Relentless Health Value

In this episode, host Stacey Richter speaks with Sunita Desai, PhD, a health economist and assistant professor at NYU Grossman School of Medicine, about the real-world impact of price transparency in healthcare. They break down the intended progression from transparency to consumerism to lower costs and higher quality care—and why, in practice, that progression often stalls. Sunita shares key research on the barriers consumers face when trying to act on price information, and they discuss what it will take to make consumerism an effective force in healthcare. === LINKS === 🔗  Show Notes with all mentioned links:  https://relentlesshealthvalue.com/episode/ep334 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue 🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/ 06:23 Why is everyone so interested in price transparency right now? 07:30 How does price transparency enable consumerism? 08:05 What are the two aspects to consumerism in order to enable it in health care? 11:01 Does access to price transparency tools lower costs and spending? 15:19 Why is there such low utilization of price transparency tools? 16:13 What’s the first barrier to using price transparency tools? 17:10 Why bypassing the physician at the point of care limits the use of price transparency tools. 17:53 EP284 with Carm Huntress.23:20 EP308 with Mark Fendrick, MD.23:31 How does reducing spending with high-deductible health plans negatively affect high-value health care? 25:23 “There is not a strong correlation between prices of providers and quality.” 28:48 How does a reduction in physician choices undermine price transparency? 29:30 “We owe that information to patients … it’s useful for patients to know what out-of-pocket costs they should expect.”

In this episode, host Stacey Richter engages with a panel of experts—including Jeff Hogan, Darrell Moon, Dr. Grace Terrell, Dr. Rich Klasco, Nicole Bradberry, and Kelly Conroy—to discuss the practical implementation of care plans in real-world settings. The conversation delves into the challenges and successes of integrating care plans into healthcare practices, offering insights into effective strategies and common pitfalls. Listeners will gain valuable perspectives on enhancing patient outcomes through the thoughtful application of care plans. === LINKS === 🔗  Show Notes with all mentioned links:  https://relentlesshealthvalue.com/episode/ep331 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue 🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/   02:10 Jeff Hogan (EP309) talks about the consequences of when there’s a disconnect between what the patient thinks is happening and what is actually happening in a care plan.03:48 EP315 with Bob Matthews. 03:58 Merrill Goozner’s perspective on successful population health.04:55 Why did Darrell Moon (EP305) give up being a hospital administrator because of care plans? 08:02 “It’s a myth that population medicine … and precision medicine are incompatible or opposites.”—Dr. Grace Terrell (EP319) 11:28 Dr. Rich Klasco (EP321) explains “noncognitive” medicine and why it bogs physicians down.14:45 What is at the core of appropriateness for care? 16:33 “You start to bring that data to the physician, and it really does open their eyes.”—Nicole Bradberry (EP324) 16:51 Nicole Bradberry and Kelly Conroy (EP324) discuss how to really change the way physicians work.

In most other industries, it’s the customer who consumes the services and engages with the purveyor of services. In health care, not so much. Legacy health care has evolved to honor the insurance carrier as the customer or, in some cases, the fancy surgeon or other driver of revenue as the customer. Listen to the podcast with Marshall Allen for more on that front, but yeah. And here we are.  Health care should be designed so that patients get the best outcomes at a financially not-toxic price point. Otherwise, what are we doing here besides putting profit over patients? In this health care podcast, the conversation is about PCVS, otherwise known as creating a “patient-centered value system,” otherwise known as building a new OS, or operating system, for health care—one that is built around the patient and their experience. The general idea here is to rationalize the patient journey from start to finish: to create a longitudinal flow that guides a patient from here to where they need to be with a minimum of being told you need a follow-up appointment but having no idea with whom or how that’s supposed to happen and when, or getting discharged with no instructions, etc. So, PCVS … let’s talk about this, how this works, real quick before we dive in with Dr. DiGioia. In a nutshell, the first step is to really, really carefully trace the patient journey from beginning—really the very, very beginning of the experience, which might start in the parking lot or with the first digital interaction or at the PCP referral—to the very last interaction, which might be after discharge from the SNF (skilled nursing facility) after their last follow-up appointment. It’s figuring out what matters to the patient at each step in that journey and then documenting that flow map. Then the next step is to compare the current patient journey, the current state, to what the team decides is the ideal patient journey. Then the last task, which may be obvious, is to implement—for implementation teams to devise and implement action plans to get from here to there. Here’s an interesting point to ponder: We often talk about fragmentation and interoperability, and when I said these words, your brain immediately snapped to technology fragmentation and interoperability. But bear this in mind: The patient is the only commonality between all the settings of care that are using all those varied technologies. When you rationalize the patient journey, you also, to some extent, create the foundation to integrate technology. Why a PCVS process, you might ask, if you’re in charge of the P&L and regard patient centeredness as a nice to have if there’s extra cash lying around? Here’s why: If you’re going to successfully roll out a prospective bundle, for example, to employers, you better have gone through a PCVS process. Other things, too, but being intimately aware of the patient journey and where patients fall through the cracks or get disgruntled can easily spell the difference between bundle success and failure. This is probably also true for really almost any sort of risk-based/capitation arrangement. It’s probably also true for great customer satisfaction scores. It’s probably also going to become increasingly true when competing against some of these virtual-first operations that may have been built from the ground up to be sticky and engaging for patients, as well as guide them through a longitudinal journey. For more on the WIIFM (the “what’s in it for me?”) if you are a provider organization and are thinking about patient-centered care, listen to one of our most popular episodes over here at Relentless Health Value—the one with Joe Selby, MD, from PCORI—on this topic. In this health care podcast, I’m talking with Tony DiGioia, MD, about PCVS (patient-centered value systems). Dr. DiGioia is a practicing orthopedic surgeon at the Bone and Joint Center over at UPMC Magee-Womens Hospital and also the medical director of the UPMC Innovation Center. Dr. DiGioia wrote a book aptly titled The Patient Centered Value System.  One thing I thought of as I listened to this conversation again in preparation for releasing the episode: Dr. Shantanu Nundy has written that on the front lines of health care, clinicians and other frontline workers know what to do for their patients. They know what’s the matter and what matters to the patient and, really, what they need. Dr. Nundy talks about how, to efficiently transform health care, one thing that we need to do is “decentralize” control or shift power in terms of decision-making authority and resources back to the front lines and to patients. The point that I’m making is that the PCVS might be the OS that health care needs for “decentralization” to happen at a system level and in a way that everyone works together toward a common, aligned goal—as opposed to clinicians and patients all doing their own thing, making their own assessments about what is needed at any given moment at potentially cross-purposes to one another, re-creating all kinds of wheels that are going all kinds of different directions. You can learn more at discoverdrd.com and goshadow.org. Anthony (Tony) DiGioia, MD, is an entrepreneur, engineer, and practicing orthopedic surgeon, and a pioneer in care delivery transformation. “Dr. D” developed the Patient Centered Value System (PCVS), a personalized, replicable approach to care that improves clinical outcomes and experiences while reducing costs. His book, The Patient Centered Value System: Transforming Healthcare Through Co-Design, helps you understand what matters most to patients, map the current state of care in your organization, identify what can be improved, and build teams that co-design sustainable change. Using “What Matters to You?” surveys and shadowing to keep patients and families at the core of care, the PCVS serves as the care delivery model for Dr. D’s current award-winning practice at the Bone and Joint Center at UPMC Magee-Womens Hospital.  Dr. D most recently used the PCVS to develop the Center for Bone and Joint Health, flipping the script of routine health care visits by putting patients in the driver’s seat. In this relationship-based program, patients team up with providers to engage in their own care and personalize a plan based on their needs and priorities. But the PCVS is not just for orthopedics. It is increasingly being adopted nationally and internationally and has been applied to over 65 clinical conditions. Dr. D is medical director of the Magee Bone and Joint Center as well as the UPMC Innovation Center and a Fellow of the American Academy of Orthopaedic Surgeons and the American College of Surgeons. He is a faculty member for the Institute of Healthcare Improvement and an adjunct faculty member in the Department of Biomedical Engineering and the Robotics Institute at Carnegie Mellon University. Dr. D founded the not-for-profit AMD3 Foundation, which leads the Operation Walk Pittsburgh medical mission effort. 06:19 What is the Patient-Centered Value System, and why should it be the operating system for all health systems moving forward? 07:47 “It’s the infrastructure to allow us to redesign care delivery.” 09:00 “These artificial silos that we have in health care have to be crossed and broken down.” 10:03 “The patient is the common denominator. We have to follow the patient.” 10:33 Why does the disjointed patient experience affect a patient’s trust in their care delivery? 12:00 What are the steps to creating a patient-centric system? 12:30 “The challenge is to view all care through the eyes of patients and families.” 13:19 “Our end users are patients and families. Period.” 16:36 What’s the difference between asking patients, “What is the matter with you?” and “What matters to you?” 19:56 How are nonclinician staff included in a patient-centric value system? 25:40 “We can give them the tools, wherever they’re coming from.” 29:33 “The bottom line is, these are engagement tools and technologies that we do need to start looking at to help redesign care delivery.” You can learn more at discoverdrd.com and goshadow.org. @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity What is the Patient-Centered Value System, and why should it be the operating system for all health systems moving forward? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “It’s the infrastructure to allow us to redesign care delivery.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “These artificial silos that we have in health care have to be crossed and broken down.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “The patient is the common denominator. We have to follow the patient.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity Why does the disjointed patient experience affect a patient’s trust in their care delivery? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity What are the steps to creating a patient-centric system? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “The challenge is to view all care through the eyes of patients and families.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “Our end users are patients and families. Period.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity What’s the difference between asking patients, “What is the matter with you?” and “What matters to you?” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity How are nonclinician staff included in a patient-centric value system? @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “We can give them the tools, wherever they’re coming from.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity “The bottom line is, these are engagement tools and technologies that we do need to start looking at to help redesign care delivery.” @drtonydigioia of @UPMC discusses #PCVS on our #healthcarepodcast. #healthcare #podcast #digitalhealth #patientcentric #patientcentricity

  In this episode, host Stacey Richter interviews Al Lewis, founder and “quizmeister-in-chief” of Quizzify, about the misleading tactics wellness and point-solution vendors use to inflate their cost savings claims. They explore statistical tricks like regression to the mean, flawed participant comparisons, trend inflation, and overstated engagement metrics.  Al also shares advice for employers on spotting these deceptive practices and ensuring their brokers or benefit consultants are acting in their best interests. For more details, check out the Validation Institute’s PDF linked in the show notes. Links below. === LINKS === 🔗  Show Notes with all mentioned links:  https://relentlesshealthvalue.com/episode/ep331 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue 🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ X   https://twitter.com/relentleshealth/ 04:49 Are brokers going to have to become more transparent about where their money is coming from? 07:33 Are carriers transparent? 08:09 What’s the goal of the Validation Institute? 08:55 “You either get a true statement put up or learn what you have to do in order to get a true statement put up.” 11:18 How is Regression to the Mean (RTM) used in a flawed way? 16:32 “If you do wellness for employees instead of to employees, the people who want the wellness will be able to access it.” 21:13 What is plausibility testing? 23:17 What about actuaries and validation? 23:40 “That’s one of the reasons the Validation Institute exists, is because actuaries are easily corrupted.” 25:18 What is a prime example of population health economics? 26:20 What does it mean to overstate engagement? 27:15 “How often did you use this and was it useful?” 28:55 “Are you validated by the Validation Institute, and if not, why not?”

In this health care podcast, I’m interviewing John Marchica, who is the CEO at Darwin Research Group. Starting last year in the middle of the worst of the COVID pandemic, Darwin Research Group conducted a study about what was going on at health systems or integrated delivery networks (IDNs), and they’ve updated it every quarter since then. The goal was to try to stay on top of the effects of COVID-19 on care management and the business of care delivery. I loved having this opportunity to quiz John about what health systems are saying about how they are doing and what they are doing, both strategically and reactively, coming out of the pandemic and in response to the pandemic. Now this is a half-hour conversation about an extensive research report, so we’re kind of aggregating all of the health systems in one big bucket. Said another way, we’re obviously not going to play the deep cuts here. No worries—the insights that John lays out are fascinating and give an insider’s look into what’s going on at these really powerful institutions. By the way, when I say powerful institutions, I just was looking at some stats the other day. Something like 50% of all prescriptions these days run through IDNs (that was in 2020). And also in 2020, aggregate IDN market size was $1 trillion. And by 2027, their anticipated combined revenues may exceed $2 trillion. That’s double. (I know, that was some quick math by me. You’re welcome.) We’ll see, though, what the recent Executive Order yields—the one to look into the market power that some of these consolidated IDNs wield. Regardless of who you are, it is tough to deny the mountain of evidence showing that IDN health system consolidation considerably jacks up prices that patients, employers, and taxpayers pay in any geography where consolidated IDNs, otherwise known as monopolies, have destroyed all competition. Probably the most striking takeaway I had from this conversation was how much there is to read between the lines. At the end of the day, IDNs are, and are run, like businesses; and regardless of whether they have a nonprofit on the door or not, that is still true. Before I get into this, let me just clearly say that my heart goes out to the frontline workers—doctors, nurses, everybody else—and all they have done and continue to do for us, and I mean that with three underlines. While I really admire and support some of the rural and urban truly safety net hospitals who are trying to cobble together positive net revenue against all odds, I am far less sympathetic to some of the huge institutions who will engineer an “it’s good for patients, honestly” cover story for any and all endeavors which all seem to have one thing in common: their profitability. Like, nobody mentioned 340B revenue opportunities or how much money there is in specialty pharmacy when explaining the rationale for standing up specialty pharmacies within some health systems’ walls. Maybe it goes without saying. Here’s my conversation with John Marchica, CEO of Darwin Research Group and host of the Health Care Rounds podcast, by the way. You should check that out. You can learn more at darwinresearch.com or by emailing John at jm@darwinresearch.com. You can also listen to the podcast Health Care Rounds wherever you listen to podcasts. John Marchica is a veteran health care strategist and CEO of Darwin Research Group, a health care market intelligence firm specializing in health care delivery systems. He’s a two-time health care entrepreneur, and his first company, FaxWatch, was listed twice on the Inc. 500 list of fastest-growing American companies. John is the author of The Accountable Organization and has advised senior management on strategy and organizational change for more than a decade. John did his undergraduate work in economics at Knox College, has an MBA and MA in public policy from the University of Chicago, and completed his PhD coursework at The Dartmouth Institute. He is a faculty associate in the WP Carey School of Business and the College of Health Solutions at Arizona State University and is an active member of the American College of Healthcare Executives. 03:50 What were John’s top three health system findings during COVID? 05:24 What is priority for integrated delivery network health systems right now? 08:57 Why do health systems have a renewed focus in primary care? 10:07 How did infusion centers manage throughout the pandemic? 13:58 “It’s not just in cancer, people not getting screened and being diagnosed; it’s in other areas as well.” 14:17 Which of these telemedicine changes are permanent? 19:39 “A visit is a visit … so why would you reimburse at a lower rate?” 19:57 “Telemedicine … is, by its nature, more efficient … and they should be able to figure out how to make money.” 27:17 What are health system plans that own their specialty pharmacy groups doing right now? 29:57 What does Darwin Research Group focus on? You can learn more at darwinresearch.com or by emailing John at jm@darwinresearch.com. You can also listen to the podcast Health Care Rounds wherever you listen to podcasts. @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What were John’s top three health system findings during COVID? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What is priority for integrated delivery network health systems right now? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions Why do health systems have a renewed focus in primary care? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions How did infusion centers manage throughout the pandemic? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “It’s not just in cancer, people not getting screened and being diagnosed; it’s in other areas as well.” @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions Which of these telemedicine changes are permanent? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “A visit is a visit … so why would you reimburse at a lower rate?” @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “Telemedicine … is, by its nature, more efficient … and they should be able to figure out how to make money.” @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What are health system plans that own their specialty pharmacy groups doing right now? @johnmarchica of @DarwinHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions

In a recent article in STAT news, TJ Parker, the VP of pharmacy at Amazon and the founder of PillPack, explained that Amazon’s plan to stand out in the pharmacy space is simple: “Better selection, better convenience, and better prices.” He added, “It really is the Amazon playbook.”  Better selection, better convenience, better price. The playbook of arguably one of the most successful companies ever, Amazon has decimated and bankrupted anybody standing in its way toward total market dominance. This same better selection, better convenience, better price trio—maybe with “better selection” inferred to mean “getting the right care to the right patient at the right time”—is the vision of many of the virtual-first health care providers starting to pop up. And when I say “pop up,” I mean that in Q1 of this year, according to data from Rock Health, $6.7 billion was invested in digital health companies.  In this health care podcast, we’re talking about the proliferation of these “virtual-first” health care solutions. Before we begin, though, let me just clarify that in our conversation, virtual first doesn’t mean virtual only. Most of the time, actually, virtual first means that the connective tissue of the operation is virtual/digitized. In other words, we’re not just talking about some random mobile app here. There are likely human providers involved, and the goal is to offer patients not only a sticky engaging entry point and journey but then also a continuous longitudinal care experience. The patient journey should be clear, and the virtual-first solution is making sure that the patient isn’t getting lost somewhere in their journey from diagnosis to better outcomes. Here’s my main point: The big contrast between these newer virtual-first solutions and traditional health care enterprises is that humans involved in these virtual-first solutions are connected to each other and to their patients with technology designed for that purpose—as opposed to software and systems designed to maximize billing, which, sadly, many software tools and systems used in legacy health care were. The promise of these virtual-first solutions is to fill care gaps for patients who are currently having issues. It sometimes takes 10 years for people to get properly diagnosed. Care for chronic conditions is also abysmal in this country. Now, this all being said, much of the promise of these virtual-first, also called point solutions when someone is not a fan, has yet to be realized. Tune in to my interview with Al Lewis next week for more on that front. One area of concern is that if you have a point solution for MSK (musculoskeletal) care and a point solution for diabetes and a point solution for mental health, you wind up with silos. PCPs have complained that they don’t know what’s going on with some of these solutions, and it makes it harder to manage patients. Here’s my inadequate response to these two criticisms: Well, how many silos currently exist in the health care system? When a specialist gets ahold of a patient, do the specialists talk to one another much less the PCP if we’re talking about an average here? Sometimes patients have multiple PCPs even, who, I’m not exactly sure if they hold regular discussions. So, if the status quo is the benchmark to beat, then at least with some of these virtual-first silos, you have the patient getting longitudinal care within that silo. That’s not the case with many specialists who, at best, manage one episodic or a series of episodic visits. On the other hand, consider that $6.7 billion of investment. Some PE company there is looking for 4x on their investment, so $6.7 billion of PE investment means that they expect to get $28 billion out of health care spend, meaning $28 billion paid for by patients, employers, or taxpayers. On the other other hand, $28 billion is a drop in the bucket compared to the almost $3 trillion that this country spends annually on health care. I talk about all this and more with Joe Connolly in this health care podcast. Joe was originally in medical devices and has created his share of digital health solutions. Currently, Joe serves as CEO and founder of Visana, a virtual-first solution for women’s health. You can learn more at visanahealth.com or by emailing Joe directly at joe@visanahealth.com.  Joe Connolly is the founder and CEO of Visana Health, a virtual-first women’s specialty care clinic focused on high-cost chronic gynecologic conditions like endometriosis. Visana works with payers and self-funded employers to improve access to best-practice women’s health care. Joe also writes a popular blog consisting of long-form, in-depth analyses on the burgeoning virtual-first care industry. Prior to Visana, Joe led digital health and strategy efforts at Boston Scientific, a large medical device company.  05:01 What does it mean to be virtual first? 05:50 “It’s meeting people where they are and where they want care to be delivered. It does not mean virtual only.” 07:01 How do payers and purchasers know that a virtual-first program is available to them? 07:34 “We need to come up with new ways to increase engagement with these services.” 10:59 Will virtual care replace in-person care? 15:01 What needs to happen in order to have an empathetic care delivery? 18:06 How should employers try to wade through the virtual health space? 19:41 What’s the value in administration within virtual care? 20:27 How does virtual care affect the relationship of the patient with their PCP? 22:05 What does physician abrasion mean? 25:31 What do virtual-first providers need to make sure they’re doing? 27:16 “There is the possibility for perverse incentives, and it’s up to the virtual-first space to make sure that we don’t give in to those perverse incentives.” 28:28 Who is Visana and what do they do? You can learn more at visanahealth.com or by emailing Joe directly at joe@visanahealth.com.  @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What does it mean to be virtual first? @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “It’s meeting people where they are and where they want care to be delivered. It does not mean virtual only.” @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions How do payers and purchasers know that a virtual-first program is available to them? @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “We need to come up with new ways to increase engagement with these services.” @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions Will virtual care replace in-person care? @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions What needs to happen in order to have an empathetic care delivery? @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions How does virtual care affect the relationship of the patient with their PCP? @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions “There is the possibility for perverse incentives, and it’s up to the virtual-first space to make sure that we don’t give in to those perverse incentives.” @JConnol of @VisanaHealth discusses #virtualhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #virtualfirst #healthcaresolutions

“Scientists Announce Successful Experiment to Bankrupt Mouse That Can’t Afford Cancer Drug.” That’s a recent headline from The Onion, which is, by the way, a funny satire newspaper, if you haven’t heard of it. You could swap out “Cancer Drug” in that headline with “a Trip to the ER”—or pretty much any aspect of health care in this country. No matter what health care service you stick in there as the potential cause for a mouse’s bankruptcy, it’s a pretty LOL headline, right? But the reason why it became a headline is because obviously it’s based on a truth that resonates with your regular citizens in this country. Think about that. A critical mass of people around here believe that health care will bankrupt you. This is one of those sociological signals that has implications to health care leaders. Here’s another signal with implications. In this health care podcast, I’m interviewing the incomparable Marshall Allen. That’s not the signal. His book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, a book with that title being on the New York Times best seller list, is the signal. Marshall’s book is an instruction manual for patients on how to fight back against unfair and/or egregiously inaccurate bills.  This interview with Marshall Allen is different from others that you may be hearing. Marshall wrote a book to motivate patients, a critical mass of patients, to get empowered relative to their health care bills. Because listeners of this show are health care executives, I wanted this interview to be relevant to you. What does this book mean for you? Doug Aldeen told me one time, unless something has a direct impact on the CEO or leadership team at a health system or insurance company, they’re just bored. Let me sum up this interview in one sentence: This is not boring. If you want to skip to the exact examples of “not boring,” you can skip ahead to about the 30-minute mark. We go through the ways that health systems can and probably will be hurt by the financial toxicity that they create. Here’s the three-ish ways that Marshall and I talk about: Doctors who no longer trust their employers (ie, the health systems they work for) leave and then you have to recruit new doctors—#problematicandexpensiveonanumberoflevels, but I don’t need to tell you that. Reputational damage. When the slogan on the door becomes a joke, that’s a problem. Employers and taxpayers reading best-selling books like this one and Marty Makary’s (which also is or was just recently on the best seller list) and learning how to not be basically passive suckers anymore.  You can find Marshall’s book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, anywhere that books are sold. Marshall Allen investigates why we pay so much for health care in the United States and get so little in return. He is the author of the new book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win. He is also the founder of Allen Health Academy, which produces a curriculum of short on-demand videos to equip and empower employees to navigate the health care system. Marshall has investigated the health care industry for 15 years, including a decade at ProPublica. He has also spent a decade as an educator at the Craig Newmark Graduate School of Journalism at The City University of New York. His work has been honored with many journalism awards, including some of the top business reporting honors, the Harvard Kennedy School’s Goldsmith Prize for Investigative Reporting, and twice as a finalist for the Pulitzer Prize. Before he was in journalism, Marshall spent 5 years in full-time ministry, including 3 years in Nairobi, Kenya. He has a master’s degree in theology.  03:35 What’s the point of view that Marshall is coming from with his investigative reporting? 04:06 “How does this affect the people who are paying for it and the people who are undergoing the care?” 04:58 “There’s a lot of good people working within this very messed up system.” 05:12 Why are patients considered outsiders in the health care system? 05:55 “What’s happened in health care is that the stakeholders treat each other more as the customer.” 07:54 What is upcoding? 11:27 “These are schemes that have been created within the industry to increase revenue.” 11:56 “This system is not set up for the benefit of the patient.” 12:22 “On the financial side, the industry is actually oppressing the American people.” 12:39 Can a critical mass of patients force health systems to become more accountable? 16:02 “We have been expected to pay whatever aggregate sum is thrown at us.” 17:09 Why have patients been so passive toward this crooked health care system so far? 18:04 “They’re violating the trust of the American people when they don’t treat us fairly.” 19:28 “It’s totally legal to do that, [but] is it ethical?” 20:11 What’s the difference between making a profit and profiteering? 21:43 “It’s hard to argue against your own paycheck.” 29:57 “The things that matter most to people are their health and their money.” 33:51 What are the first-order and second-order consequences of what’s happening in health care right now, and which of these consequences will actually drive change? 34:56 “When you tell the truth about what’s going on … they become so ashamed … that they change their behavior.” 36:10 “The patient … is not their most important customer.” 39:03 “The sleeping giant is the employers.” You can find Marshall’s book, Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win, anywhere that books are sold. @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “How does this affect the people who are paying for it and the people who are undergoing the care?” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “There’s a lot of good people working within this very messed up system.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem Why are patients considered outsiders in the health care system? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “These are schemes that have been created within the industry to increase revenue.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “This system is not set up for the benefit of the patient.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “On the financial side, the industry is actually oppressing the American people.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem Can a critical mass of patients force health systems to become more accountable? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem Why have patients been so passive toward this crooked health care system so far? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “They’re violating the trust of the American people when they don’t treat us fairly.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “It’s totally legal to do that, [but] is it ethical?” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem What’s the difference between making a profit and profiteering? @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “It’s hard to argue against your own paycheck.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “The things that matter most to people are their health and their money.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem “The sleeping giant is the employers.” @marshall_allen, author of “Never Pay the First Bill,” discusses #financialtoxicity in the #healthcaresystem on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystem

If I had a nickel for every guest on this show who went on to achieve wild success … TJ Parker from PillPack three years before they were bought by Amazon. Anyway, let me introduce this show with a clip from the recent podcast (EP325) with Dr. Mai Pham. We were talking about the rampant and very open secret of excessive upcoding in Medicare Advantage (MA) that is costing American taxpayers a fortune and is very not correlated with actual spend. Here we go with Dr. Mai Pham:  Stacey: Do you have any thoughts relative to how you ensure that these MA plans that are becoming vast are still accountable to not game the system? How do you plug loopholes in a way that doesn’t invite additional and more nefarious gaming? Dr. Pham: My fantasy has always been that CMS can develop, or somebody can develop, a black box machine learning–driven, risk-adjustment algorithm that no one can see into—not even the payer. It would very much level the playing field, assuming that it was developed correctly, appropriately, and you used unbiased data; but that’s the kind of system and extreme solution that I think starts to sound almost necessary given the state of things and the rate of acceleration in upcoding. So, people may not have noticed that CMS had put out a request for — I think it was a challenge grant, maybe? And they recently announced a couple of winners. They were asking for artificial intelligence–driven approaches to predicting health outcomes, which I believe is just the first shadow approach, the first step that you take in thinking about artificial intelligence–driven risk adjustment. I also want the audience to understand, it’s not like we’re talking about replacing a really superlative gold standard, right? The majority of the most commonly used risk-adjustment approaches today produce a correlation with actual spend of only like 0.2. This is the best we can do? This is how we’re deciding how we’re going to spend a trillion dollars each year? Surely, we can do better. And, by the way, the winner of that CMS AI contest was ClosedLoop.ai; and Andrew Eye from ClosedLoop.ai was on the show. Cue Encore Episode here!   In the original version of this show, there was a whole prelude about whether AI is or is not anything beyond an overused marketing pitch; but I think, in the time-space continuum, we’re beyond that conversation now. Don’t get me wrong, everybody still has AI in their cloud analytics platforms. And some of them are still, as they say, programmed in PowerPoint (that was a joke); but real deals are emerging from the fray. As mentioned, in this health care podcast I talk with Andrew Eye about AI. (He was born for this job.) Andrew is CEO over at ClosedLoop.ai. ClosedLoop.ai beat out over 300 rivals with their system that forecasts adverse health events and then plops warnings even in the EHR with action steps for clinicians to avoid the calamity in the making. You can imagine many things that CMS might be contemplating using this tool for, including as a control for false upcoding and all of the financial toxicity that goes along with that. By the way, keep in mind all the top-performing Medicare Advantage plans are using today, right now, some form of advanced analytics and artificial intelligence to risk stratify their populations and predict which members will, without intervention, become high cost in the near term. Others are using AI right now to do the kind of predictive analytics that you need to excel at population health. I get to ask Andrew some of the hard questions that have been bothering me about all the AI hype, and he set me straight a couple of times. Love it when that happens. You can learn more at closedloop.ai or by following Andrew (@andreweye) on Twitter.  Andrew Eye’s executive and entrepreneurial experience spans over 20 years in business to consumer and business to business for start-ups and Fortune 500 companies. Andrew founded and sold three technology companies and today is the CEO and founder of ClosedLoop.ai. In 2012, Andrew cofounded the mobile software company Boxer. Boxer developed mobile productivity software for individuals and large corporations. Boxer’s flagship email product was downloaded by millions of users and received significant industry praise for its exceptional user interface, including a 2015 Webby Nomination as one of the top 5 productivity applications in the world. Boxer was purchased by VMWare (one of the top 10 largest software companies in the world) in 2015. Prior to Boxer, Andrew cofounded the cybersecurity firm Ciphent in 2007. Ciphent grew to nearly 100 employees with 1000 customers by 2010 before being acquired by Accuvant (now Optiv). With a three-year growth rate of 8900%, Ciphent was recognized by Inc. magazine as the 16th fastest-growing private company in the United States. During his tenure as SVP of services at Accuvant, Andrew oversaw a $50-million, 200-person organization and was responsible for doubling revenues in 18 months. Andrew also served as CEO of Bodkin Consulting Group, where he worked with Fortune 500 brands and technology companies to define their interactive marketing strategies. Andrew began his career as a software architect working with NASA, i2 technologies, and the US Marine Corps. Andrew graduated summa cum laude from Virginia Tech with a degree in management information technology. Andrew lives in Austin, Texas. 04:34 What exactly predictive analytics is. 05:05 The use cases of predictive analytics value. 07:23 The oversimplification of how people think about risk. 09:03 “Did you have an impact or not?” 09:17 The public scorecard for predictive analytics. 13:59 “Explainability is a real hot topic in artificial intelligence, specifically in health care.” 15:24 Data shaming—what’s wrong with it, and why incomplete data are still important. 17:34 The possibilities that machine learning allows for in patient care in health care. 23:45 “Our health care system can’t afford for that level of inefficiency.” 24:57 “It’s not a question of if; it’s a question of when.” 26:04 The diminishing returns of interoperability and more data for machine learning. 29:21 “You’re running your business today, and whatever data you’re using to run your business … you can use it to provide better patient care.” 30:01 Andrew’s advice: Get started now. You can learn more at closedloop.ai or by following Andrew (@andreweye) on Twitter.  Check out our newest #healthcarepodcast with @andreweye of @ClosedLoopai as he discusses #populationhealth and #artificialintelligence. #healthcare #podcast #ai #pophealth #digitalhealth What is #predictiveanalytics value to health care? @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence Oversimplifying risk. @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence “Did you have an impact or not?” @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence “Explainability is a real hot topic in artificial intelligence, specifically in health care.” @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence What is data shaming, and why is it an issue? @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence #Machinelearning in #patientcare. @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence “Our health care system can’t afford for that level of inefficiency.” @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence “It’s not a question of if; it’s a question of when.” @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence “You’re running your business today, and whatever data you’re using to run your business … you can use it to provide better patient care.” @andreweye of @ClosedLoopai discusses. #healthcarepodcast #populationhealth #podcast #ai #pophealth #digitalhealth #artificialintelligence

You can subscribe to this show two ways. One way is through the iTunes podcast app or your podcast app of choice. That’s a cool way to subscribe because then the show just kind of turns up in your podcast app each week and you can decide to listen to it on the fly. The other way is to subscribe on our Web site. This is more like a newsletter subscription. If you subscribe this way, you get an email each week that transcribes the show introduction, plus includes timed show notes. Many people subscribe both ways, just saying, because each way has different benefits that are pretty complementary. If you subscribe to the newsletter, you only get the newsletter. We are frankly way too busy doing other things to send out other emails. Also, you can easily unsubscribe at any time. I saw a post the other day in Twitter. Someone wrote, “So much can be done to improve community and share lessons to improve outcomes. The trick is making money without selling patient data to Pharma.” Here’s my question for you, and I’m legit asking: I have seen many use cases that benefit patients and that are incredibly worthwhile. But no one is willing to pay for them. That’s the first point this Tweet I just read infers. And I’ve seen it time and time again: gaps in care no one is willing to fill. If you’re speaking about very specific patient populations in very specific therapeutic categories, like some rare diseases, you’re not going to find basically anyone besides Pharma who has the bandwidth, the money, the expertise, and the reach to fill that gap. If you contemplate this further, and I have, Pharma might be the only entity who, if they do it, the price of health care doesn’t immediately go up. Hear me out here because I’m wading into controversial waters, so let me make my point before you jump me in a dark alley. If Pharma does something and it comes out of their existing marketing budget or their R&D budget or some other existing budget, them spending money on filling a patient gap versus them spending money on some TV ad is not going to impact the price of the drug either way. If the price of the drug is already too high, the price of the drug is still too high. That’s going to be true regardless. Why not let Pharma pay the freight for making sure their own patient populations get the best care possible? This show is posted on LinkedIn and Twitter. Let me know what your thoughts are. I’m very interested. In this health care podcast, I am really pleased to be speaking with Naomi Fried, PhD. Dr. Fried has had and continues to have a storied career. Each of her roles has always circled around innovation. She’s been the chief innovation officer at Boston Children’s, where she built their first digital health accelerator. She was recruited by Biogen after that to be their VP of innovation and external partnerships. She founded a consulting practice focused on innovation, and her latest endeavor, which she talks about later on in this show, is PharmStars, which is, in my own words, a sort of 10-week crash course/accelerator for digital health start-ups looking to work with Pharma—and for Pharma looking to work with digital health start-ups. You can learn more about PharmStars at pharmstars.com. Naomi Fried, PhD, is the founder and CEO of PharmStars, the first and only pharma-focused accelerator for digital health start-ups, dedicated to driving digital health adoption to improve patient outcomes. PharmStars understands and addresses the challenges that Pharma and start-ups face when seeking to collaborate. Its PharmaU™ program supports its digital health start-ups and pharma members seeking to “bridge the gap,” leading to greater success and faster adoption of “beyond the molecule” solutions for patients. PharmStars provides education and mentoring to digital health start-ups seeking engagement with pharma and biotech firms. Its pharma members are committed to working with its graduating start-ups. Applications for participation in the first cohort are due July 21, 2021. Dr. Fried is also the co-founder and managing partner of Ambit Health Ventures, an early-stage venture capital fund focused on digital health investments. Previously, she was the CEO of the consulting firm Health Innovation Strategies, VP of innovation and external partnerships at Biogen, the first chief innovation officer at Boston Children’s Hospital, and the first VP of innovation and advanced technology at Kaiser Permanente. She advises and serves on the boards of digital health start-ups. 03:42 What does the pharma–start-up gap look like? 05:49 Why is it hard to navigate Big Pharma when trying to partner with start-ups? 09:53 “A lot of what contributes to that pharma–start-up gap is a lack of understanding.” 10:05 What’s the best way to navigate the pharma–start-up partnership? 10:55 “There’s not a clear path as to who should be engaged from the pharma side, because the value proposition wasn’t well articulated.” 12:27 “Even if … the product is better, if it’s such an uphill battle to get them through the hoops and to work with them, they may not be the partner of choice.” 13:45 Why are start-ups surprised at who all is involved with the decision-making process on the pharma side? 15:51 Where might start-ups run into regulatory oversight compliance issues? 20:41 “Setting expectations and talking early on … really, just understanding on both sides … they have to meet each other and work around these requirements.” 22:02 “Start-ups really are under financial pressure.” 26:33 “Pharma has a lot to offer digital health start-ups.” 27:40 Is Pharma any good at selling something to a provider? 29:22 What do start-ups need to keep in mind when pitching to Pharma? 30:35 “Understanding Pharma’s needs, how they work, what they will pay for is so important for start-ups.” You can learn more about PharmStars at pharmstars.com. @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What does the pharma–start-up gap look like? @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why is it hard to navigate Big Pharma when trying to partner with start-ups? @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “A lot of what contributes to that pharma–start-up gap is a lack of understanding.” @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What’s the best way to navigate the pharma–start-up partnership? @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Even if … the product is better, if it’s such an uphill battle to get them through the hoops and to work with them, they may not be the partner of choice.” @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Start-ups really are under financial pressure.” @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Pharma has a lot to offer digital health start-ups.” @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What do start-ups need to keep in mind when pitching to Pharma? @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Understanding Pharma’s needs, how they work, what they will pay for is so important for start-ups.” @NaomiFried of @AmbitHealth discusses @PharmStars on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma

Here’s the context, friends: As you may have noticed over the past few episodes, we have been digging into value-based care here at Relentless Health Value corporate work-from-home headquarters. Many lessons have been learned, and it’s important that we sit back and think hard every now and then about how we are going to use these learnings to improve. While this show tackles the Hospital Readmissions Reduction Program (HRRP)—and wow, I was glued to my seat during this interview—the show is really about more than that, which I’ll get into in 30 seconds. But let’s start here: HRRP was originally part of the Affordable Care Act in 2010. In 2012, HRRP began imposing penalties on hospitals with higher-than-expected 30-day readmission rates for three conditions: heart failure, myocardial infarction, and pneumonia. Spoiler alert: More recently, CABG, THA/TKA, and COPD were added to the list. So basically, if a patient is in the hospital for any of these six things and then is readmitted to the hospital for any reason within 30 days, penalties can happen. 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 health care podcast. His findings are fascinating and relevant on a number of levels.  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. Dr. Wadhera works on policy at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.  But here’s the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this health care 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. For example, teaching to the test may not actually lead to students who deeply understand a subject. Here’s another example, and Rebecca Etz, PhD, talks about this in EP295: If you want PCPs to do an amazing job managing diabetes, for example, the best measures are ones that quantify the doctor’s relationship with the patient and the amount of trust between them. The second you start using their panel’s average A1C as the performance metric, A1Cs at best don’t improve. Why? 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. It doesn’t go well. It’s like salespeople who try to close before they build a relationship. Time to goal counterintuitively is slower, and performance is poorer. Anyone building value-based care or quality programs might really want to include Goodhart’s Law in their thinking. 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. Rishi’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 health care 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). 03:10 What was the Hospital Readmissions Reduction Program intended to do? 05:05 Why did the Centers for Medicare & Medicaid (CMS) think some readmissions were preventable? 05:46 “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.” 06:54 How has research in the last few years changed the thoughts on the effectiveness of the Hospital Readmissions Reduction Program? 08:14 “The 30-day readmission measure—it’s an incomplete measure.” 12:12 “I think patients … are smart, and they know what’s going on.” 14:01 “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.” 14:22 “The weird thing about the HRRP is that when it evaluates hospitals’ 30-day readmission rates, it’s a yes-no phenomenon.” 15:30 “What CMS does is, it risk adjusts … and that is what we should be doing.” 19:16 “This program has been incredibly regressive.” 19:51 “Poverty, neighborhood disadvantage, housing instability—these factors are out of hospitals’ control.” 22:56 “Blunt policies like this that are rolled out nationally probably elicit mixed behavioral responses.” 23:12 “It just makes no sense to take resources away from hospitals.” 25:22 What’s the way to improve quality of care globally? 27:19 “CMS’s approach to improving quality of care has really anchored … [that] to payment.” 27:49 “It’s time for us to rethink what our approach to quality improvement should be.” 31:28 “Policy makers have an obligation to rigorously test the impact of these types of policies before they roll them out nationally.” 34:05 Can you scale health care nationally? You can learn more at Dr. Rishi’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 health care nationally? @rkwadhera of @BIDMChealth discusses #HRRP on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc #hospitalreadmission