solutions is the number one priority for large employer health initiatives. That's something. In the T&L investor slide deck, slide 14 shows the TAM—otherwise known as total available market—that T&L thinks they're going to get. Spoiler alert: It's a $121 billion market, and they're coming for you. Anybody who thinks you're going to continue to care for patients with chronic conditions all by yourselves, at a minimum, enter your new frenemy. Here's another reason why I think the T&L merger is the tip of the iceberg of disruption: They talk about, again in their investor deck, how they're going to be fully scalable across multiple conditions, including CHF (chronic heart failure) and CKD (chronic kidney disease), plus integrated behavioral health; and also, they've been rumored to be courting MSK (musculoskeletal) outfits like Hinge Health. So, it's not just diabetes anymore. Here's another point: the referral flow. T&L are looking to start to disrupt the referral flow of traditional models. I mean, think about this. If they intercept the patient at the PCP level with Teladoc, then they can refer to a provider in the cloud, like Hinge Health or Livongo or one of the many behavioral health/mental health services lighting up our skies right now. Or consider this: Say I'm in Pennsylvania. I might not want my prostate specialist to be a few hours away if I have to go there on the regular. But let's just say the specialist offers telemedicine appointments and now I only have to go there, like, once a year. Here's the point I'm making: Vertical integrations like the one that Teladoc created by acquiring Livongo is a model that has all the potential of vertical integrations in the traditional sphere. Captive populations are a goal for a reason. And having a digital front door could enable all kinds of very geographically dispersed competitors that traditional health systems may not have realized are competitive. Is this my hypothesis? Nope. T&L say it flat out in their investor deck. Their goal is to increase enrollment and utilization by referring individuals across Teladoc and Livongo products. Here's some other facts to throw in the stew that I thought were interesting: You've got consolidated health systems right now who, some studies show, have raised their rates 23% higher than in markets with competition. And the outcomes of said consolidated health systems in patient satisfaction and quality—pick a measure—aren't any better as a trend line than health systems in competitive marketplaces with a whole lot lower prices. So, you've got costs going up and up, meaning that, as an equation, value is going down and down. Employers are getting pissed. Consumers are just done. You have Medicare Advantage (MA) collecting data and worrying about social determinants of health and holding providers accountable to deliver. If I'm an employer or a managed Medicaid plan, maybe an MA plan, and if I'm in an area where the only games in town are wildly expensive (like 23% more expensive) with low patient satisfaction or whatever—even average—and half my star ratings are based on patient satisfaction, you can see where I'm going with this: that these virtual options that are springing up might be attractive to people paying the bills. In this health care podcast, our lineup includes Bob Matthews, who can offer an interesting perspective because he is the president and CEO of MediSync, an entity doing some neat stuff in the cardiology space, also managing chronic conditions. He's also the VP of quality for PriMed Physicians in Ohio. So, he can kind of represent the entrepreneurial perspective but then also the PCP perspective. Then we're also going

Medicare Advantage (MA) enrollment has nearly doubled over the past decade. It grew 37% from 2016 to 2020. Right now, MA comprises nearly 40% of the Medicare population—and that number is only expected to grow. So, in case you've been out of the loop, at the beginning of 2020, CMS (Centers for Medicare & Medicaid Services) rolled out a third category of these "chronic supplemental benefits." And these chronic supplemental benefits allow plans to offer basically services to attenuate social determinants of health to offer stuff like nonemergency transportation, meals, home modifications … that whole list. This is all, really, part of a broader bipartisan effort to move Medicare from an acute care to a chronic care program. Then … corona. So, the question I'm kind of wondering about at this juncture is, Were/Are MA beneficiaries able to maintain their health status better than, say, other plan designs, especially given some of these chronic supplemental benefits, which you'd think would be super helpful in the middle of a pandemic? This should make sense, and it should really be true. At its core, MA is, as John Gorman put it when he was on the show last year, the biggest value-based payment experiment in the universe. And patient outcomes have definitely improved for MA patients over traditional FFS (fee for service), especially in the south and in other areas rife with cardiovascular and metabolic disease. So, that sounds great. Now let's talk about the cash money denominator in the value equation. Humana reported $1.8 billion in profit for the second quarter. That was nearly double its haul in Q2 2019. So far, 2020 has seen a profit that is a 94.5% increase year over year. Humana's earnings are not an outlier. MA plans across the board did very well, thank you very much, in the middle of a pandemic. Given that MA hasn't actually reduced PMPM (per member per month) costs last time I looked at it, you'd think and hope that the confluence of higher rates and less restrictions on extra benefits should definitely lead to greater scrutiny on the plans by CMS. We'll see what happens. Anyway, it occurred to me that it might be interesting to get a bead on what MA plans themselves have been contemplating and thinking about relative to the supplemental benefits et cetera. In this health care podcast, I speak with Betsy Seals, cofounder of the Rebellis Group. Betsy spent many years working with and for Medicare Advantage plans. I thought Betsy would be the perfect person to talk to to get a bead on what's happening on the MA front right now. You can learn more at rebellisgroup.com. Betsy Seals is a cofounder and chief operating officer at Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage organizations and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 18 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the Medicare landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that addresses social determinants of health, and health plan operations. Betsy got her start in managed care on the health plan side, where she held roles in compliance and operations. Betsy also spent many years as a managed care compliance and operations consultant with Gorman Health Group, where she exited as chief consulting officer in the fall of 2018. 03:45 What is a Medicare Advantage plan? 04:02 The core imperatives for leaders of Medicare Advantage plans. 04:31 "How is risk adjustment functioning?" 04:34 Making disenrollment rates and member complaints top of mind for MA leaders. 05:40 "We all want to know why members are leaving. Well, they're telling you!" 05:50 Star rating measures. 07:33 "Will Medicare beneficiaries really have confidence … going into the doctor's office … next year?" 09:11 "Now, it's not just 'Is your doctor in the network?' It's 'Does your plan also offer telehealth?'" 12:13 "When you really look at Medicare beneficiaries aging into the program or … younger … beneficiaries, their shopping trends and their consumer expectations are very much the same as yours and mine." 13:58 CMS's adjustment in April that allows MA plans to make changes to their benefits midyear to provide to beneficiaries' changing needs during the pandemic. 16:01 Supplemental benefits as a decision-making factor in enrollees' Medicare Advantage plan selection. 16:28 "The decisions made during this time with how to increase benefits or how to address the issues going on with your membership will have a really great impact on [your] AEP [annual enrollment period]." 18:12 "I think that there's a real lack of understanding … around what issues are impacting their actual membership … but really understanding the demographi

There is a land grab going on right now, the likes of which the health care industry hasn't seen before—at least in our generation. Spoiler alert: There's a whole episode of Relentless Health Value coming up on the impact of the Teladoc-Livongo hookup. And that is totally relevant to the point I'm about to make. But let me just start with a little bit of background: American patients—let's get real here—have no more money to spend on health care every year. Really. I mean, you look to employers. The government? Who knows? But let's just say for the purposes of this discussion that what's going on right now is a zero-sum game—that the dollars in the system every year are the dollars in the system, and if you want to increase your revenue as any given health care stakeholder, you've got to take those dollars from somebody else. Alright … now consider this: Previously, if a health system, say, were going to make a list of their competitors, they'd probably list the health system down the street, maybe the one in the next town over if there seems to be a lot of commuting. Oh, my, how we no longer live in that simple world! Enter the pandemic and patients not only accepting but kind of digging virtual care and its convenience and its accessibility. Now consider what happened to brick-and-mortar stores who didn't add online retailers to their list of competitive threats. Virtual entities doing chronic care management, diabetes, musculoskeletal, other population health endeavors … these are now or will soon enough be head-to-head competitors to in-person care settings. My local health system, they may also decide to stand up to telehealth—and many of them did. But if the playing field is now in the Cloud, how's the patient experience on their systems? Everybody accepted that, in the beginning, they were kind of buggy and calls dropped and all you could see was the doctor's ear in a weirdly dark room or something. But six months later or a year later? Not exactly sure when patients' patience will run out, especially when there are companies out there who built amazing virtual experiences from the ground up and who, by the way, are often hired by health plans, who, by the way, make it financially, let's just say, attractive for patients to use those services that the plan is providing instead of the big expensive consolidated health plan that raised their rates 30-fold over the past couple of years like one of them anecdotally did. So, you start to see why, if I were a health system or a provider executive, I'd kind of shuffle the patient centricity, design thinking, patient experience—that whole bunch—to the first tab of my spreadsheet. Patients have, at this moment, unprecedented choice; and so do their employers, nothing for nothing. As Dr. Matt Anderson told me the other day, if a health system thinks that it's going to make the difference by doing more specialty services and expensive procedures, that might be a risky bet. So, anyway, I thought it might be a good idea to replay my conversation with Dr. Joe Selby from early last year. Dr. Selby is the [now-retired] executive director of PCORI, otherwise known as the Patient-Centered Outcomes Research Institute. PCORI is an independent nonprofit organization in Washington, DC. Since December 2012, PCORI has funded hundreds of studies that compare health care options to learn which work best given patient circumstances and preference. So, it's definitely good background information. Anyone driving for the best patient experience might want to have it at their fingertips. You can learn more at PCORI.org.

Here's a couple of sentences ripped from the headlines recently: It is free to be tested for COVID-19 in the US, but the cost of treatment can be shocking. Even if you're insured, the deductible and co-pay can add up to several thousand dollars. And if you're uninsured, the financial toll is even uglier. That's what Boston resident Danni Askini learned when she got a $34,927 bill after receiving treatment in a local emergency room for COVID. That's from Time magazine. Episode 260 of the show was about the Shkreli Awards and the worst profiteering in health care. The judges of the Shkreli Awards bucketed the winners into a few categories. One of the categories of "winners" was called Schizophrenic Compartmentalization, and this schizophrenic behavior seemed super applicable to hospitals this past year. This schizophrenic compartmentalization happens when the person who wrote the mission statement and probably doctors and nurses are on a totally different planet than the billing department. So, I wanted to take a look at a couple of mission statements just as a reference point, including the mission statements of the hospitals that won Shkreli Awards in the Schizophrenic Compartmentalization category. Luckily, there is a Web page where hospital mission statements are all collected in one place, so I did not need to travel far to confirm that they are all very, very similar—something along the lines of treat patients with compassion, be a productive member of the community, ease suffering, and give the highest value to all concerned. That's very noble and what I would expect a hospital, honestly, to be striving toward. Here's the thing, though. This is what the whole hospital is supposed to be doing. I didn't find one mission statement that said everybody except the finance team is subject to this mission statement. Those guys over there? They have their own. In this health care podcast, I speak with Doug Aldeen. Doug is an attorney. He is generally hired by self-insured employers. He has dealt with hospital finance teams for two decades, so he is the perfect person to dig into the delta between the hospital's mission statement and the finance team's mission statement. This is what we talk about in this podcast. Doug also offers up some solutions at the micro and the macro level. One vocabulary word before we get started: RBP is otherwise known as reference-based pricing. This means when a health plan, usually a self-insured employer's health plan, says that they're going to pay for health care services based on usually the Medicare rate. So, they'll pay, like, 1.5 times or 2 times what Medicare pays, for example. Do I want to be a little bit sensitive right about now to some of the hospitals that are struggling under the weight of COVID and the shutdowns that have been transpiring across the country? Yeah, I do. At the same time, there is absolutely no excuse to take advantage of those that you claim to serve. There's a big delta between charging a fair price and wrenching dollar bills out of the sweaty hands of hard-working Americans just because you can. You can learn more by emailing Doug at [email protected] or following him on LinkedIn. Doug Aldeen is an Austin, Texas–based health care and Employee Retirement Income Security Act (ERISA) attorney who recently served as ERISA counsel on behalf of the Berkeley Research Group in New York City to the $7.7 billion May 2016 acquisition of Multiplan and its medical bill repricing product Data iSight by the private equity firm Hellman and Friedman. Since 1997, he has represented reference-based pricing organizations, a bundled payment software platform, PPO networks, medium to small self-funded plans, third-party administrators, and provider-sponsored health maintenance organizations in various capacities, including Herdrich v. Pegram, which was argued before the US Supreme Court in 2001. Moreover, he serves as a resource to national news organizations regarding issues on health care and as a consultant with the Governmental Relations Committee at the Self-Insurance Institute of America in Washington, DC, and as an adviser to RIP Medical Debt, which has abolished over $1.2 billion in medical debt. Doug received his JD from the University of Illinois. 03:59 Exploitive hospital billing practices. 04:20 The impact these exploitive billing practices have on patients. 04:45 Why would a hospital exploit the patient with their billing practices? 09:31 "You could adversely affect 3 million people." 10:53 The "scorched earth" policy. 11:33 EP242 with Marty Makary, MD.12:28 "I think the long-term plan … is preserving the network." 13:08 EP186 with David Contorno. 16:03 A third exploitive billing process: hospital-owned insurance plans, or "payviders." 20:35 MOOP: maximum out of pocket. 21:07 RBP: reference-based pricing. 21:58 Exploitive tactic #4. 26:03 The solution to changing exploitive billing strategies. 26:39 "You have to be willing to travel." 28:34 EP240 wit

You may or may not know (I don't know why you would, honestly), but I speak Swedish. I mention this because there's this famous and really culturally emblematic Swedish word which is this: lagom. It means "the exact right amount." In Swedish culture, the exact right amount deserves its own word. For example, "Did you have enough watermelon?" "Why, yes, I had half a slice. It was lagom." Lagom has no direct translation in US English because, in the United States, we don't need a word for "the exact right amount." Why? Because the exact right amount already has a word: the most. More. More is always better. I think this shows up in health care in this country, and it definitely showed up in my conversation with Dr. Bishal Gyawali in this health care podcast. There's this cultural bias in this country that more is better. The point I'm making is that there's a sort of fundamental belief that aggressive therapy—the most aggressive therapy—is the best therapy and conservative therapy, or following the treatment pathway that works for the majority of patients, is kind of like a surrender. It's not about being pro or anti anything. It's about being data driven. It's about finding the "lagom" amount of care that the data suggest is the best amount of care and not immediately assuming that if something isn't done that it's been a subpar outing. In this health care podcast, I'm talking with Bishal Gyawali, MD, PhD. Dr. Gyawali is a practicing oncologist; assistant professor at Queen's University in Kingston, Canada; and he has studied and worked in Nepal, Japan, and the US, and now in Canada. He's a thought leader in studying the data impartially and finding ways to help patients and oncologists systematically make the best decisions toward high-value oncology care that is not financially toxic. You can listen to Dr. Gyawali sum this up in his own words or read his paper on the topic, but here's his top-line suggestions: Follow NCCN and ASCO guidelines. Payers: Negotiate drug prices based on clinical benefit—and this means you, too, Medicare. Hospitals: more price transparency up front but also for the doctors. Financial toxicity is a thing. It's been shown that patients who are suffering from financial toxicity die earlier. So, this is definitely data that a doctor needs to know as much as some kind of clinical decision-making factor. Hospitals: Have a financial advisory desk. Correct the misincentives at the physician/patient level (ie, all that's going on with "buy and bill"). You can read Dr. Gyawali's published paper in JAMA and connect with him on Twitter at @oncology_bg. Bishal Gyawali, MD, PhD, is a medical oncologist with work experience in various low- and high-income countries. He graduated medical school in Nepal with seven gold medals and received his PhD from Nagoya University, Japan, as a MEXT scholar. He then practiced as a medical oncologist at Civil Service Hospital, Kathmandu, Nepal. He currently works as a medical oncologist and scientist in the Division of Cancer Care and Epidemiology at the Queen's University Cancer Research Institute in Kingston, Ontario, Canada, where he is also an assistant professor of public health sciences. He was a research fellow at PORTAL (Program On Regulation, Therapeutics And Law) from 2018-2019. He also serves as a medical consultant for the not-for-profit Anticancer Fund, Belgium, and as editorial board member for the Journal of Global Oncology and ecancer. His clinical and research interests include cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. Dr. Gyawali is an advocate of the "cancer groundshot," a term he coined to imply that research investment should be made on known high-value interventions in cancer care that are affordable and easy to implement globally. Dr. Gyawali is active in the oncology and clinical research communities on Twitter. 03:18 Oncology decisions on the individual level and oncology policy decision making. 05:10 Reverting to the mean. 06:29 "We're assuming … more care is good care, which is not necessarily true." 06:49 "What we need to focus on is above-average level of health outcomes." 07:55 "Sometimes we forget the goal, and we get so entangled in the path itself that we forget the destination."11:19 Cutting out low-value care during the pandemic. 12:09 Reevaluating cancer screens and looking at the evidence for appropriate use cases. 13:24 Distinguishing the term "survival" from "mortality." 16:34 "If a person dies, it does not matter what the person died of." 17:26 "A lot of the things that we do routinely in medical practice need to be reevaluated." 18:53 The FDA approval of oncology agents and things that make a difference. 20:37 "What exactly are we gaining from these drugs?" 20:53 EP282 with Aaron Mitchell, MD, MPH.23:15 Dr. Gyawali's advice to policy decision makers. 23:42 Policy decision-making interventions that are possible. 24:50 "

Disclaimer before we get started here: This show is probably a 300-level class in pharmaceutical/PBM relations. If you are tuning in for the first time and you aren't pretty familiar with the role of PBMs, I would go back and listen to, say, episode 241 with Vinay Patel or episode 166 with Tim Thomas from Crystal Clear Rx. OK, now that that's out of the way, if you're still with me, this episode is like a ride on a roller coaster. In this health care podcast, I talk with Mike Schneider, who's a principal over at Avalere Health. And we get into, you know, kinda deeply, the what and the why behind the "Big Three" traditional PBMs deciding that now might be a fantastic time to set up GPOs. PBMs are pharmacy benefit managers—there's three huge ones. GPO stands for group purchasing organization. Traditionally, these GPOs have purchased drugs and supplies for hospitals and other providers at, according to their marketing materials, volume discounts. So, the unfolding story here, in a nutshell, is that ESI (Express Scripts) set up a GPO called Ascent in Switzerland. Optum has had an Ireland operation going in full swing for a while. And now we have CVS Caremark setting up a GPO called Zinc. These GPOs are not like normal GPOs working with hospitals, but instead, these GPOs are the entity which is now going to negotiate with pharma companies. In the past, it was the PBM that was negotiating with the pharma company to get rebates. Now it's this GPO entity. "But wait," you may say. "Wasn't there an executive order the other day requiring PBMs to, for example, pass through all of the rebates that they're collecting to patients?" Indeed, there was. And that rule doesn't say anything about GPOs having to do the same, especially GPOs in, let's just say, Switzerland. It's a tangled web we weave. You can learn more at avalere.com. You can also connect with Mike on LinkedIn. Mike Schneider is an experienced health care executive with over 20 years of experience in the pharmaceutical manufacturer, pharmacy benefit manager, and payer side of health care. He previously spent 9 years at CVS Caremark, where he was a director of industry relations with responsibility for trade strategy development, rebate negotiations, and contract execution for CVS Caremark's own Medicare Part D plans and that of its clients. He held a similar position at Universal American (UA) before it was acquired by CVS Health, where he also negotiated UA's commercial business. Mike has held various sales and market access roles with pharmaceutical manufacturers with increasing responsibility. Before entering health care, Mike began his career as a researcher at the Procter & Gamble Company in Cincinnati, where he worked on hair care product formulation development focusing on the key markets of China and Japan, and then moved on to work in drug development. Mike holds a BS degree from the University of Illinois and an MBA from the University of Akron. 02:30 What does a GPO add to a PBM? 05:05 Rebates vs driving more revenue. 10:20 PBMs vs safe harbors. 12:07 The net impact on the commercial side. 13:48 PBMs vs pharmaceutical manufacturers. 14:35 How the "Big Three" PBMs compete with each other, and how employers would choose between them. 15:37 What the net-net is here. 17:48 How PBMs are shifting their models. 20:23 How GPOs may be making things even less transparent. 21:11 "The PBM world as a whole is not very transparent." 24:40 "One of the biggest beneficiaries of this whole rebate [system] is the government." 25:25 "The question is, 'Who's paying those costs?'" 25:40 EP216 with Chris Sloan.26:40 A better way to move money from Pharma to employers and plan sponsors. 27:43 "Put your money where your mouth is." You can learn more at avalere.com. You can also connect with Mike on LinkedIn. Check out our newest #healthcarepodcast with Mike Schneider of @avalerehealth as he discusses #PBMs and #GPOs. #healthcare #podcast #digitalhealth #healthcarefinance #pharma What does a GPO add to a PBM? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma Rebates vs driving more revenue. Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs safe harbors. Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma What is the net impact on the commercial side? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs pharmaceutical manufacturers. Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How do the "Big Three" PBMs compete with each other? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #h

In this health care podcast, I'm speaking with Dan O'Neill, MA, MS. Dan says that, in many ways, this is a fantastic time to be an entrepreneurial physician leader. We are in a place to reinvent the practice model, meaning finding ways to increase value while losing bloated business practices in labor and capital. It's more possible than ever to make a medical practice more efficient and effective with less overhead and, at the same time, meet the needs of patients in ways that are, you know, were impossible in the business model of five years ago and earlier. It's just a new world, and I don't just mean because of COVID. I mean in all the ways that everybody—including me—has been squawking about for years: consumerism, the rise of technology and its attendant expectations, Medicare running out of money, and employers who have cried uncle on rising health care costs and/or gone out of business. The silver lining in everyone getting used to telehealth and aggregated FFS (fee-for-service) revenue tanking for a couple of months is that suddenly some of the cushy cha-ching reasons to keep the old model don't feel quite as much of a sure thing for the risk averse any longer. On the flip side, it's also a fine time for you insurers to step up. Consider what some of the plans are doing right now to help PCPs (primary care providers), for example, transition to value and help independent docs stay in practice at the same time. I could say the same for some of the self-funded employers. It's gonna suck for you all if the PCPs not connected to consolidated health systems go belly-up. Now is the time that you really can help them help you, and everybody wins from a quality and cost standpoint now and down the line. My guest on this health care podcast is Dan O'Neill, MA, MS. Dan's a consultant who spent most of 2019 working in the Senate on the professional staff of the health committee focused on issues related to health care cost mainly. Now he's doing consulting with entrepreneurial physician leaders and also start-ups. You can learn more at dponeill.com. Daniel O'Neill, MA, MS, is an executive in the digital health and health care technology industry. He has a track record of building teams, executing successful go-to-market strategies for new and established solutions, and structuring effective partnerships to scale venture stage businesses, particularly in health care/digital health. Dan works as consultant with venture-backed firms to define, develop, commercialize, and scale new health care services and software solutions. His areas of focus include bundled payments in the commercial population; virtual networks for specialist consults; tools for Medicare Advantage, Managed Medicaid, and other quality-rated and risk-adjusted plans; interoperability and clinical data exchange infrastructure; and new approaches to streamline the revenue cycle. Prior to becoming a consultant, Dan spent a year in Washington, DC, as a Robert Wood Johnson Foundation Fellow at the National Academy of Medicine, working on health policy in the US Senate. Dan has assembled and managed teams in product, sales, professional services, and account management. He also led the launch and growth of several products to facilitate care coordination and population health initiatives for primary care practitioners, accountable care organizations, hospitals, health plans, and other clinicians. In addition, he has worked on the development and commercialization of decision support tools to implement clinical pathways and avoid medical errors, and on predictive analytics using early versions of artificial intelligence. Dan completed his undergraduate study at Claremont McKenna College. He earned a Master of Arts from Johns Hopkins University and a Master of Science from the Stanford School of Engineering, where he focused on health care operations management and clinical informatics. 02:37 Why switching revenues to a different model isn't simple. 03:45 The segmentation approach we need to focus on. 04:15 The straightforward answer for PCPs. 04:27 The path forward for specialists. 05:21 Moving away from "buy and bill" economics. 05:31 EP282 with Aaron Mitchell, MD, MPH. 07:36 Are health systems buying more practices, or are more practices becoming independent? 09:22 "It starts from why are they making the investment and what is the thesis?" 11:01 Separating the venture-/growth-oriented approach from the financial engineering approach. 12:47 Opportunities for physicians with an entrepreneurial mind-set. 15:55 "What services am I currently delivering?" 21:37 The opportunity to do well by doing good. 24:00 Health insurers as a barrier to change. 24:54 "This is a good opportunity to affect real change." 25:40 "If you're just waiting around for change, it's probably not gonna walk in the door." 27:43 The attempt to reinvent care delivery. You can learn more at dponeill.com. Check out this week's #healthcarepodcast with @dp_oneill as he discusses #entrepren

John Rodis, MD, MBA, is an OB/GYN specializing in high-risk pregnancies. He's been a board examiner and a department chairman. He's been a COO and a CEO of a 600-bed Level 1 trauma center. He's also an author working on a book to help consumers make better choices. Dr. Rodis has said he feels an inflection point is coming in the transition to value. First, we have the pressure of large employers. Second, we've got doctors themselves who are being crushed by the current environment and who may also have realized that FFS (fee for service) is kinda risky in the middle of a pandemic. The third force toward the inflection point is the new breed of fee-only transparent brokers. And then fourth, we've got the government, particularly state governments who are struggling fiscally coming out of this pandemic and also realizing that the current health care system is pretty rigged to profit on the backs of taxpayers and firefighters and teachers. In the face of this transition, health systems who aren't keeping up with the times are at increasing risk. Given that Dr. Rodis has held pretty much every job in health care at this point, he's probably the perfect person to ask how to quantify that risk, number one, and then what health system leaders should be doing in the face of it. You can learn more by emailing Dr. Rodis at [email protected]. John F. Rodis, MD, MBA, is a high-risk obstetrician by training and has had a long and illustrious career as a renowned health care leader. Most recently, he was the president of Saint Francis Hospital and Medical Center in Hartford, Connecticut. Dr. Rodis had two stints at Saint Francis, starting there early in his career as a maternal-fetal medicine fellow in 1985. In between, he was head of obstetrics and gynecology at Stamford Hospital, served as its chief medical officer, was a faculty member at the UConn School of Medicine, and became chair of OB/GYN at Saint Francis in 2011. Dr. Rodis took the helm at Saint Francis as a recent state provider tax was quickly expanding into a huge fiscal burden on Connecticut's acute care hospitals. In December 2015, he was named its eighth president. Dr. Rodis was the first physician to be appointed president in Saint Francis's 118-year-history. He guided the hospital through an era of consolidation and rising state taxes. His last challenge arrived in spring 2020 as he oversaw an expansion of temporary facilities as the hospital faced the crush of the coronavirus pandemic. Also, during his tenure as president, Dr. Rodis ushered the Saint Francis team through significant change and transformation, much of which has been recognized at the national and regional level. Those transformations led them to achieve an "A" Safety Grade from Leapfrog seven of the last eight grading cycles. Saint Francis was also named Best Regional Hospital in 2019 by US News & World Report and was the only hospital in Connecticut named one of the nation's 100 Top Hospitals by IBM Watson Health. Dr. Rodis's passion is patient safety and, in particular, providing consumers (patients) with reliable data to make informed health care decisions. He departed his post as president of Saint Francis in May 2020. Dr. Rodis has now started his own consulting firm, Arista Health, and is finishing a book entitled You Put Your Life in Their Hands. 02:16 How the scales are starting to rebalance. 02:44 "There's going to be a day of reckoning." 04:18 The risk a health system is taking by not adjusting to the market. 05:20 Where are the nominal dollars coming from, and where might they come from in the future. 08:04 EP279 with Peter Hayes.08:15 EP281 with Rob Austin.08:56 The difference in today's market when it comes to cost setting. 10:02 Why the conversation is shifting from cost comparisons to value comparisons. 11:34 Value is quality over cost. 11:55 The four domains that go into value. 12:32 EP242 with Dr. Marty Makary.14:01 "The problem in this market: It's not that free." 16:48 Who is best equipped to be an arbiter of value in this new market system? 18:49 "I think that trust is starting to erode." 20:30 How payers are leading the charge on this market change. 21:37 Dr. Rodis's advice to hospital and health system executives to get ahead of this market change. 24:45 EP257 with Karl Bilimoria, MD.26:53 "I think you have to take ownership." 28:08 "There's no real Four Seasons business [model] in health care." 28:30 "Look at the entire episode of cost." 29:51 Where bundling falls into this equation. 31:45 Dr. Rodis's upcoming book. You can learn more by emailing Dr. Rodis at [email protected]. Check out our newest #healthcarepodcast with John Rodis, MD, MBA, as he discusses #healthsystems, #consumerism, and #valuebasedcontracts. #healthcare #podcast #digitalhealth #vbc #valuebasedcare How are the scales of the market starting to rebalance? John Rodis, MD, MBA, discusses #healthsystems, #consumerism, and #valuebasedcontracts on our #healthcarepodcast. #healthcare #podcast

I'm going to summarize some points that Dr. Marty Makary made in his manifesto for why he wrote his most recent book. The Price We Pay is its name. You can hear this manifesto in his own words—in Dr. Makary's own words—on Relentless Health Value episode 242, but here's his point: He said that the 2007 banking crisis, writ large, resulted from complexity that kept onlookers confused. So, when people questioned the banks being overleveraged and selling mortgages to, you know, those who couldn't afford them, experts responded by saying, "You know, it's very complicated. Leave it to us." But on the ground, it was clear there was a problem. And in hindsight, there obviously was a problem. Here's the point that Dr. Makary was making, which I think is super valid: Many of the entrenched stakeholders in medicine fend off criticism by claiming that these are highly complex systems that should be left to experts. They say, "You wouldn't understand. Leave it to us." And just like the experts in the banking industry got us into the calamitous Great Recession in 2007-2008, the experts that we're leaving it to in health care have driven ever-higher prices for care that I'm gonna say that most in the health care industry who actually care about patients are certainly not proud of. In this health care podcast, I'm speaking with Dawn Cornelis, cofounder and director of transparency at ClaimInformatics. We get into what sounds so simple: self-insured employers having their medical bills paid by a third party who specializes in paying medical bills. Maybe these third parties even say that they give all the bills the once-over before they pay them—except when a company like ClaimInformatics reviews the same bills, they find savings in the double digits from paying bills that are wrong at some level or just flat-out fraud. Considering that by some estimates there's like a trillion dollars lost in this country to some level of fraud, waste, and abuse, this is pretty much the opposite of poking around in the couch cushions looking for change. While there's certainly a lot of details, it's not really that complicated. You can learn more at claiminformatics.com or by emailing Dawn at [email protected]. Dawn Cornelis is cofounder of ClaimInformatics and serves as its chief transparency officer. With 25 years of experience in health care claim review and cost containment, Dawn brings a personal passion for rooting out fraud, waste, and abuse. Dawn's work includes building strong national alliance partnerships with major insurance companies and health systems such as AIG World Investigative Resources, Global Options, Mutual of Omaha, Principal Financial Group, Deloitte, PHCS/Multiplan, Jefferson Health System, and Seton Health System. Dawn has identified and recovered hundreds of millions of dollars of improper payments through pre- and post-payment cost containment programs while navigating the payment systems of all of the national health carriers. In 1993, Dawn cofounded Claim Recovery Services, the industry's first audit and recovery firm, and served for 17 years as its chief operating officer, assisting several Fortune 100 companies. She then spent 3 years as the chief operating officer of ClaimReturn. Dawn has been an expert speaker at national forums such as The Institute for HealthCare Consumerism on various health care audit topics and participates in roundtable sessions on federal and state regulations. 02:54 The story in the data. 03:32 Who's submitting these claims? 04:10 The three problems with the data. 07:19 The varying factor between carrier systems to stop fraud, waste, and abuse. 07:59 Why carriers don't push for better systems to stop inappropriate dollars. 10:07 The difference between fraud, waste, and abuse. 11:46 "When it becomes the norm, that's what's very bothering." 12:13 The barriers or hurdles in the marketplace. 15:35 What we don't know about but could do better at when looking at the data. 18:01 "It's not so much the health system and what they are charging. It's about … what the contracted rate is agreed to. That's what drives our costs." 19:02 "Data's fixed for itself." 22:09 Identifying and eliminating fraud. 22:14 Unbundling and the lack of enforcement behind preventing illegal billing. 28:59 How providers ensure they aren't inadvertently harming employers and patients through billing. You can learn more at claiminformatics.com or by emailing Dawn at [email protected]. Check out our latest #healthcarepodcast with Dawn Cornelis of @claiminformati1 as she discusses saving billions through health care billing. #healthcare #podcast #digitalhealth #healthtech #healthcarebilling The story in the #data. Dawn Cornelis of @claiminformati1 discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #healthdata Who's submitting these claims? Dawn Cornelis of @claiminformati1 discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healtht

There is a transparency zeitgeist kicking off right about now. In June was the biggie, the one where health systems now have to divulge their contracted rates with insurance carriers starting January 1, 2021. But this zeitgeist is flowing into drug prices as well. Surescripts just released their real-time prescription price transparency tool. This price transparency tool allows detailed cost and alternative drug information to be seen in real-time. Surescripts, by the way, is owned by several large PBMs (pharmacy benefit managers). Can the prescriber see how much drugs will cost the patient as they are writing the prescription? The answer is yes if that prescriber is using a tool to display the prices in their EHR (electronic health record) or e-prescribing system. That is pretty cool and could save a whole lot of rigamarole and time for both the prescriber and the patient who doesn't now have to go the whole way over to the pharmacy to figure out the drug price is unaffordable. I just want to bring up one point to be aware of: Surescripts is, as aforementioned, owned by some PBMs. PBMs are not exactly non-profits. They do a great job for their shareholders collecting middle-man dollars from pharma and pharmacies and patients alike. The copay amount a patient pays is a decision that is made, in many cases, by a PBM. So, showing the PBM-set patient price at the point of care to doctors increases PBM leverage in conversations with at least pharma. You see what I mean? Maybe that's good if the PBM actually takes the dollars it shakes out of pharma and gives it to employers or the patients, the government or pays pharmacies they don't own fairly. Maybe it's bad if the PBM uses its additional leverage to, I don't know, start its own GPO (group purchasing organization). In Switzerland. Wait, what?! Yeah, that happened. All I'm saying is, this is a tangled web we weave with implications for pharma, pharma's PBM negotiations, pharmacies and patients as patients and also patients as members of plans. Here's a really important point that I need to make. Nobody in the health care industry is conflict free. Not PBMs, not IDNs (integrated delivery networks), not you, not me. I love transparency and I love sparing doctors and clinicians administrative burden. If I were a provider organization, I would definitely use this tool. But here's what I need to say… in addition to transparency showing the copay of a drug and the best pharmacy to get it at, these systems also make transparent the underlying levers of the system itself if you look at them in a kind of pattern-wise way. So, if I'm a doctor and I find it weird that the lowest price is always at the pharmacy owned by a PBM, for example. Yeah, it's up to you to start asking questions. My hope is that everyone sticks with the spirit of the endeavor and gets to the heart and the potential of transparency and chooses the path that benefits the patient the most. To that end, I am speaking in this health care podcast with Carm Huntress, who is the CEO and cofounder of RxRevu. We talk a lot today about how showing prescribers how much drugs cost can really help patients avoid financial toxicity and/or a whole lot of running around getting prescriptions changed to drugs that are on-formulary. You can learn more at RXrevu.com. You can also connect with Carm Huntress on Twitter at @carmhuntress. Carm Huntress is CEO and cofounder of RxRevu. As CEO, Carm has successfully taken prescription decision support from a concept to a reality for physicians, payers, health systems, and patients. At the core of this work is to transform the value of health care through better prescribing decisions. At a national level, Carm has played a key role in supporting interoperability and patient access to data through the development of the Fast Healthcare Interoperability Resources (FHIR) standards and other projects with the Office of the National Coordinator (ONC). 04:25 The protracted way doctors prescribe drugs right now. 06:15 "What is the macro thing we want to have happen here?" 08:10 Where we are today. 08:38 Value-based contracts. 10:10 Who is hurt by higher-cost alternatives. 12:50 The number one thing doctors get out of drug cost transparency. 13:20 The second thing doctors get out of drug cost transparency: patient satisfaction. 13:55 The downside to drug cost transparency. 14:40 "We gotta back up and just say, 'What do we want?'" 16:30 How real-world evidence is going to affect drug pricing and rationalization. 17:43 "They're waking up to the new world." 20:20 How copays play into this. 20:45 "What's the total cost, what's the patient cost, and what are the alternatives?" 22:00 The history of formulary and benefit. 26:41 The problem with specialty drugs. 29:30 "Can we just start with first principles here?" 29:40 "We don't really think about socio-economic factors." 29:43 "What can you really pay?" 31:00 Why do IDNs care about drug pricing transparency? You can learn more at RXrevu.

At the end of the day, health care should be about helping patients find their way to health while doctors, nurses, and other clinicians don't burn out in the process. It's becoming increasingly indisputable that the way to get to this North Star efficiently is through human-centered health care. Human-centered health care is a term coined by Dr. Sylvia Romm, and it's a play on the term customer-centered design. How do we innovate? How do we use technology to intensify the human experience for both provider and patient? How do we rid ourselves of friction points and create a continuum of care that is sticky and makes getting healthy as enjoyable as Instagram? In this health care podcast, I speak with Sylvia Romm. She's an MD and an MPH with a background as a researcher and a telemedicine entrepreneur prior to coming to Atlantic Health System as their chief innovation officer. We talk in this podcast about human-centered health care—what this means, what the success factors are, and how to make it happen. We also take into account the assorted challenges to overcome on the way there. This interview was recorded moments before COVID-19, and I say that as a good thing. Dr. Romm brings up telehealth as, let's just say, a first step toward actuating human-centered design in health care. Clearly in the past, that was quite a hurdle. No longer. So, those health systems or you other stakeholders in the mix who have gotten the telehealth thing nailed, listen on for ways that you can leverage your success. And for those of you who haven't, well, here's a little extra motivation. You can learn more by connecting with Dr. Romm on Twitter at @sylvia_romm. Sylvia Romm, MD, MPH, is driven by a passion for transforming health care delivery to patients and communities. She brings her background and expertise as a clinician and an entrepreneur to her role as chief innovation officer for Atlantic Health System. Firmly believing that a patient-centered focus is vital to health care innovation, Dr. Romm works with Atlantic Health System's team members and physicians to find new ways to improve access to high-quality, affordable care. She also forges relationships with local and national innovation partners and works to expand the organization's research profile. Dr. Romm is an avid author and speaker in the areas of health care, technology, and health information technology (IT) policy. She has written articles for various publications—including NEJM Catalyst, Forbes, KevinMD, and the Huffington Post—and was named one of Fierce Healthcare's 8 Influential Women Reshaping Health IT and Becker's Women in Health IT to Watch in 2020. A board-certified pediatrician, Dr. Romm has served in a variety of clinical leadership roles throughout her residency and as a hospitalist. Before joining Atlantic Health System, she was vice president of clinical transformation for American Well, the largest video-based telemedicine company in the United States. In addition, she was the founder of MilkOnTap, the nation's first telehealth company focused on the needs of nursing mothers and lactation support. Dr. Romm earned her Master of Public Health in global health from Harvard TH Chan School of Public Health. She holds a medical degree from the University of Arizona College of Medicine and completed her residency in pediatrics at Massachusetts General Hospital. 02:18 How Dr. Romm's background in research, public policy, and being a pediatric hospitalist intertwine to create great innovation strategies. 03:22 "How do we look at populations?" 03:31 "It's really about affecting the system in its entirety." 04:33 What human-centered health care means. 06:36 "You're only as effective as the rapport that you build with [this] person." 08:05 "What do people really need … but also, what do they find valuable?" 09:42 How data are folded into human-centered health care. 11:55 "The endgame is to figure out … how to have a better experience." 12:39 How this fits into the quadruple aim. 17:19 "We are going to have to earn and learn agility." 19:38 What has the most promise in deepening the connection between patients and providers. 20:32 "Is this about you, and how do we know … how people outside feel about creating a relationship?" 23:29 Is there a best practice for furthering the patient/doctor relationship from afar? 24:24 The need for a variety of approaches to patient/doctor connections. 27:30 What innovation initiatives need to be successful. 28:07 "People have to understand the 'why.'" 29:38 The classic tenets of change management. 30:02 A challenge Dr. Romm is proud of having solved. 31:56 Secret weapon: collaboration. You can learn more by connecting with Dr. Romm on Twitter at @sylvia_romm. Check out our newest #healthcarepodcast with @sylvia_romm of @SonderHealth and @AtlanticHealth as she discusses human-centered #healthcare. #podcast #digitalhealth #healthtech #healthinnovation "How do we look at populations?" @sylvia_romm of @SonderHealth and @Atl

This past March, I was looking forward to giving a keynote at the Arizona Technology Council. Unfortunately, that didn't happen. COVID happened. But in the process of figuring out what I was going to talk about during my keynote, I came up with an idea and I wanted to share it. It's the idea of how to measure value in health care delivery, because might as well go big or go home, right? The metrics that we use to measure value is critical, and not just because what gets measured gets managed. It's because American health care is the biggest most impressive display of game theory anyone anywhere has ever seen. I am not easily impressed, and I have to say that I am unfailingly and frequently more than impressed by the cognitive prowess and sheer determination among some parties to game the system and reach as much profit as possible at the expense of patients and taxpayers. So, coming up with the right metrics is paramount. The metrics have to be unimpeachable; they have to be immune to those who have every intention of twisting them against their spirit. 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. 01:28 Health care profiteering and the halo effect. 02:16 Dr. Robert Pearl's book, Mistreated.02:27 "If there's money on the table, it's really hard to not take it." 02:42 How Stacey came up with her first metric. 04:31 The impact of caring for the patient on patient outcomes. 06:09 The quadruple aim. 06:50 "An endgame of nouns" vs "the verbs which are going to get us there." 07:19 How are we helping patients and providers? 09:02 Making the touchstone "helping physicians help patients." 09:50 Gary Price, MD, on the Healthcare Strategies podcast from Xtelligent Media.10:36 Danielle Ofri, MD, at danielleofri.com.12:04 Eric Topol, MD, and "the gift of time." 12:36 The first metric: optimizing time for patients. 14:31 Financial toxicity in health care. 15:24 Marty Makary, MD, MPH, author of The Price We Pay.17:11 Two metrics: optimal time with patients and reduction of cost for patients. For more information, go to aventriahealth.com. Check out our latest #healthcarepodcast with our host, Stacey, as she discusses two metrics to measure the value of #caredelivered. #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery #Healthcareprofiteering and the #haloeffect. Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery "If there's money on the table, it's really hard to not take it." Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery The impact of caring for the patient on patient outcomes. Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery The quadruple aim. Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery "An endgame of nouns" vs "the verbs which are going to get us there." Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery How are we helping patients and providers? Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery The first metric: optimizing time for patients. Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery #Financialtoxicity in health care. Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery Two metrics: optimal time with patients and reduction of cost for patients. Our host, Stacey, discusses two metrics to measure the value of #caredelivered. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #valuebasedcare #caredelivery

In the April issue of Value-Based Cancer Care (that's a journal), there's an article talking about a keynote presentation and a study highlighting a big problem for patients with cancer: toxicity. It's a fact that some chemo agents are pretty toxic, but in this health care podcast I am talking about financial toxicity. The financial burden of cancer care has a seriously negative influence on patients' quality of life. This keynote speaker quoted in the Value-Based Cancer Care article implored his fellow oncologists: "Think twice before ordering costly interventions that may have little impact on the clinical course," he said. This might be difficult for a number of reasons, and one of them is that oncology centers make money, a whole lot of money, sometimes the most money, from infusing cancer medications. It's this little payment paradigm called "buy and bill." The cancer center buys the meds and then gets paid an additional fee to infuse the drug. This fee is a percentage of the drug cost. It ranges from 4.5% to about 20% of the cost of the drug. You've probably heard a lot lately about the skyrocketing costs of some of these cancer agents. Add 4.5% to 20% onto those costs and realize that if you're an oncology center, the higher the drug costs, the higher your revenue. Now consider the patient suffering under the weight of increased cost sharing and employers and taxpayers who are funding this strange payment model. In this health care podcast, I dig into this so-called "buy and bill" payment model with Aaron Mitchell, MD, MPH. Dr. Mitchell is an oncologist and health services researcher over at Memorial Sloan Kettering. He seeks to understand how changes to current reimbursement models for oncology services may be used to achieve better patient outcomes and reduce low-value care. You can learn more at drugpricinglab.org. You can also connect with Dr. Mitchell on Twitter at @TheWonkologist. Aaron Mitchell, MD, MPH, is a practicing medical oncologist and health services researcher. He is an assistant attending at Memorial Sloan Kettering Cancer Center in the department of epidemiology and biostatistics. His research focuses on understanding how the financial incentives in the health care system affect physician practice patterns and care delivery to cancer patients. He cares for patients with prostate and bladder cancer. 03:00 Following the drug and following the dollar. 03:28 The "buy and bill" system. 04:15 The perverse and problematic incentives of the system. 07:24 "It creates the incentive for us to gravitate toward the more expensive drug." 07:28 The hesitancy to address the financial toxicity of drugs for patients. 08:40 Why the only person losing in this situation is the patient. 09:40 The financial impact from the patient perspective. 13:07 Are patients realizing this impact? 13:53 Solving the problem of oncology drug choice. 16:06 Reimbursement reform. 17:49 Capitated systems and incrementalist impacts to reimbursement reform, and what these look like. 23:04 Are we at a tipping point? 23:27 "The current system … works too well for too many people." 24:47 Who isn't well served by the current system. 26:27 Who has to lead the charge for change. 29:54 Large oncology providers vs small oncology providers in the buy and bill system. You can learn more at drugpricinglab.org. You can also connect with Dr. Mitchell on Twitter at @TheWonkologist. Check out our #healthcarepodcast with @TheWonkologist of @sloan_kettering as he discusses #oncology #drugpricing and #reimbursement. #healthcare #podcast #digitalhealth Following the drug and following the dollar. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth The "buy and bill" system. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth The perverse and problematic incentives of the system. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth "It creates the incentive for us to gravitate toward the more expensive drug." @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Why is there hesitancy to address the financial toxicity of drug pricing for patients? @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Why the patient is the only one that loses. @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth What's the financial impact from the patient perspective? @TheWonkologist of @sloan_kettering discusses #oncology #drugpricing and #reimbursement. #healthcarepodcast #healthcare #podcast #digitalhealth Are patients rea

You know what the second biggest cost line item is on most health systems' profit and loss report: supplies—buying things like artificial knees, stents, service contracts. It's estimated that an average hospital can save more than $12 million a year if they manage their supply chain better. And interestingly, oftentimes care actually improves as a result. For context, that wasted $12 million could pay for 165 more nurses or 50 more PCPs. It's the cost of 3100 knee replacements. (All this, by the way, is according to Navigant.) Does it bother you that so many people in this country can't afford care and nurses and PCPs aren't getting raises and some of it is because leadership at many hospitals is not adequately managing their costs of goods? Maybe I'm an idealist, but the human consequences of this inadequacy certainly bother me. In this health care podcast, I am talking with Rob Austin. Rob is director of health systems at Guidehouse. He works a ton on supply chains at hospitals, health systems, and physician practices. Quick industry news flash: Guidehouse is a new entity comprised of legacy PWC (PricewaterhouseCoopers) government business which has combined with Navigant. You can learn more at guidehouse.com. You can also connect with Rob on LinkedIn. Rob Austin is director of health systems at Guidehouse. He works closely with health systems to help reduce the cost and improve the quality of health care in the United States. As part of Guidehouse's Healthcare Performance Excellence practice, Rob assists hospitals and systems to achieve rapid financial, clinical, and operational improvement, simultaneously reducing cost and improving quality. He previously worked at Allegheny Health Network, a seven-hospital system based in Pittsburgh, serving as director of supply chain and business development. Rob helped grow Provider Supply Chain Partners, a regionally focused group purchasing organization, from 12 hospital members to 74 and $1.3 billion in spend over three years. He also held various delivery, sales, and leadership roles at SAP Ariba. Rob writes and speaks frequently on topics relating to health system operating margin improvement, particularly around optimizing the supply chain and enhancing shared services functions within systems. 02:04 Why the pandemic is actually a good time to get a handle on hospital supply chains. 03:21 "Supply costs, nonlabor costs, are the second largest costs any health system has." 04:08 The $24 billion opportunity for hospital systems. 04:35 How efficient supply chains help patients at large. 06:18 The hospitals that would benefit the most from streamlining supply chains. 07:05 The case of the haves and have nots in the supply chain. 07:36 EP279 with Peter Hayes.09:46 "The most efficient supply chains … are also more clinically effective." 11:45 Standardizing supplies vs nonstandardization. 14:15 The biggest problems with a mismanaged supply chain. 15:50 Purchase services. 15:58 Areas of opportunity with supply chains. 19:27 The structural issues that add to the supply chain problem. 20:20 "To make an impact on your nonlabor costs … it needs to be driven initially from the C-suite." 22:10 The steps to focus on to improve your supply chain. 29:32 Value-based care in the supply chain. 31:16 How smaller organizations can get a handle on their supply chains. 31:47 "Focus on people, process, and data." 32:59 Amazon's role in the health care supply chain. You can learn more at guidehouse.com. You can also connect with Rob on LinkedIn. Check out our newest #healthcarepodcast with Rob Austin, director of #healthsystems at @Guidehouse. #healthcare #podcast #digitalhealth #supplychain #hospitalsupplychain Why is the #pandemic a good time to get a handle on your #hospital supply chain? Rob Austin, director of #healthsystems at @Guidehouse, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #supplychain #hospitalsupplychain "Supply costs, nonlabor costs, are the second largest costs any health system has." Rob Austin, director of #healthsystems at @Guidehouse, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #supplychain #hospitalsupplychain The $24 billion opportunity for hospital systems. Rob Austin, director of #healthsystems at @Guidehouse, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #supplychain #hospitalsupplychain How do efficient supply chains help patients? Rob Austin, director of #healthsystems at @Guidehouse, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #supplychain #hospitalsupplychain What hospitals would benefit the most from streamlining supply chains? Rob Austin, director of #healthsystems at @Guidehouse, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #supplychain #hospitalsupplychain "The most efficient supply chains … are also more clinically effective." Rob Austin, director of #healthsystems at @Guidehouse, discusses. #healthcarepodcast #healthcare #podcast #digitalhealt

In this health care podcast, I am talking with Yauheni Solad, MD. Dr. Solad is one of the top minds in data and data exchange. He's medical director of digital health and telemedicine at Yale New Haven Health, and he has a mission to lead digital transformation toward accessible and affordable high-quality care that's enabled by technology. Dr. Solad also does a lot of work with NODE—the Network of Digital Evidence. In the conversation we're about to have, Dr. Solad represents the provider point of view. The show also features the one and only Rahul Dubey, hero to peaceable protesters. You can search for Rahul Dubey protesters to see what I mean. And also, he is the founder of Percynal Health Innovations. Rahul is the former chief innovation officer over at AHIP—that is, America's Health Insurance Plans. In this conversation, Rahul represents the payer point of view. Here's what we're talking about, and I'm gonna keep this brief: It has been postulated that technology will be a catalyst for health care transformation. By technology, I mean the leaps many systems of care have made in their technological capabilities to deal with the realities of C-19. Dr. Solad, Rahul Dubey, and I talk about whether and how greater digital capability—which often means greater ability to care for populations vis-à-vis remote monitoring and telehealth—but whether, you know, the tail can wag the dog, so to speak, because so much investment has been made in these technology capes that we're gonna want to use them. And when we use them, we transform care delivery. You can learn more by connecting with Dr. Solad on Twitter at @ysolad or on LinkedIn. You can also connect with Rahul via email or LinkedIn. Yauheni Solad, MD, MHS, is the medical director of digital health and telemedicine at Yale New Haven Health System. He is a practicing physician, clinical informaticist, and entrepreneur with a strong hands-on experience in software and data standards development with a particular focus on enabling the next wave of value-based care innovation. Yauheni received his medical degree summa cum laude from Belarusian State Medical University and a Master of Health Science from Yale School of Public Health. He is currently completing his executive MBA at Yale School of Management. Rahul Dubey is CEO of Percynal Health Innovations and the founder of America's Health Insurance Plans (AHIP) Innovation Lab. Rahul is currently responsible for collaborating with C-level executives at his health plan. Prior to joining AHIP and launching Percynal Health Innovations, Rahul held a leadership role as a founding employee of a successful digital health care start-up based in Washington, DC. Along with the company's cofounders, Rahul was instrumental in developing a multifaceted consumer tool as well as leading the company's "go-to-market strategy," resulting in successful market penetration and revenue growth for the industry's first consumer-led shared decision making and treatment selection platform. Rahul was recognized with the Smart Health's 2018 Excellence in Healthcare Transformation award, was named the American Journal of Health Promotion's 2017 Innovators and Game Changers, and is featured in Accenture Perspectives: Minds Driving the Future of Business. In 2017, Frost & Sullivan presented Rahul with one of their highest honors, their Global Visionary Innovation Leadership Award. He is a graduate of the University of Michigan–Ross School of Business and lives in Washington, DC, with his son. He invites you to contact him directly—that is, if you're willing to roll up your sleeves and drive transformation through inflective collaborative. 03:56 How COVID-19 affects interoperability. 07:06 "It's not only the data exchange; it's your ability as a health care system to innovate."—Dr. Solad 09:11 How close are we to adopting more innovative and better technologies? 11:32 "Make docs happy. That is a very foreign concept for … people that are not delivering care to think about."—Rahul 11:47 "We want to be able to enable the primary care physician to deliver care."—Rahul 12:03 Working doctors rather than "dictating upon them." 13:16 "I can't sell burnout … I can sell value of care and outcomes of less cost."—Rahul 18:44 "There might be an increase in overconsumption of care."—Rahul 19:14 The possible increase in utilization of care and the potential for lower cost sharing. 19:57 Unlimited primary care and the benefits this might offer. 22:59 Does this pose risks to health systems? 25:22 "Everything you do for the patient should have a clear value to them."—Dr. Solad 26:35 "What type of technology can provide this missing link for your particular health care system?"—Dr. Solad 28:18 Reimbursement as the new HIPAA. 29:15 "We need more evidence in data around the delivery of this technology-enabled service."—Dr. Solad 32:20 What payers and providers should be doing today. 35:16 Care management vs consumerism. You can learn more by connecting with Dr. Sol

Let me explicitly state an implicit theme that's been running through a bunch of the latest Relentless Health Value podcasts talking about if and how the COVID-19 pandemic could possibly serve as a flash point in the health care industry—a flash point where egregious and self-interested financial pursuits take such a toll that politicians notice. Why do these legislators notice? Because the patients (also known as voters), the ones that we all serve, begin to break under the weight of a system that inappropriately enriches some of its purveyors. In this health care podcast, I speak with Peter Hayes, who is president and CEO at the Healthcare Purchaser Alliance of Maine and a national presence in health care strategy/innovation and frequent keynote speaker. One thing, among many, that Peter said during our conversation struck me. He said it will take a village to fix what ails the health care system in this country. There's just too many interdependencies. Take, for example, some of the biggest, most powerful health systems in this country. Most are, by almost every account, pretty darn inefficient in how they purchase supplies, how they pay their CEO millions of dollars, and how they put a waterfall in the lobby and don't pay any taxes. Look, here's my point—and it's both an uncomfortable time and a great time to make it. I want the doctors and the nurses and others who actually provide care to be heroes and fairly compensated for their hard and dangerous work. But that should not, and maybe even cannot, happen within the context of a larger system that is anything but fair to patients. So, this whole upcoming conversation that I have with Peter pertains to the business decisions that many huge health systems are making and have made. It does not pertain to the "scrubs," for the most part, who are doing the best they can and should be exalted—except to urge you guys to organize, please. But why should health systems change their often wildly inflated and secretive billing practices if employers just pay whatever the bill is no fuss, no muss? Short answer: They won't. It's not like no one in the health system noticed that the CEO is getting paid, like, 10x what the average worker makes. It's not like no one noticed what has been sacrificed in patient care or infection control or technology to spring for that kind of green. Health systems operate the way they operate because someone wants them to operate that way. Follow the money and you can figure out who. So, it's going to be up to someone else in the village to make it untenable for them to continue to do these things. It's going to be up to another party to slow that roll. You can learn more at purchaseralliance.org. You can also connect with Peter on LinkedIn. Peter Hayes is president and CEO of the Healthcare Purchaser Alliance of Maine and formerly a principal of Healthcare Solutions and director of associate health and wellness at Hannaford Supermarkets. He has been in innovative, strategic benefit design for the past 20+ years. During the past several years, Hannaford has received numerous national awards in recognition of the company's commitment to working collaboratively with health care providers and vendors in delivering health benefits that are focused on value (high-quality efficient care). Hannaford Supermarkets has been successful in this arena by focusing on innovative solutions for patient advocacy, chronic disease management, and health promotion programs. Hannaford was recognized by receiving the National Business Group on Health Platinum Award for the health promotion and wellness programs three years in a row. These programs, along with health care delivery strategies, contributed to a flat trend line over five years. Peter has also been involved in health care reform leadership roles on both the national and regional levels with organizations like the Center for Health Innovation, Care Focused Purchasing, and Leapfrog. He's also cofounder of the Maine Health Management Coalition (now Healthcare Purchaser Alliance of Maine) and has been appointed by two different Maine Governors to serve on Health Care Reform Commissions to recommend public policies to improve the access and affordability of health care for Maine citizens. 03:36 Why employers are spotting the margin from commercial pay. 05:20 Public pay vs commercial pay, and why profit for a hospital has to come from commercial payers. 05:51 Inefficient costs in health systems. 07:22 How the health care system evolved this way. 09:12 "If you're a business, a manufacturer, you actually do cost accounting. … Hospitals don't use cost accounting. They really don't know." 12:00 The amount that taxpayers are actually subsidizing hospital systems. 12:24 Cost shifting and how this is affecting employers and employees. 14:45 How a hospital could increase its employer prices by such a large magnitude. 17:19 The perverse incentives that have made health plan premiums what they are today. 22:11

In this health care podcast, I'm speaking with Maura Calsyn from the Center for American Progress—or CAP—and we're talking about value-based drug pricing and the impact that COVID-19 may have on its definition, operationalism, and broad adoption. I remember a situation (kind of years ago, actually) where a pharma company decided to lower its price on an infused product. Normal supply and demand would dictate that if you lower your price, you will get more overall business, which will result potentially in more overall revenue—the old supply-and-demand curve at work. In this case, though, that pharmaceutical brand's business plummeted. The Pharma had to raise their price again to capture the market share that they wound up losing by lowering their price. Why? Because doctors get paid a percentage of the drug cost to administer the product. So, the lower the drug price, the less a physician gets paid. Provider organizations have a big incentive to prescribe the highest-priced product—so, you know, the opposite of whatever you learned in Economics 101. On the other hand, and possibly more often, we have Pharma pricing products based on what they think the market will bear. And historically, that has meant a really high price point because the market will bear, it turns out, quite a lot. There's this perception that our national and employer pocketbooks are unlimited when it comes to health care spending. And I can see how the health care industry would get that idea, because it pretty much has always been a true statement. Despite a lot of grousing and complaining, the bill gets paid. But pain causes change. It is very possible that this pandemic will not only change how medical care is delivered, which we've been talking a lot about in the past few episodes; but also it will have an impact on how pharmaceutical drugs are priced and patented. If you think about it, and I started to think about it after this conversation with Maura, the optimal price for a pharmaceutical product would be an amount that enables everyone in a population who needs the drug to be able to get it. What a tragedy it is when there is a drug, when science has produced a drug that can help someone who is suffering but they can't get it. Maybe this is because a health care middleman is trying to game the system for as much profit as possible, or maybe it's because the manufacturer set their price high to earn as much money as they can from those who can pay, but at a sacrifice of those who cannot. Maura and I talk about the emerging "Netflix Model" or the "Australian Model" of paying for drugs in this health care podcast also, which is pretty interesting. Prior to her role at the Center for American Progress, my guest Maura Calsyn worked at HHS in the general counsel's office and was lead attorney and/or worked on a number of Medicaid initiatives, including the Medicaid rebate program. You can learn more at americanprogress.org. You can also connect with Maura on Twitter at @maura_calsyn. Maura Calsyn is the managing director of health policy at the Center for American Progress. In this capacity, she plays a leading role in American Progress's health policy development and advocacy efforts. She has authored and coauthored work published in The New England Journal of Medicine, JAMA Internal Medicine, US News & World Report, and The Hill. Her work covers a range of topics, including Medicare and Medicaid payment reform, health care transparency, and trends in employer-sponsored insurance. She has also testified before Congress. Prior to joining American Progress, Calsyn was an attorney with the US Department of Health and Human Services Office of the General Counsel. During her time there, she served as the department's lead attorney for several Medicare programs and advised the department on implementation of the Affordable Care Act. Before joining the Office of the General Counsel, Calsyn worked as a health care attorney at two international law firms and represented a wide variety of health care payers, providers, and manufacturers. Calsyn first worked in health policy as a health care legislative assistant for Rep. Anna Eshoo (D-CA) before attending law school. Calsyn graduated cum laude from Harvard Law School and received her bachelor's degree summa cum laude from Hamilton College. 03:48 The value of pharmaceutical products. 06:58 "We're dealing with what might seem like an infinite amount of resources, but it's really not." 07:03 The "Netflix" or "Australian" payment models vs value-based pricing. 09:35 "You need a transparent and really replicable process." 10:41 Considerations of equity and affordability. 11:10 "Everybody wants people to get the drugs that they need … I think the question really is just, 'Who is paying for it?'" 11:44 What value-based pricing really means in the pharma industry. 13:22 "We're confusing what is actually a value-based price with some of the tools that are used to try to get closer to that." 14:03 Why

Look, bottom line, value-based care has to be the future of health care delivery in this country. That's just inarguable at this point. Nobody disagrees except for health care industry stakeholders trying to reap as much reward as possible while the going is good. And they've been really successful with their reaping thus far. Here's the thing, though: There's speculation that health insurance premiums may go up, like, 4% to 40% next year if the status quo remains the status quo. Is this the moment when we all start to get real about value-based care? Not because it would be a nice thing to get up and running, but because we have to. Health care costs are already too high in this country. You can't just add 40% and think that somebody's gonna find that kind of change in the bottom of their pocket, which has already been turned inside out. But also because on the provider side of the equation, it's less risky. Here's what I mean by less risky: All of those health systems struggling right now because of the decrease in elective procedures—if they had all had a significant portion of their revenue derived from value-based agreements where they were contracted to take care of populations, they'd all still be getting paid their global/capitated payments right now and actually able to take care of patients who need care instead of sitting on the sidelines watching their bank accounts dwindle. In this health care podcast, I speak with Eric Weaver, who is the newly minted executive director of the Accountable Care Learning Collaborative based in Utah. We talk about how life could have been a lot different for PCPs and also specialists, by the way, and health systems had we lived in a value-based world instead of an FFS (fee-for-service) one. Considering that this pandemic might consist of waves that extend for months if not years, this might be a call to action for providers to get meetings set up with payers, like, right now to switch up payment terms into value. But it's also a call to action for purchasers of health care like employers and commercial carriers. When I was talking to Guy Culpepper, a PCP, in episode 272, he really wants value-based contracts; but he can't get them alone. Purchasers and payers have to be willing to come to the table and offer them. So come on, everybody! Let's belly up to the conference room table—or your little Zoom Brady Bunch box, as the case may be. Now's the time to really flip the switch to payment models that work for patients and enable physicians at the same time to provide the kind of care that's in alignment with their values. One acronym heads-up in this conversation that I have with Eric Weaver coming up: APM stands for advanced payment model, which is, at its simplest level, a kind of value-based payment model. You can learn more at accountablecarelc.org. You can also connect with Eric on Twitter at @Eric_S_Weaver or on LinkedIn. Eric Weaver, DHA, MHA, is nationally recognized for his work in payment and delivery transformation. He is the recently appointed executive director of the Accountable Care Learning Collaborative (ACLC), a nonprofit organization founded by former Secretary of Health and Human Services Mike Leavitt and former Administrator of the Centers for Medicare and Medicaid Services Dr. Mark McClellan. With a mission to accelerate the readiness of health care organizations transitioning to value-based payment, the ACLC has defined the standards for high-value organizations and the workforce skills and competencies needed to advance value-based care. Dr. Weaver has been recognized for his contribution to the health care industry by receiving the ACHE Robert S. Hudgens Award for Young Healthcare Executive of the Year and the Modern Healthcare "Up & Comers" Award in 2016. Prior to assuming his new leadership role with the ACLC earlier this month, Dr. Weaver was a senior vice president for Innovista Health Solutions, a population health MSO, and was the president and CEO of Austin, Texas–based Integrated ACO—one of the more successful physician-led accountable care organizations in the country. For more information on Dr. Weaver and his vision for the future of the ACLC, you may access this video. If you are a provider organization looking to succeed in value-based care, you can obtain a free membership to the ACLC at accountablecarelc.org/join-us. 03:23 Is this pandemic an inflection point for value-based care? 04:10 "If United Kingdom built their National Health System post-World War II, why can't we rebuild ours?" 04:40 "If it's ever gonna happen, it's gonna happen now. I just think we need to wake up." 05:04 Do volume decreases equal payment decreases? 06:10 Where value-based care plays into specialty care vs primary care. 06:21 "There just hasn't been a value on cognitive services as there has been on procedural volume-based care." 06:55 "I really think that independents have to be in the driver's seat here." 06:59 The possible silver lining in this pan

In this health care podcast, I talk with Brian Scott. Brian has a background which is perfect for the question of "Will employer health care costs go up or will they go down as a result of this pandemic?" First, Brian was an underwriter at United. Then he was in a dedicated complex claims group for Lockton that managed self-funded plans. And now he's at Point6 Healthcare, where he works to put together the best-value plan for employers, including getting stop-loss. Brian works with TPAs (third-party administrators) across the country to this end. So, this conversation that I had with Brian is a two-part affair: The first episode (episode 275) was mostly about the specific additions as a result of this pandemic used in cost models and also what some self-insured employers are doing or considering doing to address the underlying risk factors that might help drive up costs in a plan. This, however, is episode 276; and it includes Brian's advice for self-insured employers, as well as a look into the fully insured market. Why there have been those estimates that costs will go up 4% to 40% when premiums are re-upped, Brian has some thoughts. You should definitely listen to both episodes (275 and 276), although you probably don't need to listen to them in order if you just happened to hit on this show first. You can learn more at point6healthcare.com and [email protected]. You can also connect with Brian on LinkedIn. Brian Scott is an assistant vice president at Point6 Healthcare. He joined the team in 2019 to implement and lead a new type of ICU related to self-funded employers focused on implementation, consulting, and underwriting strategies on behalf of self-funded benefits plan sponsors. Point6 is an authority on employer-sponsored self-funded health care financing and risk transfer strategies in the United States and maximizes the value of interactions between those providing, receiving, and financing health care. Brian has also worked as the strategic consultant for a major consulting firm specializing in employer stop-loss and cost-containment strategies, where he managed administrator and carrier relationships and opportunities, risk transfer strategies, and self-funding overall, while growing a team to ultimately handle stop-loss placements nationwide. Prior to that, Brian worked as a senior underwriting consultant for a BUCA managing stop-loss negotiation and placement, administration, and pharmacy pricing for large and complex self-funded, fully insured, and HMO cases. Brian works to maximize employer strategies for managing high-cost claimant risk, focusing on opportunities to enhance plan designs, administrator-specific gap avoidance, and cost-containment processes. Brian has assisted with the formation of medical stop-loss captives, merger and acquisition risk coverage strategies, fully insured to self-funded conversion strategies, and reference-based pricing and alternative funding concerns as well. 02:48 What health care costs and revenue look like further out—2021. 06:13 Can and will employers meaningfully impact the price of care? 07:59 "A lot of it has to do with, 'Who do I receive direction from?'" 10:54 The fully insured market vs the self-insured market. 14:15 The cost of care for COVID-19 cases and the cost of care for cases that turn out not to be COVID-19. 14:41 "Provider billing behavior is going to be impacted well beyond COVID." 16:02 Covered California in the time of COVID-19. 17:15 Does a fully insured carrier have the incentive to cut costs? 17:40 What will happen to fully insured carriers who can no longer raise premium costs to cover COVID-19 costs. 19:13 What self-insured employers shouldn't be doing right now. 20:07 Examining cost vs value of care. 23:42 "How can you create the best chance that you're not going to have really big outlier costs on your plan?" 24:35 Where the name Point6 Healthcare came from. You can learn more at point6healthcare.com and [email protected]. You can also connect with Brian on LinkedIn. Check out our newest #healthcarepodcast with Brian Scott of Point6 #Healthcare as he discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing What health care costs and revenue look like further out—2021. Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing Can and will employers meaningfully impact the price of care? Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing "A lot of it has to do with, 'Who do I receive direction from?'" Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during #covid19. #digitalhealth #predatorypricing The fully insured market vs the self-insured market. Brian Scott of Point6 #Healthcare discusses premium increases in the fully insured market during

I have the same burning question that I think many of you have: If I am a self-funded employer, as a result of this pandemic, will my health care costs go up? This question boils down to an equation that has two parts: the additions and then the subtractions. In the Additions column, how much will an employer spend on COVID-19 treatments—you know, both the ICU visits but also employees who haven't been to the doctor in 15 years, get a cough, go to the doctor, and get diagnosed with some underlying condition (maybe after a lot of lab work and a few CT scans), and potentially wind up, for example, on some expensive therapy? Back to our equation: In the Subtractions column, we have shelter in place, whether by mandate or fear based. Everyone who is forgoing or has forwent elective surgery or follow-up visits or anything else in a fee-for-service world results in less costs for an employer. Doctor visits are down 35% to 80%, depending on the specialty. And, nothing for nothing, health care industry revenue is an employer's cost. If we disregard payer mix for a sec, this could mean that employer costs are down the same percentage as any given doctor's revenue. In this health care podcast, I talk with Brian Scott. Brian has a background which is perfect for the question of "Will employer health care costs go up or down?" First, he was an underwriter at United. Then he was in a dedicated complex claims group for Lockton that managed self-funded plans. And now he's at Point6 Healthcare, where he works to put together best-value plans for employers, including getting stop-loss. Brian works with TPAs (third-party administrators) across the country to this end. So, this conversation with Brian has two parts: This first episode (episode 275) is mostly about the specific additions used in a lot of the cost models that are being floated relative to whether costs will go up or down for self-funded employers and also what some self-insured employers are doing or considering to address the underlying risk factors that might drive up costs in a plan and help reduce them. Episode 276, which is the next one after this one, includes Brian's advice for self-insured employers, as well as a look into the fully insured market. We explore why estimates in the fully insured markets show that costs could go up anywhere from 4% to 40% when premiums are re-upped. You can learn more at point6healthcare.com and [email protected]. You can also connect with Brian on LinkedIn. Brian Scott is an assistant vice president at Point6 Healthcare. He joined the team in 2019 to implement and lead a new type of ICU related to self-funded employers focused on implementation, consulting, and underwriting strategies on behalf of self-funded benefits plan sponsors. Point6 is an authority on employer-sponsored self-funded health care financing and risk transfer strategies in the United States and maximizes the value of interactions between those providing, receiving, and financing health care. Brian has also worked as the strategic consultant for a major consulting firm specializing in employer stop-loss and cost-containment strategies, where he managed administrator and carrier relationships and opportunities, risk transfer strategies, and self-funding overall, while growing a team to ultimately handle stop-loss placements nationwide. Prior to that, Brian worked as a senior underwriting consultant for a BUCA managing stop-loss negotiation and placement, administration, and pharmacy pricing for large and complex self-funded, fully insured, and HMO cases. Brian works to maximize employer strategies for managing high-cost claimant risk, focusing on opportunities to enhance plan designs, administrator-specific gap avoidance, and cost-containment processes. Brian has assisted with the formation of medical stop-loss captives, merger and acquisition risk coverage strategies, fully insured to self-funded conversion strategies, and reference-based pricing and alternative funding concerns as well. 03:27 Contemplating the additional costs an average employer might incur relative to employees and COVID-19. 04:34 "People want to interact differently with the health care system moving forward than they have in the past." 06:55 "It's not necessarily intuitive." 07:03 The biggest point of care that's probably going to be utilized post-COVID: telemedicine. 09:19 EP273 and EP274 with Jonathan Thierman, MD, PhD.09:34 The health care shifts we're likely to see moving forward. 13:00 Some of the negative consequences of COVID-19. 15:25 What a health care model without a pharmacy benefits manager (PBM) might look like moving forward. 17:22 "Their solution might be, 'Change the formulary.'" 19:39 EP264 with Ron Wince.21:02 "Finding ways to really dig into … these individual concerns … are not necessarily top of mind." 22:37 COVID creating a flash point for change. 23:04 "I don't know if it's best to call it an opportunity." 24:52 The different health model change

Everybody's talking about the surge in telehealth usage. I wanted to talk to someone who has been ramping up their telehealth capabilities for a while to get a sense of what it takes to do it well. And, as has been said by many, doing telehealth isn't just about technology. It's about training clinicians, patients, and accounts receivable and other staff. It's about rearranging workflows and processes. So, I was super pleased to have had the opportunity to speak with Jonathan Thierman, MD, PhD. Dr. Thierman is an ER doctor. He's also the chief medical information officer for LifeBridge Health systems and medical director of the LifeBridge Health Virtual Hospital. This show has two parts. This is the second part—episode 274. In this health care podcast, we'll get into some of the operational aspects of telehealth, like what EHR integration actually means and looks like. We talk about whether laws governing telehealth that were relaxed get stringent again. We talk about natural language processing and artificial intelligence and how they fold into the telehealth answer. I also ask Dr. Thierman for his advice to those potentially more new at the telehealth thing—what lessons he's learned, what critical success factors might be. One last point: In episode 273 (and you probably don't need to listen to these in order), which is the first part of this two-part series, Dr. Thierman and I discuss what telehealth can accomplish, maybe better than a face-to-face patient encounter, and what it's not so good at. One thing that dawned on me as we were talking is that technology isn't just a video system. There's apps, there's AI, there's minivans full of lab equipment … there are other innovations that expand the capacity of a remote patient visit. You can learn more at lifebridgehealth.org. You can also follow Dr. Thierman on Twitter at @techie_doc or connect with him on LinkedIn. Jonathan Thierman, MD, PhD, is physician executive in the LifeBridge Health system and president of the medical staff at Northwest Hospital. He started his career as an engineer and inventor, earning his PhD at MIT and then training in emergency medicine at Harvard Medical School and Johns Hopkins Hospital. In the past, he has worked to bring real-world clinical experience to the engineering and design of medical devices. Currently, he is the chief medical information officer for the LifeBridge Health system in Baltimore, where he leads a team of physician informaticists to interface between the 180+-person IT department and the 3000+ affiliated physicians across five hospitals and in community practices on matters of the EMR, CPOE, and other health IT systems. Dr. Thierman is passionate about applying technology to improve health and outcomes. To this end, he helped to establish the LifeBridge Health Virtual Hospital, with affiliated clinical call centers in Jerusalem and the Philippines, to provide telemedicine services across the continuum. He also created the LifeBridge Techbar to offer in-person IS assistance to LifeBridge providers. In addition, he developed a patient "Digital Front Door" to help direct patients to the right care center with the least wait time, improving patient experience and load-balancing the emergency departments and urgent care centers in the LifeBridge Health system. 03:15 The net effect of adopting telemedicine during the pandemic. 06:42 "Data is key." 09:20 "There's a lot more communication going on now between health care providers and their patients than there was before." 09:40 "Even now, we're still scratching the surface of what insights we can gain from the data." 12:42 EP251 with Dr. Kimberly Noel and training doctors in webside manner.13:00 How telehealth and EHR systems align. 14:02 The telehealth value points that are coming. 17:23 The necessity of training for clinicians embarking on this telehealth adaptation. 18:50 "Jump in, because it's … here to stay." 19:30 "It doesn't have to be as expensive as you think." You can learn more at lifebridgehealth.org. You can also follow Dr. Thierman on Twitter at @techie_doc or connect with him on LinkedIn.

Everybody's been talking about the surge in telehealth usage—how it would have taken, like, ten years to get as far as we've gotten in the past ten days. I wanted to talk to somebody who has been ramping up their telehealth capabilities for a while to get a sense of what it takes to do it well. As has been said by many, doing telehealth isn't just about technology. It's about training—clinicians and patients and accounts receivable and other staff. It's about rearranging workflows and processes. So, super pleased to have had the opportunity to talk with Jonathan Thierman, MD, PhD. Dr. Thierman is an ER doc. He's also the chief medical information officer for LifeBridge Health systems and the medical director of the LifeBridge virtual hospital. So, this show has two parts: episode 273 that you're listening to; but the second part, episode 274, is where we're going to get into some of the operational aspects of telehealth, like what EHR integration actually means and what it looks like. In this health care podcast (episode 273), however, Dr. Thierman and I discuss what telehealth can accomplish, maybe better than a face-to-face patient encounter, and what it's not so good at. One thing that dawned on me as we were talking is that the technology isn't just, you know, a video system. There's apps, there's AI, there's minivans full of lab equipment … there are other innovations that expand the capability of a remote patient visit. Here's another point to ponder that Dr. Thierman and I explore a little bit. What is the impact of telehealth in a value-based care environment but also in an FFS (fee-for-service) reimbursement model? It's likely, if you think about it, there will be more patient visits because the barrier to getting care has diminished. And that might be a good thing if we're talking about chronic care, if we're talking about ensuring follow-up after a surgical procedure. There's any number of examples where patients getting help prior to some sort of acute event would be considered a good thing by most. But does improving access to care increase a patient's chances of getting inappropriate care? You know, 25+% of care is some variation of waste, fraud, and abuse; and additional services rendered always have the risk of negative consequences. Or do we figure that bad actors are doing a pretty good job behaving badly anyway, so the net positive for the rest of us is worth it? You can learn more at lifebridgehealth.org. You can also follow Dr. Thierman on Twitter at @techie_doc or connect with him on LinkedIn. Jonathan Thierman, MD, PhD, is physician executive in the LifeBridge Health system and president of the medical staff at Northwest Hospital. He started his career as an engineer and inventor, earning his PhD at MIT and then training in emergency medicine at Harvard Medical School and Johns Hopkins Hospital. In the past, he has worked to bring real-world clinical experience to the engineering and design of medical devices. Currently, he is the chief medical information officer for the LifeBridge Health system in Baltimore, where he leads a team of physician informaticists to interface between the 180+-person IT department and the 3000+ affiliated physicians across five hospitals and in community practices on matters of the EMR, CPOE, and other health IT systems. Dr. Thierman is passionate about applying technology to improve health and outcomes. To this end, he helped to establish the LifeBridge Health Virtual Hospital, with affiliated clinical call centers in Jerusalem and the Philippines, to provide telemedicine services across the continuum. He also created the LifeBridge Techbar to offer in-person IS assistance to LifeBridge providers. In addition, he developed a patient "Digital Front Door" to help direct patients to the right care center with the least wait time, improving patient experience and load-balancing the emergency departments and urgent care centers in the LifeBridge Health system. 03:26 What was happening with telehealth pre-COVID-19. 04:50 What's happened to telehealth and primary care practices post-COVID-19. 06:28 How quickly telehealth medicine appointments are growing. 07:30 What percentage of patients are doctors able to see via telemedicine? 08:24 Are patients getting adequately cared for? 10:20 "The vast majority of medicine, except for surgical services, really is a mental game." 14:15 "If you have a window into the home, you probably have a better view of the social determinants of health." 14:25 How AI plays into telemedicine right now. 16:52 Where telehealth visits will land after the pandemic. 18:40 "When you improve access, you also improve demand." 19:22 Is telehealth consumer driven? 20:48 "For the most part, patients are most connected to their actual physician." 21:37 Why more frequent touch points via telehealth will benefit health care quality and costs in the future. 28:20 "It's about the patient, and it's about really keeping them well."

A lot of people are wondering why independent PCPs are furloughing nurses and talking about shuttering their practices in the middle of a pandemic. Conventional wisdom would assume that PCPs would be just fine if they stand up telehealth and can take some sort of majority of their patient visits virtually. After all, it would make a lot of sense that a lot of patients are calling their doctor right now. In this health care podcast, I interview Guy Culpepper, MD. Dr. Culpepper sets us straight about what is actually going on day to day for PCPs right now. He also suggests that, right now, this pandemic is a flash point. It's a game changer. It's the trigger for an abrupt and transformational change in the business of providing patients with primary care. Just a couple of vocab words to keep us straight here: DPC stands for direct primary care. This is when a doctor bills a patient directly—no insurance in the picture. So, the doctor sends a bill for, say, $70 a month to the patient and the doctor will then take care of that patient no matter how many questions they ask or texts they send or office visits they require or don't require. Direct to employer means that the doctor contracts directly with an employer—usually a self-insured employer, again without insurance. So, the employer pays the doctor usually some capitated lump sum per month or per year for primary care. Goodbye, fee for service (FFS). Dr. Culpepper is a founder and CEO of an independent physician group in North Texas with 550 providers. He served in that role for 25 years, but as he says, his day job is being a board-certified family doctor. You can learn more at benttreemd.com. You can also connect with Dr. Culpepper on Twitter at @DrCulpepper. Guy L. Culpepper, MD, founded Bent Tree Family Physicians in 1987. His enthusiasm for health care and his focus on each patient as an individual has been rewarded by numerous recognitions as one of America's premier family physicians. Disease prevention is the primary goal of his work. He has expertise in diabetes, cholesterol management, and osteoporosis; however, caring for children is his greatest joy. Dr. Culpepper's leadership has been seen at every stage of his career. During training, he served as both chief resident in family medicine and as the president of the medical/surgical house staff of St. Paul Medical Center. He was the founding chairman of the department of family medicine at Texas Health Resources Presbyterian Hospital of Plano, where he was honored to serve as the president of the medical staff. His dedication to primary care continues to be seen in his leadership of the Jefferson Physician Group, an organization of more than 230 internists, pediatricians, and family physicians improving North Texas health care since 1995. A Dallas native, Dr. Culpepper lives in Frisco with his three sons, whose support has made his work possible and his leisure time joyful. He enjoys reading, writing, movies, sports, and collecting medical antiques and is a lifelong fan of the Dallas Cowboys. 02:22 What a PCP's average day looks like during the pandemic. 03:48 How likely is it that PCPs can transition easily to telehealth? 06:00 Why the pandemic is a flash point game changer for telehealth and PCP reimbursement. 08:54 "It's like a perfect storm of multiple tragedies coming together." 10:47 How primary care is going to alter after this. 13:24 "We need to totally change the way that our country pays us." 14:29 What is the incentive for health plans and hospitals to change financial models in all of this? 16:26 "The ones who are going to change are the ones who need to change." 18:13 Why the employers will be demanding this change in financial model. 19:12 Why being independent vs being part of an accountable care organization matters during this pandemic. 21:07 "If we don't save the independent doctors, there's nothing to break this chain of abuse." 24:34 "Higher income doesn't always mean more happiness; it often means less sense of freedom." 25:53 "There's a point where a little bit more money and a loss of freedom are no longer properly balanced." 27:53 Untangling the FFS reimbursement. 30:00 Why right now is a flash point for PCP reimbursement. 30:38 "No one else can do what we can do in effective primary care. No one … in this market." 31:49 What payers should be doing right now. 33:27 EP270 with Dave Chase of Health Rosetta.33:39 Dr. Culpepper's message to Medicare. You can learn more at benttreemd.com. You can also connect with Dr. Culpepper on Twitter at @DrCulpepper. Check out our #healthcarepodcast with @DrCulpepper as he discusses what #covid19 means for #PCPs, #employers, and #healthplans. #healthcare #podcast #digitalhealth #reimbursement #ffs What does a #primarycarephysician's typical day look like during this #pandemic? @DrCulpepper discusses what #covid19 means for #PCPs, #employers, and #healthplans. #healthcarepodcast #healthcare #podcast #digitalhealth #reimbursement #ffs How li

In this health care podcast, I'm talking to Al Lewis from Quizzify. This episode also guest stars Rachel Miner from Thrive Benefits, David Contorno from E Powered Benefits, and Doug Aldeen, a health care attorney in Texas. This episode started out being about surprise billing in the emergency room (ER) and a potential defense strategy that patients and employees can use to protect themselves from egregious billing practices. Surprise bills are when a patient gets "balance billed" for a sum above what their insurance carrier will pay. Usually this transpires when an out-of-network provider somehow or another gets involved in their care. Usually the patient has no idea this happens until after the bill comes—the big bill, in many cases, thus the surprise. But here's where surprise billing and COVID-19 connect. You might not have thought of this because you might know that patients who present in the ER with COVID-19 and then test positive are protected from surprise bills, for the most part, by the CARES Act. But there's a couple of wrinkles. What if the patient does not actually have COVID-19? Then whatever treatment they wind up getting in the notoriously expensive ER is business as usual. Here's another wrinkle: The cost of treatment for COVID-19 is not like it's capped. So even if an employee doesn't get a surprise bill, the self-insured employer or health plan might. And the CARES Act explicitly states that the employer or plan is on the hook to pay for it. And one last wrinkle: Dealing with this pandemic among other things leaves about 0.0 chance that the national surprise billing legislation is gonna happen this year. But it's not like kids have stopped running into the side of the pull-out couch and needing stitches, or drug overdoses or heart attacks have suddenly vanished. There was a news article just the other day about a private equity–run ER in the Midwest continuing to dish out nasty surprise bills to their community of taxpayers at the exact same time that they were lobbying to get a piece of the federal bailout paid by taxpayers. Al Lewis and his team over at Quizzify created this handy wallet card that patients or employees can use when they have the unfortunate experience of going to the ER themselves or with a loved one. It protects them from egregious surprise bills, thus its moniker, the surprise billing defense strategy. But nothing for nothing, this wallet card, this surprise billing defense strategy, also protects employers and health plans from these large bills in the age of COVID-19. Al Lewis and I start our conversation talking about a New York Times article (also available here for those who don't subscribe to the New York Times) that came out recently featuring Al as well as myself and chronicles my visit to an emergency room wherein I deployed the surprise billing defense strategy/wallet card. You can learn more at quizzify.com or connect with Al on LinkedIn. You can also connect with Al on Twitter at @quizzify and @whynobodybeliev. You can also connect with Rachel and David on LinkedIn and with Doug on Twitter at @AldeenDoug and on LinkedIn. Al Lewis wears multiple hats, both professionally and also to cover his bald spot. Hat #1: Employee Health Literacy. He is the founder and "quizmeister-in-chief" of Quizzify, whose mission is to help companies teach their employees to utilize health care services appropriately, using a format best described as "Jeopardy meets health benefit education meets Comedy Central." Quizzify is the only vendor authorized to display the Harvard Medical School "Veritas" shield and has received excellent reviews from users. Quizzify is best known today for its employee coronaquizzes (now exceeding 100,000 plays!) and its surprise billing "Prevent Consent" solution, which was recently featured in the New York Times. It can be taped to an insurance card, used as a stand-alone card, or downloaded into your Apple Wallet. His quiz-specific background includes authorship of the best-selling Newsweek Presents the Ultimate Trivia Game, which Games magazine lauded as having the best questions of any trivia game; hosting two quiz shows on Boston network affiliates; and appearing on Jeopardy. Hat #2: Outcomes Measurement. As an author, his critically acclaimed category best-selling book on outcomes measurement, Why Nobody Believes the Numbers, chronicling and exposing the innumeracy of the health management field, was named digital health book of the year in Forbes. Cracking Health Costs, written in conjunction with Walmart alum Tom Emerick, was also a trade best seller. Surviving Workplace Wellness has also received great accolades, and excerpts appeared in Harvard Business Review and elsewhere. He was the cofounder of the World Health Care Congress's Validation Institute. His expertise in outcomes measurement got him named one of the unsung heroes changing health care forever. He graduated Phi Beta Kappa with honors from Harvard, where he taught economics as we

Let's talk today specifically about primary care physicians (PCPs) and family medicine doctors. Data was reported in USA Today, saying that an estimated 60,000 family practices will close and 800,000 of their employees will lose their jobs by the end of June. It's hard for any practice to just snap its fingers and transfer patients over to telemedicine regardless of the reimbursement rate and/or how many payers are actually paying any reimbursement for telemedicine or remote patient monitoring. It's a thing to go virtual. It requires new processes, different staffing training, different workflows. Plus, a lot of what a PCP does (ie, fielding phone calls with quick questions, for example) aren't reimbursable; and if they were, no one's gonna, like, spend half an hour trying to send a bill for $12. What are the consequences of all, let's just say, independent PCPs going out of business? Well … first, logically, all patients served by these doctors and their teams now no longer have a place to go to get care, right in the middle of a pandemic. Second, let's just say in a thought experiment that a lot of independent physicians do go out of business and do wind up going to work in an employed model. That might very well happen. Private equity and payers like Humana and Optum have been buying up PCP practices all over the place. Why? So they can have captive populations. Patients come in the door at their PCP, and everywhere they go from there can be controlled by the vertically integrated entity. This has been stated openly. It's also pretty clear at this point that that model increases costs for any ultimate purchaser of health care like, for example, an employer. There's also other, let's just say, more unseemly motivations if you start to think about what a company who owns patient relationships with their PCPs can manage to perpetuate. It's great if you're a shareholder. It might be less great if you're a citizen of this country. In this health care podcast, I speak with Dave Chase, cofounder and CEO of Health Rosetta. Health Rosetta empowers community-owned health plans like, for example, employers and states' and town governments. Dave talks about Health Rosetta's Marshall Plan, which is an action plan right now to minimize the negative impact of COVID-19 by ensuring that family and primary care practices can stay in business. The Marshall Plan is a call to action for self-insured employers and commercial health plans. You can learn more about the Marshall Plan at healthrosetta.org/marshallplan. You can also connect with Dave on Twitter at @chasedave and follow Health Rosetta at @HealthRosetta. Dave Chase leads the vision for Health Rosetta, which is to empower community-owned health plans. Health Rosetta's blueprint and platform power the health plans of your dreams: high-quality, trustworthy, local, affordable care—that you thought had disappeared forever—from caregivers we know and trust. They free up compassionate, well-trained, community-based caregivers to rediscover love in medicine so they can do what they have always been called to do: serve their patients not just in disease but toward their fullest health. A trusted and sacred caregiver-patient bond is built through transparency and openness that equips and empowers patients wherever they can best achieve their unique health goals—at home or any setting best optimizing their well-being. By avoiding the 50% wasted health care spending, we can ensure our caregivers have the independence and resources to address the psychosocial and medical issues their patients face. Human-centered health plans restore health, hope, and well-being. Through best-selling books and The Resident (on FOX), where Dave serves as a consultant, collateral damage from the Extractive Era of health care is highlighted as well as the tremendous successes and opportunities with Health Rosetta–type health plans. The books, writing for various media outlets, TED Talk, and TV/film have reached over 10 million people, with the goal of informing, enraging, empowering, and activating a broad grassroots movement designed to restore hope, health, and well-being to our communities. Dave proudly received the Health Value Awards' Lifetime Achievement for Health Benefits Innovation at the 2020 World Health Care Congress. Dave cofounded Avado, which was acquired by and integrated into WebMD/Medscape, and founded Microsoft's $2 billion, 28,000-partner health care ecosystem. Outside of work, Dave Chase is an oxygen-fueled mountain athlete and volunteer high school track and cross-country coach. Once upon a time, Dave was a PAC-12 800 meter and 4x400 competitor. Most importantly, his devotion to faith, family, and friends underpins a desire to be a servant leader to the four million lives (and growing) stewarded through the Health Rosetta community. 03:15 The state of independent fee-for-service PCPs during COVID-19. 03:57 CMS and telehealth, and why these aren't really aiding PCP revenue. 05:

The first wave of this COVID-19 pandemic has been totally reactionary. Don't get me wrong: That does not detract from the Herculean effort made by hospitals and clinicians who have thrown everything they have at this—and more. But I don't think that anyone would disagree that if we had enough PPE (personal protective equipment) and ventilators—you know, like, proactively—we'd be in better shape. So let's stay ahead of the second wave of this pandemic, which is going to happen when, as Marty Makary put it in episode 267, the backlog of patients who were scared to or unable to get care for a few months creep out of their homes. What happens when patients who should have gotten a tumor removed or had a colonoscopy because of GI bleeding or felt the symptoms of a heart attack but did not get timely care? In this health care podcast, I am speaking with Eric Bricker, MD, from AHealthcareZ; and we're talking about how the post-COVID-19 new normal may shape up. One way to conceive of what health care will be moving forward is to look at how stakeholders are impacted by the pandemic right now and what action steps they're taking right now, because to a nontrivial degree, the moves made now will have an outsized impact on their success trajectory in the near term and long term in the months and years to come. I was super thrilled to have the chance to speak with Dr. Bricker. If you haven't watched his videos on LinkedIn or at AHealthcareZ.com, you should definitely go and check them out. You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn. Eric Bricker, MD, is an internal medicine physician and former cofounder and chief medical officer of Compass Professional Health Services. Compass is a health care navigation service that grew to 2000+ clients, including T-Mobile, Southwest Airlines, and Chili's/Maggiano's restaurants. Compass was acquired by Alight Solutions in July 2018. Alight is a 10,000-person employee benefits and HR outsourcing company that separated from Aon in 2017. Dr. Bricker has since started AHealthcareZ.com, with 170+ health care finance videos with approximately 90,000 views per month across all platforms. He is also the author of Healthcare Money Campfire Stories. 02:48 How COVID-19 is impacting insurance carriers and payers. 06:16 How COVID-19 is going to affect payers with self-insured employers. 07:59 "The carrier's revenue is going to go down because of layoffs." 09:05 Other helpful or harmful COVID-19 factors to insurance carriers. 12:37 The risk to pharmacy benefit manager (PBM) revenue. 13:14 The financial stability of recent health system mergers. 14:03 The potential "cash crunch" for health systems because of COVID-19. 17:01 The issue with telehealth revenue right now. 20:57 EP251 with Dr. Kimberly Noel. 21:32 "In health care, you add technology and the price tends to go up."—Stacey 22:02 "Telemedicine allows for geographic competition." 22:19 How COVID-19 will affect specialty from a revenue perspective. 24:31 "An economic truism … one person's spending is another person's income." 27:06 "Pain causes change." 28:01 Do population health outcomes go up or down after COVID-19? 29:15 The high number of moves from high-deductible plans to Medicaid and how that will affect patient outcomes. 32:38 EP267 and EP268 with Dr. Marty Makary.33:02 Coming out of this peak, what hospitals need to be thinking about. You can connect with Dr. Bricker on Twitter at @DrEricB and on LinkedIn. Check out our newest #healthcarepodcast with @DrEricB. #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #billing #covid19 #covid19billing #covid19healthcare How is #covid19 impacting #insurancecarriers and #healthpayers? @DrEricB discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #billing #covid19billing #covid19healthcare How will #covid19 affect #healthpayers with #selfinsured #employers? @DrEricB discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #billing #covid19billing #covid19healthcare "The carrier's revenue is going to go down because of layoffs." @DrEricB discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #billing #covid19 #covid19billing #covid19healthcare What's the risk to #PBM revenue? @DrEricB discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #billing #covid19 #covid19billing #covid19healthcare What's the issue with #telehealth revenue right now? @DrEricB discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #billing #covid19 #covid19billing #covid19healthcare "In health care, you add technology and the price tends to go up." @DrEricB discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech #healthcarebilling #billing #covid19 #covid19billing #covid19healthcare "Telemedicine allows for geographic competition." @DrEricB discuss

On Friday, March 27, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act—otherwise known as CARES. This CARES Act covers the whole $2 trillion megillah stimulus package, but in this health care podcast episode, we're talking quickly about a provision in that Act. I speak first with Doug Aldeen, an attorney specializing in helping employers settle hospital bills. Doug works with clients across the country. And then at the end of the episode, you will also hear from Al Lewis, who is a founder over at Quizzify. Al Lewis, as many of you may or may not know—but if you don't know, you should—created a "surprise billing wallet card" that is actually super relevant to this discussion as you will see. There's actually going to be a whole surprise billing episode coming up soon where we discuss this wallet card, so you can consider Al's short commentary today as kind of a coming attraction. The provision that we're going to talk about in this episode is the No Cost Sharing for COVID-19 Testing and Vaccines provision. This is where insurers are required to cover testing for COVID-19 without cost sharing to their enrollees, and they must pay for the tests based on contracts or the posted pricing of labs. So, the thing is, hospitals and diagnostic testing companies can essentially basically name their price on COVID-19 tests; and employers and insurers will be required to pay for it. This is in Section 3202, the Price of Diagnostic Testing, in that CARES Act. The plot thickens this week as health insurers—including Aetna, Cigna, and Humana—are now waiving patient cost sharing on all treatment for coronavirus, not just the testing, including hospitalizations and ambulance transfers. And they're doing this for their insured members and employer plans at their in-network health systems—emphasis intended on the "in-network" part. So, you might be thinking, "Great … no costs to anybody!" But I did emphasize that last part for a reason. If you think for a minute about this, just because patients are not paying co-pays for COVID treatments first of all doesn't mean that while they're in the hospital that their diabetes won't flare up … or their MS or their RA. COVID-19 is just one thing, and the US has a patient population that has, let's just say, no shortage of chronic conditions—otherwise known as underlying conditions, otherwise known as the people most likely to be in the ICU. My concern is that there's nothing to say that co-pays and coinsurance for treatment of other things while being treated for COVID are going to suddenly vanish, too, even if it's an in-network health system. Furthermore, there is that problem of a patient going to a hospital that's not contracted with the employer plan or the patient's insurance carrier. At that point, I'm not seeing anything that would suggest that patients with COVID-19 are going to get any different treatment billing-wise than patients with anything else. We've seen COVID-19 bills that are, for uninsured patients, $34,000 and $73,000 in the press. What if the patient doesn't have out-of-network coverage, for example? What if the patient's out-of-network deductible is tens of thousands of dollars like some of them are? I don't see anything in this bill to suggest that those are suddenly going to go away. And, oh, by the way, exactly as the bill pretty much states explicitly, regardless of what the patient pays, the employer's on the hook to pay for whatever the hospital chooses to charge—at least as far as testing goes. You can connect with Doug on Twitter at @AldeenDoug and on LinkedIn. You can learn more at quizzify.com or connect with Al on LinkedIn. You can also connect with Al on Twitter at @quizzify and @whynobodybeliev. Doug Aldeen is an Austin, Texas–based health care and Employee Retirement Income Security Act (ERISA) attorney who recently served as ERISA counsel on behalf of the Berkeley Research Group in New York City to the $7.7 billion May 2016 acquisition of Multiplan and its medical bill repricing product Data iSight by the private equity firm Hellman and Friedman. Since 1997, he has represented reference base pricing organizations, a bundled payment software platform, PPO networks, medium to small self-funded plans, third-party administrators, and provider-sponsored health maintenance organizations in various capacities, including Herdrich v. Pegram, which was argued before the US Supreme Court in 2001. Moreover, he serves as a resource to national news organizations regarding issues on health care and as a consultant with the Governmental Relations Committee at the Self-Insurance Institute of America in Washington, DC, and as an adviser to RIP Medical Debt, which has abolished over $1.2 billion in medical debt. Doug received his JD from the University of Illinois. Al Lewis wears multiple hats, both professionally and also to cover his bald spot. Hat #1: Employee Health Literacy. He is the founder and "quizmeister-in-chief" of Qui

The reaction of some hospitals and health care systems to the COVID-19 pandemic has been truly breathtaking. Doctors, nurses, first responders, other staff at hospitals and elsewhere have worked hard—so hard—to support the national effort. The same can be said to some tech entrepreneurs and other businesses who have snapped into action in order to provide PPE (personal protective equipment) and artificial intelligence to the frontline health care workers. In this health care podcast, I'm talking again with Marty Makary, MD, MPH. Dr. Makary is a surgeon at Johns Hopkins, professor of surgery and health policy and management at Johns Hopkins University, and the author of The Price We Pay and Unaccountable. So, this is episode 268. In this particular episode, Dr. Makary and I discuss the situation that will likely play out after the "reactive" phase of this COVID-19 pandemic (ie, March, April, May). After about June, the pandemic, according to Dr. Makary, will start to wind down a bit; and at that juncture, there's going to be a backlog of patients who had their elective surgeries postponed and their care journeys potentially interrupted if they required an in-person visit or a lab test or an imaging study that did not happen. There will be a need to prioritize them, something that we have never really done in this country before. This is what we're going to talk about in this episode: this second phase. Potential point of interest: Episode 267 (the one right before this episode) is about the here and now, prior to the peak, if you want to go back and listen to that when you have time. You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary. Martin "Marty" Makary, MD, MPH, is an American surgeon, New York Times best-selling author, and Johns Hopkins health policy expert. He has written for The Wall Street Journal, USA Today, Time, Newsweek, and CNN and appears on NBC and Fox News. He has written extensively on organizational culture, the science of measuring quality in medicine, and health care reform. Dr. Makary is the author of two best-selling books: Mama Maggie, a book about a Nobel Prize nominee, and Unaccountable, a book about health care transparency. He also recently released The Price We Pay: What Broke American Health Care—and How to Fix It. This book offers a road map for everyday Americans and business leaders to get a better deal on their health care and profiles the disruptors who are innovating medical care. Dr. Makary is principal investigator of a Robert Wood Foundation grant to lower health care costs in the United States by creating physician-endorsed measures of appropriate medical care and directs the national "Improving Wisely" project to reduce waste in medicine. He speaks nationally on disruptive innovation in health care. Dr. Makary is a frequent medical commentator of NBC and Fox News, commenting on the health care cost crisis, the impact of new technology, and interpreting the latest medical research for everyday consumers. Dr. Makary is director of the Center for Opioid Research and Education and founder of solvethecrisis.org, a Web site that shares expert opioid prescribing recommendations for common medical procedures for clinicians and patients. At Johns Hopkins, he has served as the endowed chair of gastrointestinal surgery, director of surgical quality and safety, and founding director of the Johns Hopkins Center for Surgical Outcomes Research and Clinical Trials. Dr. Makary is a surgical oncologist specializing in minimally invasive surgery and teaches health policy and management at the Johns Hopkins University School of Medicine. He currently serves as the chief of the Johns Hopkins Center for Islet Transplantation and director of the appropriateness in medicine project. 02:23 What "normal" will look like in June. 03:46 Why people who need basic medical care right now aren't getting that care. 06:13 "For the first time, we've got to think now about prioritizing which patients need to get in line first." 07:51 "We see gaming of the system." 08:05 "We don't do a good job of prioritizing." 10:07 Why teamwork and team building are a problem in medicine. 12:57 The incredible heritage of the medical profession. 13:52 Will there be a decrease in outcomes? 14:33 Why lowering insurance deductibles will be key in making successful strides on the other side of this pandemic. 17:23 The great things to come out of the pandemic. 21:41 "Everybody's right … [they're just] looking at it from their point of view." 21:56 What's in store for pharmacies coming out of this pandemic. 24:53 What hospital executives should be doing, looking and planning months out from now. 25:48 "We've never asked ourselves, 'What would take priority?'" You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary. Keeping up with #covid19 news, check out our second-part episode with @MartyMakary as he talks #healthcare, #hospitals, and #coronavirus in the u

Marty Makary, MD, MPH, is a surgeon at Johns Hopkins. He's a professor of surgery and health policy and management at Johns Hopkins University. And he's also the author of The Price We Pay and Unaccountable. I had the honor of speaking with Dr. Makary last week, and I learned a lot. For one, the worst is between now and June. For two, it's all about ramping up capacity as fast as possible in our hospitals. We talk a lot, Dr. Makary and I, about what that looks like and what other stakeholders like employers and Pharma can be doing right now in this very, very reactionary phase. Spoiler alert: On Thursday this week, a second episode with Dr. Makary will be out. In this second show, Dr. Makary discusses the next phase of this pandemic when all of the pent-up demand becomes a backlog of patients who need care for everything else besides COVID over the summer. You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary. Martin "Marty" Makary, MD, MPH, is an American surgeon, New York Times best-selling author, and Johns Hopkins health policy expert. He has written for The Wall Street Journal, USA Today, Time, Newsweek, and CNN and appears on NBC and Fox News. He has written extensively on organizational culture, the science of measuring quality in medicine, and health care reform. Dr. Makary is the author of two best-selling books: Mama Maggie, a book about a Nobel Prize nominee, and Unaccountable, a book about health care transparency. He also recently released The Price We Pay: What Broke American Health Care—and How to Fix It. This book offers a road map for everyday Americans and business leaders to get a better deal on their health care and profiles the disruptors who are innovating medical care. Dr. Makary is principal investigator of a Robert Wood Foundation grant to lower health care costs in the United States by creating physician-endorsed measures of appropriate medical care and directs the national "Improving Wisely" project to reduce waste in medicine. He speaks nationally on disruptive innovation in health care. Dr. Makary is a frequent medical commentator of NBC and Fox News, commenting on the health care cost crisis, the impact of new technology, and interpreting the latest medical research for everyday consumers. Dr. Makary is director of the Center for Opioid Research and Education and founder of solvethecrisis.org, a Web site that shares expert opioid prescribing recommendations for common medical procedures for clinicians and patients. At Johns Hopkins, he has served as the endowed chair of gastrointestinal surgery, director of surgical quality and safety, and founding director of the Johns Hopkins Center for Surgical Outcomes Research and Clinical Trials. Dr. Makary is a surgical oncologist specializing in minimally invasive surgery and teaches health policy and management at the Johns Hopkins University School of Medicine. He currently serves as the chief of the Johns Hopkins Center for Islet Transplantation and director of the appropriateness in medicine project. 01:38 What happened that made Marty Makary sound the alarm bells on COVID-19. 03:12 Paul Kennedy's The Rise and Fall of the Great Powers.04:21 "Everyone has an opinion, but no one's listening." 06:00 What the next 4-6 weeks will look like. 08:22 What we should do to support our highest-risk patients: health care workers. 09:16 How long will this initial phase last? 13:10 What business leaders should be doing right now. 16:11 "Critical care generally pays very well." 17:15 Marty's concern for rural hospitals. 17:30 "If we're going to overfund [something], I'd like it to be our hospitals." 20:54 "I think the pharma industry has also gotten a wake-up call … Maybe we should start working on viruses." 24:04 "We're at war with COVID-19 right now." 25:32 "We need to help researchers that are working specifically on lowering deaths from COVID-19." 28:23 "Anything that can wait 3 months must wait 3 months." 30:37 "We need everybody." 31:38 "Hospitals need to be focused on building capacity, number one." You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary. In light of COVID-19 news, check out our specially released episode with @MartyMakary, as he talks #healthcare and #hospital #coronavirus action steps. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19 What made @MartyMakary sound the alarm on COVID-19? Listen to our episode where he talks #healthcare and #hospital #coronavirus action steps. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19 "Everyone has an opinion, but no one's listening." @MartyMakary talks #healthcare and #hospital #coronavirus action steps. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19 What will the next 4-6 weeks look like? @MartyMakary talks #healthcare and #hospital #coronavirus action steps. #healthcarepodcast #podcast #digitalhealth #healthtech #covid19 How can we support #healthcareworkers, who are at hi

This episode was recorded prior to COVID-19 hitting our shores. Irrespectively, it is incredibly relevant. Right now, more than ever, we need physician leadership and we need partnership across organizations and within organizations so that good decisions can be made as fast as possible. Look, we don't have time to mess around right now. We need to be making good decisions—and fast. And these decisions on digital health solutions and other technologies and processes and workflows need to really be made by those who are participating in the care of patients directly. Or by the patients themselves. Or, best case, by both together working as partners, if you will. It doesn't go well for all kinds of reasons when decisions about what patient care is going to look like at a macro level are made by the suits and people or departments or companies who are "over there" as opposed to here in the exam rooms. In this health care podcast, I speak with Matt Anderson, MD, MBA. Matt is the innovation lead over at Banner Health. He talks about the importance of physician leadership a lot. And, by that, he means doctors and nurses and other clinicians demanding to be heard and demanding that their point of view be a decision-making criterion in how a care delivery system operates. But as we dug deeper, Dr. Anderson and I, a theme emerged. Along with multiple mentions of the Shkreli Awards and my conversation with Shannon Brownlee and Vikas Saini (which is episode 260 if you want to look back and listen to that), the theme that emerged in the conversation you're going to hear was the importance not just of physicians in leadership roles but of the scrubs partnering with the suits in almost every leadership decision. Doctors and nurses and administrators really have to work together so that the business is sustainable, for sure, but while patients continue to get the best care—also for sure. One cannot sacrifice the other without consequence. You can learn more at bannerhealth.com and drmatthewanderson.com. You can also connect with Dr. Anderson on Twitter at @DrAnderson19 and on LinkedIn. Matthew Anderson, MD, MBA, is a father, husband, and family physician living in Arizona. He serves as innovation lead and division medical director for Banner Health. Since joining Banner Health in 2018, Matthew has been an active member of the AZBio Government Affairs Committee. By providing primary care medical services to his patients in Arizona, Matthew has seen many of the inefficiencies and difficulties within their health care system. His training at Mayo Clinic taught him what it means to put the patient first, and that focus has stayed with him for every patient encounter. Recently, Matthew completed an MBA program at Arizona State University's WP Carey School of Business. His goal is to take the foundation he has in good-quality medical care and combine that with an understanding of the economics of health care to use technology to create a better, safer, and healthier medical system. 02:30 Distinguishing between billing technology and technology improving bonds between clinicians. 04:03 "The scribe is literally just there to take the burden of the EMR off the physician." 04:41 "If all of your goals begin and end with patients, you're not gonna go wrong." 06:07 "We gotta get a little bit tribal in medicine." 06:27 "Physicians have to be leaders in this space." 07:21 Suits vs scrubs. 08:47 Why low-revenue care is sometimes better than high-revenue care. 13:49 EP260 with Shannon Brownlee and Vikas Saini, MD, from the Lown Institute.16:11 "There's a role to play for all of our clinical partners in the leadership of our health care systems." 16:38 "You have to be able to be curious." 18:35 The movement to humanize medicine with technology, led by Eric Topol. 20:45 Creating a culture where it's okay to fail. 22:31 Starting the educational process on the business of health care earlier. 25:48 Technology as top-down vs physicians as bottom-up. You can learn more at bannerhealth.com and drmatthewanderson.com. You can also connect with Dr. Anderson on Twitter at @DrAnderson19 and on LinkedIn. Check out our #healthcarepodcast with @DrAnderson19. #healthcare #podcast #digitalhealth #healthtech #physicians #clinicians #healthsystems #hospitals Billing #technology vs technology that improves clinician work. @DrAnderson19 discusses in our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #physicians #clinicians #healthsystems #hospitals "The scribe is literally just there to take the burden of the EMR off the physician." @DrAnderson19 discusses in our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #physicians #clinicians #healthsystems #hospitals "If all of your goals begin and end with patients, you're not gonna go wrong." @DrAnderson19 discusses in our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #physicians #clinicians #healthsystems #hospitals "We gotta get a little bit tribal in

There is a lot going on with digital health tools these days. Which ones are the good ones and which ones are nothing burgers packaged up in beautiful marketing? That's a good question, and it would be nice to have a go-to source for such information. Some parties — mainly PBMs [pharmacy benefit managers] and to some extent payers and providers — recognize that this actually would be nice, and they see that creating digital formularies could be an opportunity to grow revenue for their shareholders by meeting a market need potentially and offering additional services to the marketplace. But the term formulary implies more than just some kind of health technology assessment. It implies, at least at some level, the promise of reimbursement. But given how local health care tends to be, especially when considering patient populations and the "bottom-up" nature of the doctor-patient relationship, here's the question I have for you: Is it even possible for a third party, disconnected from the care setting and the patient, to "top-down" select the technology which will be used and reimbursed … especially in the age of consumerism? For more on the intersection of patients and provider digital tool selections, listen to episode 250 with Vicky Tiase from NewYork-Presbyterian. In this health care podcast, I am speaking with Randy Vogenberg, PhD. Randy suggests that a more crowdsourced approach to digital health tool selection might be in order here. He says that those who are using the tools really need to have a seat at the table. He says that possibly the "formulary" within any given organization should be more of a consensus among stakeholders and less of a mandate from on high. But there are a lot of wrinkles … like, lots of wrinkles. Randy Vogenberg is board chairperson at the Employer-Provider Interface Council. He is principal over at the Institute for Integrated Healthcare. You can learn more at iih-online.com, epicouncil.org, and hope.rutgers.edu. Randy Vogenberg, PhD, is principal at the Institute for Integrated Healthcare, co-leader for the National Employer Initiative on Specialty Pharmacy, and cofounder of the National Institute of Collaborative Healthcare (NICH). He is a health care expert on health system delivery and economics as well as health-related solution innovation research. Most recently he partnered with the Hospital Quality Foundation in developing the Employer-Provider Interface Council (EPIC). His broad hospital and managed care expertise includes current or future trends around financing, market excellence, and benefit management or design. A leader and highly requested speaker on applied health systems research, he has authored programs or books on self-funded health benefits, managed markets, hospitals, and integrated medical-pharmacy benefit management. His academic relationships include Rutgers HOPE Center and former senior fellow at the Jefferson School of Population Health. Currently, he is an adjunct professor at the University of Rhode Island College of Pharmacy and Presbyterian College School of Pharmacy as well as the University of Illinois College of Pharmacy. 02:51 What a digital formulary is. 03:52 PBMs and digital formularies. 04:41 The changing landscape of PBMs and digital health. 06:00 The intersection of PBMs and digital health tools. 10:18 "Arbitrage, full on."—Mark Blum, from America's Agenda. 12:21 The inherent differences between a health plan and a PBM. 15:58 The original purpose of a pharmacy/therapeutics committee. 16:58 "There's a lot of change happening, is the bottom line." 18:18 The risk assessment behind medical software. 18:29 Harm vs digital therapeutics and digital medicine. 18:52 Cybersecurity in digital therapeutics. 19:08 Reimbursement in digital therapeutics. 19:43 The question of "how" in reimbursement. 20:37 "How do we reset health care in just one state, let alone the whole country?" 22:13 Taxpayers, patients, and employers vs the health care industry. 22:56 The slow move away from fee for service, and why. 24:13 The timeline for incorporating digital tools into the health care system. 24:33 "It's a real problem for the consumer side." 25:09 "What's really going to be worthy of reimbursement?" 25:50 "There's only two major payers in the health care system … that's the government, and it's the private sector employers and state programs or unions." You can learn more at iih-online.com, epicouncil.org, and hope.rutgers.edu.

It's kind of a vicious cycle. Payers don't trust providers to do the right thing and provide appropriate care. And OK, there's some logic there considering that 25-ish% of health care delivered is low-value or unnecessary. On the other hand, some patients actually need the care and now it's painstaking for them to get it—and that painstaking part of the sentence is borne by providers, at least logistically. So then the providers learn how to expedite getting their patients care by copying and pasting, and now they're gaming the system. Then more arduous processes get put in place, and now good physicians get caught in the same net as the less good ones and they begin to spiral toward moral injury and burnout. Let's get to the bottom of this. In this health care podcast, I speak with Ron Wince, CEO of Myndshft. You can learn more at myndshft.com or follow Ron on Twitter at @RWince. Ron Wince is founder and CEO of Myndshft Technologies in Mesa, Arizona. An engineer by training, he has two decades of experience automating and optimizing time-consuming health care administrative tasks and has held executive positions at leading financial, manufacturing, outsourcing, and customer experience companies. Ron created Myndshft with a singular but ambitious goal: to fix the "administrative plumbing" that keeps health care stuck in the past. They are working at the intersection of blockchain and artificial intelligence (AI). Through CognitiveBus, a first-of-its-kind cognitive blockchain platform, Myndshft Technologies is simplifying enterprise-grade AI and unlocking the insights hidden in the massive and growing data universe. 01:29 What is a prior authorization? 02:45 The three reasons payers put prior authorization in place. 02:49 Cost, medical necessity, and compliance. 04:24 EP200 with Stacey Worthy.05:15 "Clinicians are really managing clinicians in a lot of ways." 05:41 Why the prior authorizations system sometimes fails patients and payers. 08:13 Surprise care—can it be avoided? 09:53 The impact on providers. 14:52 The impact on patients. 16:46 Specialty pharmacy and prior authorizations. 18:43 Shkreli Awards (EP260).19:25 The most complex prior authorizations. 21:03 E-prior authorizations. 24:19 Gold carding and what that is within prior authorizations. 28:08 The "chasm of trust." 29:11 Myndshft and its goal to solve prior authorization issues. You can learn more at myndshft.com or follow Ron on Twitter at @RWince.

Here's the thing: All the top-performing Medicare Advantage plans are using, today, right now, some form of advanced analytics and artificial intelligence (AI) to risk-stratify their populations and predict which members will, without intervention, become high cost in the near term. The idea is then to intervene to mitigate risk and stop bad things from happening—bad things that stink if you're the patient and also cost a lot if you're the plan. That's what population health management is all about, after all. Others using AI, right now, to do the kind of predictive analytics that you need to excel at pop health include PCP groups and other providers, mainly those at risk to manage populations or readmissions. In this health care podcast, I talk with Andrew Eye about AI. Andrew is CEO over at ClosedLoop. 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 2017, Andrew founded his fourth technology company, ClosedLoop.ai. ClosedLoop.ai is a next-generation predictive analytics platform provider leveraging the latest in artificial intelligence and machine learning technologies to rapidly create predictive models from diverse sources of raw, messy, real-world health care data. Prior to founding ClosedLoop, 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 served as CEO of Bodkin Consulting Group, where he worked with Fortune 500 brands and technology companies to define their interactive marketing strategies. Andrew began his career as a software architect working with NASA, i2 technologies, and the US Marine Corps. Andrew graduated summa cum laude from Virginia Tech with a degree in management information technology. Andrew lives in Austin, Texas, with his two daughters and champion "Dock Dog" Sophie. 01:50 Artificial intelligence in health care, and the different things that this means to the health care community. 02:06 Image analysis, also known as replacing doctors with robots. 02:25 Chatbots for health care. 02:43 Predictive analytics. 04:39 "What they really care about is, How can this impact our business? How can this improve patient lives?" 04:51 "For us, this is all just better math." 08:13 What exactly predictive analytics is. 08:40 The use cases of predictive analytics value. 11:33 The oversimplification of how people think about risk. 13:13 "Did you have an impact or not?" 13:27 The public scorecard for predictive analytics. 18:16 "Explainability is a real hot topic in artificial intelligence, specifically in health care." 19:46 Data shaming—what's wrong with it, and why incomplete data are still important. 21:53 The possibilities that machine learning allows for in patient care in health care. 28:08 "Our health care system can't afford for that level of inefficiency." 29:21 "It's not a question of if; it's a question of when." 30:37 The diminishing returns of interoperability and more data for machine learning. 33:54 "You're running your business today, and whatever data you're using to run your business … you can use it to provide better patient care." 34:34 Andrew's advice: Get started now. You can learn more at closedloop.ai or by following Andrew (@andreweye) on Twitter.

The World Bank had a revelation a few years back. Some very smart people working there realized that countries that were easy to do business with thrived. Within these countries' business ecosystem, the best and the brightest entrepreneurs and investors grew not only their own businesses but also positively influenced other businesses and the community around them. Brian Van Winkle and Rishab Shah, both executives at Johns Hopkins, had their own revelation: Health systems who are easy to do business with attract and enable the best and the brightest start-ups or other entrepreneurs who are able to do great work within their walls, with their patients, and with their clinicians. It's becoming fairly axiomatic at this juncture that provider organizations—along with payers, by the way—cannot be good at inventing and innovating absolutely everything that's possible to conceive of and develop. It is impossible for any group, no matter how dynamic and forward thinking and awesome, to be better than everybody else at everything. For this reason, the idea of health systems and payers becoming great aggregators of amazing tech and services is definitely gaining traction. This would include internally developed as well as externally sourced technology and services. Listen to Rahul Dubey in episode 259 for more info on this evolution in the payer space. But back to Brian and Rishab. They spotted this trend in its early days and also saw the issues that health systems face and will face as the ease of doing business becomes more and more of a rate critical of success. Thus was born the Ease of Doing Business Initiative, health care–style, based on the World Bank's Ease of Doing Business model. In a nutshell, what the World Bank did in their Ease of Doing Business Initiative is they came up with a set of measures and hived those measures into categories and then they ranked countries against those measures. Brian and Rishab decided to do the same thing. They created a list of questions for health systems to self-rank (at least initially) themselves on how well they did within these seven categories of measures. Twelve to fifteen of the leading health systems agreed to participate. Most are members of NODE.Health, where Brian is the former executive director. And this Ease of Doing Business Initiative is under the NODE.Health umbrella. In this health care podcast, Brian and Rishab speak only for themselves during this interview. They do not speak for their employer or anybody else. (Note: I also interviewed Brian and Rishab at the NODE.Health Digital Medicine Conference.) You can learn more at the Sibley Innovation Hub (@SibleyHub) on Twitter or by connecting with Brian and Rishab on LinkedIn. Brian Van Winkle, MBA, is the executive director of innovation at the Sibley Innovation Hub. His focus is on transforming the health care system by being a conduit between passionate clinicians and some of the most advanced solutions emerging around the world. Brian brings more than 10 years of experience helping some of the most complex health care systems in the world with transformation, process improvement, and strategy design. Brian has a dual degree in economics and English from the University of Virginia and earned his MBA at Fuqua School of Business at Duke University. Rishab Shah, MHS, is the head of digital innovation and strategic partnerships at the Sibley Innovation Hub. He leads the Hub's charge in development, implementation, and oversight on driving innovation through strategic partnerships with emerging technologies around the world as senior manager of tech innovations. Rishab is a strategist inspired to innovate while empowered to create. He has helped companies around the world with corporate strategy, business operations optimizations, and large-scale technology transformations—primarily within the health care and life sciences industries. Rishab has a bachelor's degree in biomedical engineering from Virginia Commonwealth University and a Master of Health Science from Johns Hopkins University. 03:46 Focusing on "outside-in" innovation. 04:09 The downside to hospitals and health systems not being easy to work with. 05:17 "You have to acknowledge that we're in a crisis state."—Brian 06:56 "Are we putting ourselves at a disadvantage by not … being easy to interface with?"—Rishab 08:25 Why hospitals might not be so easy to work with right now. 09:11 The correlation between a partnership strategy and health outcomes and metrics that matter. 09:42 The gap between health care players' workload and collaboration. 12:04 "Who is putting the focus on the requirements?"—Rishab 12:44 What the Ease of Doing Business Initiative is. 14:56 The opportunity for entrepreneurs to be involved in this process. 16:07 Ecosystem-based work groups. 17:22 "What box do you exist in?"—Brian 18:29 The seven success factors an organization needs to be good at to improve their ease of business. 18:53 Customer support and governance. 19:02 Cont

Today I speak with Fred Goldstein. Fred knows a lot about population health. His credentials, in fact, are about as long as my arm, so I'm just going to call him president and founder of Accountable Health, LLC and also co-founder and lead co-host at PopHealth Week—a podcast you should check out. Today Fred and I get into not just what 'good' looks like when it comes to population health, but also the six steps to achieve it. If you are looking to deploy some population health or if you are currently engaged in pop health and are looking to evaluate or benchmark what was done and how it was done, then, yeah, you might find this conversation helpful. You can learn more by contacting Fred at Accountable Health LLC, via email, or on Twitter. Fred Goldstein is the president and founder of Accountable Health, LLC, a health care consulting firm focused on population health, health system redesign, new technologies, and analytics. He has over 30 years of experience in population health, disease management, health maintenance organization (HMO) and hospital operations. Fred is considered an expert in population health, care management, behavioral health, risk management, health information technology (HIT), and health system design and development. During his career, he founded a disease management company that provided services to employer groups and ten state Medicaid programs, operated a Medicaid/commercial HMO that was ranked the highest-quality Medicaid health plan in Florida, developed an award-winning mobile health app, and worked with employers, health systems, and vendors to develop population health programs, services, and platforms. He was also directly responsible for the inclusion of the Medicare Annual Wellness Visit in the Affordable Care Act. Fred is an instructor at the John D. Bower School of Population Health at the University of Mississippi Medical Center and an adviser to the Validation Institute. He serves on the editorial board of the journal Population Health Management and the founding advisory board of Population Health News and is past chair of the board of directors of the Population Health Alliance. Fred has testified before the legislature in the states of Alaska, Florida, Kentucky, and Texas on disease and population health management and their application to state employees and Medicaid. He is also the co-founder and lead co-host of PopHealth Week, a weekly podcast featuring thought leaders and companies working in population health. Fred received his master's degree in health care administration from Trinity University and a BA in zoology from the University of California, Berkeley. 01:20 Population health vs precision medicine. 02:46 "What precision medicine allows us to do in population health is to get an even more precise and better intervention." 03:16 Pop health as precision medicine. 03:30 "We need to first note who our population is... and we take that group and we then assess them." 04:57 The variation in care, and how this effects outcomes and care. 05:46 How assessing individuals has improved over the years. 06:28 What the goal of assessment is. 06:46 "What does 'good' look like?" 09:18 The purpose of stratifying individuals. 10:50 The impact of social determinants and how this is being incorporated into individual assessment. 11:15 How the use of behavioral economics has helped. 11:37 "It's really about changing the culture." 12:57 Interventions and what these look like in population health. 17:03 Measurement in population health. 18:45 Population health outcomes, and what these might look like to patients. 19:38 Promising population health outcomes. 21:10 The importance of patient-reported outcomes. 24:47 How providers can tell if they're doing population health well. 26:15 Fred's advice to payers. 27:29 "Forget pilots, build something scalable." You can learn more by contacting Fred at Accountable Health LLC, via email, or on Twitter.

In this health care podcast, Josh LaRosa from the Wynne Health Group is back to give us an update on the snowball of drug pricing initiatives zigzagging their way around Washington right now. For the details, listen to episode 243. That's where we really drill into the details. This conversation is more of a status report. (Note: This episode was recorded on February 6.) You can learn more at wynnehealth.com or reach out to Josh at [email protected]. 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. 01:01 Updates on the drug pricing front on the national level. 01:44 The three major updates on national drug pricing. 01:48 Part D redesign legislation. 02:54 Giving private industry more stake in the game of keeping costs lower. 03:01 Check out EP243 for more info on drug pricing deals.05:18 The legislative deadline for any of these drug pricing bills to take place. 06:39 The International Pricing Index Model. 08:49 The administration's importation plan. 10:13 The end of the comment period and how long stakeholders have to give their input on the importation plan. 12:29 Updates on 340B hospitals and Health & Human Services (HHS). You can learn more at wynnehealth.com or reach out to Josh at [email protected].

Rahul Dubey is the founder of Percynal Health Innovations. He's also the former chief innovation officer at AHIP—that's America's Health Insurance Plans. AHIP is a trade group for insurance carriers, health systems, best-in-breed solution providers, and others. Rahul has created what he calls strategic working groups, in which he gets together essential stakeholders within a regional geography to collaborate and figure out innovative best-in-class emerging solutions and approaches. The first thing they do in these strategic working groups is to identify common problems. Since the best solutions solve the best problems for the most stakeholders, this seems like a pretty decent way to start. What are some of the challenges that Rahul has identified with payers and providers and other stakeholders to solve for? Here's your listicle: Really get to population health management and just population health Operational inefficiencies Information trafficking without getting anything out of it is not gonna work anymore Level up health literacy Here's a point Rahul makes that I'm continuing to think about. He says that payers should be grade aggregators—aggregators of data, aggregators of solutions that they should be able to distribute to other essential stakeholders. I heard somebody else say the other day that the new payer is more like an entity that provides comprehensive services. You can learn more by connecting with Rahul via email or LinkedIn. Rahul Dubey is CEO of Percynal Health Innovations and the Founder of America's Health Insurance Plans (AHIP) Innovation Lab. Rahul is currently responsible for collaborating with C-level executives at his health plan. Prior to joining AHIP and launching Percynal Health Innovations, Rahul held a leadership role as a founding employee of a successful digital health care start-up based in Washington, DC. Along with the company's cofounders, Rahul was instrumental in developing a multifaceted consumer tool as well as leading the company's "go-to-market strategy," resulting in successful market penetration and revenue growth for the industry's first consumer-led shared decision making and treatment selection platform. Rahul was recognized with the Smart Health's 2018 Excellence in Healthcare Transformation award, was named the American Journal of Health Promotion's 2017 Innovators and Game Changers, and is featured in Accenture Perspectives: Minds Driving the Future of Business. In 2017, Frost & Sullivan presented Rahul with one of their highest honors, their Global Visionary Innovation Leadership Award. He is a graduate of the University of Michigan–Ross School of Business and lives in Washington, DC, with his son. He invites you to contact him directly—that is, if you're willing to roll up your sleeves and drive transformation through inflective collaborative. 02:08 The stated needs of payers. 03:24 "Where are the inefficiencies that we can actually cut out of the system?" 05:14 A reverse approach to meeting the needs of payers. 06:35 Information transfer—what this means. 09:42 "Innovation is a team sport." 13:12 The "optimal solution." 18:49 "The lines of communication and business model creation … it's getting very creative right now." 20:10 Data play and finding key insights. 20:49 "A more definitive risk." 21:24 Vendors as "solution providers." 21:33 "The great aggregators"—collaborating optimally. 22:39 Brian Van Winkle and Rishab Shah on NODE.Health's "Ease of Doing Business." 25:16 "It's more relationship innovation and business model innovation than technology." 27:02 Rahul's advice to health plan collaborators, like insurance carriers. 29:44 Rahul's advice on how providers can collaborate better. 30:37 What's essential to payer success. 30:56 "Who are we trying to serve?" You can learn more by connecting with Rahul via email or LinkedIn.

In this health care podcast, seven thought leaders talk about the areas of promise they see in health care in 2020. Seven thought leaders include: Kimberly Noel, MD, from Stony Brook Medicine Eric Weaver, from Innovista Health Solutions Suzanne Delbanco, from Catalyst for Payment Reform Sue Schade, from StarBridge Advisors Naomi Fried, from Health Innovation Strategies Joe Grundy, from Grundy Consulting Adrian Rubstein, from Merck Just a couple of comments up front here. I don't want to further my reputation for dropping major spoilers, however, so I'll keep this short. Many of the thought leaders today talk about AI in various contexts. Are you rolling your eyes right now? If so, let me remind everyone about the Gartner Hype Cycle. The first step is wild-eyed enthusiasm. The next step in the hype cycle is anger, the old trough of disillusionment. I'd suggest that as far as AI is concerned, we are coming out of that trough and AI—be it artificial intelligence or augmented intelligence or machine learning or deep learning or whatever you choose to call it—it is being used, for reals, for various applications. Other corroborations among our thought leaders include the importance of exalting primary care, in the form of what some may call direct primary care and Zeev Neuwirth calls complex-condition care or condition-specific care—a relationship model, if you will. Another idea that comes up in various ways is the idea of breaking down silos and getting everyone with a stake in patient health to the table and focused on achieving better patient outcomes using all the technology and wherewithal available to us in 2020. By all the stakeholders, I mean going beyond the usual suspects of providers and insurance carriers—meaning employers. Also meaning Pharma, in the sense of Pharma taking the opportunity to collaborate more deeply toward outcomes their medications can potentially confer … IRL with RWE. Today's episode features the following guests: Kimberly Noel, MD, MPH, is a board-certified, preventive medicine physician. She serves as the telehealth director and deputy chief medical information officer of Stony Brook Medicine, where she provides leadership to all telehealth activities of the health system. Dr. Noel is also the chief quality officer of the patient-centered medical home (PCMH) for the family medicine department, working on quality improvement and population health management for National Committee for Quality Assurance (NCQA) designation. She practices occupational medicine clinically and provides digital solutions for employee wellness programs. She is an appointee the New York State Department of Health Regulatory Modernization Initiative Telehealth Advisory Committee and has won many service and innovation awards for health care. In academia, her research areas are in machine learning, risk models, and remote patient monitoring. Dr. Noel has developed several educational curriculums, including a 40-hour telehealth curriculum for the School of Medicine, as well as interprofessional educational curriculums with the School of Health Technology and Management, Nursing, Dentistry, and Social Work. Dr. Noel is a graduate of Duke, George Washington, and Johns Hopkins Universities. She is a proud graduate of the Stony Brook Preventive Medicine program, whereby she is now working collaboratively with the residency program leadership on development of a telehealth preventive medicine service. Eric Weaver, DHA, MHA, is nationally recognized for his work in primary care transformation and value-based care. As a corporate vice president for Innovista Health Solutions, he oversees enterprise strategy and technology adoption for a fast-growing population health management services organization. Dr. Weaver has been recognized for his contribution to the health care industry by receiving the ACHE Robert S. Hudgens Award for Young Healthcare Executive of the Year and the Modern Healthcare "Up & Comers" Award in 2016. Prior to joining the Innovista leadership team in 2015, he was the president and CEO of Austin, Texas–based Integrated ACO—one of the more successful physician-led accountable care organizations in the country. Suzanne Delbanco, PhD, is the executive director of Catalyst for Payment Reform (CPR), an independent, nonprofit corporation working to catalyze employers, public purchasers, and others to implement strategies that produce higher-value health care and improve the functioning of the health care marketplace. In addition to her duties at CPR, Suzanne serves on the advisory board of The Source on Healthcare Price & Competition at the University of California–Hastings and the Blue Cross Blue Shield Institute. Previously, she was the founding CEO of The Leapfrog Group. Suzanne holds a PhD in public policy from the Goldman School of Public Policy and an MPH from the School of Public Health at the University of California–Berkeley. Sue Schade, MBA, is a nationally recognized health IT leader and Pri

In this health care podcast, I talk with Karl Bilimoria, MD. Dr. Bilimoria is a surgical oncologist and a VP of quality over at Northwestern Medicine. Plus, he is also a John B. Murphy professor of surgery. The second I heard that Dr. Bilimoria and his colleagues had worked on an initiative to "rate the raters" of hospital and physician quality, I reached out to get him on the show. I had just had about four conversations with various people about the difficulties of judging quality. And I had also had a confounding personal experience visiting a patient at a hospital judged a top hospital by a well-known national rating scale. And this "top" hospital had some readily apparent issues, and I am no expert. That got me wondering about the validity of some of these quality raters. Given the importance and the need for health care quality transparency, Dr. Bilimoria and his colleagues set out to fill this gap by undertaking a (as mentioned) Rating the Raters process to evaluate and compare probably the major publicly reported hospital quality rating systems in the United States. These include the CMS (Centers for Medicare and Medicaid) Hospital Compare Overall Star Ratings, Healthgrades Top Hospitals, Leapfrog Safety Grade and Top Hospitals, and the U.S. News & World Report Best Hospitals. Interestingly, that "top" hospital I was in was scored a top hospital by one of the lowest-rated raters. You can learn more at the New England Journal of Medicine Web site, thesecondtrial.org, and the NEJM Catalyst Web site. Karl Bilimoria, MD, is a surgical oncologist and a health services, quality improvement, and health policy researcher at Northwestern University's Feinberg School of Medicine. He is the vice president for quality for the Northwestern Medicine system. He is also the vice chair for quality in the Department of Surgery and the John B. Murphy professor of surgery. His clinical practice is focused on melanoma and sarcoma. Dr. Bilimoria is the director of the Surgical Outcomes and Quality Improvement Center of Northwestern University (SOQIC), a center of 50 faculty and staff focused on national, regional, and local quality improvement research and practical initiatives. He is also the director of the 56-hospital Illinois Surgical Quality Improvement Collaborative (ISQIC).

You know how in JAMA recently it said that 25% or more of health care spending is frittered away wastefully? Some of that wasteful spending comes from unnecessary care. And some of that unnecessary care happens when a patient is misdiagnosed and then, based on that misdiagnosis, gets care for the wrong thing. And "wrong thing" care obviously isn't going to fix the actual problem because its intention is to fix something else. How do some of these misdiagnoses occur? Considering all of the diagnoses that begin with an MRI or a CT scan or an ultrasound or some other kind of imaging, it's not hard to gin up thought that if a radiology report or radiology veers into the "not exactly correct" zone, then you have a treatment plan immediately zipping off on a poor-quality and likely wasteful trajectory. That's what I speak with Ron Vianu about in this health care podcast. Ron, by the way, is the founder and CEO over at Covera Health. We don't have time (Ron and I) to get into the AI (artificial intelligence) and machine learning in radiology aspect, but (spoiler alert) a follow-up on that is forthcoming. You can learn more at coverahealth.com. Ron Vianu is the CEO and co-founder of Covera Health and a serial entrepreneur and problem solver by nature. He has spent the last 20+ years founding ventures in the health care, technology, and insurance spaces. Ron studied chemistry and philosophy at NYU.

Dr. Richard Zane is the chief innovation officer at UCHealth. He's also the executive director of emergency services there. Besides that, he chairs emergency medicine at the medical school and he's a professor at the business school and at the medical school. At the recent NODE Digital Medicine Conference, I asked Dr. Zane to talk about the 2019 innovations that he is most proud to have rolled out in their hospital system. We talk about three of these innovations, and then we get into the challenges that Dr. Zane and his team faced and overcame in the pursuit of those rollouts. What struck me most is the underlying dependency on data of all three of these innovations. Optimally complete data sets are really needed to make each one of these programs work as well as they possibly could. And as a corollary to that, the necessity of collaboration with payers like insurance carriers and PBMs (pharmacy benefit managers) to even get close to that complete optimal data set. Sidebar (because I can't help myself): It's going to be really interesting to see which payers and PBMs are ultimately willing to share data with providers—and, honestly, which providers are willing to share data with other providers—to help their patients get the right treatments in pursuit of better patient outcomes, because that's kind of a proxy to which ones value better patient care more than, let's just say, other things. I think the organizations that choose to share and choose to collaborate—you know, which ones self-sort into that category—that information is going to become more and more publicly available, and I wonder when and if that transparency will influence organizational decision making. In this health care podcast, Dr. Zane uses the term ethnographic a couple of times. Call me "out of the loop" but I had not heard that term before. So, just in case you haven't either, let me reference my go-to for mostly accurate information, otherwise known as Wikipedia. Ethnographic research, says Wikipedia, is a qualitative method where researchers observe and/or interact with a study's participants in their real-life environment. You can learn more by connecting with Dr. Zane on Twitter at @richardzane. Richard Zane, MD, currently serves as the George B. Boedecker Professor and chair of the department of emergency medicine at the University of Colorado School of Medicine, professor of health administration at the University of Colorado Business School, and chief innovation officer for UCHealth. Dr. Zane completed medical school at Temple University in Philadelphia, followed by residency training in emergency medicine at the Johns Hopkins School of Medicine. Following residency, Dr. Zane joined the faculty at Johns Hopkins as assistant chief of service. In 1998, Dr. Zane joined the faculty at Harvard Medical School and Brigham and Women's Hospital in Boston.