Relentless Health Value

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

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

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

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

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 po

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 a

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 int

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.

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 physicia

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 transf

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

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

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 dec

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

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

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 artificia

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 podc

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 tak

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. B

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, ri