The Race to Value Podcast

This week we have the great honor of hosting one of the most respected American political leaders over the last few decades, a visionary who ushered in a new era of value-based care in our country during his tenure at HHS. Someone who is known for a strong track record of building collaborative relationships that achieve measurable results, who also is an entrepreneur at heart.  Of course, we are talking about no other than the legendary Michael O. Leavitt! As the former Secretary of Health & Human Services and a three-time Governor of Utah, Michael Leavitt earned a reputation for leading change through collaboration. He is one of the most influential leaders in the value movement because he sees how it can balance human compassion with the need for global economic leadership.  Michael Leavitt is also an early pioneer in competency-based education and co-founded Western Governors University – the leading nonprofit online university in the country, serving over 100,000 students with over 250,000 alumni.  This week marks the 25th Anniversary of WGU’s Founding, and we spend considerable time honoring Michael Leavitt’s legacy by discussing both his leadership in value-based care and his vision for competency-based education to drive workforce development in health value transformation. Additional resources on the future of workforce development for value-based care: Why Workforce Development for Value-Based Care is a Vital Issue to Address Value-Based Care Certificate program at WGU WGU College of Health Professions The Accountable Care Learning Collaborative (ACLC) Episode Bookmarks: 01:40 An introduction to the legendary Michael O. Leavitt and his storied leadership in value-based care 03:10 Balancing human compassion and Global Economic Leadership to ensure compassionate delivery of healthcare 04:00 Gov. Leavitt’s cofounding of Western Governors University on January 15th, 1997 (this week marks the 25th anniversary!) 05:05 “The language of health is heard by the heart. The richest and poorest of us are bound together by the uncertainty of our mortality, the health conditions of those we love and, in some cases, the desperation of our pain.” 06:30 Michael Leavitt provides an extensive history of the U.S. healthcare system and how poor system design led to high cost, low value care 10:40 How high healthcare costs (as a percent of GDP) compromises global competitiveness for the United States 11:30 “Value-Based Care” entered into the healthcare lexicon during Leavitt’s tenure as HHS Secretary 12:40 “We are in a race to make value work. If we can, we’ll have the kind of compassionate care we want to provide and maintain our economic leadership.” 14:20 “Health is going to be one of the fields of competition between economic competitors, and getting our health system right will be critical to that. And value will be the means by which that can occur.” 15:30 Leavitt explains how the adoption of value-based contracts has been impacted by the COVID-19 pandemic 17:20 Leavitt describes his proactive leadership during the H5N1 pandemic as HHS Secretary and the influence of “The Great Influenza: The Story of the Deadliest Pandemic in History” 19:20 The failure of human beings to realize that pandemics as a part of natural history and how that leads to lack of preparedness. 22:00 “When it comes to pandemics, anything you say in advance sounds alarmist. Anything that you have done after it starts is inadequate.” 24:20 “Moving to value will require us to learn and change. You can fight this change and lose, you can accept this change and survive, or you can lead this change and prosper.” 26:10 Solving complex problems through collaboration and how cooperation only seems to come about in times of great exigency. 28:50 Referencing his book, “Finding Allies, Building Alliances: 8 Elements that Bring—and Keep—People Together” 29:45 Building an alliance of 19 U.S. Governors twenty-five years ago led to the founding of Western Governors University (read more about WGU’s History) 31:30 Governor Leavitt discusses how the founding of WGU originated by recognizing the problem that higher education needed to be disrupted 33:50 The visionary concept of delivering competency-based education over the Internet 35:20 The influence of Clayton Christensen’s “The Innovator’s Dilemma” on the founding of WGU 36:30 Overcoming challenges to succeed at delivering high-quality, low-cost education 38:30 Michael Leavitt discusses the founding of the Accountable Care Learning Collaborative and why it was important to have it housed at WGU 40:30 Establishing the “DNA of Value-Based Care” through an expansive network of peer learning and collaboration 41:10 “The ACLC and WGU is of such importance to the value movement. They provide learning to make this part of the American ethic, and I think that’s the way the race to value is going to be won.” 43:00 Governor Leavitt explains how competency-based education provides the opportunity for persistent, lifelong learning in the new skills-based economy 46:40 How nondegree credentials that “move beyond the degree” will be the future for Workforce Development in Value-Based Care 48:00 The philanthropic support and vision of Dr. Richard Merkin to build new learning pathways to reskill and upskill the healthcare workforce for value 50:30 Mike Leavitt discusses the importance of “rapid, repeated, retraining of healthcare professionals” with the Value-Based Care certificate program at WGU 51:30 Equity in health cannot happen without equity in access and attainment of education for underserved learner populations in the health professions 53:20 How we can improve access and outcomes in healthcare by employing workers from underserved communities, and how WGU is solving for that through higher education 55:00 “Stackable certificates are a key part of a national strategy for both value-based care and making progress in social inequities in health.” 56:30 Retraining an entire healthcare workforce to address health disparities and the capacity that WGU has to make a successful contribution 57:45 Mike Leavitt explains why the movement to value-based care is taking so long by telling a story of a cattle stampede and how to best “nudge forward”

As it is entering its second decade, the Center for Medicare and Medicaid Innovation (CMMI) has launched a bold new strategy for achieving equitable outcomes through high quality, affordable, person-centered care. To achieve this vision, the Innovation Center has organized around five objectives: Drive Accountable Care, Advance Health Equity, Support Innovation, Address Affordability, and Partner to Achieve System Transformation.  Over the last decade, CMMI has been the driving force for value-based care at the federal level and launched more than 50 alternative payment models.  In the next decade, CMMI will apply lessons learned in establishing this strong foundation to lead the way towards broadened and more equitable health system transformation in our country. The ultimate goal is to have all Medicare beneficiaries in a care relationship with accountability for quality and total cost of care by 2030. Our guest this week is Liz Fowler, J.D., Ph.D., the director of the Center for Medicare and Medicaid Innovation (CMMI) and deputy administrator of the Centers for Medicare and Medicaid Services at the U.S. Department of Health and Human Services. She is leading CMMI in an effort to streamline the model portfolio and reduce complexity and overlap, and to help scale what works. From reengineering payment policies, to overcoming the complexities of model design that impede scalable transformation, and considering equity in all stages of model development – it is clear that health value remains a top priority for the Biden administration. Join us this week as we explore model design, equity, benchmarking, capital investment, beneficiary engagement and more. Dr. Fowler is truly leading the charge in the race to value! Read the transcript here. Read the CMS Innovation Center Strategy Refresh here.   Episode Bookmarks: 02:00 An introduction to Liz Fowler’s background in health policy leadership and industry transformation 03:00 Referencing the Innovation Center Strategy Refresh, a bold new strategy with the goal of achieving equitable outcomes through VBC 04:00 The need to reexamine the CMMI portfolio of APMs 06:40 Applying lessons learned over the last decade of CMMI to inform future payment models 07:00 “We have to have a cohesive articulation of a model portfolio, and explain how all the CMMI payment models fit together. That’s what we’re trying to do with our new strategy.” 07:30 Do the models support objectives? (i.e. drive accountable care, advance health equity, support innovation, address affordability, or achieve system transformation) 08:50 Healthy People 2030 defines health equity as “the attainment of the highest level of health for all people.” 10:15 Dr. Fowler describes how CMMI is embedding health equity into all aspects of payment model design (“Advancing health equity has become one of the most important areas of focus for the Innovation Center, and for CMS and HHS more broadly.”) 12:50 Dr. Fowler discusses how CMMI’s strategy to focus on equity to promote accountable care extends to Medicaid. 14:15 Referencing the CMMI Health Equity Roundtable last month (download slides here) 14:30 Conducting focus groups with providers and patients to better understand what equity means to them 16:40 Dr. Fowler discusses how CMMI will moving more Medicaid and Medicare Advantage beneficiaries into accountable care relationships (CMMI’s 2030 Goal) 18:20 Engaging local leaders to provide more care at the community level in addressing social needs (Accountable Health Communities Model) 19:30 The importance of creating the right incentives to address social determinants of health and the right tools to remove them as well 19:50 Data collection and measurement to assess health equity performance in value-based payment 22:10 Dr. Fowler discusses the importance of capital investment for providers to succeed in taking downside risk. 24:00 Lessons learned from the ACO Investment Model (AIM Model) 25:40 Eric outlines an extensive list of challenges with current CMS benchmarking methodologies 28:00 Dr. Fowler on the work CMMI is doing to refine financial benchmark methodologies 29:00 Dr. Fowler discusses how CMMI is exploring opportunities to improve or replace current risk adjustment methodology and the importance of multi-payer alignment 30:40 Risk adjustment and risk score gaming and the negative consequences of inappropriate risk score growth 31:10 Dr. Fowler discusses Direct Contracting financial specifications related to risk adjustment (Coding Intensity Factor and Symmetric 3% Cap) 34:00 DCE Risk Score Growth associated with Voluntarily-Aligned Beneficiaries 35:00 How risk score growth constraints protect the Medicare Trust Fund, while simultaneously allowing DCEs to benefit with Voluntarily-Aligned Beneficiaries 38:00 CMMI’s strategy to align specialty care with primary care and how integrated value-based specialty care will be complimentary (not competitive) to primary care 43:00 Dr. Fowler provides comprehensive overview of the Global and Professional Direct Contracting (GPDC) Model and potential plans to expand the program in 2023 46:30 The power of peer learning in value-based care (the Accountable Care Learning Collaborative and the Health Care Payment Learning & Action Network) 52:00 Dr. Fowler provides closing thoughts on CMMI’s 2030 Goal and the importance to reinstate the sense of inevitability that we’re moving towards value 54:00 The use of mandatory payment models in CMMI’s future value transformation strategy

Joining us this week, we have the legendary Dr. Dean Ornish who will be discussing his most recent book, “Undo It! How Simple Lifestyle Change Can Reverse Most Chronic Conditions” which just came out on paperback. Dr. Ornish is “The Father of Lifestyle Medicine” which is the fastest-growing trend in medicine today.  With its impact on both health costs and population health, lifestyle medicine is the future of value-based care! For more than four decades, Dean Ornish, M.D. has directed revolutionary research proving, for the first time, that lifestyle changes can often reverse—undo!—the progression of many of the most common, costly, and disabling chronic diseases and even begin reversing aging at a cellular level.  This often occurs in just a few weeks or less—and at any age. Medicare and many insurance companies are now covering Dr. Ornish’s lifestyle medicine program for reversing chronic diseases because it consistently achieves bigger changes in lifestyle, better clinical outcomes, larger cost savings, and greater adherence than have ever been reported—based on 40 years of clinical research published in the leading peer-reviewed medical and scientific journals. Today, January 4th, 2022, the “Ornish diet” has again been rated the “Best Heart Healthy Diet” by a panel of experts at U.S. News & World Report (and has been for the last ten years). He is the author of seven books, all national bestsellers, including UnDo It! (co-authored with Anne Ornish). Dr. Ornish was the “inaugural recipient of the American College of Lifestyle Medicine Lifetime Achievement Award” recognizing his extensive contribution to the field of Lifestyle Medicine – TheACLM is the sponsor of today’s episode! Episode bookmarks: 02:00 The obesity epidemic that causes 300,000 premature deaths each year 03:15 Ayurvedic proverb: “When diet is wrong, medicine is of no use. When diet is correct, medicine is of no need.” 03:30 The storied background of Dr. Dean Ornish and his most recent book, “Undo It! How Simple Lifestyle Change Can Reverse Most Chronic Conditions” 06:00 Dr. Ornish was the inaugural recipient of the ACLM Lifetime Achievement Award” recognizing his extensive contribution to the field of Lifestyle Medicine. 06:15 Commercial message from our sponsor, the American College of Lifestyle Medicine 08:00 Lifestyle Medicine is the future of Value-Based Care 09:00 Eric cites healthcare cost estimates reflecting the impact of obesity and chronic disease on our nation. 09:45 Lifestyle medicine programs can reverse coronary heart disease, type 2 diabetes and obesity, prostate cancer, high blood pressure, and high cholesterol 11:00 86% of the 3.7 trillion dollars that we spend on healthcare is for treating chronic diseases 11:30 Very simple lifestyle changes that prevent or reverse chronic diseases: “Eat well, Move more, Stress less, and Love more” 13:00 Dr. Ornish describes how his research over the last four decades has proven that heart disease can be reversed 14:00 Dr. Ornish on how his work with hospitals and physicians is demonstrating that changes in lifestyle lead to better clinical outcomes, better cost savings, and better adherence 14:45 The importance of showing cost savings from lifestyle medicine interventions in the first year 15:00 Highmark Blue Cross Blue Shield cut healthcare costs in half in the first year of implementing the Ornish program for reversing heart disease! 16:00 Lifestyle changes can also reverse a wide variety of other costly chronic diseases, including cancer and diabetes 16:30 Referencing research collaboration with Craig Venter showing that lifestyle changes can modify gene expression 17:00 Dr. Ornish discusses his treatment of President Clinton and how his cardiologist overstated the role of genetics on his heart disease 17:30 Referencing research collaboration with Elizabeth Blackburn showing that lifestyle changes can reverse aging at a cellular level 18:00 Current randomized trial to see if lifestyle changes might stop or reverse the progression of early-stage Alzheimer’s disease 19:15 The extremely high cost of the recently approved Alzheimer’s drug (Aducanumab) due to the desperation to find an effective treatment 19:30 Reversal is possible with all of the most common and costly chronic diseases because they are not so different from each other 21:30 “When we treat the cause, these lifestyle choices, our bodies have a remarkable capacity to begin healing and much more quickly than we once realized.” 23:00 The biggest roadblock in creating lifestyle change is the “Power of Leverage” and how the desire to avoid pain or gain pleasure influences behavior 24:00 Dr. Ornish references his debates with Al Gore on why the fear of dying is not a sustainable motivator to change human consumption patterns that create climate change 25:00 Dr. Ornish discusses the documentary “The Game Changers” (on the topic of plant-based eating) made by his good friend, James Cameron 29:00 Not treating the cause of disease is like mopping up the floor from an overflowing sink when no one bothered to turn off the faucet! 29:30 Dr. Ornish on how reversing disease saves a lot of money in the first year and why this ROI potential is so important in value-based care 31:20 “Bypassing the bypass” – observations from medical school on how patients keep coming back for more heart surgeries (i.e. failure to treat the cause) 32:20 Stents and angioplasties in stable patients don’t prevent heart attacks or prolong life. 34:00 Dr. Ornish shares a miraculous patient story of heart failure reversal from someone who went through his program and no longer needed a heart transplant! 34:30 Medicare coverage of Dr. Ornish’s program for reversing heart disease in 2010 (a bipartisan commitment to create a new reimbursement category for intensive cardiac rehabilitation) 35:30 Patient adherence outcomes with Dr. Ornish’s reversing heart disease program and the recent decision for Medicare to cover it when delivered virtually 37:00 Dr. Ornish explains why he is optimistic from the early findings of his current Alzheimer’s research study and how this may be his most important work yet. 41:00 COVID-19 has exacerbated the health status of Americans and the opportunity for a post-pandemic era that refocuses on public health and value-based care 42:30 Dr. Ornish discusses research that shows how a plant-based diet provides a lower risk of getting sick from COVID-19 44:00 The impact of Dr. Ornish’s lifestyle program with underserved and homeless populations 45:00 The fast food industry and the economics of meat subsidization which makes unhealthy food cheaper than healthy food 46:30 The alarming lack of nutrition education in the medical profession 47:00 Changing of reimbursement is what changes medicine and medical education at a critical mass (not medical research) 48:00 Food insecurity in marginalized and minoritized communities costs $77 billion in excess healthcare expenditures each year. 50:30 Dr. Ornish explains how more global warming is caused by livestock consumption than all forms of transportation combined and why food insecurity should not exist. 52:00 Lifestyle changes have better adherence than statins because they make you feel better. 52:30 Dr. Ornish further explains how we can make meaningful and sustainable changes if they pleasurable. 55:00 The soaring obesity rates, higher rates of cancers, and behavioral health challenges observed within the Millennial generation 56:00 Dr. Ornish on the breakdown of social networks that used to provide people a sense of love and connection and community. 56:30 “The more time you spend on Facebook, the more depressed you are. Because it’s not an authentic intimacy. It’s a fake intimacy.” 58:00 “Anything that creates a sense of connection and community is really healing. Even the word healing comes from the root, to make whole.” 58:30 “People who are lonely and depressed are 3-10 time more likely to get sick and die prematurely than those who have a sense of love and connection and community. I don’t know anything in medicine that has that kind of power.” 60:00 “Pain can be a great catalyst for transforming lives in ways that make it so much more joyful and meaningful.” 64:00 How the practice of lifestyle medicine can revitalize the medical profession and reduce physician burnout 65:00 Interdisciplinary care teams, physician quarterbacking, and “the most meaningful work that I can imagine” 66:00 Lifestyle medicine alleviates suffering for the vulnerable (way beyond just unclogging arteries!) 67:00 Lifestyle medicine and the “food as medicine” movement is the future of value-based care! 69:00 Dr. Ornish discusses “radical simplicity”, the overstated implications of nutrigenomics, and the impact of Western diet on China, Japan, and other Asian countries 71:00 Referencing Sheldon Cohen’s study that shows a correlation between lack of social connection and susceptibility to the common cold 72:00 Dr. Ornish emphasizes the art of simplicity and lessons learned from his good friend, Steve Jobs 74:00 Parting thoughts from Dr. Ornish (“Just understand that these simple changes can make a powerful difference!”)

We must remain steadfast in our desire as healthcare professionals to ensure that patients who lack access to safe and stable housing are not forgotten. In this special bonus episode of the Race to Value, you will learn how organizations can build alliances to serve the public good and build hope in marginalized communities through investments in housing.  There is strong evidence characterizing housing’s relationship to health. Housing stability, quality, safety, and affordability all affect health outcomes, as do physical and social characteristics of neighborhoods.  Lack of housing security leads to increased mortality (lower life expectancy); physical traumas, crime, and gun violence; long-standing impacts on psychological well-being (depression, anxiety, suicide); increased ED and inpatient hospital utilization; increased pediatric asthma and chronic disease burden; and substance use disorder.  The impact of housing on health is now being widely considered by policy makers as it is one of the most researched social determinants of health.  Needless to say, housing interventions by healthcare organizations and community partners is the future of value-based care! In this episode, you will learn about how ProMedica (a non-profit health and wellness organization of 11 hospitals and a physician network of 2,600 physicians) formed a community-based housing investment partnership with the Green & Healthy Homes Initiative (GHHI). Their comprehensive, flexible approach to addressing unhealthy housing is being shown to improve health, academic success, job retention, neighborhood safety, and intergenerational wealth transfer all for a relatively low per-person cost. Joining us in this interview is Ruth Ann Norton (President & CEO, GHHI) and Rachel Krausman (Vice President, National Strategy and Partnerships, ProMedica). We invite every value-minded professional listening to this conversation to join in your own community effort to care for your most vulnerable patients. A healthy home leads to a healthy life! This bonus episode comes from an ACLC Peer Learning Session – click here to watch the video with slides and download the Case Study: https://www.accountablecarelc.org/publications/investments-housing-health-and-equity-through-partnership-promedica-and-green-healthy Episode Bookmarks: 02:00 How does value-based care and housing intervention go together? 04:00 Introduction to the Accountable Care Learning Collaborative 05:50 Introduction to Rachel Krausman and Ruth Ann Norton 06:45 Background on ProMedica, a non-profit health and wellness organization of 11 hospitals and physician network of 2,600 physicians 08:35 The ProMedica National Social Determinants of Health Institute and its focus on SDOH interventions (e.g. food insecurity, housing) 10:00 The ProMedica Impact Fund that has raised $1B over 8 years to drive innovation and scale in SDOH interventions that have a measurable impact on health 11:30 ProMedica’s Partnership with the Green & Healthy Homes Initiative (GHHI) to test ROI and clinical outcomes improvement associated with SDOH investments 12:20 The founding of GHHI in 1986 through a grassroots effort to end childhood lead poisoning due to unhealthy homes 13:30 Ruth Ann explains GHHI’s accomplishments in reduction of lead poisoning and how that led them to view health and housing more holistically 14:00 Elimination of fall risk injuries in senior population can save Medicare over $20k per beneficiary 14:15 Energy efficiency and weatherization services to reduce energy burden and improve air quality 14:45 Building a future for “intergenerational wealth transfer” through improved health outcomes 15:15 Influencing Medicaid payment policy in the states of New York and California to invest in healthy homes programs 16:40 30M families with housing-related health conditions (e.g. pediatric asthma, brain damage due to lead poisoning, injury) at a cost of $150B in avoidable healthcare services 18:20 The ROI evidence for healthy homes interventions 19:45 Raising $100M for Healthy Homes in 7 Cities (Baltimore, Chicago, Cleveland, Philadelphia, Pittsburgh, Toledo) to return $545M in economic benefit! 21:00 Leveraging other funding sources and community partners as a multi-partner strategy outside the core health system 22:00 Effective project implementation and workforce training needed for long-term financial sustainability 23:00 Maximizing interventions impacts at the neighborhood-level 23:45 The importance of family engagement, housing risk assessments, and an equitable referral system 25:20 Hiring employees from impacted communities to address long-term SDOH and the use of evidence-based impact measures 26:20 Building trust with SDOH interventions leads to improved health plan retention, care plan adherence, and wellness activities 27:30 The Evidence: How reducing fall-related injuries creates intergenerational wealth transfer, reducing lead exposure improves educational outcomes, etc. 29:00 The impact of stable housing on Health Equity (“a better baseline to which to thrive”) 30:00 Reduction in crime and creation of jobs through housing interventions 31:00 Evaluation and Impact Analysis (rigorous evaluation of services delivered, biometric data, social risk factors, care utilization, survey results to assess program impacts on health) 33:30 ROI through reduced Emergency Department Utilization associated with pediatric asthma 36:00 Rachel explains why healthcare organizations need to think differently about investments in community-based SDOH interventions 37:00 Rachel discusses why SDOH interventions (e.g. grab bars in the home, repairing a porch) should be incorporated into a clinical workflow because of implications on health. 38:30 Effective community-based interventions are based on partnerships (not the health system alone) and investments are shared and aligned 39:30 “40% of hospitalizations and ED visits come from lousy housing conditions.” 41:00 Small interventions in the home (e.g. stair tread, leaky roof) can improve health outcomes too – not all have to be major investments! 42:00 Assessing the effectiveness of service providers (e.g. translation capabilities, data capture) 43:00 Emphasis on health equity in redesigning payment models (e.g. CMMI – Liz Fowler) and how we can create scalable SDOH solutions in marginalized communities 47:00 How to develop an effective, equitable, and data-driven referral system to identify appropriate patients for housing interventions 50:00 The positive impact of housing interventions on emotional health and wellbeing

In a time of great need for our nation during the pandemic, Americans saw and celebrated an army of physician heroes. And in doing so, they overlooked an unforeseen reality that true heroism by physicians has actually yet to be realized. In the coming years, heroic physician leadership will be the crucible for the kindling of imagination to reshape our nation’s healthcare system through economic reform.  However, for physicians to lead they will need an educational guide for navigating the business of medicine to optimize their leadership potential.  Fortunately, for them, Dr. Ellis “Mac” Knight and his book “Healthcare Economic Reform:  How and Why Physicians Must Lead Change Within Our Evolving Healthcare Economy” is their guiding light in the darkness! Dr. Knight realizes that the time for physician leadership is now to salvage our economy, improve our nation’s health and wellbeing, and restore the humanity of medicine. To do this, physicians must provide more than just healing patients in front of them; they must be a reservoir for reimagining a system that can emphasize prevention over treatment. They must call for changes in a way that will lead to transparency, redesigned care delivery processes, lower costs, and improved patient outcomes. The call for physician leadership has never been higher, and the stakes have never been greater.  For true healthcare economic reform to occur, we need physicians to demand change from both an economic and moral imperative. Are you ready to take your first step in your hero’s journey as a physician leader? Or will you stay on the sideline, hoping for a top-down, political, all-encompassing solution to healthcare reform?  After hearing this podcast,  you will come to realize that building an idealized system can only occur via a bottom-up methodology that honors the voices of skilled clinicians on the frontlines to design care delivery.  And it is Dr. Mac Knight that will be your North Star! Episode Bookmarks: 01:45 Heroic physician leadership will be the crucible for reshaping our nation’s healthcare system through economic reform 02:15 Dr. Knight’s new book: Healthcare Economic Reform:  How and Why Physicians Must Lead Change Within Our Evolving Healthcare Economy 04:25 “Physicians must be a reservoir for reimagining a system that can emphasize prevention over treatment.” 07:00 “The entire healthcare economy is in need of vast redesign” 08:40 What are the goods and services traded for in the healthcare economy? 09:30 Growing up seeing his dad as a solo practitioner and realizing how different that system is from today 11:00 “The healthcare economy is corrupted. It is selling the wrong goods and services and charging way too much for those things.” 13:00 The “glass wall” that is created in large health systems between physicians and administration. 14:00 The lack of accurate Cost Accounting in healthcare as a barrier to creating value (referencing the work of Michael Porter and Robert Kaplan) 16:00 The relentless pursuit of profit within the fee-for-service based healthcare economy 17:00 “The COVID-19 pandemic has really pulled back the veil and revealed the perverse nature of the healthcare economy.” 19:00 Moving the emphasis from profit maximization to value-based care is really going to require a change to the payer paradigm 22:00 The value equation and how definitions and measurements of quality create the perception of “cookbook medicine” 23:00 The Price-Cost disconnect in healthcare and the need to connect pricing to the actual true costs of providing services. 24:00 The flawed negotiation model between health plans and hospitals and how that leads to pricing variation in the marketplace 25:00 Accurate costing and the elimination of waste as an opportunity to drive value in healthcare 27:45 Payment reform is needed. Value-based reimbursements need to become real! 29:00 The movement to value-based payment driven more by CMS than on the commercial side and the possibility of “Medicare Advantage-For All”? 31:00 Is the clinical integration of providers the best vehicle for delivering value-based healthcare? 32:20 FTC Guidelines for clinical integration and the need for physician leadership and governance 33:30 The lack of incentives for specialists to participate in many value-based payment models 34:30 A silver lining of COVID pandemic in creating the realization of the flawed healthcare economic model 36:00 Estimates are that anywhere from $760-$935 Billion of cost expenditures in healthcare is waste! 38:00 How do we optimize EHR systems so they can better serve as a vehicle to support population health and create interoperability amongst providers? 39:30 “Monstrosities of technology” – the flawed design of EHRs and how being built on a FFS chassis creates waste and prevents workflow efficiencies 43:00 Referencing Adam Smith’s “Invisible Hand” as a model for free market healthcare 44:00 Dislocation of buyers/sellers from production of services and profit-seeking maximization of the shared premium dollar 46:30 Negotiating on the basis of global services provided (instead of the procedure itself) obscures price transparency and true cost accounting 48:45 Parallels between healthcare and the luxury goods market and how that negatively contributes to the economy as a whole 50:00 The flaw in the Relative Value Scale Update Committee (RUC Committee) and the over-valuing of technical over cognitive services 54:20 The role of Advanced Practice Providers (PAs, NPs) and interdisciplinary team members in addressing gaps in primary care delivery 55:30 Physician compensation based on RVU production detracts from the provision of high quality care delivery 57:00 Dr. Knight shares his thoughts on how we can more effectively design and implement bundled payment models to improve cost and quality outcomes. 58:00 Referencing the RAND Corporation Analysis of Bundled Payment Models 59:00 Dr. Knight describes the “four player model” of care delivery in a bundled payment model 61:00 The flaws in the bundled payment model concept, i.e. the bundling up of fee-for-service payments and then taking savings out of that 63:00 Dr. Knight provides parting thoughts to physicians looking to develop new high-value business models within the healthcare economy

Healthcare worker burnout has reached crisis proportions, and we must find real solutions to address the intense psychological suffering of our workforce. The seemingly endless intensity of work, the mounting death totals and the indifferent attitudes many Americans display toward COVID safety precautions has caused depression, burnout and moral injury for a growing number of physicians, nurses, and allied health professionals.  For those of you out there feeling despair and pain on the frontlines of care delivery, an active meditation practice can bring you the peace and equanimity to transcend your suffering. In this week’s episode, we talk about realizing one’s unbound, undivided nature through meditation and how that can create a profound sense of liberation and enlightenment. If you are seeking a better understanding of how to experience a deeper sense of integrated realization that allows you to overcome an over-identification with ego that creates separation, isolation, and suffering, than this episode is for you! Our guest this week, Dr. Angelo Dilullo, a practicing anesthesiologist and author of the book “Awake: It’s Your Turn.” I’ve invited him on to the podcast to provide us with a masterclass in breaking the illusion that we are separate from life, from ourselves, from everything that is. Given the suffering that is occurring in the healthcare workforce, there is something to be learned here about how we can live moment to moment and find resilience through equanimity. In this episode, Angelo discusses the process of Awakening (which he also wrote about in his new book and talked about on the ZDoggMD show) and how non-dual awareness can be applied to the context of emotional resiliency in the healthcare workforce to overcome burnout and moral injury. Episode Bookmarks: 01:40 Eric discusses meeting Angelo during a recent 6-Day Semi-Silent Meditation Retreat and how his life has changed! 06:00 Angelo briefly discusses his Awakening journey and how he began to teach others 08:20 What Awakening is not as a starting point to understand what it is! 09:10 The end result of Awakening is the end of suffering 10:10 “Awakening is a huge reorganization in how you experience identity. It is a vast space of consciousness where one is completely at peace with one’s unbound Self.” 11:40 Awakening is the most important thing to someone once that state is fully realized. The process is self-validating. 12:30 “You didn’t realize the mental prison you were really in until you find the key, turn the key, and walk out the door.” 13:00 The paradoxical nature of Awakening and the experiential shift in spiritual insight 15:00 Thinking is a disease of the human mind that creates intense resistance to one’s true nature which, in turn, creates suffering. 17:00 Accessing the Peace and Equanimity that is already there through the elimination of incessant thinking! 19:00 You can’t fix stress and anxiety through thinking.  There is a difference way to derive identity and find peace. 21:30 Feeling and experiencing as all of consciousness (instead of identification through thoughts) 22:00 Everything is “I” – a universal sense of Being 24:00 Experiencing equanimity as consciousness itself in the present moment (not through identification of past and future) 28:40 Presence is peace and equanimity at an intimate level…a complete sense of aliveness. 31:00 Awakening it is not some exalted state or spiritual enlightenment – it is a natural state of fluidity, unbound intimacy, and freedom 33:00 Anyone can wake up from the dream of separation if they are determined to find the root cause of suffering. 36:00 The mental health impact of the COVID-19 pandemic on the healthcare workforce (“psychological warfare” and nurses leaving the profession) 37:30 Depression and suicide in the medical profession due to burnout and moral injury (“a public health crisis”) 38:45 “You should only do this if it is deeply authentic to you.” (not as a cure-all for professional suffering) 41:00 Angelo discusses the sublimination of stress he observes in the practice of medicine 43:00 How stressful environments and challenging interpersonal situations adds the necessary textures to bring out deeply buried resistance patterns that can be hard to see in a life dedicated to quiet contemplation 44:30 “Shadow work” to address the emotional pain bodies of moral injury (referencing Eckhart Tolle) 48:00 Harnessing energetic experiences in the body to encounter deeply entrenched repressed emotions 54:00 How healthcare workers can reconcile the authenticity of “being as we are” by collapsing everything into the singularity of now (and balancing that with the sense of doership and need to make decisions to improve the system for the future) 57:15 Does Awakening cause major life changes with career or family? 60:00 Angelo discusses how health systems are now embracing meditation as a way to create more resilience in the healthcare workforce 62:00 The application of self-inquiry as an advanced practice of meditation 63:00 The recognition of suffering as a starting point 64:30 Recommended Resources: The Power of Now (Eckhart Tolle), Adyashanti, and Angelo’s bookand YouTube channel

Sydney Townsend was diagnosed with cancer in June 2018, three months after giving birth to her first child.  As a former boxer, she realized she was in the fight of her life and never gave up.  After surviving her bout with cancer, her healing journey came full circle by joining the staff of Texas Oncology in 2021 (the practice that treated her cancer) as their Director of Virtual Care so she can provide care to others in the fight. Joining Sydney in this episode is Dr. Kathryn Hudson, her hematologist and oncologist. Dr. Hudson is also the Director of Survivorship for the practice which allows her to extend the impact she makes as a clinician by improving supportive care models for cancer patients and survivors. When you hear from Dr. Hudson in this interview, you will immediately realize the power of the relationship she had with Sydney and how important this is in value-based oncology care. Value-based care always starts with a deep and trusting relationship between a patient and provider.  There is no stronger of an example of this than Sydney and Dr. Hudson.  Together in this very special episode they discuss “Cancer Survivorship and the Power of Relationship-Based Care.”  This is an interview that conveys triumph and inspiration for those either fighting cancer or seeking to provide truly patient-centered care! Bookmarks: 01:40 An introduction to Sydney Townsend and her story of cancer survivorship 02:45 An introduction to Dr. Kathryn Hudson – hematologist, oncologist, and Director of Survivorship at Texas Oncology 04:30 Dr. Hudson provides a brief overview of the patient-centered model of care at Texas Oncology 05:30 Sydney explains how “telemedicine is more than just a tool for episodic care” and discusses how cancer survivorship is a “superpower” 07:00 Dr. Hudson discusses how her work as an oncologist and survivorship leader connects to her personal “Why” 08:15 Dr. Hudson provides a comprehensive overview of TXO’s cancer survivorship program 10:00 Sydney’s shares her heartfelt and deeply personal story of her cancer fight and healing journey over the last three years 15:20 The beautiful connection of motherhood between Sydney and Dr. Hudson and how that cultivated a deep and trusting relationship 17:30 Dr. Hudson discusses the deep empathy and personal connection she has for Sydney and how that informed her treatment decisions 20:30 Sydney describes the initial difficulties in establishing trust and how she eventually overcame her fear and suffering in the early stages 22:45 “Trust is something that takes time to build between a physician and a patient.” 25:15 Dr. Hudson discusses the importance of involving a patient’s family during cancer treatment 28:15 Sydney draws parallels between her bout with cancer with her prior experiences as a boxer 29:40 Dr. Hudson shares how inspired she was by Sydney’s mental fortitude during cancer treatment and survivorship 30:20 Sydney’s goal of getting back to the boxing gym in her “path to a new life” 31:30 Sydney describes her “ultimate Zen training” experience during chemotherapy and how mindfulness and meditation helped her to heal 33:15 How “being in the present moment” taught Sydney how to carry on through her survivorship (“I’ve been forged in fire, and it feels good!”) 35:20 Malnutrition during cancer is a main reason for avoidable ED visits and hospital admissions, and cause 1 in 5 cancer-related deaths 36:20 Dr. Hudson discusses the role that nutrition care plays in cancer treatment and how it lowers total cost of care and improves outcomes 39:10 Sydney discusses what she learned about nutrition during her cancer journey 41:45 Sydney explains how changes in telemedicine payment rules catalyzed adoption 42:45 How virtual care can be utilized to improve health equity and provide care in underserved areas 43:10 The challenges of “the digital divide” in the deployment of virtual care and how government and communities are solving for it 44:10 The deployment of telemedicine at TXO during the pandemic and how that transformed care 46:30 Dr. Hudson on building a patient community that promotes survivorship skills and wellness for cancer survivors and loved ones 50:00 Dr. Hudson provides additional information on the importance of virtual care during survivorship 50:45 Sydney describes how telemedicine and telehealth is related to value-based oncology care 52:10 Dr. Hudson explains the importance of using telemedicine to treat patients who are immunocompromised or have transportation issues 53:35 Parting thoughts from Sydney: Leaning in to your care team, family, and friends to create a universe of support. 54:40 Parting thoughts from Dr. Hudson and how to find out more about Texas Oncology

Mahatma Gandhi once said, “The true measure of any society can be found in how it treats its most vulnerable members.”  The same can be said of healthcare organizations serving patients within their local communities.  In value-based care, the truest measure of any healthcare organization’s success (from both an economic and a moral imperative) is how it treats its most vulnerable patients.  It doesn’t get any clearer than that – serving the underserved…the 5% that drives 50% of medical spend…those that are dealing with serious illness due to chronic disease, mental health issues, or substance abuse is the most important focus we should all have as an industry. And with this intersection between vulnerability and minoritized populations, we have to start thinking about value-based care and health equity as one and the same.  In this week’s episode, we are joined by two mavens, Michael Radu, CEO, and Dr. Gregory Foti, Chief Medical and Transformation Officer of AbsoluteCare. AbsoluteCare, is a leading innovator in patient-centered, value-based care. They are what I would call an integrated Chronic Care Patient Centered Ambulatory ICU that partners with health plans to care for only the most vulnerable complex patients. They are similar to other high-touch, relationship-based primary care centers; however, they don’t spread risk by accepting global capitation within the entirety of a normalized managed population, including caring for those who are relatively healthy.  AbsoluteCARE sees only the sickest of the sick, and they are getting positive results with their comprehensive multidisciplinary care model by focusing on all aspects of a patient’s life issues – social, behavioral, substance use disorders and medical – to give patients the resources they need to fully change their lives. Listen today to learn from these leaders in the race to value! Episode Bookmarks: 05:00 The AbsoluteCare Care Model and its clinical and utilization impressive outcomes 07:00 Dr. Greg Foti explains his personal “Why” and how his disillusionment with FFS made him a champion for value-based care 08:20 Building trust with members as the “secret sauce” and why it is important for clinicians to take time to listen 09:45 How relationship-based care supports SDOH interventions and closing gaps in care 10:25 Mike Radu discusses how AbsoluteCare takes time with patients by lowering the patient panel per clinician and adding support teams 12:00 Promoting literacy and understanding of care plan and discharge instructions with post-visit follow-up from care team coordinator 12:50 Social workers and RNs as an additional wraparound support model to enhance member outcomes 13:45 “Beyond Medicine” and SDOH – an example of how AbsoluteCare helped a member overcome housing instability 15:45 Focusing on the top 4-6% of highest utilizers within the most vulnerable, complex, marginalized populations 16:50 Dr. Foti describes how AbsoluteCare provides housing interventions and build partnerships with communities and health plans 18:30 Addressing food insecurity through food bank partnerships and a “food as medicine” strategy 19:05 Helping members dealing with social isolation by building a community-based outreach structure 20:00 Mike Radu provides additional context on AbsoluteCare helps members dealing with food insecurity, housing instability, and health illiteracy 22:00 Using Member Rewards (re-loadable gift cards) that incentivizes members to engage in their own health 23:10 Dr. Foti discusses how innovative care delivery is only possible with value-based contracts that provide prospective funding for investments 24:30 “Dismantling the fence” in society to remove barriers (such as institutional racism and SDOH) that create inequities 27:00 Mike Radu provides perspective from his time with CMMI on how value-based care innovation is solving for health equity 29:30 The need for CMS to innovate Risk Adjustment methodology to include SDOH data 30:30 Measurement of impact (e.g. ER diversion, rehospitalizations) is needed to justify value-based care program investments 31:00 Reporting voluntary Z codes to capture SDOH data and how AbsoluteCare uses them for risk stratification and attribution logic 32:00 “Our North Star is to change the trajectory of a child’s life and address health equity for the next generation.” 34:00 The importance of culturally competent care to better connect with complex populations in minoritized communities 35:30 How AbsoluteCare provides transgender care through trust building and culturally competent care 36:45 Building health centers only in those communities most in need and the importance of recruiting employees from those communities 39:40 Suboptimal health literacy is an independent risk factor for poor health outcomes, including increased risk of hospitalization. 41:00 Dr. Foti describes the difficulties in navigating the healthcare system and why care coordination is needed (especially for most vulnerable) 43:00 Using information exchanges and ADT feeds to provide alerts to Interdisciplinary care team 44:00 “Hub and Spoke” care model (health centers and embedded community-based care teams) 44:45 How AbsoluteCare approaches integration of behavioral health and pharmacy within primary care model 46:00 Infusion Center for acute care treatment of chronic disease exacerbation 47:45 In-house Laboratory to support members at the point-of-care 49:00 Workforce development for all care team members and the importance of daily team huddles 51:00 Mike Radu describes the data and analytics infrastructure at AbsoluteCare 53:00 Transportation services to pick up members for primary care visits and also delivery medications to their home 54:15 The need for complex medication review (average member has 13 diagnoses and 10 medications) 55:30 Dr. Foti fully describes the integrated pharmacy model at AbsoluteCare 61:00 Dr. Foti fully describes behavioral health integration (Collaborative Care Model) at AbsoluteCare 66:00 Mike Radu on how AbsoluteCare leverages complex algorithms to drive community-based interventions 69:30 Entrenched economic interests and the difficulty of burning the ships to settle in the “New World” of value-based care 71:00 A reason for optimism in the value movement

In recent years, the role of retail in health care has grown beyond the co-location of clinics and pharmacies, with many large retailers now expanding their care delivery practices to include full-service health centers, telehealth offerings, and home delivery of pharmaceuticals. Retailers like Walmart, CVS, Amazon, Walgreens, and Target are all pursuing a healthcare strategy. The opportunity to bring consumerism to the forefront in healthcare has never been more promising, and these retail companies are looking to deliver consumer-centric innovation in a way that the traditional healthcare system has been unable to. In addition to the provision of a high-touch, technology-enabled primary care delivered in existing brick-and-mortar facilities that are highly convenient and familiar to patients, these companies have begun to leverage other assets, including online platforms, robust supply chain and delivery infrastructures, and access to capital to grow their health care offerings. In this episode, you are going to hear from three thought leaders with unique perspectives on this important topic. We have Dr. David Nash (Founding Dean Emeritus at Jefferson College of Population Health), Marcus Osborne (Senior Vice President of Walmart Health), and Darrell Moon (the Founder and CEO of Orriant). Episode Bookmarks: 02:00 Retail companies (e.g. Walmart, CVS, Amazon, Walgreens) are bringing consumer-centric innovation to healthcare 03:15 Introductions to Marcus Osborne (SVP, Walmart Health), Dr. David Nash (Dean Emeritus, Jefferson College of Population Health), and Darrell Moon (CEO, Orriant) 04:30 The traditional American healthcare is one of the least consumer-centric models ever developed in a capitalist economy 06:25 Dr. Nash describes the current socioeconomic challenges of Philadelphia as a construct for how poverty contributes to adverse health outcomes 08:50 Dr. Nash reference the seminal article by Dr. David Kindig, “What is Population Health?” and how population health relates to SDOH and institutional racism 11:30 Is retail-based primary care the answer to improved population health through more effective patient engagement? 13:00 Referencing Fred Lee’s book, “If Disney Ran Your Hospital” in thinking about how we can optimize the patient experience and deliver personalized service 14:40 Marcus describes how supply and demand challenges of primary care in the effective management of chronic disease 16:30 “The biggest issue we face in healthcare is variation in care delivery.” 18:00 Technology, innovation, and interdisciplinary care teams as the ultimate solution to address population health challenges 19:00 The role of the “Professionally Nice Person” in consumer-centric care delivery and how Community Health Workers can be used to improve outcomes 20:00 Our challenge is getting the system comfortable with the reimagining of team-based care (not the patients!) 23:00 Darrell describes the importance of “massively powerful primary care” and the power of relationships 25:00 Nuka System of Care – Southcentral Foundation as a leading example of the “best healthcare system in the world” and how it emphasizes relationships, trust, and patient convenience 30:00 Marcus describes the absurdity of the “balanced interest” model in designing healthcare reforms (the interests of the consumers are all that matters!) 34:00 Dr. Nash on how unexplained clinical variation supersedes SDOH in importance when it comes to population health 35:00 Keeping only the wealthy healthy in a retail-based care model will perpetuate health inequities 37:00 Life expectancy is determined primarily by the zip code to which you live (e.g. SDOH disparities contributing to a 20-year variance in adjacent zip codes) 39:00 For-profit, private-equity backed SDOH companies are a driving force to community-based interventions 40:30 Marcus describes how Walmart Health is addressing social determinants of health as both a healthcare provider and an employer 42:00 The Walmart ZP (“Zero Pressure”) platform to share stories with peers and how that contributed to massive weight loss among Walmart associates 45:30 Darrell describes the power of behavior, influence, and storytelling in improving population health 47:00 Storytelling is the primary way to change consumer behavior and reorient them to innovative models of care delivery 48:00 Subscription-based primary care as a foundation to relationship-based primary care, community support models, and realignment of incentives 54:00 Marcus describes the Walmart philosophy of “save money, live better” and how it applies to its price transparency model for consumer-driven healthcare 58:00 Darrell discusses how we will see retail power-players expand beyond massively powerful primary care models, telemedicine, and virtual care to build individual insurance plans in a public marketplace 60:00 The inevitable migration away from employer-sponsored group insurance to employer-sponsored individual insurance! 62:00 Marcus explains the confluence of an emerging new individual insurance products and the focus on improved employee health and productivity 62:30 Marcus on why we should view the Haven as a unbelievably massive success and how the industry mischaracterized the experiment. 64:00 Darrell explains how Europe can be viewed as a model for how employers can support the health of their employers (once the group insurance market goes away) 65:00 Dr. Nash describes how improving employee vaccination rates should be viewed as the #1 priority for employers 66:00 Marcus provides thoughts on post-pandemic healthcare and the integration of omnichannel consumer environments to redefine healthcare

A special Thanksgiving message from Dr. Eric Weaver, host of the Race to Value, about gratitude, suffering, and the movement to value-based care.