Relentless Health Value

You would think that hospitals with the most money would offer the most charity care—trickle down and all of that. If my health system is big and I have lots of money and profitable commercial patients, I can stuff more dollar bills into the charitable donation balance sheet bucket, right? Except, in general, it’s a fairly solid no on that. Let’s talk about some of my takeaways from the conversation that I had with Vikas Saini, MD, and Judith Garber from the Lown Institute. During the conversation, there’s also mention of a powerhouse of a New York Times article. So, let’s circle up on but a few of the more interesting (according to me) reasons why some rich hospitals fail to offer the level of charity care that you might think they could or should: #1: Chasing commercial contracts because they are very profitable means building in areas where there are frankly not a whole lot of poor people. You see hospital chains doing this all of the time and saying at the 2023 JPM (J.P. Morgan) conference that they intend to do more of it, opening up in a fancy suburb with no affordable housing. When this happens, there is just less opportunity to offer charity care. The need for financial aid in that ZIP code is just less. #2: The Ambulatory Surgical Center (ASC) movement, which is weird to say because, in other respects, I’m a big fan. There are a lot of services and surgeries moving out of the hospital into ambulatory surgical centers or just the outpatient setting, and this is going on for a bunch of reasons, including Medicare and employers being very on board with this to save facility fees. But here’s a consequence: Surgeons and other docs are now not in the hospital. So, indigent patient shows up in the emergency room and needs an emergency surgery or some intervention. But wait … those physicians and their teams are no longer in the hospital. And now the hospital doesn’t have the “capability or the capacity” to serve that patient. I heard from a surgeon the other day, and when he’s on call at his hospital, he’s getting patients shipped to him on the regular from hospitals in other states. Now, about this “oh, so sorry … we can’t possibly help you so we’re gonna stick you in an ambulance and take you to another state” plan of action. I called up emergency room expert Al Lewis. He told me that if this “ship ’em out” is being done routinely as a pattern by hospitals who have an ER, you could call it evidence of an EMTALA (Emergency Medical Treatment and Labor Act) violation on several levels. You can’t have an emergency room and then routinely not be able to handle emergencies, especially when the emergencies you can’t handle always seem to be of a certain kind and for a certain kind of patient. Speaking of violations, one more that reduces the need and level of charity care is canoodling with ambulance companies to take the poor people to some other hospital and the rich people to your hospital, which was allegedly transpiring in New Jersey, based on a recent lawsuit. #3: [play some foreboding music here] This last one is the big kahuna underlying reason why some very rich hospitals may not offer the level of charity care which you’d think they would. This was superbly summed up by Tricia Schildhouse on LinkedIn the other day. She knew a physician leader who would go around saying, “Non-profit and for-profit is a tax position, not a philosophy.” Bottom line, this whole thing boils down to what has been normalized as OK behavior at some of these rich hospitals. You have people in decision-making roles taking full advantage of their so-called tax position to jack up their revenues—revenues which they have no interest in frittering away on charitable causes. Why would they do that when they can use the money to, I don’t know, stand up a venture fund or make Wall Street investments? Don Berwick’s latest article in JAMA is entitled “The Existential Threat of Greed in US Health Care.” And, yeah … exactly. Back to that New York Times article that we talk about in this healthcare podcast, here’s what it says about a hospital in Washington State. It says: “The executives, led by [the hospital’s CFO] at the time, devised … a program called Rev-Up. “Rev-Up provided [the hospital’s] employees with a detailed playbook for wringing money out of patients—even those who were supposed to receive free care because of their low incomes.” All of this being said, there are hospitals out there who are, in fact, living up to their social contract and serving their communities well with very constrained resources. You also have hospitals just in general working within some really whack payment models that we have in this country, which easily could be a root cause precipitating this suboptimal-ness. Dr. Saini and Judith Garber mention three direct solves for hospital charity shortfalls and also the larger context of the issue. So, there’s, of course, better reporting and better auditing, which is pretty nonexistent in any kind of standardized way right now. I also really liked one of the solutions that Dr. Saini mentions on the show: Maybe instead of all the hospitals doing their own charity care thing, they all should pool their money regionally and then put a community board in charge of distributing it. That way, if there is a hospital in an area where the charity care is really needed, even if the rich hospital nearby doesn’t have a facility there, they can help fund this care that their larger community really needs—including, by the way, public health needs, which is currently a big underfunded problem. As mentioned earlier, I am speaking with Vikas Saini, MD, and Judith Garber. Dr. Saini is president of the Lown Institute. Judith Garber is a senior policy analyst there. They’ve studied hospitals from a number of dimensions, not just charity care.   You can learn more at lowninstitute.org and lownhospitalsindex.org.   Vikas Saini, MD, is president of the Lown Institute. He is a clinical cardiologist trained by Dr. Bernard Lown at Harvard, where he has taught and done research. Dr. Saini leads the Institute’s signature project, the Lown Institute Hospitals Index, the first ranking to measure hospital social responsibility. The Index, first launched in July 2020, evaluates hospitals on equity, value, and outcomes and includes never-before-used metrics such as avoiding overuse, pay equity, and racial inclusivity. In his role at the Lown Institute since 2012, Dr. Saini led the development of the Right Care series of papers published by The Lancet in 2017, convened six national conferences featuring world-renowned leaders in healthcare, and guided other Lown Institute projects such as the “Shkreli Awards.” Dr. Saini also serves as co-chair of the Right Care Alliance, a grassroots network of clinicians, patient activists, and community leaders organizing to put patients, not profits, at the heart of healthcare. Prior to the Lown Institute, Dr. Saini was in private practice in cardiology for over 15 years on Cape Cod, where he also founded a primary care physician network participating in global payment contracts. He also co-founded Aspect Medical Systems, the pioneer in noninvasive consciousness monitoring in the operating room with the BIS device. Dr. Saini is an expert on the optimal medical management of cardiologic conditions, medical overuse, hospital performance and evaluation, and health equity. He has spoken and presented research at professional meetings around the world and has been quoted in numerous print media, on radio, and on television. Judith Garber is a senior policy analyst at the Lown Institute. She joined the Lown team in 2016, after receiving her Master of Public Policy degree from the Heller School of Social Policy. Her research interests include hospital community benefit policy, overuse and value-based care, and racial health disparities. She has authored several white papers, journal articles, op-eds, and other publications on these topics. Judith previously worked at the Aspen Institute Financial Security Program, the Midas Collaborative, and Pearson Education. She has a bachelor’s degree in American studies and political science from Rutgers University.   06:50 Why does America need socially responsible hospitals? 08:23 What standards are hospitals beholden to with their charitable spending? 08:47 “It’s the honor system, essentially.”—Dr. Saini 11:38 What is fair share spending? 13:43 Which hospitals are paying their fair share? 15:05 Why do hospitals that are financially more strapped tend to give back to their communities more? 17:25 Why is it hard for hospitals with the most privately insured patients to do the most for their community? 18:56 “These outcomes … are the outcomes of the [current system].”—Dr. Saini 21:23 “A key problem here is [that] systems have gotten so big.”—Dr. Saini 22:30 What’s the solution to fixing the problem with hospital charity care? 23:52 EP374 with Dave Chase. 29:21 What would be the level of acceptance with changing the system as it stands with hospitals?   You can learn more at lowninstitute.org and lownhospitalsindex.org.   @DrVikasSaini and @JudiTheGarber of @lowninstitute discuss #hospitalcharitycare on our #healthcarepodcast. #healthcare #podcast #hospitals Recent past interviews: Click a guest’s name for their latest RHV episode! David Muhlestein, Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari  

Hey, thanks so much to kwebs14 for your super nice review on iTunes the other day. Kwebs wrote: [I have] learned so much, shared so many episodes with colleagues, clients … and gained so much value from regularly listening to [Relentless Health Value]. … Thank you … for providing the platform for so many that believe that we can consistently do better in healthcare. Thanks much for writing this. I think our Relentless Tribe is a unique group, and every day of every week I admire your willingness to hear some things that might be pretty hard to hear because they may hit pretty close to home. Dr. Benjamin Schwartz was talking about the podcast on LinkedIn the other day, and he said he doesn’t always agree with guests or the discussion but he always learns something and each episode stimulates and challenges his thoughts and opinions. Yes … to all of this. This is our goal in a nutshell: to help those who want to do better in healthcare to have the insight, the information, the other side of the story, the differing opinion, whatever you need to conceive of the action that you want to take. So, thank you so much to everybody who listens. You are the ones who are going to make a difference, and I thank you from the bottom of my heart for doing what you do every day for patients and communities. Alright, so in this healthcare podcast, we are going to answer an FAQ—a listener question I have gotten a lot lately in various forms. Let me common denominator the inquiry: What does it mean to be clinically integrated, and how does a provider organization/practice/CIN (clinically integrated network) know if they are actually clinically integrated or not? Also, the corollary to this question, which is how do CINs—or anybody, really—know if they are clinically integrated enough to start thinking about taking on downside risk? I asked David Muhlestein this question, and then we talk about his answer for 25 minutes. So, like most things in healthcare, it is filled with nuance; but if I was going to oversimplify his answer in one sentence, it’s this: Did the practice change how they are practicing medicine in order to drive predetermined outcomes? This is the litmus test for whether care is integrated. Did practice patterns change within participating entities from whatever they were before to a new way of working? Did the team(s) reorient with a goal to attain some documented patient outcomes, be those outcomes patient satisfaction and/or clinical endpoints and/or functional endpoints? If no sort of fundamental change happened, probably it’s a no on the clinical integration question. Another litmus test question I’ve also heard is this: Is the practice looking to get paid more for successes they’ve already had in upside risk arrangements with kind of little or no desire to transform the practice into a new practice model? If yes, then again, it’s gonna be a no on the clinical integration question. The thing is with all of this … well, let me quote Dr. John Lee, who said this pretty succinctly on LinkedIn recently. He said, “Downside risk fundamentally changes how you have to think as a physician and how you manage your patient cohort. You start thinking about team-based care and using analytics.” Yes … interesting. The point Dr. Lee is making — which is kind of inferred, actually, in the listener questions, so let me just state the obvious, which is so obvious it could easily be overlooked — if you are able to take on downside risk and succeed, you’re probably clinically integrated. If you’re not, you probably aren’t. Said another way (this might get a little chicken and egg-y), do you clinically integrate so that you can get the kind of risk-based contracts that enabled Iora, for example, to represent 5% of One Medical’s patient base and 50% of its revenue? I have heard similar profitability stories about ChenMed and Oak Street. They all have capitated downside risk accountable care contracts. And have you seen what some of their leadership teams are minting? Obviously, the capitated downside risk when you’re integrated gig can be highly profitable. But ... seems like also the community and outcomes are kind of great. Are they doing well by doing good? I’ll grant you I might be convinced based on what I’ve seen. Galileo is another one. Cityblock. But the fundamental question is, do you integrate first and then go after the contracts? Or is it best to wait until there’s a decent accountable opportunity on offer and then, sufficiently incented, change the practice? I do not know. I do know, however, what Scott Conard, MD, said in episode 391. I will poorly paraphrase. He said that if better patient outcomes are desired, there must be clinical integration and practice pattern changes. He said his practice went ahead and instituted these changes to improve patient care and did so within a pretty full-on FFS (fee-for-service) environment. My conclusion with all of this? It takes strong leadership with team-building skills and a strong family/community-centric mission to pull off a successful foray into accountable care with downside risk. These same talented and mission-driven leaders probably could manage to improve patient care and lower costs in an FFS environment as well. The converse of this is also likely true: Weak and ineffectual leaders can make a quadruple nothing burger mess in even the best VBC (value-based care) model. Yes … lots to unpack there. I am interested in your thoughts. In this episode, as mentioned, I am speaking with David Muhlestein, who is the chief research and innovation officer with Health Management Associates, or HMA. He has spent the past decade-plus studying ACOs (accountable care organizations) and value-based care, trying to understand what works, what doesn’t, and how you change the business models to be successful under these new models of payment. Here is a short version of David’s advice to clinically integrate and be ready for downside risk: ·       Step 1: Understand where you are—this includes doing a very clear-eyed self-assessment. ·       Step 2: Assess the needs of your patient population and focus on things where your capacity meets the needs of the population that you serve in the most impactful way. ·       Step 3: Take the outcome of step 2—which is basically whatcha gonna do to fix the most consequential problems that your patients have—and identify the processes by which you will do this. ·       Step 4: Do not boil the ocean. Start with a subset of patients and figure out the exact plan to do better to manage that population—easier said than done, of course. (Betsy Seals, by the way said something along these exact same lines in the shows giving advice to Medicare Advantage plans. And Karen Root [EP381] also alludes to something similar as she talks about how to socialize innovation. So clearly, this advice can be universalized.) You can learn more by emailing David at dmuhlestein@healthmanagement.com and by connecting with him on LinkedIn. David Muhlestein, PhD, JD, is chief research and innovation officer for Health Management Associates (HMA). He is responsible for the firm’s self-directed research and supports strategic planning and innovation. David’s research and expertise center on healthcare payment and delivery transformation, understanding healthcare markets, and evaluating how the broader healthcare system is changing. He is a self-identified data nerd and regularly speaks and writes about healthcare system evolution. David joined HMA via its acquisition of Leavitt Partners in 2021, where he was the chief strategy and chief research officer. Additionally, David is a visiting policy fellow at the Margolis Center for Health Policy at Duke University, adjunct assistant professor at The Ohio State University College of Public Health, and a visiting fellow at the Accountable Care Learning Collaborative. He previously served as adjunct assistant professor of The Dartmouth Institute (TDI) at the Geisel School of Medicine at Dartmouth College. David earned his PhD in health services management and policy, JD, MHA, and MS from The Ohio State University and a BA from Brigham Young University.   07:57 What does it mean to be clinically integrated? 10:23 How does changing practice patterns count as becoming clinically integrated? 11:11 How do you change the delivery of care to get better outcomes? 12:05 What does it mean to see better outcomes when becoming clinically integrated? 14:46 EP176 with Dr. Robert Pearl. 17:42 “Their structure is dictating what they are going to prioritize.” 19:02 “How do you care for the patients that have yet to come and see you?” 20:16 EP391 with Scott Conard, MD. 22:38 “When you’re integrated, you realize you’re not alone.” 25:50 Why does clinically integrating require a significant mindset change? 28:55 What does this country need to do from a policy perspective for this change? 30:24 EP326 with Rishi Wadhera, MD, MPP.   You can learn more by emailing David at dmuhlestein@healthmanagement.com and by connecting with him on LinkedIn.   @DavidMuhlestein of @HMAConsultants discusses #integratedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest’s name for their latest RHV episode! Nikhil Krishnan (Encore! EP355), Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375)      

This week, I am with my Aventria team on-site at one of our clients. We are holding a full-day workshop to help our client figure out who all across the healthcare industry they will need to get aligned with to achieve greater success in the market and how to handle all of these inevitably conflicting interests strategically and also potentially from a messaging standpoint. I’m one of the subject matter experts who gets to pipe up during the part where we talk about all of these market dynamics, what everybody is up to, and who is going to want what so the client team can do their thing and get paid for it. Anyway, I say all this to say that this week, I am pretty darn busy but also thrilled to encore this episode with Nikhil Krishnan, founder of Out-Of-Pocket, and one of our most popular episodes in the past 12 months. My guest in this healthcare podcast is Nikhil Krishnan, who is the founder of the Out-Of-Pocket newsletter. I was talking with Nikhil, and we identified—or, more accurately, he identified—five business models of digital health. What makes each model distinct is a few factors. If you weren’t in the healthcare industry, you’d probably expect that I’m going to say that the biggest factor a business model must hinge on must have something to do with patient outcomes or care or something that has something to do with the hopes and lives of patients. Except no. Mostly, our models do not define themselves by attributes of their patients, except on one dimension: who is paying their bills. Who is paying has enormous downstream consequences that I don’t think people outside of healthcare, or even people inside of healthcare sometimes, really appreciate. It’s because of all of the perverse incentives. It’s a tangled web we weave. For example, let’s just say you’re a start-up founder trying to cook up your unique selling proposition. You can’t just decide you’re gonna lower costs and improve patient care as general constructs. Because let’s just say you do that—that’s your USP (lower costs and improve patient care)—and then you try to sell your thing to Medicare Advantage plans or large provider organizations. Oh, right … Medicare Advantage plans or even commercial ones—they don’t care about the total cost of care. Neither do provider organizations unless they take on sufficient risk to care, and many do not. In fact, as came out in that JAMA article the other day, it could be construed that entities such as these carrier health plans have a perverse incentive to see total costs of care go up. So right, you naively (you’re the start-up founder again in this case study, don’t forget) trot into some administrator’s office with a great something or other to reduce total costs of care—and you’ll get cast out upon your petard on the quick. Every single day of the year in my world, I see people make this same mistake over and over again: not tailoring their product market fit to any particular market, with the recognition that some in this healthcare industry have a vested interest to see costs going up and some have a vested interest in costs going down. Either way, if we’re talking about large organizations here and even some small ones, the money wins over patient care. So sad to have to say that, but listen to EP351 with Dr. Eric Bricker and you’ll get all the context you need on that point. Here’s the thing, though. I don’t know about you, but I can’t tell you how many digital health start-ups I run across where I look at their decks or have a conversation with a founder, and I ask who their customer is. Is it employers or health plans or … ? And they don’t know. They’re gonna figure this out later. I don’t get how to successfully do that. I’m indubitably wrong here given all of the pivots I hear about that seem to go OK, but the prospect of completely redefining my operational goals and operations and market positioning at some point in the future seems like a daunting and avoidable prospect. I would be remiss not to mention, however, the number of really good mission-driven healthcare companies out there really trying hard to figure out how to create a sustainable business, a fair profit, while at the same time serving patients really well. There are companies adding value commensurate with the dollars that they come by, and I certainly applaud everything that they are doing. At the same time, given all this, here’s a message for all of you VCs and private equity etc—people with money—out there. Let me quote Dr. Vivek Garg here (@vgargMD on Twitter): “If you’re financing care delivery without board-level focus on clinical outcomes, you’re part of the problem.” So, let’s talk about these five business models that health and healthcare start-ups eventually settle themselves into after they figure out who their customer is. Nikhil Krishnan, my guest today, and I discuss how they can be financially viable and if we think they’ll actually be able to provide superior patient outcomes. [Trumpets play here] In no particular order, this is what we’ve got for our five business models: Completely avoiding incumbents, creating a cash-pay ecosystem Better middleware (being the pipes, as I’ve heard so many times these past couple of weeks) Companies serving incumbents either by being a virtual front door for them or disrupting the competitive landscape somehow Joint ventures Old-school digital health who are now incumbents in their own space My guest in this episode, Nikhil Krishnan, has a bunch of things going on. He might be best known for his newsletter, Out-Of-Pocket Health, which you should certainly subscribe to. He’s also working on a healthcare 101 crash course to teach newcomers about the Wild West we call American healthcare. Besides all of this, Nikhil does some early-stage investing. You can learn more at outofpocket.health and with Nikhil’s upcoming course. Nikhil Krishnan is the founder/thinkboi at Out-Of-Pocket, where he’s trying to make the business of healthcare more easily understandable and (hopefully) entertaining. He runs a newsletter (yes, yet another one) and an online healthcare community and does some digital health investing on the side. He’s “extremely online,” and you can find him firing off obscure healthcare memes plus the occasional insight on Twitter at @nikillinit.   06:20 What are the different models of digital health? 08:05 What are the different motives for cash-pay digital health models? 13:54 “One of healthcare’s original sins is that every solution deployed has been a custom solution for the end user.” 14:19 How willing will these companies be to share their data with third parties? 18:07 “I don’t think selling tech to large incumbents is going to move the needle.” 21:14 “These companies, most of them are actually getting extra money for the more expensive stuff.” 22:58 How did joint-venture digital health business models come about? 26:37 Why do you see partnerships more on the payer/provider side? 27:29 Who are the old-school digital health companies that could be considered incumbents? 29:36 Why do so many digital health start-ups have a hard time pinpointing who will pay for their services? 32:10 “The ability to go through the idea maze is way faster now.” 34:55 “The field is wide open to help teach people how healthcare works.”   You can learn more at outofpocket.health and with Nikhil’s upcoming course.   @nikillinit discusses #digitalhealth on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Emily Kagan Trenchard, Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase  

So, a few things to remind everybody. First of all, don’t forget EHRs (electronic health records) were purpose built originally for billing. This is no secret. People quite openly have called EHR systems glorified cash registers. If I want to be generous, maybe I would restate this to say that EHRs were designed to document patient interactions. This is what their core architecture was built to achieve. But today, there’s a lot that goes on that isn’t a traditional patient interaction. First of all, me even calling it, frankly, a patient interaction should give longtime listeners a clue where this is headed. I mean, say you’re sitting at home on your couch. I don’t know. You’re probably not considering yourself a patient. You’re considering yourself a person sitting on your couch. However, say you’re sitting on your couch and you haven’t taken your COPD maintenance therapy. Potentially that is something of clinical significance that maybe should get figured out and noted somewhere—potentially prior to the acute event going down. Or, still talking about things that are relevant to patient health but which don’t naturally tuck into an EHR system’s native architecture, maybe we have social workers and nutritionists and all kinds of people who are not doctors or nurses or PAs (physician assistants) in this mix. Most of the time, these people don’t even have access to the EHR. I mean, what percentage of things that are going to impact a person’s health outcomes can be classified as traditional patient encounters that EHRs were designed to document? I mean, you’ve got your scheduler who wants to tell the transportation company something about a patient. Anything RPM. Where’s the caregiver or the family in that garden-variety patient interaction? In sum, what is happening between codes getting written in patient health records? Where’s all that information going? I mean, what order set are you gonna use to get all that in and out of the system? Am I saying anything revolutionary that many of you don’t already know extremely well? No, I am not. But I am shining the spotlight on it to challenge what might have become a sort of default position at provider organizations today, which is to make the EHR the one ring to rule them all, which might be something to consider revising strategically. My guest in this healthcare podcast, Emily Kagan Trenchard, makes a super point about all of this that I haven’t heard made so succinctly or so eloquently. Emily puts it this way: She says just integrating into the EHR as a reflex without contemplation is kind of the olden days. She talks about identifying the core functionalities, the centers of gravity that are needed to bring together providers and patients and everybody else in the mix. Then you find the best systems—call them platforms if you want. But if, at a fundamental level, you have a technology designed for one thing and you’re trying to shoehorn it to do something else and this something else is a critical business function, maybe this is something to think about at the highest levels. Of course, it goes without saying that these platforms have to work together (obviously); but you kind of gotta get the right platform for the right job. Now, to make one point clear as glass, what we are not talking about here is cobbling together a bunch of point solutions. What we are talking about is getting the fundamentals, the core architecture here, solidified. Pam Arora talks about this at length in episode 246. She’s the CIO at Texas Children’s. Pam Arora says that if a health system doesn’t get its technology infrastructure rock solid, if that infrastructure is janky in any way, then everything built on top of it will require duct tape and workarounds and probably not go as well as planned. On the show today, Emily Kagan Trenchard continues that theme. She talks about the four platforms that she feels are very necessary to underpin or be the chassis to best support helping providers and others help patients and people in and out of the clinic. She calls each platform a tentpole. These four platforms are: The EHR A CRM (customer relationship manager). And, by the way, when Emily says CRM, she’s talking about more than software. It’s more like a philosophy or a whole approach around relationship building with patients/people/customers. A cloud platform for data and analytics A data exchange One last takeaway, for me at least. Emily has talked about two basic facts that inform her thinking: (1) Providers and patients alike are increasingly not tolerant of friction. (2) What is easiest is the most likely to happen. Something that we don’t get into in this show but certainly bears considering is the larger context here. Yeah, we got Amazon, we got Google—not only what they are doing alone but also what they are investing in. They have platforms that are purpose built to remove friction and to be really, really easy … one-click easy. So, let’s talk about the WIIFM (the “what’s in it for me?”) here for health systems to get a move on. When Merrill Goozner was on the show a few weeks ago (EP388), he says that when patients and employers and taxpayers start crying uncle on both healthcare prices as well as just bad friction-filled experiences and also when, at the same time, technology and new competitors move in on the supply side, he says what’s gonna happen then is older incumbents like hospitals could find themselves getting their lunches eaten. So, probably intuitively as well as intellectually, health systems really getting their technology clearly optimized to support their communities, their patients, and their providers might seem to be mission critical, especially as we contemplate the stuff that Mike Thompson was talking about in episode 389 about how there is increasingly data out there which identifies hospitals who are very inefficiently run. And so, if at a very basic level a hospital has misaligned tech that’s requiring a lot of workarounds and stuff, which is another way to say wasting a lot of staff time, having the right technology deployed in the right way will certainly ground efforts to be effective and also help compete with some of these lurking entities who are looking to take a piece of the $3 or $4 trillion healthcare industry in this country—of which hospitals account for something like $1 trillion. And as Eric Bricker, MD, says in episode 351, this is why hospitals have a big red target on their back. Also, I would be remiss not to mention that non–purpose-built, dare I say bad, technology causes bad clinician burnout, which causes bad turnover, which is really expensive. Arshad Rahim, MD, MBA, FACP, talks about this in episode 323. By the way, I interviewed Emily Kagan Trenchard at NODE.Health’s Annual Digital Medicine Conference in New York City this past December—always a great conference. Emily is SVP and chief of consumer digital solutions over at Northwell Health. Northwell, in case you haven’t heard of this health system, is very large: 21 hospitals, 850 outpatient clinics, 300,000 patients a year. Yeah, it’s big. You can learn more at northwell.edu and connect with Emily on LinkedIn. Emily Kagan Trenchard offers a unique perspective from within the American medical system: A spoken-word-poet-turned-healthcare-executive, she is on a mission to remix the human in healthcare, challenging entrenched assumptions about what it means to give and receive care in the digital age. As senior vice president, chief of consumer digital solutions, for New York State’s largest health system, Northwell Health, Emily leads teams that push the limits of how we use technology to make healthcare seamless and steeped in humanity while keeping the company competitive at a time of radical change. She is a big believer that innovation is an ongoing process, not just a box to check, and launched Northwell’s first UX department to ensure that patient perspectives and needs drove the design of digital tools and systems. Prior to joining Northwell, Emily led Web systems for New York City’s Lenox Hill Hospital, where she drove the development of many early consumer health tools, including the first-ever implementation of the Zocdoc scheduling platform for a hospital. Emily holds a master’s degree in science writing from Massachusetts Institute of Technology and a bachelor’s degree from the University of California at Berkeley.   07:55 How does customer digital solutions fit into the larger technology infrastructure in healthcare? 09:54 “Where else do you have centers of gravity that you should respect in the architecture?” 10:11 “There is a constellation of need here.” 11:51 “We interact with way more than just patients.” 14:28 “We have to be able to understand the network of relationships in a population.” 15:11 How do EHRs and CRMs interact as two tentpoles in healthcare? 17:32 “The question is, where does a human being work?” 19:54 How are patients staying on a nonfragmented care journey in a proactive way? 23:46 “Anybody who’s a consumer of our digital offerings has a relationship with us.” 29:33 “The medicine is being practiced not only on our physical bodies but on our digital bodies.” You can learn more at northwell.edu and connect with Emily on LinkedIn.   @ektrenchard of @NorthwellHealth discusses #EHRs and #CRMs on our #healthcarepodcast. #healthcare #podcast #EHR #CRM   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Scott Conard, Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373)  

On Relentless Health Value, I don’t often get into our guests’ personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here. Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point blank that Dr. Conard’s experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today. Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of the show. He says: So, this isn’t about punishing or blaming aspects of care that are being overrewarded today. It’s really about what’s the path forward for corporations, for middle-class Americans, and for primary care doctors who don’t choose to be part of a big system. We have to figure out how to solve this problem. I hope people don’t hear this and think that there are horrible people at some not-for-profit hospital systems, for example. There are some great people at not-for-profit health systems, but they have some really screwed-up incentives. A few notable notes from Dr. Scott Conard’s journey and words of wisdom that I will just highlight up front here: He says that as a PCP, you actually can produce high-value care in a fee-for-service model … if you think differently and you change practice patterns. I have heard this from others as well, including most recently David Muhlestein, PhD, JD, who says this in an upcoming episode. Now here’s a surefire way to fail at that, though: Be a physician who is getting asked to basically do everything a patient needs done alone and by themselves with little or no help and being told to do all of this within a seven-minute visit. This surefire way to not do well also could mean working on a team that’s a team in name only because it’s more of a marketing thing than an actual thing. As Dr. Scott Conard says later in this episode, healthcare organizations must embrace the art of medical leadership. So, I guess that’s a spoiler alert there. Another point that Dr. Conard makes very crisply toward the end of the show is that doctors can kinda get pushed and pulled around in this mix. You have docs just trying to provide good care, and they work for one entity that gets bought and now it’s some other entity … and what’s happening upstairs and the prices being charged or somebody somewhere deciding not to make prices transparent, or deciding to sue low-income patients for unpaid medical bills or what charity care to offer or not to offer. These are not doctors in clinics making these calls, and we need to be careful here not to homogenize what some of these health systems are choosing to do like some kind of democratic vote was taken by everybody who works there. Health systems, hospitals, are many-celled complex entities. And a third takeaway—there are a bunch of takeaways in this show, but a third one I’ll highlight here from Dr. Conard’s story—is the old fiduciary responsibility code word being used by health system administrators as a euphemism for strategies that might need a euphemistic code word because the strategy has questionable community benefit. In the case study that we talk about today, the local health system managed to raise healthcare spend in North Texas by $100 million year over year. Employers and employees in North Texas, communities, wound up paying $100 million more year over year in healthcare one particular year. This was prices going up. It also was removing a big systemic initiative to keep heads out of hospital beds. Reiterating here, we are not talking about doctors here particularly because, of course, the vast majority of doctors are trying to prevent avoidable hospitalizations. But suddenly in North Texas, physicians did not have the population health efforts and the team really standing behind them helping to prevent avoidable hospitalizations. That sucks for everybody trying to do the right thing, and, as has been said, burnout is moral injury in a cheap Halloween costume. Moral injury happens when you have good people, clinicians, doctors, and others who realize that what is going on, at best, is not helping the patient. You can learn more by emailing Dr. Conard at scott@scottconard.com. Scott Conard, MD, DABFP, FAAFM, is board certified in family and integrative medicine and has been seeing patients for more than 35 years. He was an associate clinical professor at the University of Texas Health Science Center at Dallas for 21 years. He has been the principal investigator in more than 60 clinical trials, written many articles, and published five books on health, well-being, leadership, and empowerment. Starting as a solo practitioner, he grew his medical practice to more than 510 clinicians over the next 20 years. In its final form, the practice was a value-based integrated delivery network that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the chief medical officer for a brokerage/consulting firm and an innovation lab for effective health risk–reducing interventions. Today, he is co-founder of Converging Health, LLC, a technology-empowered consulting and services company working with at-risk entities like self-insured corporations, medical groups and accountable care organizations taking financial risk, and insurance captives to improve well-being, reduce costs, and improve the members’ experience. Through Dr. Conard’s work with a variety of organizations and companies, he understands that every organization has a unique culture and needs. It is his ability to find opportunities and customize solutions that delivers success through improved health and lower costs for his clients. 05:26 What triggered Scott’s career journey? 06:02 What caused Scott to rethink what is good primary care? 06:42 Why did Scott realize that he is actually a risk-management expert as a primary care doctor rather than someone who treats symptoms? 07:56 Encore! EP335 with Brian Klepper, PhD. 08:24 How did Scott’s practice change after this realization? 08:35 What is a “Whole-Person Risk Score”? 09:39 Scott’s book, The Seven Numbers (That Will Save Your Life). 11:37 “You start to move from a transactional model to a relationship model.” 14:02 Did Scott have any risk-based contracts? 14:39 Why is it so important to look at total cost of care and not just primary care cost? 19:39 Scott’s book, The Art of Medical Leadership. 20:44 EP381 with Karen Root. 29:14 Why did Scott move over to help corporations? 31:42 EP364 with David Muhlestein, PhD, JD. 32:22 “Everybody thought they were honoring their fiduciary responsibility, and the incentives are completely misaligned.” 33:02 EP384 with Wendell Potter. 33:15 “It’s the system that’s broken; it’s not bad people.” You can learn more by emailing Dr. Conard at scott@scottconard.com. @ScottConardMD discusses #privateequity on our #healthcarepodcast. #healthcare #podcast #PCP #patients Recent past interviews: Click a guest’s name for their latest RHV episode! Gloria Sachdev and Chris Skisak, Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372)    

If you go to the Sage Transparency dashboard Web site, you get a really graphical representation of the prices that any given hospital actually needs to charge so that they break even. You can see precisely which hospitals are operating on thin margins and which ones are not. You might be thinking, “Okay, so ... what’s the big deal about this? Why is the Sage Transparency information so meaningful? Aren’t hospitals (most of them) providing their financial statements already?” Well, let’s discuss. First of all, we have the main hospital lobbying organization coming out with press releases such as this one saying (here’s some quotes): “Hospitals have incurred serious losses …” “The vast majority of America’s hospitals [are] in serious financial jeopardy …” Combine quotes like these (and there are many) with some of the funny stuff going on in some (not all) hospital financial reporting—like counting investment losses from their venture funds, not counting endowments or their big trusts in the math, paying C-suites way more than the average doctor or worker, or all of the varied things that get counted or overcounted as charity care or community benefit—yeah, these hospital balance sheets are too often as much of a PR campaign as the PR campaigns. When you dig into them, you find some very wealthy organizations dressing up in Tiny Tim Cratchit pants and leaning on a crutch … at least whenever the cameras are rolling. So, where are patients in all of this? Chris Deacon linked to a Qualtrics study recently. It seems that in 2020, 48% of people deferred care as a result of the pandemic. In 2022, 43% deferred care because of cost—48% from the pandemic, 43% deferred due to cost this past year … wow! There are patients saying, “Hey, I have this giant thing growing on my arm. Is it melanoma? I don’t know, but I do know if I go to the doctor, I’ll be $600 in the hole … so I’ll wait.” It doesn’t matter how many medical advancements are made when almost half of the patients are making decisions like this, including patients with so-called “good” insurance. Look, no one would or is arguing that hospitals aren’t vital. They are essential. Hospitals can be amazing places where lives get saved. Amazing doctors and clinicians work in hospitals. But putting everything I just said together, let me summarize a textbook hospital chain one-two punch. The halo effect many hospitals enjoy is massive, and those administrators who choose to can take advantage of that halo for financial gain. When hospitals’ administrators cannot manage to curtail their own spending and then demand that their communities foot the bills, then the good that a hospital can do starts to go bad. If you are a legislator, you might want to be paying attention to all of this. And when I say might be wanting to pay attention, I mean pretty much you want to be paying attention to all of this. With all of the data that is now available to especially more sophisticated employers, some companies are not building offices or plants in areas which are known to have healthcare prices that are multiples over what they should be. That might be in your legislative district or state. Healthcare prices can be the largest cost for employers after payroll. Starbucks famously spends more on healthcare than they do on coffee beans. Nearly 8 of 10 employers considered healthcare costs a significant threat to affordability. So, too high hospital prices are a community problem at the chamber of commerce as well as at the family and the patient level. After you listen to this show, go back and listen to the one last week with Mike Thompson (EP389) if you haven’t already. It adds some context that you might want to have. Also stay tuned for a show coming up where we talk about just all of the anticompetitive stuff that some of these hospital system administrators have decided to subject their communities to. In this healthcare podcast, I have two titans of employer coalition building on the episode. Gloria Sachdev from the Employers’ Forum of Indiana, who was instrumental in standing up the Sage Transparency dashboard that we talked about last week and we’ll discuss a little bit more this week. Gloria is a pharmacist, which I did not know. She also sits on the board for the National Alliance of Healthcare Purchasers Coalition and Hoosiers for Affordable Healthcare. Also on the show is the one and only Chris Skisak, who leads the Houston Business Coalition on Health. He also speaks for the state of Texas through his role with Texas Employers for Affordable Healthcare. You can learn more at txeahc.org and houstonbch.org. You can also check out the Employers’ Forum of Indiana Web site as well as sagetransparency.com. Gloria Sachdev, PharmD, serves as president, CEO, and board chair of the Employers’ Forum of Indiana. She also serves as adjunct associate professor at Purdue College of Pharmacy. Forum initiatives focus on hospital price and quality transparency, value-based health benefit and payment strategies, and health policy. She serves as a member of the Board of Governors for the National Alliance of Healthcare Purchaser Coalitions and as board vice chair for Hoosiers for Affordable Healthcare. Dr. Sachdev received her bachelor of science and doctor of pharmacy degrees from the University of Oklahoma and completed a primary residency at the VA in Madison, Wisconsin. Thereafter, she practiced in primary care physician offices managing patients with chronic diseases for 12 years, followed by consulting in the space of incorporating clinical pharmacists into team-based care for 6 years. She retired from Purdue College of Pharmacy after 15 years but still teaches a few classes for fun. Chris Skisak, PhD, is the executive director of the Houston Business Coalition on Health, a multi-stakeholder but employer-centric 501(c)(3) focused on improving the cost, quality, and consumer experience in healthcare delivery. He is also the executive director of Texas Employers for Affordable Healthcare, a legislative advocacy organization focused on creating a competitive healthcare delivery ecosystem. Dr. Skisak also serves on the boards of directors of the National Alliance of Healthcare Purchasing Coalitions and Texas Business Group on Health. He serves on the leadership councils for Houston Cities Changing Diabetes, Houston Health Equity Collaborative, and Center for Houston’s Future. He had previously worked 25 years with Houston Fortune 50 energy companies in a variety of population health management positions. He is originally from Chicago and attended the University of Illinois. He received his master of science degree and PhD from the University of Texas School of Public Health. 06:04 How could the healthcare market correct itself? 08:27 EP334 with Sunita Desai, PhD. 09:38 What strategies are needed to make changes in the healthcare market? 10:13 What can be done with respect to market forces? 12:33 What needs to happen in regard to healthcare legislation? 13:03 Gloria’s ideas for legislation. 15:44 Why is it important to allow physicians to be independent again? 17:41 EP373 with Cora Opsahl. 18:21 Chris’s thoughts on legislation. 22:51 Why is it important that employers become present in the legislative process? 26:48 What has been immensely helpful to better understand hospital financials? 31:08 EP385 with Dan Mendelson. 31:16 EP379 with AJ Loiacono. 32:11 Why is transparency foundational for healthcare market change? You can learn more at txeahc.org and houstonbch.org. You can also check out the Employers’ Forum of Indiana Web site as well as sagetransparency.com.   @GloriaSachdev and @ChrisSkisak discuss #hospitalpricing and #legislation on our #healthcarepodcast. #healthcare #podcast #healthcarelegislation   Recent past interviews: Click a guest’s name for their latest RHV episode! Mike Thompson, Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308)    

For the past few shows and in a few coming up, we are circling our wagons around a theme: In healthcare in this country, there are two teams. One team is employers, taxpayers, patients … those trying to keep healthcare prices down. Then on the other team, we have those looking for healthcare prices to continue to go up, meaning, as just one example, some health systems and some hospitals. There was a New York Times article recently, and Peter Hayes wrote an interesting comment about it on LinkedIn. He wrote: “This article is troubling on so many levels and clearly demonstrates that patient health and well-being are not the top priority of many in healthcare leadership in our hospitals. Unfortunately, it is much more about patient revenue than patient health. … The non-profit status of our health facilities is a huge hidden tax and wealth transference from every taxpayer that is estimated to be about $39 billion annually.” Look, for sure, not talking about everybody in healthcare leadership here, and increasingly I’m kinda thinking we need to maybe have more than one word for hospitals and their leadership because lumping them all together into a homogenous blob is really unfair to those rural and safety net organizations contending with all kinds of adversities—which is very, very different in circumstance to those so-called “well-resourced” hospital chains in suburban markets really raking in the cash and virtue signaling in very well-resourced press campaigns. And the irony of this whole thing is that a reason hospitals (that want to) get away with doubling down on profit-centric business models is actually their nonprofit status. This is a major loophole. If you are a nonprofit, you get to be excluded from some of the powers of the FTC (Federal Trade Commission), for example. But then there’s also the lack of financial discipline, as Mike Thompson puts it in the show today. These nonprofit organizations have never had to run efficiently. They have never been asked to justify the new building or the other adds to their infrastructure that ultimately increase their costs of doing business in ways that, on the whole, might not benefit patient care. And I say “might not benefit patient care” fairly confidently because there is absolutely no correlation between high prices and high quality in healthcare. In fact, it can just as easily be the opposite. But if you overbuild and you buy too many MRI machines or whatever, then you gotta feed the beast. And then the downward spiral starts, and the anticompetitive, financially toxic behavior really kicks into high gear—which, again, is tough to regulate because our laws and legislation expect nonprofits to, you know, behave like nonprofits. In this healthcare podcast, I am thrilled to speak with Mike Thompson, who is the CEO and president of the National Alliance of Healthcare Purchasers. Interestingly, Mike is an actuary by background; and I am sure that that has come in handy as more and more data is becoming available for purchasers and also regulators. The National Alliance has created a playbook to help employers get a fair price from hospitals. In short, the playbook’s five strategies to do so include (1) looking up what the fair commercial price is for your local hospital, which is really easy to see if you go to dashboard.sagetransparency.com. This Sage Transparency dashboard was created by the Employers’ Forum of Indiana. Not to drown you in acronyms, but the Sage Transparency dashboard very elegantly combines RAND data showing what hospitals are actually charging employer plans and compares that to what’s called the NASHP commercial break-even price. NASHP is the National Academy for State Health Policy, who crunched a lot of numbers to figure out this commercial break-even price. Once you know the fair commercial price for hospitals in your area, then one way to go could be (2) using an RBP (reference-based pricing) strategy and paying based on the fair commercial price plus a markup. Another strategy is to (3) start monitoring your ASO/TPA (administrative services organization/third-party administrator) carefully and see that they are paying this fair price and getting performance guarantees to hold them accountable to do so. Yet another strategy is to (4) gang up with other employers in coalitions, which is often necessary, given how much market power some of these hospitals have consolidated and all the anticompetitive practices they’ve managed to tuck into their FTC-exempt quiver. And last is to (5) regulate through legislation. One point that Mike makes very clear is that if nonprofit hospitals cannot remain true to their mission and if they are also not subject to market dynamics, that’s a lose-lose for their communities. At that point, a very viable option is to regulate them like utilities. This is also what I talk about next week with Chris Skisak and Gloria Sachdev. The sad part about this whole thing is that hospitals and communities really should be sitting on the same side of the table working together to improve the health and well-being of their communities. And that should include—according to me, at least—keeping financial toxicity in check, especially just given everything we know for sure about how financial toxicity negatively impacts patient health. Oh, hey, here’s a thing: Turns out I had a fever when I recorded this show, so yeah, Mike deserves a little extra kudos for very eloquently just going with it when occasionally my questions sort of ended without, you know, actually asking a question. You can learn more at nationalalliancehealth.org. Michael Thompson is the president and CEO of the National Alliance of Healthcare Purchaser Coalitions (National Alliance), the only nonprofit, purchaser-led organization with a national and regional structure dedicated to driving health and healthcare value across the country. Prior to joining the National Alliance, Mike was a Principal at PricewaterhouseCoopers (PwC) for 20 years. He is a nationally recognized thought leader for business health strategies and health system reform. Mike has worked with major employers and other stakeholders on sustainable cost reduction, integrated health, wellness and consumerism, retiree health, private health exchanges, and health reform. Known for developing and promoting collaborative cross-sector health industry initiatives, Mike participated on the steering board of the World Economic Forum’s “Working toward Wellness” initiative and co-founded the Private Exchange Evaluation Collaborative. Prior to PwC, Mike served as an executive with diverse roles with Prudential Healthcare for over 17 years. Mike is a Fellow of the Society of Actuaries, serving on the Health Practice Council, and chairs the Medicare Sub-Committee of the American Academy of Actuaries. He is board president of the Innovation and Value Initiative. He is also widely recognized as a leading national advocate for mental health and well-being and was past president of the New York City chapter of the National Alliance for Mental Illness. 05:37 Check EP372 with Cora Opsahl; EP358 with Wayne Jenkins, MD; EP388 with Merrill Goozner; and EP346 with Peter Hayes for a deep dive. 05:48 Why should an employer health plan be concerned about how much area hospitals are spending? 07:01 How are hospitals quantifying their prices? 08:10 “I think we’re not paying a fair price is the end game.” 10:45 How do we bring rigor back into the market? 11:12 What is NASHP? 15:10 What does the NASHP commercial breakeven take into account? 18:24 Why are hospitals conflicted when it comes to building a health system based on value and health? 20:17 Why is the onus on hospitals to defend the way they’ve spent the money they have? 21:58 “Where there are market dynamics, we typically see prices in that fair price range.” 25:06 What can employers do from a market standpoint, a program design point, and a policy standpoint? 27:11 What is the National Alliance of Healthcare Purchaser Coalitions playbook? 30:15 Why is changing the dynamics in the press important to changing hospital pricing? 33:02 How fundamental is the employer’s role in making sure that they’re paying a fair price for the healthcare services their employees are receiving?   You can learn more at nationalalliancehealth.org.   @IWLMikeT of @ntlalliancehlth discusses #hospitalpricing on our #healthcarepodcast. #healthcare #podcast #hospitals #healthcarepricing   Recent past interviews: Click a guest’s name for their latest RHV episode! Dr Rishi Wadhera (Encore! EP326), Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371)

HRRP stands for Hospital Readmissions Reduction Program, by the way. I wanted to encore this episode with Dr. Rishi Wadhera because it’s a great representation of a common root cause reason why quality metrics sometimes don’t end well in real life. This root cause is otherwise known as Goodhart’s Law, and we dig into Goodhart’s law later on in this healthcare podcast. But the actual and ultimate impact of HRRP is also a pretty good representation of the consequences, what happens, when you create a blunt-force policy that assumes hospitals with very different circumstances are the same. Before we kick in to the episode, I asked Dr. Wadhera, my guest today as aforementioned, if there’d been any updates regarding HRRP since this show originally aired last year; and he told me that two key pieces have come out this past month in JAMA journals calling out CMS (Centers for Medicare & Medicaid Services) to move on from/retire this policy: A Decade of Observing the Hospital Readmission Reductions Program—Time to Retire an Ineffective Policy Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns? Thanks so much to Dr. Steve Schutzer and also BoneDoc66 for your really nice reviews this past month. So appreciated … thank you so much! And here is your encore. Today’s guest is Rishi Wadhera, MD, MPP. Dr. Wadhera authored a retrospective analysis in the BMJ about the HRRP, which we will talk about in this healthcare podcast. Dr. Wadhera is a cardiologist at Beth Israel Deaconess Medical Center. He also has a master’s in public policy at the Harvard Kennedy School of Government and also a master’s in public health from the University of Cambridge. But here’s the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this healthcare podcast and which my nerd heart could not love more: Goodhart’s Law. This law is the root of so very many problems. Goodhart’s Law is this (which I learned from Dr. Wadhera): “When a measure becomes a target, it ceases to be a good measure.” In other words, when we set a goal, people will try to take a shortcut to the goal, regardless of the consequences. And sometimes the consequences, paradoxically, are to do worse at the goal. Maybe because bean counters and admins and maybe even goal-oriented clinicians themselves will go right to the end goal, inadvertently skipping a whole bunch of (it turns out) rate-critical steps. For example, teaching to the test may not lead to students who deeply understand a subject. And anyone trying to achieve value-based care success, improve quality, form collaborations, or make sales might want to remember that old proverb, “Sometimes the shortest way home is the long way around.” You can learn more at Dr. Wadhera’s Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site. Rishi K. Wadhera, MD, MPP, MPhil, is an assistant professor of medicine at Harvard Medical School, a cardiologist at Beth Israel Deaconess Medical Center (BIDMC), and the associate program director of the cardiovascular medicine fellowship at BIDMC. He is also health policy and equity researcher at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. Dr. Wadhera received his MD from the Mayo Clinic School of Medicine as well as an MPhil in public health as a Gates Cambridge Scholar from the University of Cambridge. He completed his internal medicine residency and cardiovascular medicine fellowship at Brigham and Women’s Hospital in Boston. During this time, he also received a master’s in public policy (MPP) at the Harvard Kennedy School of Government, with a focus on health policy. Dr. Wadhera’s research spans questions related to healthcare access, quality, and disparities, as well as understanding how local, state, and national policy initiatives impact care delivery, health equity, and outcomes. Dr. Wadhera has published more than 80 articles to date, and he receives research support from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health (NIH)   03:30 What was the Hospital Readmissions Reduction Program intended to do? 05:22 Why did the Centers for Medicare & Medicaid (CMS) think some readmissions were preventable? 06:02 “The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge planning, transitions of care, and post-discharge follow-up and care.” 06:58 How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? 08:16 “The 30-day readmission measure—it’s an incomplete measure.” 11:48 “I think patients … are smart, and they know what’s going on.” 13:34 “What’s happening is, we’re just increasing the number of times they need to come back to the ER within that 30-day period.” 13:55 “The weird thing about the HRRP is that when it evaluates hospitals’ 30-day readmission rates, it’s a yes-no phenomenon.” 15:03 “What CMS does is, it risk adjusts … and that is what we should be doing.” 18:30 “This program has been incredibly regressive.” 19:04 “Poverty, neighborhood disadvantage, housing instability—these factors are out of hospitals’ control.” 21:50 “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.” 22:06 “It just makes no sense to take resources away from hospitals.” 22:32 EP295 with Rebecca Etz, PhD. 23:47 What’s the way to improve quality of care globally? 25:37 “CMS’s approach to improving quality of care has really anchored … [that] to payment.” 26:08 “It’s time for us to rethink what our approach to quality improvement should be.” 29:22 “Policy makers have an obligation to rigorously test the impact of these types of policies before they roll them out nationally.” 31:41 Can you scale healthcare nationally?   You can learn more at Dr. Wadhera’s Harvard Catalyst profile and the Beth Israel Deaconess Medical Center Web site.   @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission What was the Hospital Readmissions Reduction Program intended to do? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission Why did CMS think some readmissions were preventable? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “The spirit of the Hospital Readmissions Reduction Program was to incentivize hospitals to improve … discharge planning, transitions of care, and post-discharge follow-up and care.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “The 30-day readmission measure—it’s an incomplete measure.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “What CMS does is, it risk adjusts … and that is what we should be doing.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “It just makes no sense to take resources away from hospitals.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission What’s the way to improve quality of care globally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission “It’s time for us to rethink what our approach to quality improvement should be.” @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission Can you scale healthcare nationally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission   Recent past interviews: Click a guest’s name for their latest RHV episode! Ge Bai (Encore! EP356), Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370)

This show was one of the most popular episodes in the past 12 months. So, here it is again for your listening pleasure. Mostly this whole episode is about the so-called “Big Three” PBMs that provide between the three of them pharmacy benefit services for 95% of insured Americans. PBM stands for pharmacy benefit manager, and the Big Three PBMs being ESI, otherwise known as Express Scripts; OptumRx, which is a part (a big profitable part) of UnitedHealth Group; and then also CVS. Yes, CVS is not just for your retail pharmacy needs; they are also a huge pharmacy benefit manager. Now, we get to the GoodRx part of our story. If you don’t know how GoodRx works, I would strongly encourage you to go back and listen to “An Expert Explains” with Dr. Ge Bai from last year (AEE13). That said, here’s the super short semi-reductive version to keep us all level set here. If you already know how GoodRx works, you can skip forward about four minutes. So, first of all, let’s all understand that GoodRx’s business model only exists because the pharmacy supply chain dominated by these three big PBMs that we just talked about is such a cluster. GoodRx profits from that dysfunction. So, as I said, here’s the short version of how they do that. It all hinges on so-called spread pricing, and this is what I mean by that. Patient goes into pharmacy with a prescription for generic drug X. The patient has insurance—good news! Pharmacist checks the computer and sees that this patient should be charged, I don’t know, $50 for drug X. The patient’s insurance carrier picks up, say, $30 of the $50 cost; and the patient is left with, say, a co-pay of $20. Who did that little math there in the computer? The PBM (the pharmacy benefit manager) did that math. That’s their thing, these PBMs. They adjudicate claims. That’s what this math is called. Anybody who goes into a pharmacy with a prescription, it’s the PBM on the back end who figures out how much the patient owes and how much their insurance will pay and what the patient responsibility is, etc. Goodness, you might say. How much are the PBMs being paid to perform this useful service? Turns out, it’s free. That’s right … the Big Three PBMs do all this adjudication for free. No charge to plan sponsors. Isn’t that nice? Except it’s actually not free if you dig into it. The PBM is certainly getting paid by means of arbitrage. They’re taking a little something something out of the middle of every single transaction. Here’s what that looks like in the example aforementioned. Recall the patient’s insurance paid $30, and the patient themselves paid $20. The question is, how much did that drug cost the PBM? Remember, that’s commerce: Buy low, sell high, and all that. You buy something, and then you sell it for more than you bought it for. OK, so we’re talking about a generic drug here. They’re cheap (usually). So, let’s just say drug X costs, I don’t know, $5. The PBM pays the pharmacy $5 for that generic script—and you can see how much money the PBM just made right there. The patient and their plan sponsor got charged $50, and the PBM’s cost of goods was $5. Multiply that profit margin by the billions of generic prescriptions in this country that run through insurance, and you have a tidy little business model there. UHG, the parent company of OptumRx, made $24 billion in profit in 2021. Not all of that was from generic drug arbitrage (ie, taking advantage of spread pricing), but some of it was. And $24 billion is an awfully big amount when you consider whose paychecks all those pennies were lifted from. PBM services are anything but free. PBMs are collecting massive windfalls in the so-called spread between what the patient and the plan pay and what the PBM is actually buying those drugs for. Here’s another wrinkle: When a PBM contracts with a pharmacy, part of their contractual terms is that the pharmacy’s list price for drugs cannot be lower than a certain amount usually having something to do with the PBM’s rates. So, pharmacy list prices become artificially high as a result, meaning that cash-pay patients who just wander into a pharmacy and try to pay cash pay an artificially high price. Into this mess swoops GoodRx with a killer idea. They see all that money on the table that PBMs are cleaning up in that spread. They want a piece of that action. And in the beginning, PBMs were fully on board with this. They were fully on board because the market GoodRx was going after was the uninsured market, meaning untapped turf for PBMs. And because PBMs make so much money off of each transaction, PBMs are always hungry for more transactions (the Big Three PBMs, anyway). They love more transactions. The more more more with the transactions, the more more more with the money. So, GoodRx goes to the PBMs and says, “Hey … if a cash-pay patient shows up in a pharmacy, what price would you charge them for you to adjudicate that claim? You know how much money you have to pay the pharmacy, so what can the patient price be? What spread are you willing to accept? GoodRx will take a little off the top, but you can keep your spread on this new frontier of patients that you haven’t historically had access to because … uninsured. Oh, by the way, we, GoodRx … we’re gonna go around to all your competitors, too (just saying)—the other two PBMs—and we’re gonna show their prices, too, in our GoodRx app at different pharmacies. So, you’re gonna have to compete with other PBMs in this model.” This is why GoodRx cash prices for generics are so very very often less than what the patient will pay if they use their insurance. In the GoodRx app, PBMs have competition. So, by not using their insurance, patients often pay less for generic drugs—which, by the way, are 90% of the scripts written in this country—and also, as an added bonus, patients don’t have to jump through all the weird and arduous prior auths or step therapies or other hurdles that a PBM might toss in the mix. So, from a patient perspective, using GoodRx could save money, save time, and you could get your drugs faster because you don’t have to wait around for some prior auth to go through. But this was not what PBMs had originally thought they were signing up for. They were working with GoodRx to gain new market share from the uninsured market, not lose market share to more and more patients forgoing their insurance, meaning forgoing shelling out to the PBM their spread on the transaction. Cue my conversation today with Dr. Ge Bai. Ge Bai, PhD, CPA, is a professor of accounting at Johns Hopkins Carey Business School and a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. In this healthcare podcast, Ge Bai and I discuss the reactions of the Big Three PBMs to consumers getting all consumer-y when it comes to buying their generic drugs—despite the fact that, in my interview with Dr. Sunita Desai (EP334), she said that studies have shown that 67% of patients are unaware that they might be able to get a better price by not using their insurance and shopping around on GoodRx or Amazon or at a cost-plus pharmacy like Blueberry in Pittsburgh or Mark Cuban’s new thing. Despite that, it means 33% (one-third) of patients are aware that they can price shop and potentially get a better price not using their insurance on generic drugs; and apparently, it’s making some people at some PBMs nervous. Check the ESI (Express Scripts) blog post about their new prescription benefit that automatically applies discounts. Hmmm … sounds like a defensive play to me? What do we make of this? That’s my first question to Dr. Ge Bai in this episode. Also, if you’re really intrigued by generic drug goings-on, go back and listen to the show with Dr. Steven Quimby (EP344) when you have a chance. It’s about the high cost of generic drugs, and we go deep into supply chain machinations.   You can learn more on Ge’s Web site at Johns Hopkins University. You can also connect with her on LinkedIn. Ge Bai, PhD, CPA, is professor of accounting at the Johns Hopkins Carey Business School and professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on healthcare pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies.   08:39 What is ESI doing by automatically applying discounts to generic drugs? 09:53 Why are PBMs losing money when consumers don’t use their benefit? 10:40 “GoodRx disrupted the ongoing game.” 10:58 How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? 12:07 Amazon pricing versus GoodRx pricing. 12:44 How much money is a PBM really making? 13:54 EP344 with Steven Quimby, MD. 14:24 EP334 with Sunita Desai, PhD. 14:37 How is future fear playing into the PBM business model? 16:49 Is there a negative consequence to subtracting from the bottom line in a PBM model? 17:44 “I think to have strong PBMs does not mean necessarily bad things for patients.” 19:33 What happens if everyone uses Amazon for drugs? 22:33 If every PBM gets their own discount cards, what will happen? 25:32 “We are actually witnessing a potential sea change.” 26:19 How do cost-plus pharmacies factor into the current market? 29:09 Is a profit shortfall inevitable? 29:28 “PBMs have to give a slice of their profit back to consumers. That’s just reality.” 30:05 Can anything be done on the PBM side to generate a higher margin in the generic space? 31:34 “Naive plan sponsors are a big problem.” You can learn more on Ge’s Web site at Johns Hopkins University. You can also connect with her on LinkedIn.   @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing What is ESI doing by automatically applying discounts to generic drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Why are PBMs losing money when consumers don’t use their benefit? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “GoodRx disrupted the ongoing game.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How are PBMs using the Amazon discount card to discourage their patients from moving away from using their benefits? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Amazon pricing versus GoodRx pricing. @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How much money is a PBM really making? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How is future fear playing into the PBM business model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Is there a negative consequence to subtracting from the bottom line in a PBM model? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “I think to have strong PBMs does not mean necessarily bad things for patients.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing What happens if everyone uses Amazon for drugs? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing If every PBM gets their own discount cards, what will happen? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “We are actually witnessing a potential sea change.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing How do cost-plus pharmacies factor into the current market? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Is a profit shortfall inevitable? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “PBMs have to give a slice of their profit back to consumers. That’s just reality.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Can anything be done on the PBM side to generate a higher margin in the generic space? @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing “Naive plan sponsors are a big problem.” @GeBaiDC of @JohnsHopkins discusses #PBMs on our #healthcarepodcast. #healthcare #podcast #healthcarepricing Recent past interviews: Click a guest’s name for their latest RHV episode! Dave Dierk and Stacey Richter (INBW37), Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman

We have done three inbetweenisodes so far on healthcare stakeholder collaboration. In sum, there are two major issues that patients have with our healthcare industry, and both can only be solved for if healthcare stakeholder collaboration happens: Patients falling into care gaps and winding up with bad downstream consequences Patients not being able to afford their care This show, we are moving on to talk about an actionable solution here to the care gap problem—the very ubiquitous issue of patients with some pretty serious health issues who remain either undiagnosed or not on optimal treatment or follow-up. Our team at Aventria Health has a big success story that I would love to share relative to care gaps and how to think about solving for them at the local, regional, and national level. Spoiler alert here: What we’re talking about in this healthcare podcast, which we call our Groundswell Solution™, improved the usage of best-practice clinical guidelines for patients with end-stage liver disease by 23% nationally. Also keep in mind that what is fast becoming a major factor in developing liver disease is obesity, and the incidence of liver disease is growing. As aforementioned, we are talking about an Aventria Health Group Groundswell Solution, which is the idea of getting diverse stakeholders who are enthusiastic to be empowered as part of a team to help solve for gaps in care and really improve patient outcomes. It definitely takes a village, and if we can find ways where different organizations can work together to contribute and leverage strengths along shared priorities, then great things can really happen. Before we kick in to the show here, let me bring up the miracle of the commons. This is cool. This was a term that was coined by Elinor Ostrom. Ostrom, by the way, won the Nobel Prize for this work. She saw how humans have such an amazing capacity to work together through what she called design principles and come up with some really unique and inspiring solutions that benefit everybody. You can connect with Stacey and Dave on LinkedIn. If you are interested in contributing to Groundswell, please complete this short questionnaire.  Dave and Stacey are co-presidents of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups. They are also co-presidents of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. 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. Dave is a 30-year veteran helping clients work at the intersection of payers, providers, pharmacy, Pharma, and medical device companies. He is an accomplished strategist, providing innovative customer marketing, access, quality, and health intervention solutions for large clients and has directed the development of numerous industry-leading campaigns in primary care and specialty markets. Dave has helped dozens of clients achieve top rankings in their respective categories. He is also an active member of the Pharmacy Quality Alliance.   03:03 How can areas of improvement be flagged in such a fragmented patient care journey? 04:06 What is “the miracle of the commons”? 04:54 How is the miracle of the commons being used at Aventria and QC-Health? 07:51 What is Groundswell, and how does it utilize the miracle of the commons? 11:13 “Is the answer, then, to drive more knowledge and more awareness?”—Dave 11:35 “What about using technology to provide curated, highly targeted information that can support them at the point of care?”—Dave 13:25 “You want to identify where these gaps are across the full spectrum of the journey.”—Dave 15:08 “This is something that is not commonly happening on its own.”—Dave 16:40 “Done in the right way, people are excited … to improve care and improve outcomes.”—Dave 18:50 “Our aim is really to meet people and teams where they are.”—Stacey 19:35 “You don’t have to know how or why or where—merely that I think this outcome is not what it could be. That’s the place to start.”—Dave 20:01 “You have to understand the different goals of the different stakeholders.”—Dave 21:14 “If we can do the right things the right way, then we can serve many masters.”—Dave   You can connect with Stacey and Dave on LinkedIn. If you are interested in contributing to Groundswell, please complete this short questionnaire.    Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast How can areas of improvement be flagged in such a fragmented patient care journey? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast What is “the miracle of the commons”? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast How is the miracle of the commons being used at Aventria and QC-Health? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast What is Groundswell, and how does it utilize the miracle of the commons? Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “Is the answer, then, to drive more knowledge and more awareness?” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “What about using technology to provide curated, highly targeted information that can support them at the point of care?” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “You want to identify where these gaps are across the full spectrum of the journey.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “This is something that is not commonly happening on its own.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “Done in the right way, people are excited … to improve care and improve outcomes.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “Our aim is really to meet people and teams where they are.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “You don’t have to know how or why or where—merely that I think this outcome is not what it could be. That’s the place to start.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “You have to understand the different goals of the different stakeholders.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast “If we can do the right things the right way, then we can serve many masters.” Our host, Stacey, and Co-President Dave Dierk discuss the miracle of the commons on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest’s name for their latest RHV episode! Merrill Goozner, Betsy Seals (EP387), Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Nick Stefanizzi, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282)