Relentless Health Value

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Let’s get a fast bead on what’s going on with drug pricing reform, shall we? Every time I wade into these waters, my head about explodes. So, I very much appreciate the opportunity to quiz Josh LaRosa from the always-well-informed Wynne Health Group. Here’s the goings-on in a nutshell: There’s goings-on. This infrastructure bill that’s in all the news all over the place right about now? You know what the plan is to fund all those bridges? Yeah, well, part of it is for Medicare to save money on drugs and then apply the savings to cover the costs of all those roads and train tunnels. There are three major potential ways that the federal government might conceive of collecting these drug savings: (1) They could try to get others to pick up some of the Medicare Part D costs—others meaning private payers and pharma manufacturers. (2) Also, they can limit how much manufacturers could raise prices via this “inflation rebate” proposal. Interestingly, this “you can’t raise prices more than the rate of inflation or else you have to rebate the difference” legislation is also being bandied about for Medicare Part B (as in boy) drugs. And those Part B drugs? Those are frequently the really expensive ones (ie, the oncology meds that are infused). And then the third way (3) to save some shekel that might wind up in the infrastructure bill is permitting HHS (the Department of Health and Human Services) to negotiate for drug prices. This last one is always a hot potato, but the winds might be changing some. On the Executive Branch front, we also may have a reboot of the Most Favored Nation rule, but I’ll let Josh explain that one. In fact, I’ll let Josh explain the brouhaha on all of these possibilities. For more information on any of this, read the article that Josh LaRosa and his Wynne Health Group colleagues wrote for The Commonwealth Fund blog recently.  You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.  Josh LaRosa, MPP, is a policy director at Wynne Health Group, focusing primarily on regulatory affairs with a focus on the US Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS). His interests lie in delivery reform and innovations in payment and care delivery models. Josh also supports the firm’s Public Option Institute, which studies the emergence of public option programs at the state level. Prior to Wynne Health Group, Josh consulted for the CMS Innovation Center, where he worked to implement, monitor, and spread learning garnered from the center’s high-profile demonstration projects, most recently including the national primary care redesign effort, Comprehensive Primary Care Plus (CPC+). Josh holds a Master of Public Policy from the University of Virginia’s Frank Batten School of Leadership and Public Policy. He also completed his undergraduate studies at the University of Virginia, graduating cum laude with a BA in political philosophy, policy, and law. 02:56 Where are we on drug pricing reform in legislation? 05:06 What things have the greatest potential for consideration on drug pricing reform legislation? 06:07 How is the Part D benefit design and reform shaping up? 07:55 Who is one of the largest offenders of high federal spending? 09:15 Who is going to pay in the reform of the catastrophic pricing phase? 12:04 What are inflation rebates? 15:36 “The interesting part of the inflation rebates … is that it not only … had these inflation rebates as applying to … Medicare Part D drugs but also Medicare Part B … drugs.” 16:20 How likely is this reform? 18:43 What’s happening on the regulatory and administrative side of drug pricing? 24:23 When will we start to see what the White House intends to do about drug reform pricing? You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.  @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Where are we on drug pricing reform in legislation? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What things have the greatest potential for consideration on drug pricing reform legislation? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma How is the Part D benefit design and reform shaping up? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Who is one of the largest offenders of high federal spending? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Who is going to pay in the reform of the catastrophic pricing phase? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What are inflation rebates? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma How likely is this latest drug pricing reform? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What’s happening on the regulatory and administrative side of drug pricing? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma
I don’t know what I thought we were going to talk about during my interview with David Carmouche, MD; but I’m glad it turned out exactly as it did. Lately, we’ve had a number of guests on Relentless Health Value talking from the point of view of the employer: what a self-insured employer wants and needs from the large, and small, providers in their network. In this episode, we’re flipping the script and talking about what a large provider organization wants and needs from the commercial side of its payer mix. If value-based care or risk shares are to be a thing, we can’t have, as Troy Larsgard has put it, all risk and no share. In this health care podcast, I had the honor and pleasure of speaking with Dr. David Carmouche. Dr. Carmouche started out as a physician in a multi-specialty group. He practiced there for about 15 years before leaving to become chief medical officer at BCBS (Blue Cross Blue Shield) of Louisiana. Five years ago, Dr. Carmouche transitioned to Ochsner Health, where he is currently executive vice president of value-based care and network operations. At Ochsner, Dr. Carmouche helps lead the value-based care agenda—that’s everything from managing strategic partnerships with payers, as well as managing risk in value-based contracts for Ochsner and affiliated network partners across their ACO (accountable care organization) and CIN (clinically integrated network). Highlighting one point that Dr. Carmouche makes early in our chat, there’s four things that have to come together for meaningful value creation for providers: (1) willingness of providers and provider leadership to think and do things different than they have historically; (2) they have to be able to affect payment for those things; (3) they have to have data and be able to access it; and then (4) some control over steering patients. This kind of sets the stage, actually, for our fast dive, in this conversation, right into employer and commercial collaborations. Three of the four things on that list—affecting payment, data, steering patients—are right in the wheelhouse of forward-thinking employers, or commercial payers/TPAs (third-party administrators) trying hard to compete for or serve employers. Just a quick heads-up here: Coming soon, we’re going to release a second episode with Dr. Carmouche giving some great advice for the leadership of provider organizations who are trying to figure out their transition away from FFS (fee for service) to a more risk-based, value-based model. One quick point that I thought was also relevant to the show here: It was super interesting to me how quickly Dr. Carmouche got from “transition to value” to “knows how to collaborate with other organizations.” Here’s the pretty obvious inference: You can’t transition to value if you don’t know how to play well with others to co-create value and share the rewards of such an endeavor. There might be a broader lesson in here for whoever you are in the health care ecosystem. And I’m looking at you, pharmacy, Pharma, tech, societies, BUCAs, etc. Thanks so much to Brian Klepper for the introduction to Dr. Carmouche. You can learn more by visiting Dr. Carmouche’s LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  David Carmouche, MD, views health care from three distinct perspectives: as a physician provider, an executive for an insurance company and as a leader in a health system. Specifically, he built a large, multidisciplinary internal medicine and preventive cardiology practice in Louisiana; served as the chief medical officer for Blue Cross Blue Shield of Louisiana; and currently has a triad of responsibilities with Ochsner Health, the largest nonprofit academic health care system in the Gulf South. He was recently promoted to serve as executive vice president of value-based care and network operations in addition to his duties as president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network. He is known as an expert in value-based care. He led one of the top 25 performing accountable care organizations in the United States, managing billions in care spend and generating millions in year-over-year shared savings. Dr. Carmouche earned a bachelor’s degree from Tulane University and a medical degree from Louisiana State University School of Medicine in New Orleans. He completed his residency in internal medicine at the University of Alabama at Birmingham. 04:15 Who needs to be working together to create value-based success? 04:31 “I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers.” 04:45 What four things have to come together for meaningful value? 06:02 “We’re focusing specifically on payer employers today. We think that’s where there’s the biggest opportunity.” 07:23 What’s the overarching reason for health systems to want to grow their commercial market share? 14:00 Is the competition moving upstream? 16:20 “In all honesty, we’re competing for pieces of the business.” 16:23 What’s the ultimate competition? 18:36 “There is a consumer experience that is available inside these … collaborative efforts.” 20:53 “We really haven’t changed the paradigm of benefit design as it comes to drugs.” You can learn more by visiting Dr. Carmouche’s LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare Who needs to be working together to create value-based success? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare What four things have to come together for meaningful value? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “We’re focusing specifically on payer employers today. We think that’s where there’s the biggest opportunity.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare What’s the overarching reason for health systems to want to grow their commercial market share? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare Is the competition moving upstream? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “In all honesty, we’re competing for pieces of the business.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “There is a consumer experience that is available inside these … collaborative efforts.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare  
Medicine is complex. It’s getting more complex. We double what we know in medicine every 73 days. There’s 800,000 journal articles published every year. It is impossible for any human to keep up. It’s just impossible. There’s a lot of talk about amazing technology to help humans manage the 26,000 variables in heart failure treatment or what have you. And, yeah, I’m a huge fan of technology doing what technology is good at doing. But here’s a point to ponder: Just like meds don’t work if the patient doesn’t take them, technology kinda doesn’t work unless it’s part of a bigger framework. Who in the practice uses it or deploys it? Who checks the dashboard and follows up with patients and how do they follow up with patients? This is all process. Of course, there’s good processes and not-so-good processes. But a value of process as a construct is you can incrementally improve a process. You can’t incrementally improve everybody doing different things at different times. Nobody seems to talk about this in the “cool” circles, but any quality expert will tell you that complexity can only be mastered with process. Said another way (and this is inarguable), if anyone is trying to improve the quality of care delivered in any provider organization or any organization really—regardless of whether that organization is a solo practitioner or employs thousands of clinicians—the only way to improve the quality of care across time and the entire patient population is to standardize care at some level (ie, you have to have processes or care plans or pathways or whatever you want to call them). If you don’t, the quality of care will always regress to the mean. The average of care will always be the top of the bell curve. You’ll always hover around 65% of whatever measure. Why will you never be better than average if everybody is doing whatever they decide to do solely based on their own individual experience at that moment in time? Because you’ll always have your great doctors (the 95 percenters) and your not-so-great doctors (the 45 percenters). So, if you want to level up, you have to deploy care standards that push up the poor performers. But those great performers? Consider this: Probably those great performers have a process. Otherwise, they wouldn’t be consistently great, whether they realize it or not. Furthermore, great consistent performance generally happens with a team-based approach. That’s more and more indisputable. And the second you have a team, you need a playbook—otherwise known as a book of processes. This is one of those boring aspects of delivering great care that gets lost in the hype of cool technology. Everybody’s an individual, but every individual is a human—and there are some basic truths and precepts and research for what good care includes and constitutes at different points in care journeys and for differing diagnoses. In this health care podcast, I’m talking with Bob Matthews, president and CEO of MediSync. He’s also VP for quality and care redesign for PriMed Physicians. Our conversation spirals in a few different directions, but the central theme is this: How and why does a provider organization level up care? And speaking of leveling up care, we talk about the business reasons to do so right now for organizations who base their decision making on their financials, which many in the health care space do. And once a provider organization has decided that they’re going to produce better outcomes across their whole patient population, what are the major constructs necessary to pull it off? Process is a long tentpole in that big tent. So is culture. So is technology. So are the right incentives in quality measures. An upcoming Relentless Health Value episode with Grace Terrell, MD, also digs into this topic, so stay tuned. You can learn more at medisync.com.  Bob Matthews is president and CEO of MediSync. Bob has led multiple medical groups over 20 years. He is Black Belt trained in the Six Sigma quality methods. The MediSync team creates sophisticated processes and AI technologies to enable physicians to achieve best-in-the-nation clinical outcomes, especially in chronic disease management.     04:47 How do you address concerns about chronic care costs? 06:15 What are the disjunctures in the health system? 07:01 “Very few organizations today know how to do a great job in managing [chronic care].” 09:58 “Some medical group organizations … put the pressure on, but they don’t offer much help.” 10:09 “There’s something inherently difficult about the work, or we wouldn’t have this problem.” 10:44 What is the increasing pressure on practices to manage chronic conditions? 11:51 “We just simply cannot afford to get the outcomes we need with the system we have.” 13:37 “The pressure to improve outcomes is just really now starting to heat up.” 14:00 What things need to be focused on to improve outcomes? 17:32 “The only thing you get rewarded for is speed.” 19:20 “Just because you start the journey doesn’t mean that you’re going to succeed.” 23:18 “Complexity can only be mastered with process.” 25:38 “We do need to work on ways to help patients want to take their own medicines.” 29:21 Who is MediSync? You can learn more at medisync.com.  Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech How do you address concerns about chronic care costs? Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “Very few organizations today know how to do a great job in managing [chronic care].” Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “Some medical group organizations … put the pressure on, but they don’t offer much help.” Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech What is the increasing pressure on practices to manage chronic conditions? Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “We just simply cannot afford to get the outcomes we need with the system we have.” Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech What things need to be focused on to improve outcomes? Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “Complexity can only be mastered with process.” Bob Matthews of @MediSyncHealth talks #medtech on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech
Have you never heard of the Nuka System of Care? If that’s the case, it is an award-winning and really remarkable health system in Alaska. In this 5-minute “An Expert Explains,” Dr. Douglas Eby, medical director over at Nuka, gets directly to the point. A key component to making sure that the people/customers in your plan get the best care is to make sure that they have access to a team of providers who know them well enough to have earned their patient consumers’ trust. Both the trust and the access part of that last sentence are important. Both are needed in spades to reduce downstream costs. The access part might be a little counterintuitive and has a disclaimer or two that Dr. Eby articulates. But, yup, when you restrict access, what winds up happening is that people demand more when they finally get seen. They want their money’s worth, so to speak, and will nab any lab diagnostic or expensive follow-up they can get while they’re there, since they may never have the opportunity or the money or the time to arrange being seen again—or at least how it might feel to them at the time. Circling around to trust, listening to Dr. Eby talk, it makes me even more frustrated by providers who regard shared decision making endeavors or building trust with patients as a waste of time unless they’re getting paid for it directly somehow. If a patient isn’t going to do anything you tell them to do because they don’t trust you, and if they have to do what you tell them to do to get the outcomes that they probably should be getting, then it’s a bigger contemplation for providers and provider organizations than whether there’s a billing code for that—for provider organizations trying to create the best patient outcomes for their patients, that is. If you’re an employer and you recognize the criticality of access and trust, select your network accordingly would be my advice. Douglas Eby, MD, MPH, CPE, is the physician executive/VP of medical services at the Southcentral Foundation Nuka System of Care. This “An Expert Explains” sums up Dr. Eby’s advice for employers, but if you haven’t listened to it yet, when you’re done with this “mini-sode,” you might want to go back to the main episode I just did with Dr. Eby that gets into the how to provide effective health care from the provider organization clinician and kind of community standpoint.  You can learn more at southcentralfoundation.com. Douglas K. Eby, MD, MPH, CPE, is vice president of medical services for Southcentral Foundation’s Malcolm Baldrige Award–winning Nuka System of Care. Doug is a physician executive who has done extensive work with the Institute for Healthcare Improvement and other organizations around the Triple Aim, accountable care organizations (ACOs), patient-centered medical homes, whole system transformation, workforce, cultural competency, health disparities, and other topics. His speaking and consulting include work across the US, Canada, and portions of Europe and the South Pacific. Doug has spent more than 20 years working in support of Alaska Native leadership as they created a very innovative integrated system of care that has significantly improved health outcomes. Doug received his medical degree from the University of Cincinnati in Ohio and his master’s in public health degree from the University of Hawaii. 03:19 “The employer is the total-cost provider.” 03:23 “The people who don’t like us are people who are trying to make profits … extremely high use of high-end medicine.” 03:47 “Health care, for chronic disease management, should be provided when, where, and how the person on the receiving side wants and needs it.” 07:05 “People think demand is driven by … paranoia … but when you replace all of that by trust … that’s a massive replacement for all of that other stuff.” You can learn more at southcentralfoundation.com. @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “The employer is the total-cost provider.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “The people who don’t like us are people who are trying to make profits … extremely high use of high-end medicine.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “Health care, for chronic disease management, should be provided when, where, and how the person on the receiving side wants and needs it.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “People think demand is driven by … paranoia … but when you replace all of that by trust … that’s a massive replacement for all of that other stuff.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth
This episode is for anyone as curious as I have been about pharmaceutical supply chain goings-on in long-term care facilities like skilled nursing facilities, otherwise known as SNFs. There are a lot of players in the mix: You have your PBMs. You have your wholesale pharmacies. You have your LTC (meaning long-term care) pharmacies. You have the facilities themselves. You also have Medicare Part A and Medicare Part D and, in some cases, Medicare Advantage. Let me just lay some groundwork here before we dive headfirst into the confoundingly messy middle. If we’re talking about patients who have been in a SNF for services not covered by Part A—maybe because the patient needs help with basic activities of living—then their drugs are covered by Part D (Med D) or maybe their Medicare Advantage plan. The point I’m making is that it’s not a global payment at that point in the SNF. The patient’s Part D drug coverage is gonna be the same as if that patient were outpatient. They may have deductibles and coinsurance just like an outpatient. In this health care podcast, I speak with Sheldon Weiss, MD, who I pretty much interrogate about the who, what, and when of the various parties involved in getting a drug into a long-term care facility. Dr. Weiss is a great guy to ask because he is a practicing physician and operating efficiencies consultant and a previous COO of an LTC pharmacy. Now, let me editorialize a moment: At its core, the model of having a consultant pharmacist working with a medical director and a director of nursing at a long-term facility is a really interesting one. I just saw another article (this one in Health Affairs) the other day that came out proving yet again that provider teams outperform solo providers in managing chronic diseases. In theory, having a team including a pharmacist should definitely level up care. But there are confounders when it comes to the care of older Americans in facilities. One of them is that physicians—and I say this as an unfair broad stroke—sometimes don’t listen to the advice of consultant pharmacists because they’re just a pharmacist and not an MD. I’ve heard this go down myself and not just with pharmacists. In fact, in my recent interview with Dr. Douglas Eby from the Nuka System of Care, he said the same thing about doctors and behavioral health specialists. At the beginning, the docs are, like, “Oh, we don’t need behavioral health specialists. That’s what we do very well, thank you very much.” It didn’t take them long to revise that opinion, but it’s really common pooh-poohing that I hear repeatedly. And so, for possibly this reason and others, we have a situation where one of the main reasons why patients wind up in the ER from SNFs is that they have adverse drug events. Now, this being said, patient care in SNFs is a hard row to hoe because patients and SNFs are often highly complex and under the care of, in some cases, 10 or more specialists, all prescribing drugs without any knowledge of what other specialists are prescribing. Will the medical director of a facility want to take on the responsibility of contradicting a cardiologist or a pulmonologist or an oncologist and unprescribe some med? It takes a certain amount of fortitude and willingness to take on that risk. Keep in mind one point to ponder, however: Most people “aging in place” at home right now are not going to have anybody at all looking over their shoulder and even partially coordinating care reconciling meds. You can learn more by connecting with Dr. Weiss on LinkedIn. Sheldon Weiss, MD, practiced OB/GYN for over 30 years and has a master’s degree in health care management from the Harvard School of Public Health. He was the chief strategy officer for Indiana University Health system for 5 years and was the chief operating officer of a long-term care pharmacy for 2 years. He now does consulting for operational efficiencies in the health care space and has founded a start-up company focused on developing a health care record interoperability solution.   04:19 What’s the role of a wholesale pharmacy in a SNF? 04:48 What’s the connection between a wholesale pharmacy, a long-term care pharmacy, and a retail pharmacy? 07:00 Why does a SNF need two players? Why can’t a long-term pharmacy also take on the role of the wholesale pharmacy? 09:43 Why don’t long-term care pharmacies negotiate directly with PBMs? 10:02 “The key for … getting the best prices for medications is on volume.” 10:11 Who are these wholesale pharmacies negotiating the best prices? 11:19 “The goal of driving health care costs down by helping out the residents is a good model.” 13:43 “Ultimately the resident gets the same quality of medication, but yet it’s at a much more reasonable price.” 14:35 How does overmedication happen in the long-term care pharmacy model? 15:19 “The lower the amount of medicines, the less the chances of someone to become overmedicated.” 17:50 “I would think that most of the time it’s subtractive.” 19:00 “The idea in health care should be and is … that we only prescribe medications that are necessary.” 20:26 How does aging in place impact pharmacy? 22:11 “When you’re aging at home, there’s no one there looking out for you like a consultant pharmacist.” 24:39 How do we make aging in place safer from a pharmacy perspective? 25:58 “Physicians are very intelligent, but they tend to know their medications in their field.” 26:21 “Anything that increases the multidisciplinary approach model is going to benefit the patient.” 27:10 “The cost of medicine and the outcome of medicine really don’t equate.” You can learn more by connecting with Dr. Weiss on LinkedIn. Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply What’s the role of a wholesale pharmacy in a SNF? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply What’s the connection between a wholesale pharmacy, a long-term care pharmacy, and a retail pharmacy? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply Why does a SNF need two players? Why can’t a long-term pharmacy also take on the role of the wholesale pharmacy? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply Why don’t long-term care pharmacies negotiate directly with PBMs? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “The key for … getting the best prices for medications is on volume.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply How does overmedication happen in the long-term care pharmacy model? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply How does aging in place impact pharmacy? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “When you’re aging at home, there’s no one there looking out for you like a consultant pharmacist.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply How do we make aging in place safer from a pharmacy perspective? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “Anything that increases the multidisciplinary approach model is going to benefit the patient.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “The cost of medicine and the outcome of medicine really don’t equate.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply
Let’s talk about one aspect of health care that’s not talked about possibly often enough: big national health care players siphoning money out of local communities—potentially a lot of money depending on where you are and considering that health care is inching toward about 20% of the GDP. But besides the money leaving the community, another downside of large national players is that sometimes problems—even kind of seemingly simple problems—can be totally intractable and unsolvable because there’s just so much diversity of need and intricacies if you’re trying to come up with a broad-stroke solution that works for everybody across the land. On the other hand, by thinking and acting locally, these same problems can be solved. Besides, at a local scale, community and relationships within the community can become powerful forces for good. In this context, I was super thrilled to have had the chance to interview Dan Strause from Hometown Pharmacy and Drew Leatherberry from Avergent about a collaboration model they put together pairing up local PCP teams hired by self-insured employers with their local hometown pharmacy. Together, they’re similar to a team-based advanced primary care model that also has a level of navigation built in. Considering that patients visit their local pharmacy something like 35-ish times a year, it’s the expertise right in front of your face to help manage patients with chronic conditions. Add to this equation a pharmacist’s education and a local pharmacy’s position as a member of the community. Local pharmacies who are patient first and entrepreneurial could be a great way to keep health care local and solve for the needs of their communities at the same time. This episode is the first-ever simulcast between Health Rosetta and the Relentless Health Value podcast. It was recorded live at the recent Health Rosetta Summit. Thanks much to the Health Rosetta team, including Dave Chase, for inviting me and Relentless Health Value to be a part of the summit. In this episode, the CPESN Pharmacy Network comes up. Should you wish to learn more about the CPESN Pharmacy Network, listen to the Relentless Health Value interview 129 with Troy Trygstad.  You can learn more at hometownrxpharmacy.com and avergent.com. Dan Strause is a partner at Hometown Pharmacy of Wisconsin, a group of 70+ independent pharmacies focused on personalized patient care. Hometown Pharmacy educates and empowers patients and communities to make informed decisions about their health.     Drew Leatherberry is founder of Avergent, a Wisconsin-based benefits advisement firm serving employers around the country, guiding them to 20% to 40% cost savings on top of next-gen benefits and patient experiences. He has spent over a decade leading employers to restore health care to sustainable levels for their team members.     05:02 What has Avergent’s collaborative care model accomplished? 06:07 How did Drew and Dan connect? 07:08 “We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care.”—Drew 07:31 Why would a pharmacy make it their goal to get their patients off their medications? 08:20 “Prescription medicine is the most expensive, most dangerous form of a plant.”—Dan 08:39 “We believe we can help people by giving up prescription medicines.”—Dan 08:45 Is a pharmacy equipped to create a personal relationship with their patients? 12:50 “It’s a spin on traditional navigator-advocate-type roles.”—Drew 16:15 What does helping the patient look like through this partnership program? 19:18 “We’re really unifying the patient health record … and then … cross-referencing all those different data points … on a micro level [and] a macro level.”—Drew 20:53 “Everyone is onboarded into the collaborative care model.”—Drew 21:05 How does this collaborative care model cross the spectrum? 22:13 “Pharmacists are one of the unique professions that doesn’t get paid for time and knowledge [but rather] because of the product they dispense.”—Dan 23:06 “We can see the day where … patients will get a prescription from mail order but still need us.”—Dan 25:46 “We would love to get paid to keep you healthy.”—Dan 27:15 Why are pharmacists wanting to get patients off prescriptions, and how are they involved? 27:36 “In some cases, we are misapplying expertise that’s sitting right in front of our face that can help us deliver a better patient outcome.”—Drew You can learn more at hometownrxpharmacy.com and avergent.com. Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma Why would a pharmacy make it their goal to get their patients off their medications? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “Prescription medicine is the most expensive, most dangerous form of a plant.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We believe we can help people by giving up prescription medicines.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma Is a pharmacy equipped to create a personal relationship with their patients? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “Everyone is onboarded into the collaborative care model.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma How does this collaborative care model cross the spectrum? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “Pharmacists are one of the unique professions that doesn’t get paid for time and knowledge [but rather] because of the product they dispense.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We can see the day where … patients will get a prescription from mail order but still need us.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We would love to get paid to keep you healthy.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “In some cases, we are misapplying expertise that’s sitting right in front of our face that can help us deliver a better patient outcome.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma
This episode is a master class in raising health outcomes at lower costs from an award-winning health care system in … Alaska?! Who knew? In fact, I learned about the work of the Southcentral Foundation and the Nuka System of Care only because I happen to listen to Swedish health care podcasts and heard about them on one of those shows. Color me surprised when the interview suddenly switched to English and the guest was from Alaska. Here’s the short version of what’s happening with the Nuka System of Care, which serves Alaska Native and American Indian people. They have gone as close to the Triple Aim as I’ve seen in this country. Health outcomes are superior at costs about half the average. Patients—or, as they call them, customer owners—are happy. So are clinicians. How this was achieved (spoiler alert here) was not through incrementally trying to jigger the earlier and pretty much failing model of health care delivery that had been going on in Alaska for Alaska Natives at that time. No can do! The Nuka System of Care was rebuilt pretty much from the ground up to be, for reals, patient- and community-centric and to be relationship based, not transactional. Behavioral health is a built-in, not dangling off the back bumper. It’s also about assembling a multidisciplinary primary care team, one in which each clinician on the team really can work at the top level of their license. In this health care podcast, I had the honor and pleasure of speaking with Douglas Eby, MD, MPH, CPE. Dr. Eby is the physician executive/vice president of medical services, Southcentral Foundation Nuka System of Care. This episode is sort of two parts. There is the main episode, which you’re listening to now, that gets into the how to provide effective health care from the provider organization, clinician, and community standpoint. In a few days, we’ll release “An Expert Explains” episode, where Dr. Eby specifically goes over the lessons a self-insured employer might take away from all of this. If you are intrigued by what you hear in this episode, Dr. Eby will also be speaking on July 14, 2021, at the Aspirational Healthcare Conference, which will be virtual. Go to aspirationalhealthcare.com for more info. Yours truly will be there as well on July 15, and I’m very much looking forward to it.  For those of you into more immediate gratification, some of the themes that Dr. Eby covers in this health care podcast are expanded on in my interview with Greg Makoul (EP203) about listening to patients and Darrell Moon, who is the founder of the Aspirational Healthcare Conference. You can hear in EP305 talking about the 1% year over year most expensive claimants and the best way to help them and help your cost management at the same time.  You can learn more at southcentralfoundation.com. Douglas K. Eby, MD, MPH, CPE, is vice president of medical services for Southcentral Foundation’s Malcolm Baldrige Award–winning Nuka System of Care. Doug is a physician executive who has done extensive work with the Institute for Healthcare Improvement and other organizations around the Triple Aim, accountable care organizations (ACOs), patient-centered medical homes, whole system transformation, workforce, cultural competency, health disparities, and other topics. His speaking and consulting include work across the US, Canada, and portions of Europe and the South Pacific. Doug has spent more than 20 years working in support of Alaska Native leadership as they created a very innovative integrated system of care that has significantly improved health outcomes. Doug received his medical degree from the University of Cincinnati in Ohio and his master’s in public health degree from the University of Hawaii. 03:52 What’s the what and where of the Nuka System of Care? 04:49 What does the word Nuka mean? 05:25 “It’s all built around this idea that we’re raising … the ability for people to take control of their own health issues, and then we are just advisors … on that journey.” 06:39 “The reason why people do pay attention to us is … the proof in the pudding.” 09:09 What did the Southcentral Foundation do to create an ideal health system? 11:09 “It’s access, it’s relationship, it’s partnering, it’s being known … it’s getting at the whole family and the whole person.” 12:02 “There’s two huge problems with modern medicine all across the world. One is how money is handled … [and the other] is this blind acceptance of the medical model.” 14:14 “For 20 years, we’ve established a base of companionship and relationship.” 16:06 What does advanced primary care look like? 19:25 How does this new style of chronic management work, and why does it get better results than Centers of Excellence and other health system models? 23:25 “We refer out to specialists 65% less often than we used to.” 24:17 “It’s a ballet; it’s continual … all day, every day.” 25:33 How big are the patient panels in this system? 28:49 “I would say that 95% of what we do here is directly translatable to any location in the world.” 29:20 “Your workforce needs to look and feel like the community you’re trying to influence.” 32:12 “This is all designed and driven by the community that I am hired to support.” You can learn more at southcentralfoundation.com. @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth What’s the “what” and “where” of the Nuka System of Care? @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “It’s all built around this idea that we’re raising … the ability for people to take control of their own health issues, and then we are just advisors … on that journey.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “The reason why people do pay attention to us is … the proof in the pudding.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth What did the Southcentral Foundation do to create an ideal health system? @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “There’s two huge problems with modern medicine all across the world. One is how money is handled … [and the other] is this blind acceptance of the medical model.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “For 20 years, we’ve established a base of companionship and relationship.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth What does advanced primary care look like? @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “We refer out to specialists 65% less often than we used to.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “It’s a ballet; it’s continual … all day, every day.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “Your workforce needs to look and feel like the community you’re trying to influence.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth
In this health care podcast, Ge Bai explains GoodRx’s business model and how PBMs and pharmacies fit in to that business model. Here’s the short version: GoodRx takes advantage of the dysfunction in the pharmacy supply chain. And while they help patients save money, their master plan only works because pharmacies would be charging cash pay patients too much in most circumstances. Why, you might ask? Well, one reason is the big PBMs have contracts with pharmacies that stipulate the PBM must get the best prices. So, any patient wandering in off the street without a PBM card is going to always pay more than the rate a PBM can get for its patients. So, a pharmacy’s list price will always be more than the PBM price. I’ll let my guest in this episode, Ge Bai, explain this better and get into a few details; but that’s kind of the general level set there. Ge Bai, PhD, CPA, is an associate professor of accounting at Johns Hopkins Carey Business School and associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. This “An Expert Explains” goes very nicely with EP306, in which Ge Bai and I talk about Amazon’s pharmacy and pharmacy model. So, you might want to check out that episode if you have not listened to it yet. You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. Ge Bai, PhD, CPA, is an associate professor of accounting at the Johns Hopkins Carey Business School and associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on health care pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies. 01:53 What’s the difference between GoodRx and Amazon Pharmacy? 02:17 “GoodRx pharmacy makes money from one fact, and one fact alone.” 03:43 “On the surface, it looks like the patients are paying cash without any middleman; but in reality, the patients are paying cash by using a network created by a PBM.” 04:52 “GoodRx contracts with a network of PBMs.” 06:06 Where does the pharmacy fit in this deal? You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What’s the difference between GoodRx and Amazon Pharmacy? @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “GoodRx pharmacy makes money from one fact and one fact alone.” @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “On the surface, it looks like the patients are paying cash without any middleman; but in reality, the patients are paying cash by using a network created by a PBM.” @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Where does the pharmacy fit in this deal? @GeBaiDC discusses how GoodRx makes money on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma  
This episode might be about local providers getting disintermediated not by virtual front doors like I discussed with Jeff Hogan in EP309 but by entities providing virtual continuous care at home. Predictivae and proactive, the idea is to help reduce acute events requiring on-premises care. But if someone does wind up needing ramped-up care, they can get it hospital at home or SNF (skilled nursing facility) at home instead of them going anywhere. So, there’s a baseline level of home monitoring followed by periods where care is stepped up. The point is, everything is going down at home with the care coming to the person at the care level that they need, so it ramps up or down depending on what they’re going through or need at the time.  I’m talking in this health care podcast with Sumit Nagpal, CEO and founder over at Cherish Health. We talk about the goings-on in the whole aging in place or, as he calls it, living in place vertical. A couple of takeaways from our conversation I think are notable: First of all, who is going to drive first change here isn’t going to be, for example, hospital systems at scale suddenly deciding to work against their own perverse incentives to keep heads out of beds. Our first movers here—the ones who will push assisted living at home or SNF at home or CCRC at home or whatever you want to call it at home—is going to be consumers and their families who either can’t afford to or don’t want to send Grandma to an assisted living institution. So, this is how it’s gonna go down: Families across the country install technology to keep Grandma safe at home. A natural ally here, if you think about it, is Big Retail, by the way. Why wouldn’t Big Retail and Big Tech sell these solutions to grandmas’ families like they sell televisions today? But the second that grandmas everywhere have monitoring software in their homes is the second that FFS-dependent hospitals and other providers have a problem on their hands—a business problem, that is. And assisted living facilities and SNFs working a similar model are in the same boat. Here’s why. Actionable population heath data is now available, and once that data is available and looked at predictively and proactively, grandmas are not going to go to the ER like they once were for two reasons: (1) Proactive and predictive technology in the home will reduce acute events and (2) because if and when Grandma does have an acute event, she’s not calling an ambulance. The technology is notifying someone. Maybe it’s notifying the Medicare Advantage plan that Grandma’s on, who has realized the power of all this at-home stuff. And the Medicare Advantage plan maybe just hooked up with a forward-thinking hospital that built an ER at home service or a hospital at home service. Or maybe there’s some national technology player who is providing similar services. Sumit Nagpal and I talk through how this might look and also the essential factors for the health care industry to eventually adopt an at-home model. You can learn more at cherishhealth.com. Sumit Kumar Nagpal is the CEO and founder of Cherish Health, a consumer electronics company that develops advanced sensors and artificial intelligence combined with medical evidence and human touch. Cherish Health solutions improve the lives and enable the supported self-care of people aging or living with health challenges—our grandparents, parents, children, many of us. Sumit is a serial entrepreneur and has cofounded and grown five digital health companies over the past two and a half decades that have tackled progressively bolder challenges facing our health care economies. He serves on important industry boards, including HIMSS and Health eVillages. Prior to founding Cherish Health, Sumit was global lead for digital health strategy at Accenture. He is sought after for his expertise and unstoppable energy as an entrepreneur, change agent, strategist, and technology architect. 03:55 What does “health care is coming home” truly mean? 07:35 “It’s not like we’re cheese and we’re aging in place. We’re living. We’re living our lives.” 07:51 “Give us the ability to live where we want for as long as we want as safely as possible.” 10:31 “The challenge with wearables beyond the initial cost is … you have to remember to wear them.” 10:53 “The tech itself is not unreliable, but we as human beings are unreliable.” 13:34 “The conversation typically begins with privacy and goes into other kinds of risks.” 15:50 “Our health care economy is fundamentally misaligned.” 17:57 “The incentives … today don’t really enable this kind of proactive, preventive engagement.” 23:30 How do we solve this cost problem at scale? 23:44 How do you align incentives for those that will care to solve these problems? 26:47 “I don’t think that we’re going to have mass, large-scale change in health care moving home until people are starting to adopt … these kinds of services in their homes.” You can learn more at cherishhealth.com. @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth What does “health care is coming home” truly mean? @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It’s not like we’re cheese and we’re aging in place. We’re living. We’re living our lives.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Give us the ability to live where we want for as long as we want as safely as possible.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The challenge with wearables beyond the initial cost is … you have to remember to wear them.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The tech itself is not unreliable, but we as human beings are unreliable.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The conversation typically begins with privacy and goes into other kinds of risks.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Our health care economy is fundamentally misaligned.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The incentives … today don’t really enable this kind of proactive, preventive engagement.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do we solve this cost problem at scale? @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do you align incentives for those that will care to solve these problems? @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealt 
  The Shkreli Awards have been published each year, for the past five years and counting, by the Lown Institute. The Shkreli Awards are a much-anticipated top 10 list of the worst examples of profiteering and dysfunction in health care. This year’s list, celebrating the most excellently egregious profiteering in 2020, are unique in the sense that everybody on this list this year—every one of them—decided, deliberately, that a pandemic might be a super opportunistic global stroke of luck to exploit fear and anguish to line their own pockets. The list is named for Martin Shkreli, the price-hiking “pharma bro” that is easy to point to as a model of pure, unadulterated health care profiteering. Here’s the point: Just because you can be clever and shifty enough to make a whole lot of money in health care doesn’t mean you should. Every dollar anyone earns without adding commensurate value back is just one more nail in the financially toxic coffin that patients and employers face in this country—and taxpayers. The Lown Institute is a nonpartisan think tank advocating bold ideas for a just and caring system for health. Their work is centered around four main topics: low-value or unnecessary care, accountability, health equity, and the human connection. In this health care podcast, I am looking so forward to speaking with Vikas Saini, MD, and Shannon Brownlee from the Lown Institute about this year’s Shkreli Award winners. (I wish I had a soundtrack of audience clapping. I’d cue it right now.) There are 10 winners, and we talk about most of them in this episode. You can learn more by connecting with Dr. Saini (@DrVikasSaini) and Shannon (@ShannonBrownlee) on Twitter.  Vikas Saini, MD, is president of the Lown Institute. He is a clinical cardiologist trained by Dr. Bernard Lown at Harvard, where he has taught and done research. He has also been an entrepreneur as scientific cofounder of Aspect Medical Systems, the pioneer in noninvasive consciousness monitoring in the operating room with the BIS device. He was in private practice in cardiology for over 15 years on Cape Cod, where he also founded a primary care physician network participating in global payment contracts. Dr. Saini is board certified in cardiovascular disease, internal medicine, and nuclear cardiology. He has served on the faculty of Harvard Medical School and the Harvard School of Public Health, where he initiated the first course focused on policy translation for cardiovascular disease prevention. In April 2012, Dr. Saini convened the Avoiding Avoidable Care Conference with the noted author Shannon Brownlee. This was the first major academic conference focused on the problem of overuse of health care services. Dr. Saini led the international writing group of the Right Care series of papers commissioned by The Lancet and published in January 2017. With Ms. Brownlee, he is a convener of the Right Care Alliance, a grassroots network of physicians, nurses, patient activists, and community leaders dedicated to creating public demand for care that is safe, effective, affordable, and just. Dr. Saini has spoken and presented research about avoiding unnecessary care at professional meetings around the world and has been quoted in numerous print media and on radio and television. Shannon Brownlee is senior vice president of the Lown Institute. She and Lown Institute President Dr. Vikas Saini are cofounders of the Right Care Alliance, a network of activist patients, clinicians, and community leaders devoted to organizing a broad-based movement for a radically better health care system. Before joining the Lown Institute, Brownlee served as acting director of the health policy program at the New America Foundation. As a senior fellow at New America, she published the groundbreaking book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, which was named the best economics book of 2007 by the New York Times. She was a senior writer at US News and World Report and Discover Magazine and is the recipient of numerous awards, including a Congressional Commendation, and was named one of “four writers who changed the world” by the World Congress of Science Journalists. Her stories and essays have appeared in such publications as The Atlantic, New York Times Magazine, The Washington Post, Times of London, Time, New Republic, Los Angeles Times, BMJ, The Lancet, and Health Affairs. Brownlee is a nationally recognized speaker, has been featured in several documentary films, and has appeared on such broadcast outlets as ABC World News, Good Morning America, Fox News, NPR, and The Diane Rehm Show and is quoted regularly in the press. She is the author of several peer-reviewed articles in medical journals and has served on numerous scientific panels, working groups, and roundtables. From 2014-2016, she was an editor of the “Less is More” section of JAMA Internal Medicine and was a lecturer from 2011-2014 at the Dartmouth Institute for Health Policy and Clinical Practice. She is currently a member of the boards of the Robert Graham Center of the American Academy of Family Practice and Families USA and is a visiting scientist at the Harvard T.H. Chan School of Public Health. Brownlee holds a master’s degree in marine science from the University of California, Santa Cruz. 02:51 “COVID was like … just a glare of x-ray that revealed everything … going on in the health care system.” 05:14 “There’s always profiteering whenever there’s a buck to be made.” 05:33 Is profiteering in the health care system deteriorating? 06:07 How did the winners of the 2020 Shkreli Awards get chosen? 07:18 “The categories that this falls into is really the stakeholders in health care.” 08:11 What did Connecticut internist Steven Murphy, MD, do to earn his place at #8 on the awards list? 09:29 How did big pharma companies (some of which have been developing COVID vaccines) like Pfizer get on the Shkreli Awards list? 11:16 “We do have to start asking some hard questions about who is supposed to benefit from the … public funding that goes into these kinds of products—vaccines and drugs.” 12:49 “The thing about private equity … is that the business model really is profiteering in health care.” 19:43 Why did the federal government win the first place in the Shkreli Awards? 24:13 “Most of this is not illegal. It’s merely unethical.” 26:56 “There really is a radically better health care system that’s possible, but we’re not really going to get there if people are shy about talking publicly about some of these issues.” You can learn more by connecting with Dr. Saini (@DrVikasSaini) and Shannon (@ShannonBrownlee) on Twitter.  @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering “COVID was like … just a glare of x-ray that revealed everything … going on in the health care system.” @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering “There’s always profiteering whenever there’s a buck to be made.” @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering How did the winners of the 2020 Shkreli Awards get chosen? @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering “The categories that this falls into is really the stakeholders in health care.” @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering How did big pharma companies (some of which have been developing COVID vaccines) like Pfizer get on the Shkreli Awards list? @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering “We do have to start asking some hard questions about who is supposed to benefit from the … public funding that goes into these kinds of products—vaccines and drugs.” @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering “The thing about private equity … is that the business model really is profiteering in health care.” @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering Why did the federal government win the first place in the Shkreli Awards? @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering “Most of this is not illegal. It’s merely unethical.” @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering “There really is a radically better health care system that’s possible, but we’re not really going to get there if people are shy about talking publicly about some of these issues.” @DrVikasSaini and @ShannonBrownlee discuss the 2020 Shkreli Awards on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #profiteering
This episode is a tale of what happens when some employers decide to open up a few virtual front doors and when these virtual front doors lead only to referrals to providers who are willing to be accountable and offer financial predictability. That’s what these employers want, after all. They want accountability and financial predictability. Many employers now have access to all claims databases and other data like the RAND 3.0 report. Therefore, employers can and are using this information in a big way to steer their plan member populations. Given these goings-on, some slower-moving providers could easily find themselves on the outside looking in. So, who are those providers who are or will be getting shut out of referral flows? They’re definitely FFS-centric, but they could be a large health system, an urgent care center, or a hospital-owned PCP. In this health care podcast, I speak with Jeff Hogan, the northeast regional manager for Rogers Benefit Group and also president of Upside Health Advisors. We talk in this episode not about what might be theoretically possible but about what is happening right now. You can learn more at jhogan@rogersbenefit.com and connect with Jeff on LinkedIn. Jeffrey Hogan is the northeast regional manager for Rogers Benefit Group, a national benefits marketing and consulting firm. Jeff has been with Rogers Benefit Group for 30 years. Additionally, Jeff operates a consulting firm, Upside Health Advisors, where he provides expert witness services on health care–related litigation, is a consultant to payers and large provider groups for product development and launch, and is a resource to employers desirous of implementing strategies to manage their health spend. Jeff is focused on health care payment reform, health policy, care coordination, value-based health care, health care quality, and precision medicine. Jeff regularly appears on national forums focused on moving to value-based health care and is actively working to promote health care–related transparency measures in the market. He serves as the group’s liaison to the National Alliance of Healthcare Purchaser Coalitions. Jeff is the regional leader for The Leapfrog Group. He is also one of the coordinators of Connecticut’s Moving to Value Alliance. 01:43 What are self-insured employers doing right now to impact referral flows? 03:29 Are any virtual tech companies moving in on the local provider space? 07:46 “What we’re trying to do … is to help the member have the best outcome.” 10:32 “It’s a continuum, if you will.” 10:44 “There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence].” 11:13 “What is value for employers coming out of COVID? Accountability and predictability.” 13:40 What are second-order effects? 14:29 “People like and want better access.” 14:46 “Fee-for-service providers fear the informed health care consumer.” 22:19 “Many of the brick-and-mortar providers are realizing that they have to up their game.” 24:52 “Things will change.” 25:07 “People not only want convenience, but they want safety, they want data.” 26:11 “We are at an inflection point … After 35 years in the business, I really finally feel like we’ve broken through.” 27:31 “This requires people to really think; it requires employers to actually know what their biggest problems are.” 29:53 “We can’t go back to the fragmentation of fee for service.” 30:25 “Data is critical.” You can learn more at jhogan@rogersbenefit.com and connect with Jeff on LinkedIn. Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth What are self-insured employers doing right now to impact referral flows? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth Are any virtual tech companies moving in on the local provider space? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “What we’re trying to do … is to help the member have the best outcome.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence]” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “What is value for employers coming out of COVID? Accountability and predictability.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “People like and want better access.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “Fee-for-service providers fear the informed health care consumer.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “People not only want convenience, but they want safety, they want data.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “We are at an inflection point … After 35 years in the business, I really finally feel like we’ve broken through.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “This requires people to really think; it requires employers to actually know what their biggest problems are.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “We can’t go back to the fragmentation of fee for service.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “Data is critical.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth
And here I thought I knew a lot about value-based care. In this health care podcast, I am speaking with Mark Fendrick, MD, who is the director over at the University of Michigan Center for Value-Based Insurance Design. This conversation is for those of you who already know pretty much about value-based care concepts. If you do not, I’d go back and listen to, say, Encore! EP206, with Ashok Subramanian, before this one.   Dr. Fendrick talks in this health care podcast about what it takes for value-based care to happen in the real world. No kidding, it’s about making sure that reimbursement is aligned with good things (no great surprise there). Everybody is always talking about properly aligning provider incentives. And, although often discussed, it really matters. But two light bulb moments I had in this conversation with Dr. Fendrick: Here we are at the beginning of the year. How many doctors and nurses, inspired to do the right thing, have told their patients with diabetes, say, to go get an eye exam to check for diabetic retinopathy? No one would disagree that this is definitely a good idea. Diabetic retinopathy causes blindness. But here’s the reality of that conversation. Doc says, “Go get an eye exam.” And patient says, “I can’t. My deductible is huge, and I can’t afford it.” So, the patient doesn’t get the follow-up care and winds up in the hospital or blind. And the doctor gets dinged on his or her quality scores. Suboptimal outcomes all around, I’d say. This also happens on the pharmacy side of the equation, but I think a lot of us are a little bit more familiar with that scenario—like type 1 diabetics who can’t afford to pick up their insulin because of a Medicare Part D or commercial deductible that they haven’t met yet. I just never really connected the dots back to the provider getting black marks because their patient has a benefit design that’s not aligned with the quality measures. In a majority of benefit designs, consumer price sharing is based not on the value of the service but on how expensive the service just happens to be. Wow! Think about that. So, we’re trying to get our plan members to be consumers and use the power of their wallets to make good health care choices. And what we’re really doing is driving them toward cheap things or no care and discouraging them from indulging—and I say that sarcastically—in expensive things. But the expensive things might be the high-value care, and the relatively cheap things might be crap that’s fully unnecessary or harmful and, over a whole population, adds up to a lot of zeros. Health care is not like a consumer market where the expensive things are usually a better version of the cheap things. For all you economists out there, you don’t want the demand curve to be elastic when what’s cheap and what’s expensive has no correlation to quality or necessity. Nobody should be super flabbergasted when a $35 cure-all supplement peddled on YouTube makes some random influencer a millionaire. That’s how supply and demand works. Much to ponder in this episode. You can learn more at vbidcenter.org. There’s also a great newsletter you can sign up for there. A. Mark Fendrick, MD, is a professor of internal medicine in the School of Medicine and a professor of health management and policy in the School of Public Health at the University of Michigan. Dr. Fendrick received a bachelor’s degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School. He completed his residency in internal medicine at the University of Pennsylvania, where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Fendrick conceptualized and coined the term Value-Based Insurance Design (V-BID) and currently directs the V-BID Center at the University of Michigan (vbidcenter.org), the leading advocate for development, implementation, and evaluation of innovative health benefit plans. His research focuses on how clinician payment and consumer engagement initiatives impact access to care, quality of care, and health care costs. Dr. Fendrick has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design. His perspective and understanding of clinical and economic issues have fostered collaborations with numerous government agencies, health plans, professional societies, and health care companies. Dr. Fendrick is an elected member of the National Academy of Medicine (formerly IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the US Senate Committee on Health, Education, Labor and Pensions; the US House of Representatives Ways and Means Subcommittee on Health; and the US Senate Committee on Armed Services Subcommittee on Personnel. 03:53 Is back surgery high-value care? 04:46 If care is patient to patient, how is high-value care decided upon? 05:36 “Flintstones delivery: We have to move from the sledgehammer to the scalpel.” 10:19 “Almost all of the services that we recommend to reduce cost sharing … do not save money.” 11:36 “I didn’t go to medical school to learn how to save people money.” 16:14 “When a patient and their clinician agree … the patient should be able to get that [service] easily, and the clinician should be paid generously.” 17:14 “When patients and providers are aligned, they do much better.” 19:07 What services are deemed high value, and what services should be pre-deductible? 21:04 “Are primary care visits high value? … The answer is, it depends.” 25:13 What are V-BID’s core pillars to address value-based care? 27:24 How does Dr. Fendrick’s method of value-based care and reimbursement actually enable better consumerism? 29:11 What do providers think about changing reimbursement on low-value and high-value care? 30:21 “We have incentives that are run amok.” 31:34 EP176 with Dr. Robert Pearl. 32:12 “It’s all about incentives.” 33:05 “You do have the funding; you just have to have the courage.” You can learn more at vbidcenter.org. There’s also a great newsletter you can sign up for there.  Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth If care is patient to patient, how is high-value care decided upon? Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Flintstones delivery: We have to move from the sledgehammer to the scalpel.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Almost all of the services that we recommend to reduce cost sharing … do not save money.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “I didn’t go to medical school to learn how to save people money.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “When patients and providers are aligned, they do much better.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Are primary care visits high value? … The answer is, it depends.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “We have incentives that are run amok.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “You do have the funding; you just have to have the courage.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth
In this health care podcast, I speak with Loren Adler, who is the associate director of USC-Brookings Schaeffer Initiative for Health Policy and has a particular focus on surprise billing. I wanted to talk to Loren about the surprise billing legislation that is going into effect on 1/1/22. I will let Loren explain, but, in short, this legislation removes the patient from the mix. If a provider decides to send a surprise bill, the patient will just pay the co-pay or coinsurance they normally would have if the provider had been in network. Then, it’s up to the provider who sent the bill and the insurer to duke it out on the back end. What this back end duking out consists of is the provider sending their big surprise bill to the insurer. The insurer may reply, with regrets, “Hey, we’re only gonna pay you … whatever … a fraction of the big bill.” The provider may at that point say, “Fine … whatever. I’ll take it.” Or the provider may say, “No can do. I’ll see you in arbitration.” This arbitration that then happens is a style called baseball arbitration, and Loren gets into the “why” there. Also, a provider cannot trigger an arbitration more than once every 90 days for the same service. So, there’s a wrinkle that will slow the roll of any provider with a plan to clog up the system by arbitrating every claim. I quiz Loren mercilessly about exactly what the provisions of this legislation are and the winners and the losers. But we also talk a lot about potential ramifications. For example, making surprise bills illegal will potentially accelerate bundled payments, if you think about it, because one of the reasons why bundles have stalled is because various parties who enjoy surprise billing refuse to be a part of the bundle—and then the whole thing just flies off the track. Also, premiums will go down approximately 1%, they say, for self-insured employer plans. And Loren and I get into the “why” of that—or, more accurately, Loren gets into the “why” of that. In listening to this recording, I realized we do sort of pick on anesthesiologists a bit here. So, apologies to those anesthesiologists who have been billing fairly this whole time, which is definitely the majority. You can learn more at brookings.edu. Loren Adler is associate director of the USC-Brookings Schaeffer Initiative for Health Policy. His research focuses on a range of topics in health care economics and policy, including provider payment and consolidation, insurance markets, Medicare, the Affordable Care Act, prescription drugs, and COVID-19 testing. Previously, he served as research director for the Committee for a Responsible Federal Budget and as a senior economic policy analyst for the Bipartisan Policy Center. Adler holds a bachelor’s degree in mathematical economics from Wesleyan University and a master’s degree in applied economics from Johns Hopkins University. 03:04 What is this surprise billing legislation? 04:27 What happens when a patient is sent a huge bill from the provider? 06:15 What is “the going rate”? 09:44 “If you weren’t leveraging surprise billing beforehand, this law has no effect on you.” 11:14 Will this legislation push the industry toward one hospital bill? 12:20 What will providers have to do if they don’t like what insurance wants to pay them? 15:26 What is benchmark pricing? 17:37 “Fundamentally … it’s really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other.” 18:19 Is this surprise billing legislation a compromise? 19:48 “Arbitration really isn’t meant to adjudicate every single claim.” 20:11 “The idea is really to kind of push the facility … to negotiate and figure this all out.” 20:50 Are hospitals being impacted by this bill? 24:56 What happens to providers who decide to send surprise bills anyway? 26:09 What are the implications of this legislation for self-insured employers? 28:48 Why have ground ambulances been left out of this surprise billing legislation? 32:23 “At the end of the day, I think this is a net positive for consumers and should be considered a win.” You can learn more at brookings.edu.   @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is this surprise billing legislation? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you weren’t leveraging surprise billing beforehand, this law has no effect on you.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Will this legislation push the industry toward one hospital bill? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What will providers have to do if they don’t like what insurance wants to pay them? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is benchmark pricing? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Fundamentally … it’s really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is this surprise billing legislation a compromise? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are hospitals being impacted by this bill? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the implications of this legislation for self-insured employers? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why have ground ambulances been left out of this surprise billing legislation? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “At the end of the day, I think this is a net positive for consumers and should be considered a win.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth
Here’s a trigger warning: This show gets pretty deep into some of the nether regions of PBM (pharmacy benefit manager) contractual terms with pharmacies. If you are not, I’m gonna say, pretty familiar with PBM goings-on, I’d suggest you listen to EP241 with Vinay Patel first or skip the first third of this show.   In this health care podcast, I am speaking with Ge Bai about Amazon’s pharmacy business. Ge Bai, PhD, CPA, is an associate professor of accounting at Johns Hopkins Carey School of Business. She is also associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. Ge trained as an accounting researcher who originally started looking into chargemasters for her dissertation. From there, she started checking out health care pricing and contracting issues. Who knew chargemasters were like a gateway drug into health care? I ask Ge questions such as, “Why the heck does Amazon need a PBM for cash pay patients?” and “What’s this Amazon Pharmacy model that some self-insured employers are talking about?” And then we get into rebates and the impact that Amazon will have on rebates. Right up front, I want to just say flat out, I learned a mind-blowing detail from Ge. There’s a contracting term that PBMs put in their contracts with pharmacies. Basically, a pharmacy cannot sell a drug to a cash pay patient for an amount that is less than the price a PBM pays the pharmacy for the drug or the pharmacy charges the PBM for the drug—I guess it depends how you perceive that relationship. So, the pharmacy’s list price paid by cash pay patients can’t be less than the contracted price that it has with any third-party payer. The PBMs will always have to get the better price than cash pay patients. There’s one exception, though: unless the cash pay patient wanders in with a coupon (like a GoodRx coupon, for example). There are a whole lot of implications to this if you start to think about it. Spoiler alert: There will be an “Ask an Expert” with Ge Bai coming out after the show, where Ge and I get deeply into GoodRx’s business model. So, stay tuned for that if you are interested. You might be subscribed to the show on iTunes, but I’d also encourage you to sign up for our newsletter on relentlesshealthvalue.com. Every week, you get a transcript of the introduction to the show that’s coming out that week, so you can prioritize your listening accordingly.   You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. Ge Bai, PhD, CPA, is an associate professor of accounting at the Johns Hopkins Carey Business School and associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on health care pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies. 03:27 Why is Amazon in the pharmacy space a big deal? 04:03 “I view Amazon Pharmacy as a combination of GoodRx and mail-order pharmacy.” 05:07 What’s the difference between Amazon and other pharmacies? 06:14 Why does the third-party payer health care system keep Amazon from cutting out the PBM? 07:49 “We don’t have insurance companies, we don’t have PBMs.” 09:21 “Who’s really using prescription drugs? The majority is Medicare patients.” 11:46 Is Amazon doing anything innovative in the pharmacy space? 12:37 What options do self-insured employers have now with Amazon? 14:42 Why employees and employers might choose to use Amazon Pharmacy over other mail-order pharmacies. 21:27 Will Amazon affect pharmacy rebates? 25:28 “Fundamentally, employers want to have more power in the whole process.” 27:41 What should you be doing as a self-insured employer? 28:58 “If we do not put out effort to make the private market work, then the next option would be single payer.” You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University.   @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why is Amazon in the pharmacy space a big deal? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “I view Amazon Pharmacy as a combination of GoodRx and mail-order pharmacy.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What’s the difference between Amazon and other pharmacies? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why does the third-party payer health care system keep Amazon from cutting out the PBM? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “We don’t have insurance companies, we don’t have PBMs.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Who’s really using prescription drugs? The majority is Medicare patients.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Is Amazon doing anything innovative in the pharmacy space? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What options do self-insured employers have now with Amazon? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Fundamentally, employers want to have more power in the whole process.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “If we do not put out effort to make the private market work, then the next option would be single payer.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma
My guest in this health care podcast is Darrell Moon, who is the CEO over at Orriant. I was super intrigued by some of the work that Darrell and his team are doing regarding high-cost claimants. Said a different and probably better way, certain people in need of care were identified because they were costing so much. Year after year after year, these individuals—I call them hyper-users during this episode, but it’s possible I made that term up myself—these hyper-users were getting all kinds of expensive health care, while at the same time, they were not getting any better. So, Darrell and his team realized that something was afoot here, and it turned out to be a combination of maybe loneliness, maybe low self-esteem and low self-efficacy. And no matter how many times you go to the cardiologist or the rheumatologist or the pulmonologist, none of those things will be cured. In fact, when someone’s identity becomes their myriad of health issues, they have a sort of perverse incentive, if you think about it, not to follow any of their doctor’s recommendations to take meds or make lifestyle changes. So, while their underlying condition—low self-esteem, low self-efficacy—remains untreated, their physical health tends to actually get worse, not better, despite all the medical attention. What’s necessary to help this type of patient is the best that behavioral science has to offer. A nuance I found really interesting and important in the work that Darrell is doing is that it’s pretty easy to identify a hyper-user from someone with a horrid chronic condition simply requiring a lot of care. The hyper-users will respond and appreciate the extra attention that a behavioral health coach/program has to offer. In contrast, those with other ailments will just merely get annoyed—usually on the quick—so they exclude themselves from the program. Sidebar: My guest Darrell Moon is organizing an Aspirational Healthcare Conference for July 14 and 15, 2021. In that virtual meeting, the intent will be to highlight Southcentral Foundation’s Nuka System of Care in Alaska and other similar health care models that achieve much better health care outcomes at half the cost. So, check that out if you are so inclined. Thanks so much also to Lee Lewis from the HTA (Health Transformation Alliance) for the introduction to Darrell and Orriant. You can learn more at orriant.com. Darrell Moon founded Orriant in 1996 to change the dynamics of health care and give employers some control over the ever-increasing costs of the health care benefits they offer their employees. Darrell believed that engaging individuals in the management of their own health was a key that had to be inserted back into the economic equation of health care. Darrell received both his bachelor’s degree in finance and his master’s degree in healthcare administration from Brigham Young University. As the CEO, COO, or CFO, Darrell managed medical and psychiatric hospitals throughout the country for over 10 years prior to creating Orriant. He also has more than a decade of experience managing insurance and managed care products. Darrell is a Forbes leadership contributor. 03:11 What do CEOs want out of the health care system? 04:52 Is it a good strategy to focus on high-cost claimants? 07:04 Who are the people year over year that wind up in the high-cost claimant pool? 07:50 “Really, you have to get to the crux of the problem, which is … they’ve become a victim … to the health care system.” 08:16 Who are these “hyper-users” and how do we define them? 11:35 “Getting that person to have a regular relationship with someone isn’t the hard part; the hard part is then helping them to build their self-esteem.” 13:20 “That’s the key to building self-esteem—is helping people accomplish what’s most important to them.” 14:57 Why helping a patient not to view themselves as a victim helps them manage their care better. 17:45 “It’s often less the training and the right personality of the person.” 18:54 Do health outcomes correlate with the self-esteem of the patient? 19:28 “If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience.” 21:21 “They’re the customer/owner of their own health.” 24:23 “How do you help not just the 1% but everybody [in health care]?” 27:16 “The ideal environment is to have a massively powerful primary care team.” 27:47 “Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right.” 29:34 “It’s not about just when [people] reach out … but [getting] people to reach out early.” You can learn more at orriant.com. Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth What do CEOs want out of the health care system? Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is it a good strategy to focus on high-cost claimants? Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Really, you have to get to the crux of the problem, which is … they’ve become a victim … to the health care system.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Getting that person to have a regular relationship with someone isn’t the hard part; the hard part is then helping them to build their self-esteem.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “That’s the key to building self-esteem—is helping people accomplish what’s most important to them.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It’s often less the training and the right personality of the person.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “They’re the customer/owner of their own health.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The ideal environment is to have a massively powerful primary care team.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It’s not about just when [people] reach out … but [getting] people to reach out early.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth
Humana recently came out with their Value-based Care Report. The subhead is Physician Progress and Patient Outcomes. It’s a very fancy report with a lot of pages and graphics, and this impressive format definitely caught the attention of some of our industry. I read one blog post really keying in on one sort of depressing aspect of the report, namely, that Humana’s value-based care (VBC) program saved a rounding error of 0.4% over their non-VBC program. I wanted to get an expert’s take on this report and the reaction to the report and could think of no better person than Steve Blumberg, who has worked in value-based care delivery on the provider and on the payer side. Steve Blumberg, MBA, is the VP of practice transformation for GuideWell Health, a subsidiary of GuideWell. This Humana report, if you’d like to see it for yourself, can be found at digital.humana.com/VBCReport.  You can learn more at guidewell.com. Steven Blumberg serves as vice president, practice transformation, for GuideWell Health. In this role, he is responsible for developing and implementing strategies for the further establishment of a high-quality, economically effective clinical system across Florida. He also provides guidance on value-based care and population health models. Prior to joining GuideWell in June 2019, Blumberg served as vice president for value-based care at Baptist Health South Florida, where he led the strategy and implementation for Baptist’s population health and value-based care efforts. Prior to that, he was senior vice president and executive director of AtlantiCare Health Solutions, the New Jersey division of the Geisinger Health System, where he was responsible for population health, the organization’s provider physician group, and home care and hospice continuum services. Earlier in his career, he was chief planning and business development officer at UHealth–The University of Miami Health System. Blumberg also held leadership roles at UF Health–Shands Healthcare and Baptist Health Jacksonville. Blumberg has been active in community and professional organizations, including serving on the boards of the Ronald McDonald House, Community Hospice, and the Northeast Florida Health Planning Council. He has also served nationally on the Premier Population Health Steering Group and on the National Institute of Standards and Technology’s Baldrige Board of Examiners. Blumberg holds a bachelor’s degree in business administration and marketing from the University of Florida and a Master of Business Administration from Florida State University. He is a fellow of the American College of Healthcare Executives. 02:11 Does value-based care really reduce cost, according to the Humana report? 03:02 Why we should look at outcomes and not just raw costs. 04:06 Is the impact of a value-based model that much better than a fee-for-service model during COVID? 04:38 “At the end of the day, I think … the lack of a cost difference is notable, but one must think there’s more to it than that.” 05:44 “You have to look at these things over time.” 06:02 “I think in health care we’ve been looking for the ‘what will save 10%’ solutions … and there’s just no such animal.” You can learn more at guidewell.com. Steve Blumberg of @_GuideWell discusses the 2020 Humana Value-based Care Report on our #healthcare #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth Does value-based care really reduce cost, according to the Humana report? Steve Blumberg of @_GuideWell discusses the 2020 Humana Value-based Care Report on our #healthcare #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth Why we should look at outcomes and not just raw costs. Steve Blumberg of @_GuideWell discusses the 2020 Humana Value-based Care Report on our #healthcare #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth Is the impact of a value-based model that much better than a fee-for-service model during COVID? Steve Blumberg of @_GuideWell discusses the 2020 Humana Value-based Care Report on our #healthcare #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “At the end of the day, I think … the lack of a cost difference is notable, but one must think there’s more to it than that.” Steve Blumberg of @_GuideWell discusses the 2020 Humana Value-based Care Report on our #healthcare #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “You have to look at these things over time.” Steve Blumberg of @_GuideWell discusses the 2020 Humana Value-based Care Report on our #healthcare #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “I think in health care we’ve been looking for the ‘what will save 10%’ solutions … and there’s just no such animal.” Steve Blumberg of @_GuideWell discusses the 2020 Humana Value-based Care Report on our #healthcare #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth
In this health care podcast, I speak with Steve Blumberg, VP of practice transformation for GuideWell Health, a subsidiary of GuideWell. How’s this for an interesting career trajectory? Steve spent the last decade working on population health and value-based care delivery ... on the provider side. Recently, he transferred over to the payer side, working for GuideWell Health, which is the health services arm of GuideWell, which is part of a family of companies including Florida Blue. So, a payer, in other words. I wanted to find out a bunch of things from Steve, but the main one is this: How do—if they, in fact, do—payviders improve care for patients? Or what does it take for an organizational structure to drive Triple Aim results? Going into this conversation, here is what I was thinking about: Payviders have access to longitudinal data (potentially) that siloed entities will certainly not. They also have a goal to keep care affordable in a really real way, especially if the patient/member/client is on the ACA (Affordable Care Act) marketplace and shopping for premiums. My big concern with payviders, though, is whether they’re an “HMO in drag,” as they say. On the other hand, payers and providers, in the most cynical sense, have wildly divergent goals. Search #medtwitter any day of the week—you will find a galaxy of tweets wherein doctors complain about payers—to just get a tiny sense of those wildly divergent goals. Do separate payers working with separate providers offer a kind of check and balance? A historical knock on this hypothesis is the inarguably crappy outcomes for chronic conditions that US patients have the privilege of paying comparatively ridiculous sums for. I couldn’t tell you whether those crappy outcomes are a result of the separateness of payers and providers or some other factor, but so it is. Here’s the short version of one of Steve’s main points: It’s not about control. It’s about connection. It’s about being able to connect with patients over their continuum of care. It’s also about how consumers and employers are increasingly trading out choice and broad networks for an assurance of quality. You can learn more at guidewell.com. Steven Blumberg serves as vice president, practice transformation, for GuideWell Health. In this role, he is responsible for developing and implementing strategies for the further establishment of a high-quality, economically effective clinical system across Florida. He also provides guidance on value-based care and population health models. Prior to joining GuideWell in June 2019, Blumberg served as vice president for value-based care at Baptist Health South Florida, where he led the strategy and implementation for Baptist’s population health and value-based care efforts. Prior to that, he was senior vice president and executive director of AtlantiCare Health Solutions, the New Jersey division of the Geisinger Health System, where he was responsible for population health, the organization’s provider physician group, and home care and hospice continuum services. Earlier in his career, he was chief planning and business development officer at UHealth–The University of Miami Health System. Blumberg also held leadership roles at UF Health–Shands Healthcare and Baptist Health Jacksonville. Blumberg has been active in community and professional organizations, including serving on the boards of the Ronald McDonald House, Community Hospice, and the Northeast Florida Health Planning Council. He has also served nationally on the Premier Population Health Steering Group and on the National Institute of Standards and Technology’s Baldrige Board of Examiners. Blumberg holds a bachelor’s degree in business administration and marketing from the University of Florida and a Master of Business Administration from Florida State University. He is a fellow of the American College of Healthcare Executives. 03:30 How does thinking like a payer change the way you build out a primary care provider practice? 04:37 “When I was on the provider side, I definitely worried about the total cost of care … but making the products affordable was … someone else’s concern.” 09:12 How would you define practice transformation? 13:29 “We’re curating networks.” 16:56 “If they come to the market, they’ll be hard to ignore.” 17:38 How integrated is the physicians network? 18:35 “Control isn’t the right word … it is the connection with the patient … that’s where we think the most effective primary care takes place.” 18:59 Where does attempting team-based care fall apart the most? 21:25 Are employers trading out for an assurance of quality? You can learn more at guidewell.com. Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth How does thinking like a payer change the way you build out a primary care provider practice? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “When I was on the provider side, I definitely worried about the total cost of care … but making the products affordable was … someone else’s concern.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth How would you define practice transformation? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “We’re curating networks.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “If they come to the market, they’ll be hard to ignore.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth How integrated is the physicians network? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “Control isn’t the right word … it is the connection with the patient … that’s where we think the most effective primary care takes place.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth Where does attempting team-based care fall apart the most? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth Are employers trading out for an assurance of quality? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth
Alex Azar, who is the current Health and Human Services (HHS) secretary (until January 21 anyway), came out with a reboot of the proposal that effectively halts the practice of pharma manufacturers paying rebates to Part D plans. This reboot is supposed to go into effect on 1/1/2022. But this podcast is less about this may-or-may-not-actually-happen rule and is more about the actual impact of removing drug rebates within this unintuitively constructed health care system of ours. Should rebates go away, it’s actually a big deal that fundamentally could upend the heretofore-not-transparent messy middle of drug pricing. I’ll let Chris Sloan, associate principal over at Avalere Health, explain. Spoiler alert: The impact of killing pharma rebates to plans and PBMs (pharmacy benefit managers)? Bottom line, everybody’s insurance premiums go up in the current model when rebates go away. A few episodes from now, I’m talking with Ge Bai about why this is a suboptimal and not forgone conclusion. But this is what we’ve got going on right now. So, look for EP306 coming up for more on that. You can learn more at avalere.com.   Chris Sloan, associate principal at Avalere, advises a number of clients—including pharmaceutical manufacturers, health plans, providers, and patient groups—on key policy issues facing the health care industry. Chris’s economic analyses of key policy proposals and issues, including drug pricing and the repeal and replace efforts around the Affordable Care Act, have been featured in a wide range of publications, including the Wall Street Journal, the New York Times, the Washington Post, Politico, Axios, and Vox. 02:35 “Rebates are a really big part of Medicare Part D.” 02:49 What the “follow the dollar” looks like in this scenario. 04:14 How rebates between PBMs and manufacturers work, and how list prices play into this. 05:31 How this system can hurt the patient, and how this new proposal works to change that. 06:42 Pricing a product as a PBM. 08:06 The total dollar value of PBM rebates. 10:50 Do we know how much PBMs are making in incentives? 13:29 Are PBMs helping or hurting the process? 16:18 Why pharmaceutical manufacturers may be more compelled to raise their prices thanks to large PBMs. 17:13 Perverse incentives in the system. 17:57 “At the end of the day, PBMs are still going to be employed by health plans.” 18:56 How a new model is combating the perverse incentive that raises prices for patients. 22:11 The trade-off involving premium prices in this new proposal. 24:38 “We’re not talking astoundingly large amounts of money.” 25:12 Why PBMs and health plans are against this proposal. 26:02 Why Pharma is for this. 26:51 The perverse incentives for health plans. 28:39 The benefit of Part D. 29:25 The advantage of huge rebates. You can learn more at avalere.com.   @avalerechris discusses eliminated #drugrebates in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Rebates are a really big part of Medicare Part D.” @avalerechris discusses eliminated #drugrebates in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What does following the dollar really look like? @avalerechris discusses eliminated #drugrebates in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Do we know how much #PBMs are making in incentives? @avalerechris discusses eliminated #drugrebates in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Are #PBMs helping or hurting the process? @avalerechris discusses eliminated #drugrebates in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “At the end of the day, PBMs are still going to be employed by health plans.” @avalerechris discusses eliminated #drugrebates in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “We’re not talking astoundingly large amounts of money.” @avalerechris discusses eliminated #drugrebates in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma
In November 2020, there was an Executive Order entitled “Lowering Prices for Patients by Eliminating Kickbacks to Middlemen.” And we had HHS (US Department of Health and Human Services) Secretary Alex Azar and the HHS Office of Inspector General finalizing a regulation to eliminate the current system of drug rebates in Med D (Medicare Part D). And what they were trying to do is create incentives to reduce out-of-pocket spending on prescription drugs by delivering discounts directly at the pharmacy counter to patients. Those discounts delivered at the pharmacy counter? Not insignificant. In 2019, Part D rebates totaled $39.8 billion. The new rule stipulates that federal spending can’t be increased as a result of this action. But in summary, it’s pretty much a reboot of the same ruling from earlier last year. Here’s a couple of points: The rule is only for Medicare (Med D)—Medicaid and commercial aren’t included—but … there’s a but, and we get into that in this episode. Also, the start date for this ruling is 1/1/22 if it continues to stand in the new administration, which is a big if. What was at stake the first time this rule was drawn up by HHS and is likely still at stake is the implementation flowchart. Who exactly is involved in adjudicating these “potential discounts for patients at the pharmacy counter”? Since any middleman who gets themselves involved in anything takes a buck, there is a massive land grab, if you think about it, that if any middleman can grab a buck, this could be a lot of money. So, the first time this HHS proposal was presented in 2019, I talked to AJ Loiacono, who’s the CEO over at Capital Rx. I have to say I was a little over-cocky relative to how well I really understood the hidden machinations behind pharmacy Rxs being adjudicated, and AJ does an amazing job explaining it. This is incredibly relevant as we contemplate potentially who gets a piece of the action moving forward. But regardless of, in some respects, what happens with this HHS rule, I found it interesting and valuable to understand what exactly happens in the dark messy middle, maybe underbelly, of a pharmacy adjudication. You can learn more at cap-rx.com. Anthony J. “AJ” Loiacono is a serial entrepreneur with over 20 years of experience in pharmacy benefits and software development. As the CEO of Capital Rx, a pharmacy benefit manager (PBM) that is bringing transparency and fair pricing into an otherwise opaque industry, his mission is to change the way prescriptions are priced and administered to create enduring social change. AJ spent his career studying the pharmaceutical supply chain and producing engineering solutions that have continually redefined the pharmacy benefit industry. At its core, Capital Rx is a technology-first company that has received multiple awards for the innovations that have propelled the company to record growth (Accenture Health Technology Champion, AMCP Gold Ribbon, EHIR Innovation Award, NYC Digital 100, etc). Prior to Capital Rx, AJ was a co-founder of Truveris, where he served for eight years as CEO, CIO, and board member, leading the company to rapid expansion (Deloitte Fast 500 and Crain’s Fast 50). Before Truveris, AJ co-founded SMS Partners, a joint venture with Realogy (RLGY), and in 2010 exited the partnership with a buyout. In his first venture, AJ started Victrix, a pharmaceutical supply chain consultancy, and successfully sold the company to Chrysalis Solutions in 2007. 03:03 HHS’s plan to remove safe harbor from the rebates that Pharma pays to PBMs to buy their way onto formularies. 03:13 Creating more transparency by eliminating the anti-kickback. 03:58 What the anti-rebates process flowchart looks like. 04:20 Changing the term from “rebate” to “charge-back.” 04:25 Charge-back at the point of sale rather than post-adjudication. 04:37 How putting the pharmacy in the middle of the transaction changes everything. 05:36 “From a cash flow perspective, this matters.”—Stacey 07:18 “Who is in charge of this payment workflow?” 09:25 “Why the switch?” 10:56 The potential players in the role of paying pharmacies: PBMs, wholesalers, the switches (McKesson), banks/fintech, government contractors. 12:04 The likelihood that this will spill over into commercial medicine. 14:11 Why PBMs want to maintain the status quo, and how that works. 15:44 “Where there’s variability, there’s variable profitability.” 17:28 How do you check that the patient is getting the charge-back amount they deserve? 18:28 Is it still possible to pay to be on a PBM’s formulary? 19:16 Can you ever get away from the pay-to-play formulary? 22:31 “If you think about it, who’s writing the checks at the end of the day?” 22:59 What questions should employers be asking right now? 25:20 The problem with implementing HHS’s primary goal. 30:51 “Really what we should be focusing on is, ‘What are we solving for?’” 32:26 Capital Rx and what they do. You can learn more at cap-rx.com. What’s @HHSGov’s new plan revolving around the #rebates that #pharma pays to #PBMs? AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg Creating more #transparency by eliminating the anti-kickback. AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg What would the anti-rebates process look like? AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg Changing the term from #rebate to #chargeback. AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg Changing the point at which the #chargeback occurs and how this changes the status quo. AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg Why putting the #pharmacy in the middle of the transaction changes everything. AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg “From a cash flow perspective, this matters.” AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg “Who is in charge of this payment workflow?” AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg Why #PBMs, #wholesalers, #switches (McKesson), #banks/#fintech, and #governmentcontractors could all potentially pay the #pharmacy. AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg What’s the likelihood that this will spill over into the commercial side of things? AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg Why do #PBMs want to maintain the status quo? AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg “Where there’s variability, there’s variable profitability.” AJ Loiacono of @cap_rx explains in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg Can we ever get away from the #paytoplay #formulary? AJ Loiacono of @cap_rx discusses in our newest #podcast episode. #healthcare #healthtech #digitalhealth #healthcarepodcast #hcmkg
I had a vision for this inbetweenisode. I wanted to highlight the wisdom of our amazing guests this year. I really wanted to find some theme that might be a key to our health care transformation. To achieve maximum suspense, here’s the very short story of how I got from “Is there a common thread of wisdom throughout all the RHV episodes this year?” to “Why, yes, there is … and it’s a good one!” So, let’s start our journey of discovery with this. Here’s a fact: If you talk to patients, they will often tell you that they receive poor care or their needs are not met—when they fall between different providers, or their payer and their provider and their PBM (pharmacy benefit manager) are singing off of different sheets of music. For more information, go to aventriahealth.com.   When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specializes in helping pharmaceutical, employer, pharmacy, and health system clients improve patient outcomes by creating and leveraging collaborations with other health care organizations. For more than 20 years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders and, most of all, the patient.   01:18 Don Fowls, MD, from EP298. 02:47 What will it take to get to a place where the triple or quadruple aim is met? 03:07 Sylvia Romm, MD, MPH, from EP283. 05:37 “I’d say there’s two kinds [of collaborations]: There’s the vertical kind … but also lateral or horizontal.”—Stacey 06:19 Dr. Kimberly Noel from EP251. 07:46 Rahul Dubey from EP259. 08:57 Richard Zane, MD, from EP255. 10:04 Mark Blum from EP248.   10:34 Conversation with David Contorno and Emma Fox from E Powered Benefits. 11:44 “We are human; we do serve ourselves.”—Rahul Dubey 14:56 “In so many cases, the solution already exists. … It’s just that the solution has not been adopted broadly.”—Dave Chase from Health Rosetta 15:52 George Mathew, MD, from EP253. 17:21 Alex Fair from EP229. 19:29 What are the essential ingredients of a collaboration? 19:37 Steve Schutzer, MD, from EP294. 20:29 Dave Dierk, co-president of Aventria Health Group, shares a few thoughts on this matter.21:45 “I think it’s a pretty sound assumption that we all should probably be contemplating how we can better collaborate.”—Stacey 24:04 “There’s a great willingness to work together and find new solutions to provide better patient care because there’s a need for it.”—Dave Dierk For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth What will it take to get to a place where the triple or quadruple aim is met? Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth “I’d say there’s two kinds [of collaborations]: There’s the vertical kind … but also lateral or horizontal.” Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth “We are human; we do serve ourselves.” Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth “In so many cases, the solution already exists. … It’s just that the solution has not been adopted broadly.” Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth What are the essential ingredients of a collaboration? Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth “I think it’s a pretty sound assumption that we all should probably be contemplating how we can better collaborate.” Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth
You know back in the olden days when a foot of measurement was actually the measure of your own foot? So, I might measure something and it’s, like, 19 feet. And then you measure the same exact thing and it’s 38 feet because you have tiny feet. This is the analogy that kept running through my mind as I was talking with Anna Kaltenboeck in this health care podcast about QALYs to measure the value of drugs. In this metaphor, QALYs are the ruler so that 1 foot of drug value is the same for everybody and all drugs. It’s very civilized as a concept if you think about it. QALY stands for quality-adjusted life year. The goal of a QALY is to figure out how much any given drug is worth to a society so that we, as a society, have a benchmark to evaluate the price of pharmaceutical products. QALYs are an apples to apples or a foot to foot way to compare the value of drugs for we the people. I mean, is this drug amazing and we should all pay a lot for it? Or is the drug more expensive than the current standard of treatment and it doesn’t confer any added benefit to patients? It’d be good to know that as a patient and as a payer and, frankly, as a pharma company. QALYs offer a framework for levelheaded discussions. It’s complicated. I’m gonna take the risk of oversimplifying, but here’s how I’d explain the three parts in a QALY measurement, which combines measure pharmaceutical value. The first part is, if relevant, how much additional survival can be expected with this drug? So, if it’s an oncology drug, for example, how much longer will the patient live? The second part of a QALY is, how does the drug make the patient feel? So, in an ideal world, survival is long and the patient feels super great. So, some economists and scientists get together and they do some math and they come up with the sum of these first two factors. Then the third part of a QALY calculation is the cold hard cash. How much is society willing to pay for this improvement in survival, in quality of life? This last part will depend based on the society (ie, the country) and also the condition. We’re willing to pay a lot for a drug that helps blind people see. We might be not so willing to pay a whole lot for a drug that lowers blood pressure marginally, for example. My guest in this health care podcast is Anna Kaltenboeck. She is a health economist and program director for the Drug Pricing Lab at Memorial Sloan Kettering. She knows a lot about QALYs. One last thing: ICER is the Institute for Clinical and Economic Review. It is an independent and nonprofit organization who creates a lot of these QALY assessments. Whether they succeed or not is something that is sometimes questioned, but the team over at ICER prides themselves in not working for Pharma and not working for payers in an effort to be as impartial as possible.   You can learn more at drugpricinglab.org.   Anna Kaltenboeck is the senior health economist and program director for the Center for Health Policy and Outcomes and the Drug Pricing Lab at Memorial Sloan Kettering Cancer Center (MSKCC). She focuses on the development and application of reimbursement methods for prescription drugs that reduce distortionary incentives in the supply chain and encourage pricing of treatments based on their value. Her work centers on developing an unbiased evidence base that characterizes the effect of federal policies on coverage and reimbursement decisions for branded specialty drugs and cell and gene therapies and identifying opportunities for policy changes that encourage affordability and access while maintaining incentives for innovation. Her current research interests include global comparisons of reimbursement policy and supply chain regulation, game theory in innovation decisions, and the effect of market concentration on pricing decisions. Ms. Kaltenboeck’s research and policy work is informed by her experience as a consultant for pharmaceutical clients. Prior to joining MSKCC, Ms. Kaltenboeck spent 10 years working for Analysis Group and IMS Consulting Group, where she conducted health economics and outcomes research and developed pricing and market access strategies for pharmaceutical and diagnostic products. She has published numerous articles in peer-reviewed journals and other press, including JAMA and Morning Consult, and speaks frequently on the topics of value-based pricing, economics of the supply chain, and reimbursement models. Ms. Kaltenboeck holds bachelor’s and master’s degrees in economics from Tufts University. 3:56 What is a QALY? 05:28 “You don’t get marks; it’s the treatment that gets the marks.” 09:13 What is willingness to pay? 10:52 “What we pay for drugs should be reflected in societal preference.” 12:29 Does Pharma fear the QALY? 15:38 “At the end of the day, the ideal here is simply to be able to quantify ‘This is what we’re going to pay for this additional benefit that we’re going to provide for patients.’” 17:09 “When you meet that price, patients should be getting access to that product.” 19:27 What are the significant advances being seen with QALYs and drug development? 21:23 “The challenge is when the price is so much higher than those benchmarks.” 22:27 How do we use the QALY as a tool? 25:56 Where does value-based pricing fall in the world of QALYs? You can learn more at drugpricinglab.org.   @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue What is a #QALY? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue “You don’t get marks; it’s the treatment that gets the marks.” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue What is willingness to pay? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue “What we pay for drugs should be reflected in societal preference.” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue Does Pharma fear the QALY? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue “At the end of the day, the ideal here is simply to be able to quantify ‘This is what we’re going to pay for this additional benefit that we’re going to provide for patients.’” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue “When you meet that price, patients should be getting access to that product.” @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue How do we use the QALY as a tool? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue Where does value-based pricing fall in the world of QALYs? @a_kaltenboeck discusses #drugpricing and #patientadvocacy in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #healthvalue #drugvalue
Sometimes when I overhear a conversation/argument about telehealth, it occurs to me that there’s a lot of fighting words about some things and very, very little about other things which I’d regard as equally, or maybe even more, important. Some of the sparring tends to jump immediately to tactics and UX (user experience), absent of strategy and CX (customer experience). In my experience, you can’t talk about a user interface until you talk about the overall customer experience and journey and what your goal is. So, here’s what I mean: Let’s take urgent care as an analog. Say a patient goes to urgent care with symptoms consistent of allergic asthma. The NP (nurse practitioner) gives the patient strict instructions to take an antihistamine and Flonase and Flovent. She tells the patient to be sure to make a follow-up with their PCP (primary care provider) to evaluate how it’s going. If the patient doesn’t make a follow-up visit, do we suggest it’s because the live in-person visit should have been telehealth? Or if the patient is nonadherent and winds up in the hospital with a full-blown asthma attack, do we suggest that live in-person visits diminish adherence? Let me respectfully suggest that it’d be a solid no on that. This is exactly why, whenever I listen to a diatribe about how telehealth did not work out for a patient, I find it interesting to ask a couple of questions. The question that I tend to ask when someone starts talking about some telehealth fail is “How did it fail?” How did it not work out? And the answer to this question tends to be similar to the above allergic asthma example: that the patient needed lab work or imaging or a follow-up visit, and that couldn’t be done via telehealth. There was no resolution to the patient concern, in other words. Okay … so, first of all, most practices don’t have immediate on-premises lab work or imaging, so the patient would have had to have gone somewhere else to get it anyway. But even if they did, as far as I know, you can’t have a follow-up visit at the same time that you have the first visit. Not to be cheeky, but that’s why they call it a follow-up visit. Then the next logical question is, if the patient doesn’t show up for a follow-up, if the patient were in person, what’s the greater likelihood that they would have gone for the lab test and/or come back for the follow-up? This is when you start to realize that the setting of care (ie, virtual or in person) may be a little bit less important than the agency of the provider involved. And it may be a little less important than the structure of the organization sitting around that patient encounter. Said another way, strategically, what are we doing here? What are we trying to accomplish? What’s our road map to get the patient from where they are now to wherever that goal is? A patient visit is a tactic. It’s one point in time. And that’s true regardless of whether it’s a remote visit or an in-person one, synchronous or asynchronous. A patient visit or interaction is not a care pathway. It is rarely, if ever, a magic bullet one and done. But that doesn’t stop us from thinking about patient encounters, one encounter at a time, which may be exactly why we wound up with a fragmented health care system that doesn’t work very well. But I digress. So, from what I can see, some of the flaws that some people attribute to telehealth might be more properly construed as flaws to the ecosystem in which the telehealth is being deployed. For example, how much agency or data or infrastructure does the provider behind the camera have to see where the patient is in their treatment journey and make sure that they get to that next milestone? Because in cases where the doctor behind the camera or the telephone or the text message has agency and the telehealth visit is part of a defined patient journey, telehealth results are strikingly comparable to not telehealth results, if not better. If we’re contemplating a patient journey or a treatment journey, writ large, the site of care at any moment in time is a secondary or tertiary factor—certainly not a primary one. Here’s what I want to know about telehealth. How do you best use it, not as a point solution but as part of a larger whole? How do you optimize a telehealth encounter so it pulls its weight in helping patients get a resolution to their chief complaint or manage their chronic conditions? Christian Milaster has written about this in his Telehealth Tuesday newsletter, which is great, by the way. Christian wrote that the delivery of care, when viewed through the eyes of a systems engineer (which he is), becomes a quite simple four-step process. These are the four steps that Christian says. He says, the first step is assessment, which leads to a diagnosis, which is step two. Step three is the development of a treatment plan. And then step four is the implementation of that treatment plan.   Amongst other sidebars, I talk about these four steps in this health care podcast with Blake McKinney, MD. Dr. McKinney is an ER doc as well as the cofounder and CMO over at CirrusMD. In our conversation, Dr. McKinney actually comes up with one more step to add to the four-step process. It’s kind of a pre-step, where the patient decides that he or she needs care to begin with. You can learn more at cirrusmd.com.   Blake McKinney, MD, cofounder of CirrusMD, had a vision: to enable every person to have a better experience accessing health care services. Blake observed the barriers his patients were up against in seeking care and, at the same time, saw that his friends and family were able to reach out to him directly for guidance, most often via text. CirrusMD was created so everyone seeking care could immediately connect and communicate with a real doctor in this way. Partnering with Andy Altorfer in 2012, Blake and the CirrusMD team have built a platform to achieve this vision of an improved health care experience. Through the years, this path has been guided by Blake’s clinical insight and ongoing, practice-based understanding of the needs of both patients and doctors. Dr. McKinney completed his internship and residency at the University of California Davis after graduating from the University of Texas Medical School in Houston. Prior to medical school, he served 4 years as a communications intelligence officer in the United States Marine Corps. 06:53 “Regardless of the availability of convenient options, there is one force more powerful than convenience, and that is familiarity.” 09:01 “Telemedicine that is continuity based is going to be better medicine fundamentally.” 13:21 “The fundamentals of medicine are the same, and the standard of care is the same, whether the care is in person or in clinic.” 15:16 What’s the underlying determinant of patient success? 16:08 “When it comes to the ‘What’s next,’ doctors love resources.” 16:52 How is telemedicine lacking in resources? 18:42 “Implementation to me is, first and foremost, about follow-up.” 23:10 “There’s a place for automations. My prime directive … is to build trust.” 25:13 “The best adaptive interview that you can create is human to human.” You can learn more at cirrusmd.com.   @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “Regardless of the availability of convenient options, there is one force more powerful than convenience, and that is familiarity.” @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “#Telemedicine that is continuity based is going to be better medicine fundamentally.” @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “The fundamentals of medicine are the same, and the standard of care is the same, whether the care is in person or in clinic.” @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech What’s the underlying determinant of patient success? @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “When it comes to the ‘What’s next,’ doctors love resources.” @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech How is telemedicine lacking in resources? @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “Implementation to me is, first and foremost, about follow-up.” @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “The best adaptive interview that you can create is human to human.” @BlakeMcKinneyMD of @CirrusMD discusses #telehealth in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech
There’s lots going on these days with transparency. Three cost transparency rules, as a matter of fact, just came out of CMS, for example. These rules demand that hospitals and payers make available cost information so patients can shop and employers can also shop. That last part there, about employers and/or payers being able to shop … that might wind up actually being the part of these transparency rules that has the most impact. It all goes back to kind of a first-principle assumption that many made—including me, by the way—which is turning out to be arguable. It’s the great hope for consumerism through high-deductible health plans. The thought originally was that by pushing the burden onto patients/employees to find high-quality care at a fair price, we assumed that health care delivery would level up. We assumed that prices would come down, driven by the weight of consumer demands. But anybody seeking to validate this hypothesis would be pretty hard pressed to claim any sort of broad-stroke success beyond cost shifting by brute force. The vast majority of patients don’t have medical degrees. This is why they went to a doctor to begin with. So, it’s unsurprising to learn that providers wield a lot of influence. If a doctor tells a patient to go here for an MRI or there for surgery, patients have a tendency to go, without questioning. So, logically, if we want to create a high-value health care system and high-value health care—high quality at a fair price—we need to contemplate the recommendations that providers are making. These recommendations especially matter because a patient’s entry point into the health system—where they go first—can make all the difference. This is also a particularly relevant point these days with all the discussion about digital front doors. Earlier, I spoke with Ashok Subramanian, CEO and founder over at Centivo. Centivo is a novel self-funded health plan centered around robust primary care. And I thought this episode had particular relevance given what is going on in the health care industry today. You can learn more at centivo.com. Ashok Subramanian founded Centivo in 2017 after observing the inefficiency in the health care system and the pain that has resulted for employers and employees. Prior to Centivo, Ashok cofounded Liazon, operator of the nation’s industry-leading private benefits exchange for active employees. Liazon was acquired by Willis Towers Watson in 2013, and after the acquisition, Ashok served as managing director for Willis Towers Watson’s Group Exchange business. Prior to Liazon, Ashok was an associate principal at McKinsey and Co., where he served as a leader in the firm’s health care and private equity practices. In addition to his role at Centivo, Ashok serves as an independent Board director at Artemis Health as well as a senior advisor to Silversmith Capital, a growth equity firm. Ashok received his undergraduate degree from Princeton University, a master’s degree from Stanford University, and an MBA from the Stanford Graduate School of Business. 02:58 Background for this conversation—the entry point for where a patient enters the health system. 03:56 “Broad open-access, on-demand health care simply doesn’t work.” 04:18 “What people really do do is they listen to their provider.” 04:47 Putting more emphasis on the primary care team, as opposed to putting the burden on the employee. 05:01 High-deductible plans as blunt instruments. 05:20 Creating transparency around pricing, and the reality behind this. 05:38 “People aren’t very good at [discerning] low-value care from high-value care.” 06:57 Why people don’t challenge their doctors. 07:06 The primary care physician (PCP) as the gateway into the health care system. 07:45 Two reasons why health care is so tricky. 09:09 “There is no single awesome source of data.” 11:00 What is the PCPs’ charge? 11:43 PCPs as the change agents in health care for employers. 14:47 How do you discern who the high-value specialists are? 15:15 Building the network right the first time and making it dynamic. 17:05 Narrow networks and what’s important to focus on. 19:03 Redefining “access.” 19:22 “None of us need 40,000 doctors in our network.” 21:57 Driving better total cost. 25:02 Negotiating with the biggest health care players and operating a network with or without them. You can learn more at centivo.com. Check out this week’s encore episode with Ashok Subramanian, founder and #CEO of @Centivo_Health, revisiting high-deductible plans for #quality #healthcare. #healthcarepodcast #podcast #digitalhealth “Broad open-access, on-demand health care simply doesn’t work.” Ashok Subramanian, founder and #CEO of @Centivo_Health, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth “What people really do do is they listen to their provider.” Ashok Subramanian, founder and #CEO of @Centivo_Health, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth “People aren’t very good at [discerning] low-value care from high-value care.” Ashok Subramanian, founder and #CEO of @Centivo_Health, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth “There is no single awesome source of data.” Ashok Subramanian, founder and #CEO of @Centivo_Health, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth How do you discern who the high-value specialists are? Ashok Subramanian, founder and #CEO of @Centivo_Health, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth “None of us need 40,000 doctors in our network.” Ashok Subramanian, founder and #CEO of @Centivo_Health, discusses. #healthcarepodcast #healthcare #podcast #digitalhealth
Three transparency rules have come out of CMS in the past months. My guest in this health care podcast, Jeff Leibach, calls these three rules three steps on a ladder. They build on each other. The first rule was announced last year, and it was for hospitals to post their chargemasters. You could consider this a baseline step. It’s not really all that useful in practice as many discovered. The next step on the ladder (which is coming out on 1/1/21): Providers (hospitals) for all services have to post a machine-readable file—all of their negotiated rates for all service categories. They also have to post a shoppable service file and/or some kind of patient estimator tool so patients can estimate the cost of the most shopped services. Then there’s the payer rule. This is more comprehensive than the provider rule, and the payers have some extra time—actually, they have an extra year (till 1/1/22). But basically, payers have to comply at a higher level. They have to allow price shopping across all sites of care. My guest in this health care podcast, Jeff Leibach, is a director with Guidehouse in the Healthcare Practice. He focuses on how health care services are priced and paid for, working with a lot of payers and providers. Thus, he is the perfect person to discuss these transparency rules with because of his deep knowledge of payers and provider contracting and also how pricing impacts patients, employers, and stakeholders across the industry. Jeff and I get into these three transparency rules and their likely impact and also kind of their philosophical underpinnings. We also talk about what might happen with them under a Biden administration. After our conversation, I started to think about these transparency rules in the broader context of what’s going on in the health care marketplace. There’s kind of a constellation of market factors, and these market factors increasingly seem to be necessitating hospitals and ambulatory practices to really differentiate themselves in ways that employers and patients/consumers care about. I mean, these CMS transparency rules for payers and hospitals are but one thing that is going on. But these rules ultimately mean that it’s easier for patients and employers to price shop. It also makes it easier for employers to narrow their networks and exclude providers. Consider this impact and then think about how that fits with the ONC TEFCA (Office of the National Coordinator for Health Information Technology Trusted Exchange Framework and Common Agreement) rule. So, that ONC TEFCA rule means that it’s gonna be a less effective tactic to prevent network leakage by hoarding patient data. So, if patient data is portable, patients can seek out the best care provider without the friction of some kind of PHI (protected health information) transfer. Okay … so now prices are available because of the transparency rule, and patients can walk more easily because of the TEFCA rule. So, these two together could be a forceful combination. We also have the rise of consumerism. I just saw a study the other day kind of validating that consumers are voting with their feet if a provider does not meet the quality of care, the supportive patient experience that they believe could be found elsewhere. And add to that the at-risk PCPs (primary care providers) cropping up in various concentrations across the country. But then also, you’ve got payers buying PCPs. And what that means is that you get these PCPs who control the referral flow, and they’re taking an active interest in the downstream costs and population outcomes of specialists in their referral networks. So, you’ve got specialists who maybe lack processes to minimize inappropriate care or who do not deliver consistently high patient experiences and outcomes. They could easily get excluded from those referral flows. So, you take all these things together—the transparency, the ONC TEFCA rule, consumerism, and the disruption of certain referral flows—and, if you ask me, I think all of this together means that providers who are more commodity and less brand may need to consider ramping up their Triple Aim endeavors. You can contact Jeff at jeff.leibach@guidehouse.com. You can also connect with him on LinkedIn and Twitter.   Jeff Leibach, MBA, is a director with Guidehouse’s Healthcare Practice. Over the last decade, Jeff’s main area of expertise has been in developing and implementing managed care solutions for payers and providers. These solutions include development of several analytic solutions, alignment of clinical and financial models, and negotiation training and preparation. Jeff has significant experience building and leading teams to deliver complex analytical tools to quantify opportunities into business strategies for clients. Jeff currently leads Navigant’s Strategic Pricing and Revenue Rebalancing Solutions for Navigant. Prior to his consulting career, Jeff led national nonprofit Camp Kesem, a summer camp for children affected by a parent’s cancer. Additional information: Price Transparency White Paper and 2019 Massachusetts Attorney General Report 05:31 What are the two pieces to the new transparency rule going into effect on January 1, 2021? 06:58 “Any negotiated rate … is required to be disclosed.” 07:43 What’s the payer rule, and how does it differ from the hospital rules? 10:24 Where are direct comparisons going to come in most useful with transparency rules? 11:16 How does CMS intend these rules to be used? 14:34 “I anticipate employers having a newfound power here.” 17:27 Why is there opposition to transparency in health care? 18:27 “The administrative burden is real.” 21:03 “I think commoditized is a word we’re going to hear a lot more.” 22:55 Where is CMS headed under a Biden administration? 26:22 What barriers can tech help break down, and what other opportunities are there for tech right now? 28:49 What should payers be preparing for right now? You can contact Jeff at jeff.leibach@guidehouse.com. You can also connect with him on LinkedIn and Twitter. @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency What are the two pieces to the new transparency rule going into effect on January 1, 2021? @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency “Any negotiated rate … is required to be disclosed.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency How does CMS intend these rules to be used? @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency “I anticipate employers having a newfound power here.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency “The administrative burden is real.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency “I think commoditized is a word we’re going to hear a lot more.” @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency Where is CMS headed under a Biden administration? @jeffleibach of @GuidehouseHC discusses #hospital and #payer #transparencyrules. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcaretransparency #healthtransparency
Wow! It’s episode 300. That’s a milestone. Because of you, we’ve grown to be one of the largest podcasts for health care executives—so, thank you to every one of you who has recommended the show to your friends and colleagues, which is really the highest compliment. Thanks also to all the listeners of this show who have written reviews, LinkedIn posts, and sent emails. The team over here at Relentless Health Value really appreciates your kind words. They’re super motivating. The emails we love to get are the ones where one of you talks about a success story, like an example where you’ve taken something you heard and made it actionable—how you helped patients get better care to lower cost or how you were able to collaborate with fellow stakeholders in a meaningful way. That’s really why we’re here and why it’s so motivating to hear stories like this, which brings me to a really important point. We’re in this together. All of you health care decision maker/stakeholder types out there, you who can directly effect change, it’s really you who deserve the biggest round of applause, if I do say so. We appreciate the opportunity to kick off the activity or the decision making, but it’s you all who pick up the ball and run with it. And for that, we—as both professionals and patients—thank you. Moving on to today’s episode 300, my guest in this health care podcast, Bruce Rector, MD, is an expert on drug affordability; and he has extensively studied how to make sure we get the right drugs developed by considering innovation incentives among other things. He’s done a lot of work with Doctors for America and the Center for American Progress. He also teaches medical students, pharmaceutical policy, and has worked with drug companies on drug development promotion. So, I felt like that was a pretty rounded perspective of the issues that I wanted to get into here. Let me tell you why I started to think about this. Any one of those stories where somebody dies of an infection that was resistant to antibiotics, they’re always ghastly tales that seem so unnecessary. And every time I hear one of them, I wonder why pharma companies aren’t in the antibiotic business. Clearly, there’s a need. Well, it turns out antibiotics are a great case study of what happens when drug companies don’t have the incentive to develop drugs that are a huge need to society—which brings me to the big hairy challenge I’m talking with Bruce Rector about in this podcast. How do you ensure that pharmaceutical manufacturers are fairly incented and compensated to develop the drugs that are of the most value to society? Orphan drugs, by the way, are a great example of what happens when incentives are put in place to develop drugs. At last count, half the drugs developed in the past decades have been for rare diseases—because of the 1983 Orphan Drug Act that made it quite profitable to develop for rare diseases. So, in this health care podcast, we dig in to two—arguably three—categories of incentives that are typically offered or available to pharma companies in this country today and which are, frankly, used in that Orphan Drug Act. The first two are push incentives, and then there’s pull incentives. Push incentives are when the government, generally, offers incentives to reduce industries’ costs during the R&D (Research & Development) stages, like they give grants or tax credits for clinical research—things like this. Pull incentives, on the other hand, are ways to guarantee demand after the drug is developed or to help the pharma company make more money on the drug, for example, by extending patent exclusivity—like if you, Pharma, develop this drug, we’ll promise to buy millions of doses right up front and/or we’ll bar any generics for two extra years so you get the two extra years of revenue. (You might be thinking about what’s going on with COVID right now. Just sayin’.) So, we have push incentives, we’ve got pull incentives, and then this last one, which is more of a market condition than really anything paid up front or deliberately engineered on the back end. It’s that drugs aren’t like new desk chairs or some other product that, if the price goes too high, your employer just doesn’t buy it. If someone is suffering from a deadly disease and there’s one drug for it with no competition, there’s nothing and nobody in the US marketplace that really has the power to hinder the pharma company from basically charging whatever they want for it. Dr. Vincent Rajkumar talks about this in EP296 if you want to go back and listen to that one for more info. But wait … there’s more I talk with Dr. Rector about in this health care podcast. He brings up two different ways to contemplate paying for drugs. First is the fire extinguisher model, which is really applicable to antibiotics—and we talk about a couple of things I had never thought about relative to antibiotics. And then secondly, we have the subscription model—definitely food for thought for any of you innovative health plan types or policy makers out there. You can learn more by following Dr. Rector on Twitter and LinkedIn. Bruce Rector, MD, is physician whose work spans many important areas of the health care landscape: biopharmaceutical policy advisor, health policy lecturer, life science company consultant, and physician advocate. He focuses on policies to ensure that the right drugs get developed to meet society’s needs and that they are value based and equitably priced. Dr. Rector coauthored an article on value-based pricing, “Grounding Value-Based Drug Pricing in Population Health,” which is published in Clinical Pharmacology & Therapeutics. 05:58 What’s the issue with innovation in the pharmaceutical space? 06:47 “The problem … everyone talks about is antibiotics.” 07:38 What are pharmaceutical companies launching to drive value instead of antibiotics? 08:21 What are orphan drugs? And why is development incentivized for those drugs? 11:56 What are the differences between push incentives and pull incentives? 14:37 “The pharma company is all about how much money [the drug] can make once it hits the market.” 16:28 “These contracts, they know once they hit the market, there’s billions just waiting for them.” 17:17 What are the biggest pull and push incentives in Pharma? 17:40 What are the push and pull incentives with antibiotics? 24:39 What’s the fire extinguisher theory in Pharma? You can learn more by following Dr. Rector on Twitter and LinkedIn. @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What’s the issue with #innovation in the #pharmaceutical space? @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “The problem … everyone talks about is #antibiotics.” @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What are pharmaceutical companies launching to drive value instead of antibiotics? @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What are #orphandrugs? And why is development incentivized for those drugs? @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What are the differences between #pushincentives and #pullincentives? @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “The pharma company is all about how much money [the drug] can make once it hits the market.” @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “These contracts, they know once they hit the market, there’s billions just waiting for them.” @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What are the biggest pull and push incentives in Pharma? @BERector discusses #drugdevelopment and affordability in this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma
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Podcast Details

Created by
stacey richter
Podcast Status
Active
Started
May 14th, 2015
Latest Episode
Apr 8th, 2021
Release Period
Weekly
Episodes
322
Avg. Episode Length
30 minutes
Explicit
No
Order
Episodic
Language
English

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