The Net Positive Impact of Medicare Advantage Plans

I hope you listened to episode 399, which was Part 1 of this two-part exploration of my manifesto, meaning my aims and my path or framework to achieve those aims. Regarding the first part of my manifesto, episode 399 from two weeks ago, here’s the tl;dl (too long, didn’t listen) version; but please go back and listen to that show (Part 1) because it’s about you—and it’s a compliment and a thank you, and you deserve both.

Just to quickly recap, Part 1 of my manifesto is that I started this show because I want to, and wanted to, provide information to those in the healthcare industry trying to do the right thing by patients, to get you the insights that you might need to pull that off, to create a Coalition of the Willing, as I’ve heard it called. When we get reviews like the one from Megan Aldridge, a self-proclaimed Relentless Health Value binge listener, I feel very gratified because it makes me feel like I’m chipping away at this mission and in a non-boring way. Thank you, Megan.

Along these lines, there was also a recent review from Mallory Sonagere, who says she listens to learn new things and to be a little sharper at how she approaches her day job.

And just one more I’ll mention: I loved the review from Mark Nixon calling Relentless Health Value the best healthcare podcast out there.

Every review like this I take as validation that maybe I can count some measure of success toward achieving the mission to empower others on their journeys to make it better for patients or to transform the healthcare industry.

But this whole endeavor to create a manifesto is also borne out of me struggling personally to figure out what “having personal integrity” in this business actually means when it comes to deciding what to do and what not to do, when it comes to deciding who or what to try to help or support or who or what to step away from either passively or actively. I mean, how this podcast gets funded is my business partner and I pay for it with money from our consulting business and from some tech products that we have on offer. Who do we choose to take on as clients, and what are we willing to do for them or help them with? These are questions that literally keep me up at night.

And this is what this episode, Part 2, is all about. It’s about my struggle and how I attempt to navigate my own path forward.

And holy shnikeys, it’s tough to find a path, especially when you have the sort of perspective that I’ve wound up with over these past however many years. It can feel like no matter what I do, there’s negatives as it relates to the Quadruple Aim. You raise one of the quadrants, and something else for somebody else certainly has the potential to be negatively impacted.

We cannot forget here in the short term, but, for sure, often in the longer term as well, it’s a zero-sum game. Every dollar someone takes in profit under the banner of improving health or even saving money is a dollar that someone else paid for. Is the amount of profit fair? Where’d that money come from? Is there COI (conflict of interest), and if so, what’s the impact? I think hard about things like this.

An inescapable fact is that there has been a financialization of the healthcare industry, and that includes everybody who also gets sucked into the healthcare industry whether they want to be or not (ie, patients/members and plan sponsors and, oftentimes, physicians and other clinicians, too).

But the financialization of healthcare means that most everybody at the healthcare industry party has a self-interest to either make money or save money. And sometimes the saving money means saving money for themselves, not necessarily anything that is ever gonna accrue to patients or members.

Now let’s say I’m trying to determine if I want to take on a new client or decide if I personally want to promote or do something or other. This self-interest that abounds all around matters here because it means it is often very tough to find some kind of “pure” initiative to hitch your wagon to.

The crushing reality that we all face is you gotta earn a living. The other reality is that often the person that benefits from the thing you want to do (ie, the patient) is not gonna pay for it. And frequently, physician organizations won’t either. If everybody was lining up to pay to get something fixed, the problem would not be a problem, after all. But the only way your moral compass is the only moral compass in play is if you’re doing whatever you’re doing for free, really, or by yourself—and thus you are not encumbered by anybody else or any self-interest beyond your own … and your own motives are the only motives that you can control. I hear all the time initiatives and coalitions and advocacy organizations and even research funded by grants … these things also get bashed as suspect because who’d that money come from and whose “side” are the funders on.

Nikhil Krishnan wrote on LinkedIn the other day (and I’m gonna do a little bit of editing, but yeah). He wrote:

“Patients have low trust in healthcare because they think every stakeholder is incentivized not in their best interest. Many patients think the hospitals want to keep them sick, the [carriers and plan sponsors] don’t want to pay their claims, the drug companies want to keep them on their meds, etc. And we can’t pretend like that … isn’t true.”

Every party, every stakeholder has some measure of self-interest. They have to; otherwise, they’d be out of business. It’s all a matter of degrees. No big group, no entire category gets to stand on the high ground here when you think like a patient. There’s great hospitals and great people who work at hospitals, and then there’s people doing things that cause a strikingly large percentage of patients to fear going to the hospital for clinical and/or financial reasons. Pick any other stakeholder and I’d tell you the same thing. Any other stakeholder. It’s basically up to us as individuals to do the right thing. In every sector of the healthcare industry, there’s good eggs and there’s bad eggs and there’s eggs in the middle just doing their day jobs as instructed. Personally, I want to be a good egg, and that’s what my manifesto is all about.

Let me dig into this a bit further for just a sec and then I’ll continue with my personal manifesto for how I find my own path of integrity through all of this confusion.

Here’s another anecdote. Stuff like this I make myself crazy thinking about: I was listening to a podcast, and one of the guests said, “I wanted to get my MPH [Master of Public Health] because I felt a personal calling to be altruistic.” Then, 120 seconds later, he says something like, “So then, when it came time to pick my internship, I hunted around to find the one that paid the most money—and that’s how I wound up working for an HMO in the ’90s.”

Consider how that strikes you. How do you feel about that guy right now, who, by the way, has gone on to support some very interesting and probably impactful initiatives? There’s this commonly used phrase, “Let’s do well by doing good.”

So, back to that HMO intern. Let’s just say we all agree that these HMOs were not unconflicted organizations. We all know they had a reputation for putting profits over members, and a reason they went out of business was because they denied care. They refused to pay claims for patients who had AIDS. And it turns out that the friends and families of people with AIDS are incredibly well organized and sued the crap out of the HMOs, which may have expedited their demise.

You know what the intern was doing at the HMO? He was helping them with data analytics, and his personal goal was to use that data to improve patient outcomes.

So, okay … here’s the thought experiment: Do we want this HMO taking money that they’re gonna take anyway and then not adding the value that they potentially could add with their data because they don’t have any smart, dedicated, highly compensated interns working there to keep the ship pointed in a decent direction? I mean, I guess if I know I’m gonna spend a dollar as a member of that plan, I’d prefer to get as much as possible for my dollar that is already being spent. Maybe from that perspective, this guy is doing well by doing good. You see how this gets messy when you take a theoretical statement and then apply everyone’s real-world prejudices and predilections to it.

Here’s a last point to ponder, and this is another thought experiment … so, just heads up and then I’ll get to the point here: Say you are asked to help with a program run by a Medicare Advantage (MA) plan to provide those in need of transportation a ride to their annual wellness exam. Do you help?

Those who listen to this show will fully understand there’s a lot of self-interest involved in getting patients to the annual wellness exam because … risk adjustment. Also, star ratings. Listen to the show with Betsy Seals (EP375 and EP387) if you need the full story here. Short version is, MA plans can’t upcode, either fairly or aggressively (if they are so inclined), if the patients don’t show up for their annual physical. So, there’s a lot of money for them at stake. But, then again, are physicals important for patients? Do they improve patient care and health? If we think yes, then again, is this doing well by doing good to help patients get to their appointments?

After literally years of asking myself questions like this—and most of them were not thought experiments—I came up with my manifesto. And there are three parts to it, and I will go through each of them. But here’s my manifesto in full:

If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients.

Here’s how I think about the first part of my manifesto: If the thing results in a net positive for patients, then I’ll do it. And keep in mind, I could talk about this for seven hours; so everything I’m saying is oversimplified to some degree and has as many nuances as there are stars in the sky.

So, to calculate the net-positive impact, I think through what good the thing could do and weigh that against the negatives. And there are always negatives because, most of the time, the work that I do anyway has to get paid for by somebody and that somebody has some self-interest. Self-interest means that they are attaining something that furthers their business goals.

Let me list two major upside/downside contemplations:

1. How much good does the thing actually do for patients? I think about this. What’s the value here? Is it a little? Is it a lot? Will this thing be a distraction for clinicians, because time is often the most precious currency? If we’re talking about some kind of navigation or utilization management, what’s the reason someone wants to do this? Is the reason clinically and, for reals, evidence driven? Or are we predominantly doing this to enrich shareholders or save plan sponsors money in ways that are not a win-win for patients in the clinic right now trying to get cancer treatments for their kid? I try to think like a patient and be as impartial as possible.

2. Money. Where’s the money for this thing coming from, and who wins in this particular initiative (ie, is it a win-win and patients win something worthwhile)? Now, the company doing the funding has got to win, too; otherwise, they wouldn’t fund the thing. That’s where it gets subjective, and, as aforementioned, do I care if the company in question wins if the patient wins, too? Or is this company so damn evil at its core that I am willing to sacrifice the opportunity to do a good thing for patients in order to not have anything to do with said possible funding entity. Or am I cutting off my nose to spite my face because this is a really important thing for patients and this particular company is the only one that’s gonna fund it? Because tragedy of the commons or whatever else.

Again, this gets dicey really fast. Let me poorly paraphrase a little exchange I saw on LinkedIn the other day that had me completely preoccupied during my work-from-home midday walk around the block for at least three days. Somebody wrote (maybe that Master of Public Health intern), “Given how intractable it feels to me to try to reduce healthcare spend, I think I’m going to try to help patients get more value out of the dollars that are currently being spent by them or on their behalf.”

Do you think that’s a worthy goal? Well, not everyone does. Somebody in T-minus 8 seconds responded, “That’s a toxic way of thinking. Everyone who is not actively working to reduce healthcare spend by putting patients in cash-pay models is part of the problem.”

This is a good segue into the second part of my manifesto.

The first part is: If the thing results in a net positive for patients, then I’ll do it.

Here’s the second part: The timeframe is short-term or medium-term. And here’s what I mean by that. My main focus is helping patients right now. This is what this has to do with the aforementioned exchange on LinkedIn wherein someone was trying to figure out how to get more out of the dollars we’re currently spending and someone else said that’s toxic, because we should rip it all down and build a better model.

There’s incremental change, and then there’s disruptive change. These two things are not mutually exclusive. Apparently, Mr. This Is Toxic doesn’t agree with me, but as I said in the last episode, there’s that Buckminster Fuller quote: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” And sure, I like to aspire to that as much as the next person. But does aspiring to a big hairy goal mean completely forgoing any incremental ways that patients can be helped immediately, like right now?

If you ask me—and you’re listening to this, so you de facto asked me—incremental change will probably actually support and beget disruptive change. So, incremental versus disruption is not a battle royale. These things are not diametrically opposed. They’re probably actually aligned. I could go on a tangent here to explain why, but I’m not going to … except to say tipping points.

But forget about that for a sec. Here’s the more basic question: If all parties are interested in transforming healthcare, legit, how does someone trying to do it incrementally, or improve value for patients right now, in any way negatively impact someone trying to be disruptive and/or trying to change financial models?

Keep all this in mind and now let me get back to my manifesto. I’m worried about patients, and I’m worried about them largely right now, short term to medium term. So, if I have the opportunity to help a patient—and I think about my two grandmothers (God rest their souls) here, but both of them would have died in the healthcare system multiple times in avoidable ways had my family not been there advocating for them—if I have the opportunity to help a patient, I will do so as long as I believe that the impact is a net positive in the shorter term.

Disruption is a longer-term operation. Some have said it’s a generational change. When I see stuff like Toxicity Guy wrote on LinkedIn, I really try to understand what his point is, as I always try to understand what people’s points are. Could he be arguing that no one should work to improve care right now or try to maximize what we get for the bucks that we’ve already been shelling out? And, if so, for what reason … so that what happens? So that resentment about poor-quality care builds up to a boiling point such that everybody shuns the status quo and moves to a new care model and financial models faster? Is that the aim of Toxicity Guy? To force a let-them-eat-cake moment for the purposes of triggering a faster revolution? I’ve probably thought about this guy’s motives and his potential impact harder than he has. In my manifesto, in my worldview, I don’t let grandmas suffer right now so that someone else has a better narrative, even if I am in full support of what that person is trying to do and the mission that they are on, which, by the way, is a longer-term one.

This gets me to the third part of my manifesto: The assumption is that transforming the healthcare industry will take a village and I am not alone.

When I state this outright, it’s gonna seem self-evident; but sometimes it’s hard to not push blame here like Toxicity Guy, so I say this sort of in his defense.

Here’s the point of contemplation: There’s maybe four big parts of the healthcare industry at a minimum. We have those trying to fix SDoH (social determinants [or drivers] of health). We have those trying to fix medical morbidity (ie, are patients on evidence-based pathways and taking meds appropriately, limiting polypharmacy side effects/cascades). Once a patient is in the healthcare system, what happens then? Then we have those working hard to improve behavioral/mental health. And lastly, everything going on with what I’m gonna call FDoH (financial determinants of health)—patients making decisions or having decisions made for them due to financial implications for them or for somebody else.

Lots of stuff rolls up under these categories, but even just listing out these four things, we got a hell of a lot of work to do to improve the lot of patients and taxpayers and make it easier to do business in this country.

I always try to keep in mind that it will take a village. Just because someone is working on getting patients housing or eating better does not imply that they don’t care about employers struggling to curb claims billing waste, fraud, and abuse—and vice versa. It’s just not everybody can do everything. For me personally, I tend to focus my attention on helping as many patients as possible get on what would be for them the optimal treatment plan or best care pathway.

That does not mean I’m anti-someone working on getting more competition in the payer space. Nor does it mean I’m against trying to curb the price of overpriced (as per ICER [Institute for Clinical and Economic Review]) pharmaceutical products or legislate to rein in hospitals doing stuff that, in my book, they should not be doing. I am all for getting all of these things done. I just do not have the bandwidth or the depth of expertise to do everything myself. I would suspect that no one does.

As my grandma used to say (and anyone who attended a slumber party seance in eighth grade might know), many hands make light work. You get 15 girls each holding out but two fingers, and you can lift up your friend, no problem.

When I keep in mind that it takes a village, it helps me curtail the tendency to become paralyzed in my quest to help patients because I can see a potential problem it might create somewhere else in the industry or somewhere else down the line. I have to trust that one of my fellow villagers is holding down that end of the fort.

Here’s a quote from J. Michael Connors, MD, that he wrote in his newsletter: “When you point one finger, three are pointing back at you … It’s like everything you learned in kindergarten seems to be so applicable to our approach to healthcare. Sadly, the game of finger pointing and pushing blame on others is killing real innovation in healthcare.”

This is so real, which is why inherent in my manifesto here is my efforts to remember we are all on the same team (all the good eggs, anyway). That it takes a village, that there will be some things that some people are doing that I maybe don’t fully agree with. There might be groups who don’t accomplish much. There are certain people doing well (ie, doing self-interested things) but, at the same time, creating a better place for patients. As long as, in general, we are all following the same North Star, we’ll achieve much more spending our time focused on our own missions and not worrying about what other people are doing. And when I say “not worrying about what other people are doing,” I mean people in the “good egg” village. I do not mean I intend to stop calling out conflicted and net-negative self-interested behavior, because this is what some people in the village should hopefully have their eyes on and get busy working against.

The village here, it’s a Venn diagram. At the point where other people’s circles intersect with my mission or what I think would be better for patients, these are the people I can work with and collaborate with. These are the people that I’d take their business or I’d try to help them if I can.

My manifesto is to determine when something is a positive for patients and then to find others who will win as a result of that thing happening. Then I can study why this is a win for those others, which is always going to be some self-interested why. And then I can think through what the negatives are if their self-interest comes to fruition. Is it still a net positive? If yes, proceed.

Look, this making it better for patients, this transforming healthcare, it is hard, dispiriting work. It’s a long slog. I’d like to suggest we encourage each other. Can we be the wind beneath each other’s wings when we find a kindred spirit? Can we focus on the points of intersection and spend our energy deepening what’s going on there?

So again, here’s my manifesto: If the thing results in a net positive for patients, then I’ll do it. The timeframe I’m concerned about … short-term, medium-term. The assumption is that it will take a village to transform healthcare and I am not alone.

I feel kind of exhausted having finished that. But let me ask you this: What is your manifesto? If you have one or if you have thoughts on this, go to our Web site and click on the orange button to leave a voice message. My hope is to do an upcoming show sharing what you think.

For more information, go to aventriahealth.com.

Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry.

In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.

03:16 “It’s a zero-sum game.”

03:26 Is the amount of profit fair?

03:37 What is an inescapable fact of the healthcare industry?

03:54 What does the financialization of healthcare mean?

04:19 Why does the self-interest in healthcare matter?

06:18 “It’s basically up to us as individuals to do the right thing.”

10:03 What is the first part of Stacey’s manifesto?

10:18 How does Stacey calculate the net positive of an impact?

10:41 What are two major upsides/downsides that Stacey contemplates?

13:31 Why are incremental change and disruptive change not mutually exclusive?

17:40 “I always try to keep in mind that it will take a village.”

19:19 Why finger pointing is killing innovation in healthcare.

For more information, go to aventriahealth.com.

Our host, Stacey Richter, discusses our #healthcarepodcast and where she sees the path moving forward. #healthcare #podcast

Recent past interviews:

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Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355)