Relentless Health Value

As one of our guests, Dr. Tony DiGioia (EP332), has said, healthcare has been pushed to its limits this past year; but that doesn’t mean that nothing good has come of it. Celebrating our bright spots and using our experiences to inform future innovations is really the key to more accessible, equitable, and higher quality of care. While the timing of the celebration could, in general, be better given the latest pandemic news, as they say, there’s no time like the present. So, let’s do this thing. Also, it’s just definitely good from a mental health perspective to find bright spots and to be grateful for them. So, let me kick this off with all of the gratitude I can hold in my two hands for anybody listening who is on the so-called front line of healthcare. My appreciation cannot be expressed more fiercely. I wish, in fact, that there was more that I/we could do to address the systemic issues that plague our healthcare industry and really impact you directly. Speaking of doctors as one of these frontline health

This episode is a little bit of a thought experiment, so hang with me as I bumble my way through it and then hit me up with your comments. The plan is to do another episode in the future where some of you with thoughts share your version of your own thought experiment. Here’s the topic: The ultimate impact of telehealth—in 20 minutes or less. In my version of this thought experiment, I want to do something a little bit different (maybe) than everybody who seems to be putting up a poll on Twitter right now. I want to look at telehealth as a leading indicator, not as a trend. The goal here is not to inform you of things that you don’t already know because I am entirely confident that much of what I’m gonna say right now the majority of you are already eminently familiar with—probably more familiar with than I am, frankly. So, the goal here is to put this information into a context that maybe is new—at least I hope it’s new. The goal of that is to hopefully inspire some of you to take action, right now, with all

Believe me, filling in for the uncontested master of podcasts, Stacey Richter, is just a tad unnerving! My name is Dr. Steve Schutzer. I’m an orthopedic surgeon specializing in joint replacement surgery, and I think it’s fair to say that I’m more comfortable, in my own lane, doing complex surgery than doing this introduction to our encore podcast 294 entitled “Building a Center of Excellence: A Playbook for Physician Entrepreneurs,” which aired originally in October 2020. But when Stacey graciously offered me the honor of doing so, I said to myself (sic: Steve, suck it up) what an opportunity to share with the devoted listeners of this show my humble perspectives on the prominent position COEs (also known as Centers of Excellence) are playing in this rapidly accelerating, evolving, and exciting healthcare landscape. So, there’s an ancient Chinese proverb that goes like this: “When the wind of change blows, some build walls, and others build windmills”—or in this case, Centers of Excellence! And the winds of c

This interview with Lisa Trumble is mostly about clinically integrated networks (CINs)—what they are, how they work, how data get shared. Furthermore, we talk about hybrid CINs, meaning, for example, a virtual front door that might lead to in-person care. After that, we talk about the potential impact of direct contracting, which Lisa says could significantly change the healthcare marketplace. The hybrid talk, by the way, is toward the middle of the show; and we talk about direct contracting—that’s near the end if you’re short on time and you want to skip around. But before we go there, let’s just level set a little bit, shall we, on the topics of accountability and integration as general constructs. Specifically, what’s the impact, or lack thereof at times, when the provider is not accountable for patient results? I’m talking here about fee for service, in general, where the provider is not accountable for patient results. Like, if we’re talking about a fee-for-service world and what it incents, it goes like

The discussion to follow is probably a 400-level class in payviders. If I just said the word payvider and you’re scratching your head wondering where you may have heard that term before, this show is probably not the best place for you to start. I’d go back and get some context by listening first to the episodes with Steve Blumberg from GuideWell (EP304) and/or the one with John Moore from Chilmark (EP172); and for a really retrospective lookback, check out the one episode with Dr. Kris Smith from Northwell (EP127) from back when they were still trying to become an insurance carrier. It’s like a time capsule into their ambitions.   OK, if you’re still with me, in this episode I’m looking forward to digging into payviders with Jeb Dunkelberger, who is the CEO of Sutter Health | Aetna. Sutter Health | Aetna is the payvider joint venture between, you guessed it, Sutter Health and Aetna. Not only is Jeb one who would obviously know a whole lot about payviders and how they operate given his role, but he’s also sup

I attended the STAT Summit last week and heard the heart-wrenching story told by Charles Johnson, who is the founder of 4Kira4Moms, which is a group dedicated to improving maternal health equity. Charles’s family is African American. After a planned C-section, his otherwise-healthy wife died an avoidable death because 10 hours after the clinical team was alerted that she had internal bleeding—10 hours later—they got around to wheeling her into surgery. At that point, she had three liters of blood in her abdomen. She bled out and died, leaving her newborn infant motherless. This all went down at a large, incredibly well-respected integrated delivery network. One of the biggest issues in healthcare today … well, there are many issues, so maybe I should start again. One of the biggest issues in healthcare that is going to be discussed on this podcast today is how to engage those patients or members or employees or consumers who might need our healthcare industry to work better on their behalf. This is especially

Over the holiday season here, we’re running some of our favorite episodes from years past. This one is with Mike Schneider, who actually has taken another role since this show was recorded. Other than that, the information that Mike shares during this episode from 2020 is all good. So, let’s do this thing. Disclaimer before we get started here: This show is probably a 300-level class in pharmaceutical/PBM relations. If you are tuning in for the first time and you aren’t pretty familiar with the role of PBMs, I would go back and listen to, say, episode 241 with Vinay Patel or episode 166 with Tim Thomas from Crystal Clear Rx. OK, now that that’s out of the way, if you’re still with me, this episode is like a ride on a roller coaster. I talk with Mike Schneider. And we get into, you know, kinda deeply, the what and the why behind the “Big Three” traditional PBMs deciding that now might be a fantastic time to set up GPOs. PBMs are pharmacy benefit managers—there’s three huge ones. GPO stands for group purchasing

In this healthcare podcast, I speak with Peter Hayes, who is president and CEO at the Healthcare Purchaser Alliance of Maine and a national presence in healthcare strategy, innovation, and a 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 healthcare industry in this country. There are too many interdependencies. This point obviously resonates around these parts because it’s the rationale for the Relentless Health Value podcast. We started this show on the recognition that if you want to achieve anything in healthcare, you cannot do it without collaboration/cooperation/grudging acquiescence of other stakeholders in the patient journey or the payment journey. And when I say, “You can’t do anything,” I mean you can’t sell anything, you can’t improve patient care, and, most relevant to this particular episode, you can’t contain prices. If we’re talking about health systems (for example, hospitals and the like),

At the beginning of 2021, my guest in this healthcare podcast, Paul Simms, had come up with a set of predictions for 2021. Some came true; some didn’t. But I was fascinated by a bunch of things, one of them being Paul’s sort of implicit and explicit assessment of the context of these predictions. Right now, Pharma is in a weird moment: It’s a confluence of technology, consumer expectations, changes in care delivery accelerated by the pandemic, policy at the state and federal level, and the financial realities of where we’re at today. So, if you meet patients or providers or payers where they were last year or the year before that, you’re gonna potentially be pretty far off the mark. There’s also the financial realities which Pharma kind of exacerbated for themselves when some, many, spent the past however many years making their numbers by raising prices on existing drugs and developing drugs for mostly rare diseases but then, at the same time, not innovating antibiotics or for other diseases that impact so m

I was on LinkedIn, and someone was saying, “Oh, there’s no real money in generic drugs. It’s not a huge issue if patients are paying 10 bucks instead of 93 cents for something. It’s not like anyone is getting rich off of that, and it’s not like patient impact here is super meaningful.” This is a pretty common refrain, actually; and from a conventional wisdom perspective, I get it, especially for those living comfortable middle- or upper-middle-class lives where an extra $9.07 for a prescription isn’t a huge deal—except there are big-time issues with the generic supply chain that are worth billions and billions of dollars and that have a major impact on patient health. So, let’s discuss. I started casting my eye over to what was going on on the generic drug front mainly because of the huge lawsuits in the news lately that were either filed and/or settled. Generic drug manufacturers are and have been the defendants in these lawsuits, accused of price collusion amongst other things. These lawsuits aren’t fightin

Most people who have been in the healthcare industry for a while have heard by now the metaphor about the two canoes. Provider organizations or health systems with some of their payments coming from a fee-for-service (FFS) payment model and some of them coming from value-based arrangements have the challenge of one foot in the FFS canoe and one foot in the value-based canoe. They’re probably going through a lot of metaphorical pants is the main takeaway that often comes to mind for me. But wardrobe malfunctions aside, this is a really difficult organizational challenge. That’s what I’m talking about in this healthcare podcast with Dr. David Carmouche: how to deal with the operational challenges, the cultural challenges, maybe even (very arguably) the generational challenges here. Top line (very top line), to succeed in value-based care, you gotta have three things aligned: The payment model, the construct of the contract. No kidding, you have to have value-based contracts to succeed in value-based care. The

This episode’s conversation is about the new Consolidated Appropriations Act (CAA), the fee disclosure part of it, as well as ERISA and the fiduciary responsibility that self-insured employers are responsible to comply with under the law. Don’t worry, the first thing my guest in this healthcare podcast, Christin Deacon, does is explain these terms, what they actually mean, and how they can be a tool actually in CEOs’ or CFOs’ toolboxes to get access to the employer’s own claims data, which is a linchpin here that we’ll talk about in a sec. But suffice to say here that the ERISA fiduciary responsibility has a few provisions and, in general, self-insured employer health plan administrators kind of tend to off-load worrying about these provisions to their brokers and consultants. The problem with this is that brokers and consultants do not bear the ERISA fiduciary responsibility. They do not bear the responsibility of complying with the CAA either. The employer does. You’d think that, given this, more self-insur

First, let’s talk about reducing administrative waste in the US healthcare system. There was a pretty famous 2019 study by Shrank et al. that estimated about 25% of the $3.6 trillion the US spends on healthcare annually is potentially wasteful. This is each person spending $2500 unnecessarily. Robert Kocher wrote a really interesting article about getting rid of administrative waste and inefficiencies, and he said that it is the “safest form of health care cost savings; virtually no one argues that administrative costs should remain high. Reducing administrative waste should be the highest priority … [because] everyone, including patients and clinicians, would benefit from lower health care costs.” In my mind, “everyone” means payers, policy makers, and also providers who are or want to take some accountability for the total cost of care here. To talk about the possibilities, I have the perfect guest: Gary Campbell, who is the CEO of Johnson Health Center, which is an FQHC, a Federally Qualified Health Center

There’s a next generation of digital front doors being created that open up to a patient/member experience that folds in payer, provider, and employer data—plus behavioral data the patient themselves generates when they browse through content in there. Because that’s what it takes for a so-called personalized experience or patient journey to ensue. This is what I’m talking about in this healthcare podcast with Kristin Begley, PharmD. In an ideal world, you’d have, for example, a member/patient/customer who goes to their doctor and is handed a tablet to fill out an intake form. When they hit submit, they get access to a digital front door that leads to a vast Web portal inhabited by the doctor as well as the patient’s payer and their employer. This personalized Web portal then knows this patient has asthma and is nonadherent to their maintenance medication and is using their rescue med a lot, because it’s in the payer PBM (pharmacy benefit manager) data. The portal also knows the patient is searching a lot on

Reference-based pricing, the way that most employee benefit consultants use the term anyway, refers to a methodology used by employers to pay providers for services. Usually we’re talking within a fee-for-service (FFS) environment here. The way it typically works ... there are different flavors, but how it typically works is this: Reference-based pricing (RBP) means that an employer starts with some reference-based price. Many times, it’s the Medicare rate. Medicare will pay X dollars for something. The employer—and when I say employer, I mean the vendor/company the employer is using to run this whole thing mainly—but the employer will decide that they’re willing to pay some percent over the Medicare rate to providers who render that service to the employee. Maybe it’s 10% over the Medicare rate or 20% to 50% as David Contorno talks about in this healthcare podcast. One of the biggest pushbacks against RBP schemes has been that it results in balance bills for employees, meaning that an employee goes to the ho

Let’s just start here: As a general construct, insurance carriers have every incentive for health insurance premiums to go up every year. If you’re an employer, that is a material fact. Is it counterintuitive? Maybe. Except if you’re an employer and your premiums are going up year after year, it begs the question why, every single year, the already-extravagant amount you pay continues to go up way more than the inflation rate. You’d think that if your broker and your plan administrator were so great at their fiduciary responsibility over your self-insured plan that this wouldn’t be happening. Oh right, whosever PPO network you’re using, they don’t have any fiduciary responsibility over your self-insured plan. You do, all you CFOs and CEOs and benefit professionals out there. Wait, I misspoke. Plan administrators do have fiduciary responsibility—to their shareholders. The CEO of CVS/Aetna made $36 million in 2019. He’s clearly very good at that job. The rest of them are, too. I’m not singling anyone out here.

My overarching thought throughout a lot of this interview was that improving rural health will take everyone remembering to not let perfect be the enemy of the good. If I live in rural America, there’s no subspecialists. Forget about even seeing a garden-variety kind of specialist. I might have to drive hours to even get to a PCP. There are NPs (nurse practitioners) in a lot of these remote communities, but everybody’s fighting over whether to let them practice independently, even in places where there’s zero PCPs for hundreds of miles, effectively leaving everyone in the vicinity with basically zero access to any care. Or here’s another issue: Maternal mortality in this country is not only heartbreaking—a mother dying in what should be a precious moment—it’s also embarrassing as an industrialized nation to be so far in last place. I don’t know this for a fact, really, but women who have to drive literally hours to see a provider during their pregnancy or—God forbid!—they go into labor unexpectedly … is that

Here’s the cold hard truth: The whole specialty pharmacy operational model is not built to serve patients, a fact that becomes crystal clear when you’re a patient. Instead, the specialty pharmacy model is, rather, pretty blatantly dedicated to the power struggle for revenue and captive patient populations. It’s war between providers and the whole PBM/insurer/specialty pharmacy vertical consolidations. Employers and pharma manufacturers are, of course, on the battlefield as well. The patient, meanwhile, gets to be more the product than the customer if you think about. It’s probably more similar than anyone would like to admit to the way that Facebook or Twitter users are the product, not the customer. This analog is not entirely parallel, but there’s unsettling similarities if you think about it. What is a drug that qualifies to be a specialty pharmacy drug? Usually, these drugs are complicated to store, dispense, to use, and/or they’re expensive—generally, really expensive. Lots of zeros, completely unafforda

I was listening to a panel discussion and heard Brandon Weber use the phrase the “barbarians at the gate” of the healthcare industry. I think I reached out to invite him to come on the podcast before the end of the segment. But at risk of spoiler alerts, let me sum up what I think is so interesting about Brandon’s insights, which he talks about on the show. First of all, it isn’t an “oh, heavens, some companies out there are trying to disrupt the status quo,” like this is some sort of news flash that hasn’t been tossed out with police lights and sirens however many times already over however many years. Brandon gets into the sheer magnitude of what’s going on, right now, from a capital investment standpoint but also from a human capital standpoint. How many crazy smart proven disrupter-type people have come along with that capital? Brandon also touches on something I’ve been thinking about lately: coalition building, for lack of a better word for it. If we have status quo behemoths with market caps of a third

Here’s a hot take for you. I just learned what a hot take was last week, so, of course, I needed to get me one on the quick. The thing with hot takes, from what I understand, is that they are open for discussion. What I’m talking about today is something I’ve been thinking about for a while, and I would be interested in your thoughts, since probably some finesse is needed here. I want to talk about the imperative of collaborating with organizations across the care continuum, even the ones you may have a problem with. Let us begin by discussing why collaboration is so vital if the intention is to improve patient care, quality, and lower costs. The story really begins with fragmentation. Turns out, the US ranks last among 10 other countries in a recent study on healthcare systems. One of the reasons why is the fragmentation of professionals and patients and siloed health information. This is from a Commonwealth Fund study. In fact, according to an AJMC article I found the other day—or do a Google search for any