Relentless Health Value

I’ll tell you what I wanted to figure out: How does care improve in SNF (skilled nursing) or assisted living facilities? My starting point in contemplating a possible path toward this goal was advanced primary care. There is so much talk and evidence these days about advanced primary team-based care and how much patients like it, the low-value care it could potentially prevent downstream, and the patient outcomes it can create. But in general, these advanced primary care models are talked about for patients in the community, not really for the intensely vulnerable populations inside facilities. So, where do these worlds collide if they do, in fact, collide? In this health care podcast, I’m speaking with Grace Terrell, MD. Dr. Terrell is a practicing general internist. She is also chief executive officer of Eventus WholeHealth, which is a company that is focused on medical care for medically vulnerable adults, specifically those who live in skilled nursing facilities, assisted living facilities, or reside at h

I heard someone say the other day, “Practicing medicine without pharmaceuticals is like running to the ten-yard line, putting down the ball, and walking off the field.” So, it’s pretty imperative that providers and Pharma know how to work together to get the best outcomes for patients. In this context and in this podcast, when I say “get the best outcomes for patients,” I kinda mean it. There’s a sweet spot in the middle of “won’t let those [expletive goes here] pharma reps in the building” and blatant conflicts of interest. I wanted to find out from someone who would know what a great collaborative relationship with a pharma company looks like for a large health system from their point of view. How do two, in general, gigantic bureaucratic organizations find ways to help each other help patients? No one would disagree that finding the best collaborative strategy with a health system is going to depend a lot on how that health system rolls in general. One aspect of how they roll is to take a look at their so-

Let’s get a fast bead on what’s going on with drug pricing reform, shall we? Every time I wade into these waters, my head about explodes. So, I very much appreciate the opportunity to quiz Josh LaRosa from the always-well-informed Wynne Health Group. Here’s the goings-on in a nutshell: There’s goings-on. This infrastructure bill that’s in all the news all over the place right about now? You know what the plan is to fund all those bridges? Yeah, well, part of it is for Medicare to save money on drugs and then apply the savings to cover the costs of all those roads and train tunnels. There are three major potential ways that the federal government might conceive of collecting these drug savings: (1) They could try to get others to pick up some of the Medicare Part D costs—others meaning private payers and pharma manufacturers. (2) Also, they can limit how much manufacturers could raise prices via this “inflation rebate” proposal. Interestingly, this “you can’t raise prices more than the rate of inflation or els

I don’t know what I thought we were going to talk about during my interview with David Carmouche, MD; but I’m glad it turned out exactly as it did. Lately, we’ve had a number of guests on Relentless Health Value talking from the point of view of the employer: what a self-insured employer wants and needs from the large, and small, providers in their network. In this episode, we’re flipping the script and talking about what a large provider organization wants and needs from the commercial side of its payer mix. If value-based care or risk shares are to be a thing, we can’t have, as Troy Larsgard has put it, all risk and no share. In this health care podcast, I had the honor and pleasure of speaking with Dr. David Carmouche. Dr. Carmouche started out as a physician in a multi-specialty group. He practiced there for about 15 years before leaving to become chief medical officer at BCBS (Blue Cross Blue Shield) of Louisiana. Five years ago, Dr. Carmouche transitioned to Ochsner Health, where he is currently executi

Medicine is complex. It’s getting more complex. We double what we know in medicine every 73 days. There’s 800,000 journal articles published every year. It is impossible for any human to keep up. It’s just impossible. There’s a lot of talk about amazing technology to help humans manage the 26,000 variables in heart failure treatment or what have you. And, yeah, I’m a huge fan of technology doing what technology is good at doing. But here’s a point to ponder: Just like meds don’t work if the patient doesn’t take them, technology kinda doesn’t work unless it’s part of a bigger framework. Who in the practice uses it or deploys it? Who checks the dashboard and follows up with patients and how do they follow up with patients? This is all process. Of course, there’s good processes and not-so-good processes. But a value of process as a construct is you can incrementally improve a process. You can’t incrementally improve everybody doing different things at different times. Nobody seems to talk about this in the “cool

Have you never heard of the Nuka System of Care? If that’s the case, it is an award-winning and really remarkable health system in Alaska. In this 5-minute “An Expert Explains,” Dr. Douglas Eby, medical director over at Nuka, gets directly to the point. A key component to making sure that the people/customers in your plan get the best care is to make sure that they have access to a team of providers who know them well enough to have earned their patient consumers’ trust. Both the trust and the access part of that last sentence are important. Both are needed in spades to reduce downstream costs. The access part might be a little counterintuitive and has a disclaimer or two that Dr. Eby articulates. But, yup, when you restrict access, what winds up happening is that people demand more when they finally get seen. They want their money’s worth, so to speak, and will nab any lab diagnostic or expensive follow-up they can get while they’re there, since they may never have the opportunity or the money or the time to

This episode is for anyone as curious as I have been about pharmaceutical supply chain goings-on in long-term care facilities like skilled nursing facilities, otherwise known as SNFs. There are a lot of players in the mix: You have your PBMs. You have your wholesale pharmacies. You have your LTC (meaning long-term care) pharmacies. You have the facilities themselves. You also have Medicare Part A and Medicare Part D and, in some cases, Medicare Advantage. Let me just lay some groundwork here before we dive headfirst into the confoundingly messy middle. If we’re talking about patients who have been in a SNF for services not covered by Part A—maybe because the patient needs help with basic activities of living—then their drugs are covered by Part D (Med D) or maybe their Medicare Advantage plan. The point I’m making is that it’s not a global payment at that point in the SNF. The patient’s Part D drug coverage is gonna be the same as if that patient were outpatient. They may have deductibles and coinsurance just

Let’s talk about one aspect of health care that’s not talked about possibly often enough: big national health care players siphoning money out of local communities—potentially a lot of money depending on where you are and considering that health care is inching toward about 20% of the GDP. But besides the money leaving the community, another downside of large national players is that sometimes problems—even kind of seemingly simple problems—can be totally intractable and unsolvable because there’s just so much diversity of need and intricacies if you’re trying to come up with a broad-stroke solution that works for everybody across the land. On the other hand, by thinking and acting locally, these same problems can be solved. Besides, at a local scale, community and relationships within the community can become powerful forces for good. In this context, I was super thrilled to have had the chance to interview Dan Strause from Hometown Pharmacy and Drew Leatherberry from Avergent about a collaboration model the

This episode is a master class in raising health outcomes at lower costs from an award-winning health care system in … Alaska?! Who knew? In fact, I learned about the work of the Southcentral Foundation and the Nuka System of Care only because I happen to listen to Swedish health care podcasts and heard about them on one of those shows. Color me surprised when the interview suddenly switched to English and the guest was from Alaska. Here’s the short version of what’s happening with the Nuka System of Care, which serves Alaska Native and American Indian people. They have gone as close to the Triple Aim as I’ve seen in this country. Health outcomes are superior at costs about half the average. Patients—or, as they call them, customer owners—are happy. So are clinicians. How this was achieved (spoiler alert here) was not through incrementally trying to jigger the earlier and pretty much failing model of health care delivery that had been going on in Alaska for Alaska Natives at that time. No can do! The Nuka Sys

This episode might be about local providers getting disintermediated not by virtual front doors like I discussed with Jeff Hogan in EP309 but by entities providing virtual continuous care at home. Predictivae and proactive, the idea is to help reduce acute events requiring on-premises care. But if someone does wind up needing ramped-up care, they can get it hospital at home or SNF (skilled nursing facility) at home instead of them going anywhere. So, there’s a baseline level of home monitoring followed by periods where care is stepped up. The point is, everything is going down at home with the care coming to the person at the care level that they need, so it ramps up or down depending on what they’re going through or need at the time.  I’m talking in this health care podcast with Sumit Nagpal, CEO and founder over at Cherish Health. We talk about the goings-on in the whole aging in place or, as he calls it, living in place vertical. A couple of takeaways from our conversation I think are notable: First of all

In this health care podcast, Ge Bai explains GoodRx’s business model and how PBMs and pharmacies fit in to that business model. Here’s the short version: GoodRx takes advantage of the dysfunction in the pharmacy supply chain. And while they help patients save money, their master plan only works because pharmacies would be charging cash pay patients too much in most circumstances. Why, you might ask? Well, one reason is the big PBMs have contracts with pharmacies that stipulate the PBM must get the best prices. So, any patient wandering in off the street without a PBM card is going to always pay more than the rate a PBM can get for its patients. So, a pharmacy’s list price will always be more than the PBM price. I’ll let my guest in this episode, Ge Bai, explain this better and get into a few details; but that’s kind of the general level set there. Ge Bai, PhD, CPA, is an associate professor of accounting at Johns Hopkins Carey Business School and associate professor of health policy and management at Johns Ho

The Shkreli Awards have been published each year, for the past five years and counting, by the Lown Institute. The Shkreli Awards are a much-anticipated top 10 list of the worst examples of profiteering and dysfunction in health care. This year’s list, celebrating the most excellently egregious profiteering in 2020, are unique in the sense that everybody on this list this year—every one of them—decided, deliberately, that a pandemic might be a super opportunistic global stroke of luck to exploit fear and anguish to line their own pockets. The list is named for Martin Shkreli, the price-hiking “pharma bro” that is easy to point to as a model of pure, unadulterated health care profiteering. Here’s the point: Just because you can be clever and shifty enough to make a whole lot of money in health care doesn’t mean you should. Every dollar anyone earns without adding commensurate value back is just one more nail in the financially toxic coffin that patients and employers face in this country—and taxpayers. The Low

This episode is a tale of what happens when some employers decide to open up a few virtual front doors and when these virtual front doors lead only to referrals to providers who are willing to be accountable and offer financial predictability. That’s what these employers want, after all. They want accountability and financial predictability. Many employers now have access to all claims databases and other data like the RAND 3.0 report. Therefore, employers can and are using this information in a big way to steer their plan member populations. Given these goings-on, some slower-moving providers could easily find themselves on the outside looking in. So, who are those providers who are or will be getting shut out of referral flows? They’re definitely FFS-centric, but they could be a large health system, an urgent care center, or a hospital-owned PCP. In this health care podcast, I speak with Jeff Hogan, the northeast regional manager for Rogers Benefit Group and also president of Upside Health Advisors. We talk

And here I thought I knew a lot about value-based care. In this health care podcast, I am speaking with Mark Fendrick, MD, who is the director over at the University of Michigan Center for Value-Based Insurance Design. This conversation is for those of you who already know pretty much about value-based care concepts. If you do not, I’d go back and listen to, say, Encore! EP206, with Ashok Subramanian, before this one.   Dr. Fendrick talks in this health care podcast about what it takes for value-based care to happen in the real world. No kidding, it’s about making sure that reimbursement is aligned with good things (no great surprise there). Everybody is always talking about properly aligning provider incentives. And, although often discussed, it really matters. But two light bulb moments I had in this conversation with Dr. Fendrick: Here we are at the beginning of the year. How many doctors and nurses, inspired to do the right thing, have told their patients with diabetes, say, to go get an eye exam to chec

In this health care podcast, I speak with Loren Adler, who is the associate director of USC-Brookings Schaeffer Initiative for Health Policy and has a particular focus on surprise billing. I wanted to talk to Loren about the surprise billing legislation that is going into effect on 1/1/22. I will let Loren explain, but, in short, this legislation removes the patient from the mix. If a provider decides to send a surprise bill, the patient will just pay the co-pay or coinsurance they normally would have if the provider had been in network. Then, it’s up to the provider who sent the bill and the insurer to duke it out on the back end. What this back end duking out consists of is the provider sending their big surprise bill to the insurer. The insurer may reply, with regrets, “Hey, we’re only gonna pay you … whatever … a fraction of the big bill.” The provider may at that point say, “Fine … whatever. I’ll take it.” Or the provider may say, “No can do. I’ll see you in arbitration.” This arbitration that then happe

Here’s a trigger warning: This show gets pretty deep into some of the nether regions of PBM (pharmacy benefit manager) contractual terms with pharmacies. If you are not, I’m gonna say, pretty familiar with PBM goings-on, I’d suggest you listen to EP241 with Vinay Patel first or skip the first third of this show.   In this health care podcast, I am speaking with Ge Bai about Amazon’s pharmacy business. Ge Bai, PhD, CPA, is an associate professor of accounting at Johns Hopkins Carey School of Business. She is also associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. Ge trained as an accounting researcher who originally started looking into chargemasters for her dissertation. From there, she started checking out health care pricing and contracting issues. Who knew chargemasters were like a gateway drug into health care? I ask Ge questions such as, “Why the heck does Amazon need a PBM for cash pay patients?” and “What’s this Amazon Pharmacy model that some self-i

My guest in this health care podcast is Darrell Moon, who is the CEO over at Orriant. I was super intrigued by some of the work that Darrell and his team are doing regarding high-cost claimants. Said a different and probably better way, certain people in need of care were identified because they were costing so much. Year after year after year, these individuals—I call them hyper-users during this episode, but it’s possible I made that term up myself—these hyper-users were getting all kinds of expensive health care, while at the same time, they were not getting any better. So, Darrell and his team realized that something was afoot here, and it turned out to be a combination of maybe loneliness, maybe low self-esteem and low self-efficacy. And no matter how many times you go to the cardiologist or the rheumatologist or the pulmonologist, none of those things will be cured. In fact, when someone’s identity becomes their myriad of health issues, they have a sort of perverse incentive, if you think about it, not

I had a vision for this inbetweenisode. I wanted to highlight the wisdom of our amazing guests this year. I really wanted to find some theme that might be a key to our health care transformation. To achieve maximum suspense, here’s the very short story of how I got from “Is there a common thread of wisdom throughout all the RHV episodes this year?” to “Why, yes, there is … and it’s a good one!” So, let’s start our journey of discovery with this. Here’s a fact: If you talk to patients, they will often tell you that they receive poor care or their needs are not met—when they fall between different providers, or their payer and their provider and their PBM (pharmacy benefit manager) are singing off of different sheets of music. For more information, go to aventriahealth.com.   When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specHumana recently came out with their Value-based Care Report. The subhead is Physician Progress and Patient Outcome

In this health care podcast, I speak with Steve Blumberg, VP of practice transformation for GuideWell Health, a subsidiary of GuideWell. How’s this for an interesting career trajectory? Steve spent the last decade working on population health and value-based care delivery ... on the provider side. Recently, he transferred over to the payer side, working for GuideWell Health, which is the health services arm of GuideWell, which is part of a family of companies including Florida Blue. So, a payer, in other words. I wanted to find out a bunch of things from Steve, but the main one is this: How do—if they, in fact, do—payviders improve care for patients? Or what does it take for an organizational structure to drive Triple Aim results? Going into this conversation, here is what I was thinking about: Payviders have access to longitudinal data (potentially) that siloed entities will certainly not. They also have a goal to keep care affordable in a really real way, especially if the patient/member/client is on the AC

Alex Azar, who is the current Health and Human Services (HHS) secretary (until January 21 anyway), came out with a reboot of the proposal that effectively halts the practice of pharma manufacturers paying rebates to Part D plans. This reboot is supposed to go into effect on 1/1/2022. But this podcast is less about this may-or-may-not-actually-happen rule and is more about the actual impact of removing drug rebates within this unintuitively constructed health care system of ours. Should rebates go away, it’s actually a big deal that fundamentally could upend the heretofore-not-transparent messy middle of drug pricing. I’ll let Chris Sloan, associate principal over at Avalere Health, explain. Spoiler alert: The impact of killing pharma rebates to plans and PBMs (pharmacy benefit managers)? Bottom line, everybody’s insurance premiums go up in the current model when rebates go away. A few episodes from now, I’m talking with Ge Bai about why this is a suboptimal and not forgone conclusion. But this is what we’ve g