Healthcare is Hard: A Podcast for Insiders

In the United States, 85% of the population resides within 10 miles of a CVS Pharmacy. Through continued growth and expansion since its founding as a health and beauty products retailer in the early 1960s, CVS Health has now become America’s largest health services company. That expansion accelerated over the last two decades through acquisitions of companies like MinuteClinic, Caremark and Aetna that embedded CVS even more deeply into the U.S. healthcare system and communities across the country. Josh Flum has played key roles in CVS Health’s transformation and healthcare strategy for nearly 20 years. After Yale Law School and a few years as a white-collar criminal defense attorney in Washington, DC, Josh decided on a career change and landed a job at Boston Consulting Group where he first crossed paths with CVS. In this episode of Healthcare is Hard, Josh tells Keith Figlioli about one project at BCG where he was begrudgingly selected to spend two weeks virtually living at CVS pharmacies learning everything there is to know about how they operate. That assignment proved invaluable for the rest of Josh’s career. Since joining CVS in 2004, he has held several senior roles including leading pharmacy operations and overseeing Enterprise Product Innovation and Development teams. He also co-founded and leads CVS Health Ventures, and is currently CVS Health’s Chief Strategy & Business Development Officer.Josh and Keith covered several pressing topics during this Healthcare is Hard interview including: The next evolution in pharmacy. Josh talks about fundamental shifts in the pharmacy business that have occurred in his career and what he thinks is in store for the future. While the deeply personal connection between people, families and pharmacists has always persisted – and will be integral for the future – the pharmacy business has moved from being about medication fulfilment, to clinical pharmacy care including medication adherence, to other aspects of medical care such as testing and immunizations. Josh says the future will be about pharmacists practicing at the top of their license and balancing clinical care interventions with new technology and the consumer relationships that pharmacists have always maintained.The retail threat. Keith posed the same question to Josh that he asked Walgreen’s CMO on last month’s Healthcare is Hard episode: how should incumbent healthcare delivery players think about the emerging role of retailers? To Josh, it comes down to how a company fits into three trends: patient as consumer; care in community, home and virtual settings; and technology. Josh says CVS feels very well positioned to play a big role in the future of healthcare as these trends continue to evolve, while recognizing that the company still has much more to do and will need to work in partnership with the broader healthcare system to make the kind of change that is necessary.The flip side of innovation. Through his role at CVS Health Ventures, Josh sees many of the exciting developments that are going to make care easier and more ubiquitous, but sometimes wonders if the pace of advancement could overwhelm consumers. Putting himself in the consumer’s shoes, he says it’s all about trust. He believes consumers will turn to the people and organizations they know and trust to help navigate new experiences – organizations like CVS Health. For its part in the innovation ecosystem, Josh says CVS Health Ventures is currently focusing on investment themes including care delivery, consumer centric healthcare, whole person care and disruptive tech enablement that crosses all these domains.To hear Josh and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.

Since its first store opened in 1901, Walgreens has been embracing innovation in the retail pharmacy space, fueling its expansion to become a neighborhood health destination with more than 9,000 locations. As the healthcare industry navigates major structural changes – and a global pandemic – Walgreens is staying true to its roots of innovation and guiding what the future of healthcare looks like in America.Kevin Ban joined Walgreens as Chief Medical Officer in January 2020, and by the end of February was already being thrust into pandemic planning and response. In the short time since, he’s implemented guidelines to ensure customer and team member safety, launched and expanded COVID-19 testing services across thousands of stores, and rolled out COVID-19 vaccinations, all while focusing on Walgreens’ long term goals for the strategic role it will play in healthcare.During this episode of Healthcare is Hard, A Podcast for Insiders, Kevin draws on these experiences – as well as past roles including time spent as CMO at Beth Israel Deaconess Medical Center, CMO at AthenaHealth, and Professor at Harvard Medical School – in a wide-ranging discussion with Keith Figlioli. They touch on a number of topics including:Decades of VBC Lessons – While value based care in America is still in its early days, Kevin has been a student of value-based arrangements for two decades. He describes time he spent in Italy in the early 2000s where he was exposed to the single-payer model, and what he calls the epitome of value based care. For example, he remembers the Italian health system being exceptionally good at delivering care outside of the hospital in a way that the U.S. health system would have never imagined. He also talked about how that background prepared him to become involved with one of the nation’s first VBC experiments – Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract – at a time when his peers showed little interest. (for more on AQC, listen to the Healthcare is Hard Episode with Pat Gilligan, Chief Commercial Officer at BCBSMA)Pairing primary care and pharmacy. In his time at Beth Israel, Kevin says he was amazed at how often plans for patients fell apart because of the challenges with medication management after discharge. These experiences formed Kevin’s beliefs about the imperative for getting medication reconciliation right. He says that any time you can pair primary care and pharmacy together thoughtfully, it will drive better outcomes, and talks about different strategies for ensuring synergy in the future.Community care and retail’s role. Kevin knows how important the last mile of care is and says that connecting with people outside of the hospital was a continued source of frustration during his time at Beth Israel. However, that paradigm is completely different at Walgreens. People trust their pharmacist because they’re accessible and deeply knowledgeable, but overall, they’re an underutilized resource within the health system. While not long ago, it’s even difficult for Kevin to remember a time before pharmacies administered flu shots. And now, people go very comfortably to their local pharmacy for vaccines and testing, making them an important new site for primary care – just as Walgreens is delivering through its investment in and partnership with VillageMD.To hear Kevin and Keith talk about these topics and more, listen to this episode of Healthcare is Hard. 

Investments in digital health hit an all-time high in 2020, only to surpass the new record within the first six month of 2021. Needless to say, there’s never been more attention placed on digital health innovation. But it makes for a crowded market, putting providers and health system CIOs in a challenging position where it’s impossible to vet the wave of new technologies and determine what will really help reduce costs and improve care. For 25 years, KLAS has helped providers navigate the increasingly complex healthcare IT landscape through research that’s focused on amplifying their voice in the market. With a rigorous process of collecting and assembling feedback from the people who actually use healthcare technology, KLAS forces technology vendors to face, act on, and improve from critical feedback, and gives providers a venue to seek advice from their peers.In this episode of Healthcare is Hard: A Podcast for Insiders, Keith Figlioli talks to the CEO and co-founder of KLAS, Adam Gale. They discuss his firm’s role in the digital health industry over more than two decades, and touch on topics important for providers, vendors, investors and others playing a role in the industry’s future. They cover a number of issues, such as: The beginning of health tech innovation. KLAS was established at what might feel like the beginning of digital health innovation – even before Meaningful Use was implemented – but once again Adam feels like things are just getting started. He talks about being in the right place, at the right time, to be a trusted voice during the nationwide rollout of electronic health records, and the uncertainty KLAS felt for the future once EHRs were in place. But he also talks about how being at the front edge of technology right now reminds him of those early days, and the limitless possibilities that lie ahead.Forcing change through public policy or private markets. Touching on a theme from the last Healthcare Is Hard podcast with ONC’s Steven Posnack, Keith and Adam discuss the levers for implementing change in healthcare IT. Adam shares a conversation he once had with Secretary for Health and Human Services, Mike Leavitt, where they both expressed envy for the other’s ability to help implement change. While Adam pictured government as a body capable of setting the course, Secretary Leavitt revealed how difficult this actually is. A slight move in any direction, according to Leavitt, creates waves of pushback from multiple angles. But as a private organization with influence over both vendors and providers, KLAS is in a unique position to drive change and improvements across the industry.Advice for entrepreneurs. Adam shares insights throughout the interview that are valuable for digital health startups and entrepreneurs, while providing direct advice at times too. For example, he talks about the strategic importance for early-stage companies to invest in their first customer relationships to develop one or two health system customers that will become good references. He says this might be a slower path to success, but stresses the power that word-of-mouth has in the healthcare industry and how this approach builds real value.To hear Adam and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.

The accelerated pace of innovation in digital health, record-breaking investments in the sector and even some of the technology developed to navigate the pandemic wouldn’t have been possible without groundwork laid by The Office of the National Coordinator for Health Information Technology (ONC). And there’s probably no one who understands ONC’s past, present and future role better than Steve Posnack.Steve is a fixture at ONC, joining a year after it was formed in 2004 and serving for the past 16 years in various capacities through four administrations. Since 2019, Steve has served as Deputy National Coordinator, playing an integral role in policy development, technology initiatives and investments, budget prioritization and industry-wide coordination.In this episode of Healthcare is Hard, Steve gives a background and history of ONC, explaining how it fits into the Department of Health and Human Services and the overall role it plays in the federal government. He shares insights that anyone in the healthcare innovation ecosystem should understand and his conversation with Keith Figlioli covers a number of topics including:Wins and regrets of ONC. As someone who has been at ONC for nearly its entire history, Steve has a rare vantagepoint to reflect on initiatives that have gone smoothly and lessons-learned for those that haven’t. For example, he discusses successes and challenges of Meaningful Use, recognizing its imperfections, but all the innovation that it made possible as well.Cybersecurity in healthcare. Steve entered ONC after earning a dual master’s degree in cybersecurity and health policy from Johns Hopkins University, giving him a unique skillset to address the security issues with healthcare IT that are becoming increasingly more critical. He talks about the need for better cyber hygiene industry-wide and shares thoughts about meeting that goal. But he doesn’t predict any federal mandates for security in the near future.Improving data quality. According to Steve, poor data quality is a sore point for public health professionals and an area where the private sector can help in order to benefit everyone. He says the people tasked with tracking and consolidating data spend precious time doing “data detective work,” and it’s been especially challenging through the pandemic. This requires looking upstream to know where data is coming from and where it’s going to figure out how gaps occur and how to address them.The future role for ONC. Taking all of ONC’s accomplishments into account, Keith and Steve discuss if there’s more work to be done, or if the public sector should start taking over. From Steve’s perspective, there’s a lot for the private sector to build on, but he also says there’s a lot the industry is still asking ONC to push forward. As just two examples, he talks about how work around the social determinants of health and the convergence of clinical and research operations still need broader coordination.To hear Steve and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.

In the United States, more than 90% of the landmass is rural. And in rural communities from coast to coast, the challenges in delivering healthcare can be very different than the urban and suburban centers that get most of the attention.There’s untapped opportunity in reimagining healthcare business models and the technology that will enable them in rural areas, according to Ballad Health CEO, Alan Levine. And he should know – in the three years since Ballad was formed by merging Wellmont Health System and Mountain States Health Alliance, it has had exceptional success rewriting the rules of rural healthcare.Among some of its visible and measurable improvements, Ballad Health has decreased pricing by an average of 17% for urgent care and other physician-based services, cut its mortality rate for trauma in half, reduced low acuity admissions by 16,000 per year, and saved the region in which it operates more than $200 million per year in healthcare costs. And it’s doing this with only a 20% commercial payer mix.In this episode of Healthcare is Hard, Alan talks to Keith Figlioli about how Ballad Health is achieving these milestones by better understanding the dynamics of rural healthcare and making big structural changes to address them. He shares specifics about many of the changes Ballad has already implemented and his plans to continue down this revolutionary path. Their conversation covers topics including:Trading competition for regulation. In the areas of Tennessee, Virginia, North Carolina and Kentucky where Wellmont and Mountain States operated, only 50% of hospital beds were occupied and rates were declining. To survive and give it stability, Wellmont looked to be acquired by an outside system, until Mountain States stepped in with a unique solution to merge. But the FTC opposed the merger every step, forcing legislation in Virginia and Tennessee followed by approval from both states’ governors, attorneys general and health commissioners. Against significant odds, the merger was approved with Ballad agreeing to cap pricing and price increases at a rate well below the hospital consumer price index (CPI).Eliminating duplication. Many of the structural changes at Ballad Health revolved around reducing duplicate services. Intense competition between Mountain States and Wellmont forced one system to always keep up with the other. As a result, a small town like Greenville, TN had two hospitals a little over a mile apart which had both lost $70 million at 30% capacity in the years leading up to the merger. One of Ballad’s key goals is to implement a more rational approach and business model that makes sense for rural areas.Transforming from hospitals to health improvement. While reducing duplication, Ballad is thoughtfully applying the resources it saves to improve the health of its communities upstream. For example, in one region where it consolidated hospitals, it converted one building into a residential facility for women who are pregnant, homeless, drug addicted or have other needs. It gives these women housing security, food security and resources to help ensure their babies are born into a healthy situation.The new competitive landscape. Alan says his biggest competition is no longer the health system or physician group down the street. It’s the tech-enabled company across the country or a retail chain that could provide primary care. And unlike health systems in urban areas that can offset the loss of a patient with populated growth, there’s nothing to replace that loss in a rural area. This is why technology will play a significant role in the transformation of rural healthcare.To hear Alan and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.

Dr. Farzad Mostashari’s extensive resume doesn’t fully convey the true value he brings to reimagining healthcare. He’s the former National Coordinator for Health IT at the Department of Health and Human Services, served as assistant commissioner at the New York City Department of Health, was an Epidemic Intelligence Service officer at the CDC, a fellow at The Brookings Institution and a resident at Mass General Hospital. Yet, with all that experience, he says living through the Iranian revolution before moving to the U.S. at age 14 is what fuels his ability to see things differently.As he told Keith Figlioli, “seeing an actual revolution does something for your sense that things can change; that you can be looking at one reality one day, and a different reality the next day.”In this episode of Healthcare is Hard, Farzad talks about how he’s never been totally comfortable inside – or even leading – the grand institutions he’s been part of, and at some level, has always felt like an outsider. He describes his ability to see the insider and outsider perspective, his natural disposition to see things differently, and how this trait led him to found Aledade.Most of the industry looked at the Medicare Shared Savings program in the Affordable Care Act and assumed that hospitals needed to be at the center of creating and sharing in savings. But after noticing the law didn’t require a hospital, Farzad began building a network of primary care doctors who could treat people upstream, reduce hospitalization and lower costs.Seven years later, Aledade has assembled 800 practices in 35 states and has $12.5 billion in annual medical spend under management. It’s helping independent physician practices deliver better care, reduce overall costs and preserve their autonomy in communities all across America.Farzad brings his outsider mentality and inclination to see things differently to his conversation with Keith Figlioli on this episode of Healthcare is Hard. They cover a number of topics including:Dis-economies of scale. Farzad talks about how healthcare is one of the few industries where organizations tend to lose money as they get bigger, and how it all maps back to fee-for-service. The main driver of consolidation in healthcare has been the need to build leverage at the negotiating table. But he says if you change the rules of game – including what’s being valued, rewarded, and compensated – you actually see that the small guys do better.Independent vs. Institutions. Farzad sees this as a proxy battle. He says if you’re betting fee-for-service will be the future of healthcare, bet on consolidating health systems. But if you’re betting on value, bet on the independents.Trust in policy makers. As someone who has lived on both the public and private sides of healthcare, Farzad sees that many people in the private sector are highly skeptical of healthcare policy makers. But in his experience, smart policy makers are motivated by evidence and doing the right thing to help improve care and lower cost. He says leaders in the private sector who understand this are in a better position to navigate the potential regulatory risk impacting their business.A decade of vision driving real value. It’s taken a long time to build much of the infrastructure that started under Farzad’s leadership at ONC almost ten years ago. And now, the combination of new incentives with data-driven capabilities the industry has talked about for a long time are very real. These elements have already created billions of dollars in value that couldn’t exist before, and that impact will continue to multiply.To hear Farzad and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.

Dr. Sachin Jain says he got a silent education about healthcare and medicine around the dinner table from his father, an anesthesiologist and pioneer in pain management. But he still wasn’t sold on a career in healthcare until the end of his junior year at Harvard when he took a course on the quality of healthcare in the U.S. taught by Dr. Howard Hiatt and (one of this podcast’s first guest) Dr. Don Berwick.That decision kicked-off a career where Sachin has packed experience from nearly every angle of the healthcare industry into the last 20 years. Immediately following his junior year at Harvard, Don Berwick offered him a summer internship with the Institute for Healthcare Improvement (IHI) working on its Pursuing Perfection Initiative. This provided an opportunity to visit and study the nation’s best health systems at Don’s side and opened the door to a tremendous network of national healthcare leaders.A few year later, Sachin landed in Washington, DC as Special Assistant to the National Coordinator for Health IT during the Obama Administration and then Senior Advisor to the CMS Administrator (his mentor, Don Berwick). He then jumped back to the provider side as a resident at Brigham and Women’s Hospital in Boston for four years, before seeing healthcare through the pharmaceutical lens as Chief Medical Information and Innovation Officer at Merck. In 2014, he was recruited to the west coast by Anthem Blue Cross Blue Shield, where he was CEO of its subsidiary, CareMore Health, a care delivery system for Medicare and Medicaid patients, and CEO of Aspire, a large palliative care provider that was acquired by Anthem in 2018.In July 2020, Sachin became CEO at SCAN Health Plan, a non-profit founded as the Senior Care Action Network in the late 70s that’s now a Medicare Advantage HMO with 220,000 members and revenues over $3.5 billion.At SCAN, Sachin has continued his commitment to disrupting the status quo in healthcare. On this episode of Healthcare Is Hard, he discussed many of his ideas with Keith Figlioli, including:Making hospitals less necessary. A few years back, Sachin was in the running to lead a nationally-known integrated health system and laughs at himself when he thinks of his final pitch to the board. He argued for revenues to go down, fewer beds and facilities, less fee for service revenue, and more risk-based revenue. While he fully understands how this goes against everything driving health systems for the past two decades, it aligns with his fundamental belief that healthcare needs to focus more intensely on outpatient management of people with chronic diseases to keep them out of hospitals as much as possible.Medicare advantage as a blueprint of Medicare for all. Sachin says he doesn’t think Americans trust the public sector to fund and provide healthcare, but he believes people could get behind healthcare that is government funded and privately delivered. With elements like a coordinated network, transparency around quality, incentives for consumer experience, and rewards for higher participation, he believes MA could be a solution to full coverage.Islands of innovation. While Sachin sees lots of creativity and reinvention around individual verticals and addressing single diseases, he’s frustrated with the lack of connective tissue between them and thinks this will get worse before it gets better. He says the next phase will have to be focused on connecting all these pieces to treat the full patient and that it will be incumbent on private markets to think creatively about deal structure to incentivize it.To hear Sachin and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.

Improving patient experience has been a driving focus for Winjie Miao during her twenty year career at Texas Health Resources, where she’s now senior executive vice president and chief experience officer. Texas Health cares for more patients in North Texas than any other provider through 350 access points including 27 hospital locations and a network of outpatient facilities, Neighborhood Care & Wellness Centers, preventive and fitness services, and home health services.After joining Texas Health, Winjie spent 15 years in hospital operations – first at one of the system’s largest hospitals and then at its smallest. She then embarked on a unique opportunity to build a new hospital where she planned, implemented and piloted new technology in a way that wouldn’t have been possible at an existing hospital campus.In 2015, Winjie joined Texas Health’s executive leadership team and a year later played a significant role developing its 10-year strategic plan, Vision 2026, which made patient experience a central focus. In three phases, Texas Health planned to understand everything it could about healthcare consumers, build new capabilities to activate consumers, and finally capture value for both consumers and the health system itself.Nearly halfway through its strategic plan, Texas Health had already piloted virtual primary care by the beginning of 2020 and planned a phased rollout through the rest of the year. Then COVID hit.In this special episode of Healthcare is Hard, recorded as part of the Digital Health Innovation Summit (DHIS) Virtual Spotlight Series, Winjie talks to Keith Figlioli about what Texas Health has learned through this process and how she sees the future of home health unfolding. Their conversation covers a number of topics, including:One giant pilot. While Texas Health was well on its way to piloting and implementing options for virtual primary care at the beginning of the pandemic, Winjie talks about how the first two or three months of going almost entirely virtual were still a huge learning experience. She says it forced significant changes from the original plan.Barriers to integrated virtual care. When it comes to telehealth, Winjie sees it becoming an integrated part of the care workflow within the next three years, but she discusses internal and external barriers to overcome first. These include ensuring that equal reimbursement rates for in-person and virtual visits remain permanent, and determining where new business units or processes need to be newly created, and where old ones can be adapted.A thoughtful and measured approach. Winjie points out the importance of recognizing that home health is right for certain groups, and not for others. Without reliable internet, the ability to connect multiple at-home remote monitoring systems, a support system or family member who can be there and be part of the care team, and other essential variables, home health is not the best form of care for many people. But it is absolutely the best place for others, and that determination needs to be made in a very deliberate and pragmatic manner.A fast start, but long road to home health. Many people, both inside and outside of the healthcare industry, look at the progress that’s been made due to the pandemic and think telehealth has arrived. But Winjie talks about all the work that still needs to be done, especially when it comes to connecting different types of virtual care platforms that have all matured at different rates. She says connecting them in a way that’s meaningful for the patient and the care giver is still a few years away.To hear Winjie and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.

Last year tested nearly every aspect of the healthcare system, making the 2021 J.P. Morgan Health Care Conference like none other in its 39-year history. But there’s at least one constant from the past few years – the insight Dan Michelson, CEO at Strata Decision Technology, offers in the recap he writes for Becker’s Hospital Review.With a customer base that includes 2,000+ hospitals and 400+ healthcare systems, about half of all U.S. healthcare flows through Strata’s financial analytics and performance platform. Needless to say, this gives Dan a unique vantagepoint to observe and add context around the discussions healthcare’s most influential leaders have at JPM every January.Dan’s biggest takeaway this year? While the pandemic stretched providers to the limit – placing extreme demand on care delivery and untold pressures on their financial stability at the same time – the system proved that it’s too vital to fail. But If providers want to be able to say the same thing ten years from now, they’ll have to look and operate much differently than they do today.Just like last year, Dan talked to Keith Figlioli for a special Healthcare is Hard episode where they dissect the ideas from JPM that set the stage for the months and years ahead. They talked about what was lost and gained by holding the event virtually, but more importantly, what they took away that will help health systems – and everyone that supports them – build back stronger. Some of the topics they discussed include:The Mindset for 2021. Everyone thinks the future is hard to predict, but at this point in healthcare, Dan says it really isn’t. Strata has been working with a cohort of about 50 health systems throughout the pandemic to study patient volumes and utilization, publishing findings every two weeks that have become a monitor for the financial and operational impact of Covid-19. Based on the data, he expects volumes in 2021 to remain at their current levels (which are down across the board from 2019) through most of year and begin to pick back up in the fourth quarter. He says the mindset health systems have this year is to “keep it going as best we can” and that 2022 will be the year they expect a return to “normal.” Proving the Payvider Model. As the disconnect between payer and provider continues to cause frustration for consumers, integrated models that align incentives have provided relief, offering a better experience at a lower cost. And the financial stability that integrated systems experienced through the pressures of the pandemic offered another very important proof point for the future of the payvider model. Dan points to Intermountain Healthcare – and former Healthcare is Hard guest Bert Zimmerli – as an example to emulate. The Year of Digitizing Operations. Dan expects to see a very big swing back to managing costs and driving productivity through automation and digitization in 2021. There was no time to worry about cost last year, but as volume remains low and the payer mix impairs profitability, innovation and efficiency are coming back into focus.Following the Money to Home Health. Out of necessity, the pandemic pushed home health and telehealth years ahead of where they would otherwise be. But Dan talks about how health systems won’t maintain their support for home health unless financial incentives align. The speed with which this shift happens will depend largely on CMS taking the lead and putting the right incentives in place.To hear Dan and Keith talk about these topics and more, listen to this episode of Healthcare is Hard.&a

Before the term Value Based Care existed, Blue Cross Blue Shield of Massachusetts (BCBSMA) unveiled one of the nation’s first risk-based payment models – its Alternative Quality Contract (AQC). Patrick Gilligan joined BCBSMA in 2007 to oversee the AQC’s rollout after spending nearly 14 years negotiating contracts on the provider side at Partners Healthcare (now Mass General Brigham). He left BCBSMA for a three year stint at CVS, where he led health system alliances, and is now back at Massachusetts’ largest private insurer as chief commercial officer where he is responsible for all market-facing functions for the health plan and its 2.8 million members.This episode of Healthcare is Hard taps into Pat’s unique view of the healthcare market that spans payer, provider, and pharmacy/PBM. He talks to Keith Figlioli about the market factors influencing the cost and quality of healthcare, and shares a payer’s perspective on current challenges and the path ahead. They dive into a number of topics including: The downstream impact of deferred care: While the COVID-19 economy translated into nationwide job losses – and therefore a reduction in BCBSMA’s membership – the slowdown in elective services is the more challenging, complex, and long-term issue for payers. Like many other payers, BCBSMA issued rebates to its customers and members in 2020 as a result of lower than anticipated health care costs during the COVID-19 public health emergency. Pat talks about the necessity of managing risk over the long term and the expectation for higher future costs that all payers will have to navigate.Elements of VBC success: When Pat first joined BCBSMA to introduce the Alternative Quality Contract (AQC) to providers, he insisted on sharing both upside and downside risk from the outset. Pat credits the universal approach to risk sharing as an element of AQC’s success. He also points to the long-term nature of the contracts BCBSMA offers to providers. A traditional one- or two-year contract can make it difficult for providers to fundamentally change their business – particularly as government rules change – so BSBSMA has entered into three-, five-, and even seven-year AQC agreements. Lastly, he talks about the importance of sharing data, identifying gaps in care, and truly working together once payer and provider interests are aligned.Unintended consequences of integrated models: As the lines blur between payer and provider, Pat warns of the potential for losing sight of the mission to improve affordability and quality. He uses pharmacy benefits managers (PBMs) as an example, and how a company like CVS which is traditionally a pharmacy that now operates an integrated model, will make more money prescribing than managing care. He talks about being careful to not deviate too far from what the expertise of a health plan should be and always focusing on the best interest of employers and customers.The end goal of experience: Throughout the conversation, Pat returns frequently to the theme of patient/member experience. He talks about driving better experiences through deeper partnerships and how every player in the market offers something important. This includes payers and providers recognizing each other’s core competencies, but also considering where consumer-savvy and digital-first managed care providers are trying new approaches that everyone can learn from.To hear Patrick and Keith talk about these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.