Relentless Health Value

First of all, a shout-out to all of you listeners who have shared this show with colleagues and LISTSERVs—really appreciate it. It’s because of you and your efforts to share that Relentless Health Value maintains its spot as one of the top podcasts reaching health care executives, executives who take the insights shared by our guests to drive actual change and transformation across our industry. So, thank you. Leaving a rating and/or a review on iTunes is also the bomb and really helps our RHV team stay motivated and keep it going. Weekly shows take a ton of work! Feedback is super appreciated. On to the topic this week: Who has read that white paper put out in February by the University of Pennsylvania, specifically, Penn’s Leonard Davis Institute for Health Economics? It’s called “The Future of Value-Based Payment: A Road Map to 2030.” I mentioned this paper last week, too. So, if you still haven’t read it, go back after this show and take a look. There’s links in show notes.  As with every interesting white paper, while you’re reading it, you start thinking of more questions. That’s why I was thrilled to get a chance speak with Mai Pham, MD, MPH. She is one of the paper’s authors, a physician, and a trained health services researcher. Dr. Pham is a former chief innovation officer at the Centers for Medicare & Medicaid Services (CMS). She also spent time at Anthem doing value-based care (VBC) work for the enterprise on a national level. Further, she’s the parent of an autistic child and founded the Institute for Exceptional Care to transform health care for people with IDD (meaning intellectual developmental disabilities), which I’ll get to in a second. Here’s some highlights from my discussion with Dr. Pham: Markets get distorted when insane quantities of dollars rush in. I’m thinking about Medicare Advantage and all of its attendant suppliers right now. Think about all of the amazing brainpower captivated by figuring out how to upcode at scale, which, by the way, only a minority of the time corresponds to actual spend. Dr. Pham has some words on this. Attaining value-based care results and adoption has a big problem. As a policy maker, you can’t just keep trying to sweeten the value-based care pot. You don’t want to plow even more money into the system. So, at a certain point, we all have to get real and realize that for the cost-driving entities in this country—those IDNs (independent delivery networks) with huge market clout—to get on the VBC bandwagon, value-based care probably has to be a mandate; and it also will mean making FFS (fee for service) much less attractive. Thirdly—and here’s something I never considered—commercial prices drive up Medicare prices. You have hospital systems pointing to growing disparities between commercial rates when they negotiate for higher Medicare rates, when the hospital systems themselves created those deltas with their private-sector negotiations. Lastly, we chat national versus local health care reform and about indie doctors and the “why” behind consolidation. It aligns quite a bit, our conversation in this health care podcast, with the insights from the show last week with Nicole Bradberry and Kelly Conroy (EP324).  The last 6 minutes of this podcast is Dr. Pham’s insight about the scope and impact of not caring adequately for people with neurodevelopmental disabilities. We’re talking about somewhere between 10 and 16 million people, as Dr. Pham notes for perspective. That’s the number of new cancer cases each year. Collectively, we spend as a country somewhere between 1% and 2% of the GDP all in on this patient population. You can learn more at ie-care.org.  Hoangmai (Mai) H. Pham, MD, MPH, is a general internist and national health policy leader. She was vice president, provider alignment solutions, at Anthem, Inc., responsible for value-based care initiatives at the country’s second-largest health insurance company. Prior to Anthem, Dr. Pham served as chief innovation officer at the Centers for Medicare & Medicaid Services, where she was a founding official, and the architect of Medicare’s foundational programs on accountable care organizations and primary care. She was co-director of research at the Center for Studying Health System Change and has published extensively on provider payment policy and its intersection with health disparities, quality performance, provider behavior, and market trends. Dr. Pham serves on numerous advisory bodies, including the National Advisory Council for the Agency on Healthcare Research and Quality, the Maryland Primary Care Program, and the National Business Group on Health, and was a member of the Board Executive Committee at the Health Care Transformation Task Force. Dr. Pham earned her bachelor’s degree from Harvard University, her MD from Temple University, and her MPH from Johns Hopkins University, where she was also a Robert Wood Johnson Clinical Scholar. 04:22 What are the nuances within the promises of value-based care? 05:34 “For the first 10 years of … value-based care, it was right in order to generate momentum and get as much participation as possible.” 06:41 “When you leave yourself open to tackling prices, now you open up a whole world of possibilities in terms of how you could redirect sources.” 08:00 “Not all providers are the same.” 09:24 “It’s time to stop tracking the phenomenon and actually pay for change.” 10:29 “We haven’t done our best to actually make the alternative to value-based payment as bad as it could be.” 12:14 What’s the path forward in value-based care, especially for specialists? 15:43 “There has been tremendous business opportunity in Medicare Advantage, not to the benefit of the trust funds.” 17:13 “As a citizen, I gotta ask, ‘How much is enough?’” 19:03 “It’s not like we’re talking about replacing a really superlative gold standard.” 19:34 EP263 with Andrew Eye from ClosedLoop.ai. 22:02 “It’s not just about taking dollars away from certain subsectors; it’s about reallocating some of those dollars.” 23:34 “Policy making itself tends to be siloed.” 25:02 “This is about paying some people in health care modestly less.” 25:35 “Most of the costs are driven by fixed costs.” 29:25 “Value-based care is not what has driven consolidation.” You can learn more at ie-care.org.  @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc What are the nuances within the promises of value-based care? @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “For the first 10 years of … value-based care, it was right in order to generate momentum and get as much participation as possible.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “When you leave yourself open to tackling prices, now you open up a whole world of possibilities in terms of how you could redirect sources.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “Not all providers are the same.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “It’s time to stop tracking the phenomenon and actually pay for change.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “We haven’t done our best to actually make the alternative to value-based payment as bad as it could be.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “As a citizen, I gotta ask, ‘How much is enough?’” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “It’s not like we’re talking about replacing a really superlative gold standard.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “It’s not just about taking dollars away from certain subsectors; it’s about reallocating some of those dollars.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “This is about paying some people in health care modestly less.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc “Value-based care is not what has driven consolidation.” @HoangmaiPham discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #vbc

Recently, the University of Pennsylvania Leonard Davis Institute of Health Economics, or LDI, put out a white paper called “The Future of Value-Based Payment: A Road Map to 2030.” Spoiler alert: Next week’s show is with Dr. Mai Pham, an author of that paper; and it’ll be a great show—so, tune back in next week. But, in the meantime, that paper made some really interesting points about ACOs (accountable care organizations). For example, they say that the average ACO shows a net savings of

This episode seemed particularly relevant right now because it gives insight into how large self-insured employers are prioritizing their efforts to disrupt health care revenue streams that do not provide adequate health outcomes for dollars spent. This episode’s conversation is with Lee Lewis. This is an encore episode. The original was recorded when Lee was the newly minted chief strategy officer at the Health Transformation Alliance, otherwise known as HTA. The HTA is a group of 50 major corporations that have come together in an alliance to do one thing: fix our broken health care system. Anybody who knows Lee knows he knows a lot about how to improve health and health care benefits for large employers. The most amazing thing I always find about improving health and health care benefits is that it’s like having your cake and eating it, too. On one hand, both employer and employee save money. On the other hand, employees get better care and spend less time away from work struggling to navigate the health care jungle all by themselves. Lee’s playbook consists of three chapters which we get into here. The first chapter covers the “how” of health benefits, including what Lee calls the “administrative superstructure.” The second chapter in Lee’s playbook is the “what,” which usually comprises drug spend and then, on the medical side, how care is delivered for specific clinical conditions like musculoskeletal, cardiometabolic, etc. There are a few conditions that tend to rack up the most costs categorically. The last chapter in Lee’s playbook is the “who,” meaning where employees are steered for care, especially in those high-cost areas. You can learn more by visiting htahealth.com and by connecting with Lee on LinkedIn.  Lee Lewis serves as chief strategy officer and GM medical solutions for the Health Transformation Alliance. He leads efforts across over 50 large and jumbo employers and six million employees to save lives and save millions of dollars through improved health delivery, outcomes, and experience. Key initiatives in this role include new models of health benefits administration, curated provider steerage, and improved clinical delivery and outcomes.  

One way to spot a flash point is to notice when people are using different words to describe the same concept. Throughput is one example of this. On one side of the table, you have those who grasp that if a provider organization is concerned about patient outcomes, with few exceptions, building relationships with said patients is essential. It’s not entirely clear to anyone anywhere how you manage to build relationships and trust without spending a certain amount of time with patients. These “we need time with patients” people will bring up the Quadruple Aim issues that arise from rigid 7-minute appointments or even 50-minute appointments really. On the other side of the table, you have those who have built practice fiscal models on the backbone of however-many-minute appointments. They use different terminology for this whole concept, however. They call it throughput. How many patients can a physician manage to squeeze into a day? Some of these folks will tell you that throughput success is “more is more.” In other words, throughput is one of those things that you can never have too much of. Let me back up for a sec and mention the mission of this show. It is to connect health care leaders together by helping everyone understand each other well enough to communicate effectively, which is rate critical numero uno for any collaboration. You can’t collaborate if parties don’t really grasp what anyone else is actually saying when they communicate their WIIFMs (their “what’s in it for me?”) or their organizational imperatives. If we consider that the health care industry can only transform when multiple stakeholders collaborate, these little “language discrepancies” actually can have macro implications. In this respect, this throughput example—not in all cases but at a minimum—it’s an exemplar illustration and certainly something to contemplate. Consider people arguing against 7-minute appointments without mentioning the word throughput. They’re probably not going to even reach the headspace of those who just spent the past two decades in meetings to increase throughput. It’s like two ships passing in the night. You could be sitting there right now pooh-poohing what I’m saying, but I’ve sat in enough meetings where people talk around each other using different terminology, think they’ve agreed on some collaboration or compromise or solution, except nothing happens because everyone got to walk out without addressing the elephant in the room. It sounds something like this: DOCTOR OR NURSE: We need you to enable patients to have quality time with their doctors and the rest of the care team. SOMEBODY ELSE: We need to get rid of inefficiencies, which means driving maximum throughput. ANOTHER PERSON: OK, let’s compromise. Doctors should have quality time while maximizing throughput. Don’t laugh. I’ve heard “action items” like this often enough, and so have you if you think about it. That’s why I originally started this podcast—because I can also guarantee you if this is the action item, no action will actually take place. The only way this conversation is going to net any change is if people around that table head-on confront that quality time with patients means less throughput. And how much less are we going to agree on and/or how are we going to creatively change the practice model so throughput is an archaic term (ie, asynchronous stuff, etc)? I say all this to say that this throughput business also leaks into the technology space in ways that we should probably think about. Increasing throughput, after all, is one of the key ways to increase FFS (fee-for-service) revenue. FFS is all about the need for speed. The faster you can smack a billing code on a patient visit, the more patient visits you can pack into a day, the more billing revenue you can rack up. To some extent, throughput is code word for an addiction to FFS. You can always tell a tech vendor who is used to selling in an FFS environment because the second slide of their pitch deck is always one of two things: either how much faster the tool will get patients in and out of a doctor’s line of sight or what the billing code is for the tool (but that’s a whole different topic). I just described the second slide in an FFS-centric technology vendor deck. The first slide in those “use our AI thingamajig to revolutionize your throughput” decks is always some mission statement about improving patient care. And this is where not everybody using the same language creates immense wiggle room for profit over patients under cover of mismatched terminology. To add one point of context, when I say throughput here or increasing throughput, nobody is talking about making the front desk more efficient, minimizing faxing things around, or streamlining prior auths or duplications in the workflow (ie, fixing things that are in desperate need of a fix). What we’re talking about in this health care podcast are tools like the one I saw the other day. This biz dev person of this company was up and about early promoting some AI diagnostic tool. With this tool, so their slide deck promised, a physician could see 50 patients a day. Even for this particular vendor, I guess a full-throated “Hey, let’s burn out all your doctors and make patients wonder if they imagined their doctor visit would happen so fast”—a blunt message like that—presumed a little too much avariciousness on the part of the practice. So, they tempered their message by stating the inarguable fact that there is a physician shortage in rural America and that this tool will help resolve that. OK … that’s a worthy thing to fix. But, seriously, is the goal to get rural patients an automagical visit with a doctor that, in hindsight, they wonder if they hallucinated it was so fleeting? Or is it to actually help patients get better health? Also inarguably, health care that leads to better health requires less than pedal-to-the-metal throughput. If you think differently and want to change my mind, feel free but show me the study. I say all this to say that I called up Arshad Rahim, MD, MBA, FACP, a little bit ago to see what he thought of my aforementioned burning premises (aka rants) about throughput; and he kindly agreed to come on the show again. Dr. Rahim is senior medical director of population health at Mount Sinai. He was last on Relentless Health Value on EP219 talking about population health for reals in the real world. Go back and listen to that show after this one if you want to hear more of Dr. Rahim’s sage advice.  One more recommendation: For more insights into the impact of maximum throughput, read the awesome op-ed in MedPage Today by Brian Klepper, PhD, and Jeff Hogan.  You can connect with Dr. Rahim on LinkedIn.  07:37 When does throughput negatively affect patient care? 08:55 Why does diagnostic inaccuracy become a problem with throughput? 09:27 Do population health outcomes decline with less throughput? 10:20 “The way you can also be most financially successful is by taking care of sicker patients.” 10:53 What do patients actually want and need? 11:55 “The emotionality in a health care interaction is always there … [when] you’re focused on throughput, you can definitely lose the healing and calming presence.” 14:18 What do doctors need from their organizations to sustain a high level of care? 15:59 “The actions vary across the spectrum from very supportive to not very supportive at all.” 17:02 “There definitely is a challenge of competitive pay.”

Imagine if innovators in other businesses operated in the way that some health care status quo doomsayers finger wag. So much for failing fast, iterating, and folding learnings into something that might work better. I don’t like to see screeds that seem to advocate an approach of “try it a few times at a minimum half-heartedly, fail, and then just quit, because obviously anything worth doing should be that easy.” Pieces fell into place with me as I was speaking to Monica Lypson, MD, MHPE. Dr. Lypson is an expert in a bunch of things, but one of them is thinking about next-generation primary care and health equity and what that might look like in value-based care (VBC) metrics. I asked her if because of some of the negative potential perverse incentives to these patient populations whether we should throw out the VBC baby with the bathwater. Her response was succinct and amounted to, “And go back to what? FFS? Because that’s worked out so well?” All this being said, there are big issues with value-based care right now that we really need to take a hard look at and think critically about. But that critical thinking, to be considered innovative and productive, really should inform creative thinking: What do we learn and do better next time? Cherry picking and lemon dropping is a very real potential problem with value-based care. To find out what that means, you’ll have to listen to the interview. Another issue is who gets to decide what the measures and standards are. Who determined what is high-value and low-value care? And is that determination relevant to all communities and all care settings? Then ferreting out from there the potential loopholes for people to game the system because, despite all the virtue signaling that goes on around here, it is amazing sometimes the raw ingenuity exhibited when it comes to gaming the system. Dr. Lypson brought up some points that I have not heard so succinctly before. One of them is that a national framework is pretty necessary here to enable local initiatives. You can’t have a local program, for example, help the homeless get homes when, on a national level, dollars are siloed into firewalled buckets. So, trying to take health care dollars and apply them to housing takes two years and an act of Congress—because it literally takes two years and an act of Congress, or at least someone with more time and authority than a local care team. For more insight into this topic, listen to also the upcoming interview with Mai Pham as well as Nicole Bradberry and Kelly Conroy. Also, the recent interview with Dr. Rich Klasco (EP321), Jeff Hogan (EP309), and Dr. Mark Fendrick (EP308). This is a huge, complicated topic that will take everyone sitting at the table thinking creatively to solve, incrementally, one step forward at a time. Monica Lypson, MD, MHPE, is currently vice dean for education at Columbia University Vagelos College of Physicians and Surgeons. She has practiced in a number of primary care settings, including the Department of Veterans Affairs. MHPE stands for Master of Health Professions Education, by the way. You can connect with Dr. Lypson on LinkedIn.   Monica L. Lypson, MD, MHPE, FACP, serves as a professor, vice-chair of medicine, division director of general internal medicine at The George Washington University School of Medical and Health Sciences. She will join Columbia University’s Vagelos College of Physicians and Surgeons as vice dean for medical education on June 1, 2021. Her work focuses on innovations and improvements in health professions education and assessment, health equity, workforce diversity, faculty development, medical care delivery, and provider communication skills. Dr. Lypson most recently served as director for medical and dental education for the Veterans Health Administration, where she oversaw undergraduate and graduate medical education across the nation within the Department of Veterans Affairs. 04:08 Is value-based care good for underserved communities? 05:09 “If you create perverse incentives, you actually might make known health care disparities worse … to meet the demands’ value.” 06:29 “There actually might be systematic and structural ways that the health care system might say … we’re not interested in taking care of you.” 07:12 “The incentive to have a good outcome is not there; the incentive to have another visit is there.” 08:33 “If you don’t have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots.” 08:55 “The only indictment I have on the fee-for-service system is that it’s gotten us to where we are right now.” 09:30 What are the must-haves for a value-based system that creates the patient outcomes we need? 09:58 What is a whole health model? 10:43 EP319 with Grace Terrell, MD. 11:08 EP312 with Douglas Eby, MD, MPH, CPE. 16:25 “We want to move money around with the accountability of the patient outcome. We want to be responsible stewards of that dollar.” 17:14 What does it mean to keep an equity framework? 20:48 Do we know the impact of independent physicians closing their offices? 25:20 What do we need to be mindful of when constructing a value-based system of care? 27:52 “The large health care system needs their community partners at the table.” You can connect with Dr. Lypson on LinkedIn. @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc Is value-based care good for underserved communities? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “If you create perverse incentives, you actually might make known health care disparities worse … to meet the demands’ value.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “There actually might be systematic and structural ways that the health care system might say … we’re not interested in taking care of you.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “The incentive to have a good outcome is not there; the incentive to have another visit is there.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “The only indictment I have on the fee-for-service system is that it’s gotten us to where we are right now.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What are the must-haves for a value-based system that creates the patient outcomes we need? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What is a whole health model? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “We want to move money around with the accountability of the patient outcome. We want to be responsible stewards of that dollar.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What does it mean to keep an equity framework? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc What do we need to be mindful of when constructing a value-based system of care? @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc “The large health care system needs their community partners at the table.” @mlypson discusses #valuebasedcare models on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcaremodels #vbc

If you listen to this show on the regular, you probably have a pretty good bead on a couple of things I’ve been really into lately. One of them is high-value care versus low-value care. These are terms that are really easy to throw around. You also can get pretty much everybody to agree with a plan to deliver only high-value care and quit it with the low-value care … in theory. But the wheels fall right off the bus when it comes to actually doing this. IRL (in real life), what constitutes high-value care and what is low-value care exactly and specifically? This answer is the crucible for value-based care of almost any flavor. How are you supposed to do value-based care successfully when it remains an open question, “What is care that is of value?” Here’s the good news, though. There is a bounty of unmistakably, inarguably low-value things. We can start there. Now, these low-value things may be situational in some respects, so you’ll need to listen to my interview with Dr. Mark Fendrick (EP308) for the scoop on that nuance. But there are definitely some things which are incontrovertibly low value. Here’s some more good news. There’s a few ways to ferret out low-value things, and one of them is to look at data on practice patterns across a specialty. You can index the data nationally or regionally or even within the same practice. Here’s an example: Let’s just say, on average, a dermatologist does 1.74 cuts or surgical slices for Mohs surgery, where they often get paid by the cut, by the way. However, you can find some physicians who are outliers—derms who have two standard deviations above that average. The good news is that a lot of the times, all you have to do is show the doctors the data. Show them that they’re an outlier and they’ll alter their practice patterns. So, one way to figure out what the standard of care should be is by looking at physicians’ actual experience and practices. That seems very fair. Marty Makary, Will Bruhn, and others from the team at Hopkins get a lot of credit for their pioneering work in this area. Other ways include assessing pubs and the guidelines that societies put out. I’m also sure that, more and more, it will also involve combing through real-world evidence. In this health care podcast, I speak with Rich Klasco, MD, who is chief medical officer at Motive Medical Intelligence; and we talk about the challenges and opportunities and solutions when it comes to identifying high- versus low-value care. Dr. Klasco has an interesting construct for this. We also talk about how patients, providers, and payers might have different points of view, incentives, and capacities really to distinguish the high from the low. You can learn more at motivemi.com. For more information and the case study, please visit motivepw.com/resources.   Rich Klasco, MD, FACEP, has focused throughout his career on rendering evidence-based medicine operational—that is, making the right thing the easy thing to do. He has pursued this goal in academia, in industry, in policy, and in the press. In addition to publishing extensively in both peer-reviewed journals such as JAMA and lay publications such as The New York Times, Dr. Klasco has taught at leading academic medical centers, including Harvard, Stanford, Mayo, and the University of California, San Francisco; served on the executive committee of Brigham and Women’s Hospital Center for Patient Safety Research and Practice; testified before the United States Congress on evidence-based practices; and won CMS approval for an officially designated compendium of evidence-based oncologic drug information. Dr. Klasco previously served as chief medical officer and editor-in-chief for the Thomson Reuters group of health care companies, where he had editorial responsibility for companies including Micromedex, the Physicians’ Desk Reference (PDR), and the United States Pharmacopoeia (USP) Drug Information. For the past 15 years, Dr. Klasco has served as chief medical officer for Motive Medical Intelligence, where he provides clinical leadership for the development and deployment of solutions that quantitative assess physician performance for payers, providers, and patients, and integrate scientific knowledge into workflow systems where it can be accessed and applied in real-time. Dr. Klasco received his medical degree from Harvard Medical School. He completed his internship and residency in internal medicine at Brigham and Women’s Hospital, and he completed his residency in emergency medicine at the Denver Health Residency in Emergency Medicine, where he served as chief resident. 03:31 How do you define high-value care? 04:40 How do we define what isn’t appropriate care? 05:26 Why aren’t patients good at recognizing high-value care? 07:02 “He was in the ‘more is more’ school of medicine, which is always wrong.” 11:54 Are payers good at identifying high-value care? 13:41 Why are payers so adept at understanding what high-value care really is? 15:53 “It’s not just cost cutting; it’s utilization, optimization of resources.” 16:02 “This is, again, an innovation of appropriateness.” 18:38 “We have to deal with the world that we have in front of us now.” 19:55 How do we get everyone on the same page about high-value and appropriate care? 24:16 How does a team recognize the path forward for appropriate care? You can learn more at motivemi.com. For more information and the case study, please visit motivepw.com/resources.   Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc How do you define high-value care? Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc How do we define what isn’t appropriate care? Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc Why aren’t patients good at recognizing high-value care? Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc “He was in the ‘more is more’ school of medicine, which is always wrong.” Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc Are payers good at identifying high-value care? Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc Why are payers so adept at understanding what high-value care really is? Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc “It’s not just cost cutting; it’s utilization, optimization of resources.” Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc “This is, again, an innovation of appropriateness.” Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc “We have to deal with the world that we have in front of us now.” Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc How do we get everyone on the same page about high-value and appropriate care? Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc How does a team recognize the path forward for appropriate care? Rich Klasco, MD, discusses #lowvaluecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #valuebasedcare #vbc

When I was talking with Dr. David Carmouche from Ochsner in EP316 about the importance of collaboration amongst anybody trying to actually pull off value-based care, we took a little detour, which I wound up cutting out, into the potential and challenges for health systems to collaborate and do value-based contracts with pharmaceutical manufacturers. It’s a really interesting sidebar, though, that I wanted to share with you—especially on the heels of the recent interview with Troy Larsgard from Johns Hopkins (EP318) on how Pharma can better meet the needs of their health system customers.  Here’s an interesting point that Dr. Carmouche makes in the sidebar that I thought was worth highlighting. Chalk this up as one of the challenges when trying to create some kind of risk-share agreement with a pharma company to get the manufacturer to put their money where their mouth is when they say that downstream costs will be saved or complications avoided or better outcomes attained. The challenge comes in assembling enough patients to make it worth everyone’s while. As we’re considering the assemblage of patients, we have to first consider who’s paying for the drugs. It’s a payer, usually, who contracts with a PBM (pharmacy benefit manager). So, any given health system is going to have to have enough patients not only on that one particular payer in its payer mix but also on that one payer with a plan design that uses that one PBM. As I consider this, I still have questions. Dr. Carmouche is executive vice president of value-based care and network operations at Ochsner. You can learn more by visiting Dr. Carmouche’s LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  David Carmouche, MD, views health care from three distinct perspectives: as a physician provider, an executive for an insurance company and as a leader in a health system. Specifically, he built a large, multidisciplinary internal medicine and preventive cardiology practice in Louisiana; served as the chief medical officer for Blue Cross Blue Shield of Louisiana; and currently has a triad of responsibilities with Ochsner Health, the largest nonprofit academic health care system in the Gulf South. He was recently promoted to serve as executive vice president of value-based care and network operations in addition to his duties as president of the Ochsner Health Network and executive director of the Ochsner Accountable Care Network. He is known as an expert in value-based care. He led one of the top 25 performing accountable care organizations in the United States, managing billions in care spend and generating millions in year-over-year shared savings. Dr. Carmouche earned a bachelor’s degree from Tulane University and a medical degree from Louisiana State University School of Medicine in New Orleans. He completed his residency in internal medicine at the University of Alabama at Birmingham. 01:57 Why has creating collaboration across Pharma been difficult? 03:10 “Is it better over an episode of care to add a more expensive drug … or would we be better served using less expensive drugs?” 03:51 Why has it been difficult for health systems to execute agreements directly with pharma companies? 04:36 “The question is really just whether or not there’s enough value that’s created to make it worth our while.” You can learn more by visiting Dr. Carmouche’s LinkedIn page or by reading From Competition to Collaboration by Tracy Duberman and Robert Sachs.  @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why has creating collaboration across Pharma been difficult? @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Is it better over an episode of care to add a more expensive drug … or would we be better served using less expensive drugs?” @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why has it been difficult for health systems to execute agreements directly with pharma companies? @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “The question is really just whether or not there’s enough value that’s created to make it worth our while.” @CarmoucheMd discusses #healthsystem #collaboration with #pharmamanufacturers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma

If you want to hear what my mom and dad, both Medicare Advantage patients in their late 70s, have to say about telehealth (or teleconferencing, as my dad puts it), you’ll have to listen to the episode. They are not and have never been health care professionals, but they fully get that the question “What’s better—telehealth or in-person care?” asked like it’s some kind of winner-takes-all cage fight doesn’t serve anybody’s needs. And by anybody, I mean clinicians or the patient. And by patient, I mean even Medicare Advantage patients in their late 70s. In this health care podcast, I’m speaking with Christian Milaster from Ingenium. Christian worked at Mayo for 12 years before starting his consulting firm specializing in many aspects of telehealth. He has a great newsletter, by the way. I’ve appreciated subscribing to it. It’s called Telehealth Tuesday. I would recommend it.   Christian says telehealth is a clinical tool. That’s why there’s no answer to the question of whether in-person is better than virtual. It’s like asking, “What’s better—an x-ray, a CT scan, or an MRI?” Or like, “What’s better—a daily blood pressure test at home or one super fancy EKG a year?” I guess telehealth could also be considered maybe a setting of care. Christian probably wouldn’t agree with me. Either way, few people sit around pitting Exam Room 6 against the one on the fourth floor with the extra-wide doorway. So, let’s not even talk about this. We’re over it. The relevant question to be asking about telehealth would be “What’s the best clinical workflow, patient journey, clinical pathway for X kind of patient or for this patient?” The tools that we choose to use or the care setting we choose should be a function of the best care plan for the patient. You figure out the care plan first. It’s just like you figure out what surgery someone needs, and then you stock the OR. It would be super weird to do it the other way around. You know, neurosurgeon walks into OR. “Hey, what’s this knee replacement doing here?” You get my drift. What’s the why, you might be asking, if I’m a provider and I’m kinda like the urologist that my father fired the other day? And I’m thinking I’m just going to require all of my patients to come into my office all the time because that’s the way I’ve always done it and I kinda like it. Well, let me refer you to the article written by Jane Sarasohn-Kahn the other day entitled “Virtual Health Tech Enables the Continuum of Health From Hospital to Home.” This article is great and talks about a bunch of things, but here’s a quote I particularly liked: “[The demand for telehealth] will impact every segment of care delivery and sponsor, including small to mid-sized physician practices, employers, behavioral/mental health, public/government-sponsored health [plans], and the pharma and life science industry.” She is talking about demand post-pandemic, by the way.   Let me put a finer point on this. You know who is most likely, besides my father, to fire a doctor who doesn’t know how to incorporate telehealth into his or her treatment pathway? Yes, exactly—educated working-aged people. People with commercial insurance. The people that health systems and doctors are always trying to attract because … favorable payer mix. So, there’s that. One more thing before I turn the floor over to the interview with Christian Milaster: I just wanted to call out something that matters, especially right now. I recently saw a post by Joe Kvedar on LinkedIn about how digital inclusion is actually a social determinant of health. The post referenced an article by Jill Castek and Cynthia Sieck, amongst others.   The point of it was that sometimes people have spoken about telehealth being the solution to rural health issues (eg, access issues) or people who have to work three jobs or those who have transportation issues. The problem is that it’s exactly these people who may not have internet access or maybe have less digital literacy. So, exactly the people that, at least originally, telehealth was supposed to serve are exactly the people that are having trouble taking advantage of it. You can learn more at ingeniumdigitalhealth.com and connect with Christian on LinkedIn.  Christian Milaster optimizes telehealth services for health systems and physician practices. He serves as a digital health and telehealth advisor to start-ups and established digital health companies. Christian is a master builder of digital health and telehealth programs and is the founder and president of Ingenium Digital Health Advisors, a boutique consultancy focused on enabling the effective delivery of extraordinary care through workflow optimization and the judicious use of technology. Born, raised, and educated as an engineer in Germany, Christian started his career at IBM Global Services before joining the Mayo Clinic in Minnesota, where he worked for 12 years in various roles before launching Ingenium in 2012. 06:53 What’s the biggest mistake provider organizations are making in regard to telehealth right now 08:50 Is there a downside to not investing more in telehealth? 12:28 “There’s no more geographic boundaries.” 15:25 What’s a provider organization’s first step in making telehealth a cornerstone of care? 17:20 Why is organizational change management essential to incorporating telehealth? 19:00 “Everybody involved in the in-person care experience needs to be involved and play a role in the virtual care experience as well.” 19:22 What does the patient flow look like for organizations that do telehealth well? 21:12 How does an organization use telehealth as a strategic tool? 23:55 “Telehealth gives us an opportunity to redesign the workflow of the care delivery experience.” 24:38 How is the provider reimbursed in telehealth? 26:29 “It’s really about the outcomes and it’s about value-based care … when I can just wield telemedicine … as a clinical tool.” 28:19 “Telemedicine … is vital for value-based care; it’s vital for better patient outcomes.” You can learn more at ingeniumdigitalhealth.com and connect with Christian on LinkedIn.  @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine What’s the biggest mistake #providerorganizations are making in regard to telehealth right now? @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine Is there a downside to not investing more in telehealth? @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine “There’s no more geographic boundaries.” @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine What’s a #providerorganization’s first step in making telehealth a cornerstone of care? @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine Why is organizational change management essential to incorporating telehealth? @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine “Everybody involved in the in-person care experience needs to be involved and play a role in the virtual care experience as well.” @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine What does the patient flow look like for organizations that do telehealth well? @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine How does an organization use telehealth as a strategic tool? @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine “Telehealth gives us an opportunity to redesign the workflow of the care delivery experience.” @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine How is the provider reimbursed in telehealth? @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine “Telemedicine … is vital for value-based care; it’s vital for better patient outcomes.” @HealthChrism discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech #telemedicine

Dr. Grace Terrell, a medical doctor specializing in advanced primary care, shares how advanced primary care models can improve outcomes in skilled nursing and assisted living facilities. She discusses the importance of whole-person care, the financial prospects for these facilities, and implementing coordinated care. The podcast also explores the tension between primary care physicians and specialists in providing quality care.

I heard someone say the other day, “Practicing medicine without pharmaceuticals is like running to the ten-yard line, putting down the ball, and walking off the field.” So, it’s pretty imperative that providers and Pharma know how to work together to get the best outcomes for patients. In this context and in this podcast, when I say “get the best outcomes for patients,” I kinda mean it. There’s a sweet spot in the middle of “won’t let those [expletive goes here] pharma reps in the building” and blatant conflicts of interest. I wanted to find out from someone who would know what a great collaborative relationship with a pharma company looks like for a large health system from their point of view. How do two, in general, gigantic bureaucratic organizations find ways to help each other help patients? No one would disagree that finding the best collaborative strategy with a health system is going to depend a lot on how that health system rolls in general. One aspect of how they roll is to take a look at their so-called level of control. This means how centralized decision-making is. For example, on the far one end of the control or lack thereof spectrum, you’ll have your more controlled systems of care. These systems have centralized decision-making. Most of them will tell you that this centralization signals a bunch of things like, for example, a commitment to total care of patients. More control can mean that patients can have confidence if they walk in, there’s a system of care that is standardized across all the sites of care and any drugs prescribed, for example, not only have been FDA approved but also vetted at the health system level. They’ve gone through some rigorous evidence-based decision-making. In this health care podcast, I’m talking with Troy Larsgard, who is the category manager of pharmaceuticals at Johns Hopkins Medicine. He held a similar role at Intermountain for a number of years also. As part of his role, Troy has sat on and sits on P&T (Pharmacy and Therapeutic) committees as a nonvoting member. Basically, Troy is the guy that drug companies want to meet with. Here’s a point that Troy Larsgard makes during our conversation that I found really enlightening. And I guess this could pertain to either a more open or closed health system. It would just happen at a differing scale. Some suppliers, pharma companies, have a “boots on the ground” strategy for large health systems—lots of representatives running around who don’t necessarily have a strategic framework to coordinate their efforts. From a health system perspective, this is what Troy considers not a strategic approach. As Troy says, all things being equal, he likes to work with companies who meet him where he’s at and who understand the needs of his organization. In this conversation, I paid particular note to the ways that pharma companies who are really good at crafting their collaborative strategic approach get a leg up over competitors who cling to a more transactional, maybe legacy, pharma approach. Point of note: While this whole conversation is technically about pharma company collaborations, everything that we talk about in this episode is almost wholesale applicable to others looking to work with health systems, like medical device manufacturers, purveyors of digital health technologies, etc. You can connect with Troy on LinkedIn. Troy Larsgard is a health care professional specializing in pharmacy supply chain. After working six years at Intermountain Healthcare in Salt Lake City, Utah, he joined The Johns Hopkins Health System Corporation in Baltimore, Maryland, in January 2020. One of his most rewarding career experiences is taking an active role with key stakeholders in planning for and operationalizing the COVID-19 vaccine at Johns Hopkins. After thousands of meetings, proposals, and presentations from pharmaceutical companies, he is convinced there are better ways suppliers can work strategically with large health systems. He welcomes forward-thinking ideas and engagements to move beyond the transactional and create strategic alliances and value-added opportunities. He has put this philosophy to practice helping to remove barriers and working together with suppliers to make industry changes. 04:16 What’s the rationale behind trimming the supplier list for pharmacists? 05:35 What’s the difference between a strategic model and a tactical model? 06:49 “A lot of effort goes into developing drugs and bringing them to market, but sometimes the thought of how to interact with the health system beyond that isn’t always thought out.” 09:06 “I think there’s opportunity to be more seamless.” 10:48 “Those who inform early, often, and are transparent … save much more face.” 11:04 What do account managers need to know about health systems and vice versa for them to work together? 14:15 How do drugs on formulary fall into these pharma/health system collaborations? 16:46 How do physicians know when a drug is on formulary? 19:32 Are downstream medical costs being assessed? 21:29 Why would a health system choose to collaborate with a pharmaceutical company in this system? 22:31 “What does partnership mean to you?” 26:15 “Outcomes-based contracts sometimes are called risk share, and I like to joke sometimes it’s all risk, no share.” You can connect with Troy on LinkedIn. Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What’s the rationale behind trimming the supplier list for pharmacists? Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What’s the difference between a strategic model and a tactical model? Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma “A lot of effort goes into developing drugs and bringing them to market, but sometimes the thought of how to interact with the health system beyond that isn’t always thought out.” Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma “I think there’s opportunity to be more seamless.” Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma “Those who inform early, often, and are transparent … save much more face.” Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Are downstream medical costs being assessed? Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma "What does partnership mean to you?" Troy Larsgard of @HopkinsMedicine talks #pharmacollabs with #healthsystems on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma