Relentless Health Value

Let’s get a fast bead on what’s going on with drug pricing reform, shall we? Every time I wade into these waters, my head about explodes. So, I very much appreciate the opportunity to quiz Josh LaRosa from the always-well-informed Wynne Health Group. Here’s the goings-on in a nutshell: There’s goings-on. This infrastructure bill that’s in all the news all over the place right about now? You know what the plan is to fund all those bridges? Yeah, well, part of it is for Medicare to save money on drugs and then apply the savings to cover the costs of all those roads and train tunnels. There are three major potential ways that the federal government might conceive of collecting these drug savings: (1) They could try to get others to pick up some of the Medicare Part D costs—others meaning private payers and pharma manufacturers. (2) Also, they can limit how much manufacturers could raise prices via this “inflation rebate” proposal. Interestingly, this “you can’t raise prices more than the rate of inflation or else you have to rebate the difference” legislation is also being bandied about for Medicare Part B (as in boy) drugs. And those Part B drugs? Those are frequently the really expensive ones (ie, the oncology meds that are infused). And then the third way (3) to save some shekel that might wind up in the infrastructure bill is permitting HHS (the Department of Health and Human Services) to negotiate for drug prices. This last one is always a hot potato, but the winds might be changing some. On the Executive Branch front, we also may have a reboot of the Most Favored Nation rule, but I’ll let Josh explain that one. In fact, I’ll let Josh explain the brouhaha on all of these possibilities. For more information on any of this, read the article that Josh LaRosa and his Wynne Health Group colleagues wrote for The Commonwealth Fund blog recently.  You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.  Josh LaRosa, MPP, is a policy director at Wynne Health Group, focusing primarily on regulatory affairs with a focus on the US Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS). His interests lie in delivery reform and innovations in payment and care delivery models. Josh also supports the firm’s Public Option Institute, which studies the emergence of public option programs at the state level. Prior to Wynne Health Group, Josh consulted for the CMS Innovation Center, where he worked to implement, monitor, and spread learning garnered from the center’s high-profile demonstration projects, most recently including the national primary care redesign effort, Comprehensive Primary Care Plus (CPC+). Josh holds a Master of Public Policy from the University of Virginia’s Frank Batten School of Leadership and Public Policy. He also completed his undergraduate studies at the University of Virginia, graduating cum laude with a BA in political philosophy, policy, and law. 02:56 Where are we on drug pricing reform in legislation? 05:06 What things have the greatest potential for consideration on drug pricing reform legislation? 06:07 How is the Part D benefit design and reform shaping up? 07:55 Who is one of the largest offenders of high federal spending? 09:15 Who is going to pay in the reform of the catastrophic pricing phase? 12:04 What are inflation rebates? 15:36 “The interesting part of the inflation rebates … is that it not only … had these inflation rebates as applying to … Medicare Part D drugs but also Medicare Part B … drugs.” 16:20 How likely is this reform? 18:43 What’s happening on the regulatory and administrative side of drug pricing? 24:23 When will we start to see what the White House intends to do about drug reform pricing? You can learn more at wynnehealth.com or by following on Twitter and LinkedIn.  @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Where are we on drug pricing reform in legislation? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What things have the greatest potential for consideration on drug pricing reform legislation? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma How is the Part D benefit design and reform shaping up? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Who is one of the largest offenders of high federal spending? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma Who is going to pay in the reform of the catastrophic pricing phase? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What are inflation rebates? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma How likely is this latest drug pricing reform? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma What’s happening on the regulatory and administrative side of drug pricing? @josh_larosa of @WynneHealth talks #drugpricingreform on our #healthcarepodcast. #healthcare #podcast #digitalhealth #drugpricing #pharma

I don’t know what I thought we were going to talk about during my interview with David Carmouche, MD; but I’m glad it turned out exactly as it did. Lately, we’ve had a number of guests on Relentless Health Value talking from the point of view of the employer: what a self-insured employer wants and needs from the large, and small, providers in their network. In this episode, we’re flipping the script and talking about what a large provider organization wants and needs from the commercial side of its payer mix. If value-based care or risk shares are to be a thing, we can’t have, as Troy Larsgard has put it, all risk and no share. In this health care podcast, I had the honor and pleasure of speaking with Dr. David Carmouche. Dr. Carmouche started out as a physician in a multi-specialty group. He practiced there for about 15 years before leaving to become chief medical officer at BCBS (Blue Cross Blue Shield) of Louisiana. Five years ago, Dr. Carmouche transitioned to Ochsner Health, where he is currently executive vice president of value-based care and network operations. At Ochsner, Dr. Carmouche helps lead the value-based care agenda—that’s everything from managing strategic partnerships with payers, as well as managing risk in value-based contracts for Ochsner and affiliated network partners across their ACO (accountable care organization) and CIN (clinically integrated network). Highlighting one point that Dr. Carmouche makes early in our chat, there’s four things that have to come together for meaningful value creation for providers: (1) willingness of providers and provider leadership to think and do things different than they have historically; (2) they have to be able to affect payment for those things; (3) they have to have data and be able to access it; and then (4) some control over steering patients. This kind of sets the stage, actually, for our fast dive, in this conversation, right into employer and commercial collaborations. Three of the four things on that list—affecting payment, data, steering patients—are right in the wheelhouse of forward-thinking employers, or commercial payers/TPAs (third-party administrators) trying hard to compete for or serve employers. Just a quick heads-up here: Coming soon, we’re going to release a second episode with Dr. Carmouche giving some great advice for the leadership of provider organizations who are trying to figure out their transition away from FFS (fee for service) to a more risk-based, value-based model. One quick point that I thought was also relevant to the show here: It was super interesting to me how quickly Dr. Carmouche got from “transition to value” to “knows how to collaborate with other organizations.” Here’s the pretty obvious inference: You can’t transition to value if you don’t know how to play well with others to co-create value and share the rewards of such an endeavor. There might be a broader lesson in here for whoever you are in the health care ecosystem. And I’m looking at you, pharmacy, Pharma, tech, societies, BUCAs, etc. Thanks so much to Brian Klepper for the introduction to Dr. Carmouche. 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. 04:15 Who needs to be working together to create value-based success? 04:31 “I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers.” 04:45 What four things have to come together for meaningful value? 06:02 “We’re focusing specifically on payer employers today. We think that’s where there’s the biggest opportunity.” 07:23 What’s the overarching reason for health systems to want to grow their commercial market share? 14:00 Is the competition moving upstream? 16:20 “In all honesty, we’re competing for pieces of the business.” 16:23 What’s the ultimate competition? 18:36 “There is a consumer experience that is available inside these … collaborative efforts.” 20:53 “We really haven’t changed the paradigm of benefit design as it comes to drugs.” 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 talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare Who needs to be working together to create value-based success? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “I think the most important partnerships that are likely to lead to value are those between payers or purchasers … and providers.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare What four things have to come together for meaningful value? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “We’re focusing specifically on payer employers today. We think that’s where there’s the biggest opportunity.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare What’s the overarching reason for health systems to want to grow their commercial market share? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare Is the competition moving upstream? @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “In all honesty, we’re competing for pieces of the business.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare “There is a consumer experience that is available inside these … collaborative efforts.” @CarmoucheMd talks #employers on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthsystems #vbc #valuebasedcare  

Discussing the importance of standardizing care plans and pathways in healthcare to enhance quality outcomes. Addressing the challenges of managing chronic diseases and the need for reform in the healthcare system. Emphasizing the significance of patient involvement in medication decisions and strategic shifts in ambulatory care practices towards value-based models.

Have you never heard of the Nuka System of Care? If that’s the case, it is an award-winning and really remarkable health system in Alaska. In this 5-minute “An Expert Explains,” Dr. Douglas Eby, medical director over at Nuka, gets directly to the point. A key component to making sure that the people/customers in your plan get the best care is to make sure that they have access to a team of providers who know them well enough to have earned their patient consumers’ trust. Both the trust and the access part of that last sentence are important. Both are needed in spades to reduce downstream costs. The access part might be a little counterintuitive and has a disclaimer or two that Dr. Eby articulates. But, yup, when you restrict access, what winds up happening is that people demand more when they finally get seen. They want their money’s worth, so to speak, and will nab any lab diagnostic or expensive follow-up they can get while they’re there, since they may never have the opportunity or the money or the time to arrange being seen again—or at least how it might feel to them at the time. Circling around to trust, listening to Dr. Eby talk, it makes me even more frustrated by providers who regard shared decision making endeavors or building trust with patients as a waste of time unless they’re getting paid for it directly somehow. If a patient isn’t going to do anything you tell them to do because they don’t trust you, and if they have to do what you tell them to do to get the outcomes that they probably should be getting, then it’s a bigger contemplation for providers and provider organizations than whether there’s a billing code for that—for provider organizations trying to create the best patient outcomes for their patients, that is. If you’re an employer and you recognize the criticality of access and trust, select your network accordingly would be my advice. Douglas Eby, MD, MPH, CPE, is the physician executive/VP of medical services at the Southcentral Foundation Nuka System of Care. This “An Expert Explains” sums up Dr. Eby’s advice for employers, but if you haven’t listened to it yet, when you’re done with this “mini-sode,” you might want to go back to the main episode I just did with Dr. Eby that gets into the how to provide effective health care from the provider organization clinician and kind of community standpoint.  You can learn more at southcentralfoundation.com. Douglas K. Eby, MD, MPH, CPE, is vice president of medical services for Southcentral Foundation’s Malcolm Baldrige Award–winning Nuka System of Care. Doug is a physician executive who has done extensive work with the Institute for Healthcare Improvement and other organizations around the Triple Aim, accountable care organizations (ACOs), patient-centered medical homes, whole system transformation, workforce, cultural competency, health disparities, and other topics. His speaking and consulting include work across the US, Canada, and portions of Europe and the South Pacific. Doug has spent more than 20 years working in support of Alaska Native leadership as they created a very innovative integrated system of care that has significantly improved health outcomes. Doug received his medical degree from the University of Cincinnati in Ohio and his master’s in public health degree from the University of Hawaii. 03:19 “The employer is the total-cost provider.” 03:23 “The people who don’t like us are people who are trying to make profits … extremely high use of high-end medicine.” 03:47 “Health care, for chronic disease management, should be provided when, where, and how the person on the receiving side wants and needs it.” 07:05 “People think demand is driven by … paranoia … but when you replace all of that by trust … that’s a massive replacement for all of that other stuff.” You can learn more at southcentralfoundation.com. @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “The employer is the total-cost provider.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “The people who don’t like us are people who are trying to make profits … extremely high use of high-end medicine.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “Health care, for chronic disease management, should be provided when, where, and how the person on the receiving side wants and needs it.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “People think demand is driven by … paranoia … but when you replace all of that by trust … that’s a massive replacement for all of that other stuff.” @deby59 of @SCFinsider discusses #selfinsuredemployers on our #AEE #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth

This episode is for anyone as curious as I have been about pharmaceutical supply chain goings-on in long-term care facilities like skilled nursing facilities, otherwise known as SNFs. There are a lot of players in the mix: You have your PBMs. You have your wholesale pharmacies. You have your LTC (meaning long-term care) pharmacies. You have the facilities themselves. You also have Medicare Part A and Medicare Part D and, in some cases, Medicare Advantage. Let me just lay some groundwork here before we dive headfirst into the confoundingly messy middle. If we’re talking about patients who have been in a SNF for services not covered by Part A—maybe because the patient needs help with basic activities of living—then their drugs are covered by Part D (Med D) or maybe their Medicare Advantage plan. The point I’m making is that it’s not a global payment at that point in the SNF. The patient’s Part D drug coverage is gonna be the same as if that patient were outpatient. They may have deductibles and coinsurance just like an outpatient. In this health care podcast, I speak with Sheldon Weiss, MD, who I pretty much interrogate about the who, what, and when of the various parties involved in getting a drug into a long-term care facility. Dr. Weiss is a great guy to ask because he is a practicing physician and operating efficiencies consultant and a previous COO of an LTC pharmacy. Now, let me editorialize a moment: At its core, the model of having a consultant pharmacist working with a medical director and a director of nursing at a long-term facility is a really interesting one. I just saw another article (this one in Health Affairs) the other day that came out proving yet again that provider teams outperform solo providers in managing chronic diseases. In theory, having a team including a pharmacist should definitely level up care. But there are confounders when it comes to the care of older Americans in facilities. One of them is that physicians—and I say this as an unfair broad stroke—sometimes don’t listen to the advice of consultant pharmacists because they’re just a pharmacist and not an MD. I’ve heard this go down myself and not just with pharmacists. In fact, in my recent interview with Dr. Douglas Eby from the Nuka System of Care, he said the same thing about doctors and behavioral health specialists. At the beginning, the docs are, like, “Oh, we don’t need behavioral health specialists. That’s what we do very well, thank you very much.” It didn’t take them long to revise that opinion, but it’s really common pooh-poohing that I hear repeatedly. And so, for possibly this reason and others, we have a situation where one of the main reasons why patients wind up in the ER from SNFs is that they have adverse drug events. Now, this being said, patient care in SNFs is a hard row to hoe because patients and SNFs are often highly complex and under the care of, in some cases, 10 or more specialists, all prescribing drugs without any knowledge of what other specialists are prescribing. Will the medical director of a facility want to take on the responsibility of contradicting a cardiologist or a pulmonologist or an oncologist and unprescribe some med? It takes a certain amount of fortitude and willingness to take on that risk. Keep in mind one point to ponder, however: Most people “aging in place” at home right now are not going to have anybody at all looking over their shoulder and even partially coordinating care reconciling meds. You can learn more by connecting with Dr. Weiss on LinkedIn. Sheldon Weiss, MD, practiced OB/GYN for over 30 years and has a master’s degree in health care management from the Harvard School of Public Health. He was the chief strategy officer for Indiana University Health system for 5 years and was the chief operating officer of a long-term care pharmacy for 2 years. He now does consulting for operational efficiencies in the health care space and has founded a start-up company focused on developing a health care record interoperability solution.   04:19 What’s the role of a wholesale pharmacy in a SNF? 04:48 What’s the connection between a wholesale pharmacy, a long-term care pharmacy, and a retail pharmacy? 07:00 Why does a SNF need two players? Why can’t a long-term pharmacy also take on the role of the wholesale pharmacy? 09:43 Why don’t long-term care pharmacies negotiate directly with PBMs? 10:02 “The key for … getting the best prices for medications is on volume.” 10:11 Who are these wholesale pharmacies negotiating the best prices? 11:19 “The goal of driving health care costs down by helping out the residents is a good model.” 13:43 “Ultimately the resident gets the same quality of medication, but yet it’s at a much more reasonable price.” 14:35 How does overmedication happen in the long-term care pharmacy model? 15:19 “The lower the amount of medicines, the less the chances of someone to become overmedicated.” 17:50 “I would think that most of the time it’s subtractive.” 19:00 “The idea in health care should be and is … that we only prescribe medications that are necessary.” 20:26 How does aging in place impact pharmacy? 22:11 “When you’re aging at home, there’s no one there looking out for you like a consultant pharmacist.” 24:39 How do we make aging in place safer from a pharmacy perspective? 25:58 “Physicians are very intelligent, but they tend to know their medications in their field.” 26:21 “Anything that increases the multidisciplinary approach model is going to benefit the patient.” 27:10 “The cost of medicine and the outcome of medicine really don’t equate.” You can learn more by connecting with Dr. Weiss on LinkedIn. Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply What’s the role of a wholesale pharmacy in a SNF? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply What’s the connection between a wholesale pharmacy, a long-term care pharmacy, and a retail pharmacy? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply Why does a SNF need two players? Why can’t a long-term pharmacy also take on the role of the wholesale pharmacy? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply Why don’t long-term care pharmacies negotiate directly with PBMs? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “The key for … getting the best prices for medications is on volume.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply How does overmedication happen in the long-term care pharmacy model? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply How does aging in place impact pharmacy? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “When you’re aging at home, there’s no one there looking out for you like a consultant pharmacist.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply How do we make aging in place safer from a pharmacy perspective? Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “Anything that increases the multidisciplinary approach model is going to benefit the patient.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply “The cost of medicine and the outcome of medicine really don’t equate.” Sheldon Weiss, MD, discusses the #LTCPharmacy supply chain on our #healthcarepodcast. #healthcare #podcast #pharma #digitalhealth #pharmaceuticalsupply

Let’s talk about one aspect of health care that’s not talked about possibly often enough: big national health care players siphoning money out of local communities—potentially a lot of money depending on where you are and considering that health care is inching toward about 20% of the GDP. But besides the money leaving the community, another downside of large national players is that sometimes problems—even kind of seemingly simple problems—can be totally intractable and unsolvable because there’s just so much diversity of need and intricacies if you’re trying to come up with a broad-stroke solution that works for everybody across the land. On the other hand, by thinking and acting locally, these same problems can be solved. Besides, at a local scale, community and relationships within the community can become powerful forces for good. In this context, I was super thrilled to have had the chance to interview Dan Strause from Hometown Pharmacy and Drew Leatherberry from Avergent about a collaboration model they put together pairing up local PCP teams hired by self-insured employers with their local hometown pharmacy. Together, they’re similar to a team-based advanced primary care model that also has a level of navigation built in. Considering that patients visit their local pharmacy something like 35-ish times a year, it’s the expertise right in front of your face to help manage patients with chronic conditions. Add to this equation a pharmacist’s education and a local pharmacy’s position as a member of the community. Local pharmacies who are patient first and entrepreneurial could be a great way to keep health care local and solve for the needs of their communities at the same time. This episode is the first-ever simulcast between Health Rosetta and the Relentless Health Value podcast. It was recorded live at the recent Health Rosetta Summit. Thanks much to the Health Rosetta team, including Dave Chase, for inviting me and Relentless Health Value to be a part of the summit. In this episode, the CPESN Pharmacy Network comes up. Should you wish to learn more about the CPESN Pharmacy Network, listen to the Relentless Health Value interview 129 with Troy Trygstad.  You can learn more at hometownrxpharmacy.com and avergent.com. Dan Strause is a partner at Hometown Pharmacy of Wisconsin, a group of 70+ independent pharmacies focused on personalized patient care. Hometown Pharmacy educates and empowers patients and communities to make informed decisions about their health.     Drew Leatherberry is founder of Avergent, a Wisconsin-based benefits advisement firm serving employers around the country, guiding them to 20% to 40% cost savings on top of next-gen benefits and patient experiences. He has spent over a decade leading employers to restore health care to sustainable levels for their team members.     05:02 What has Avergent’s collaborative care model accomplished? 06:07 How did Drew and Dan connect? 07:08 “We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care.”—Drew 07:31 Why would a pharmacy make it their goal to get their patients off their medications? 08:20 “Prescription medicine is the most expensive, most dangerous form of a plant.”—Dan 08:39 “We believe we can help people by giving up prescription medicines.”—Dan 08:45 Is a pharmacy equipped to create a personal relationship with their patients? 12:50 “It’s a spin on traditional navigator-advocate-type roles.”—Drew 16:15 What does helping the patient look like through this partnership program? 19:18 “We’re really unifying the patient health record … and then … cross-referencing all those different data points … on a micro level [and] a macro level.”—Drew 20:53 “Everyone is onboarded into the collaborative care model.”—Drew 21:05 How does this collaborative care model cross the spectrum? 22:13 “Pharmacists are one of the unique professions that doesn’t get paid for time and knowledge [but rather] because of the product they dispense.”—Dan 23:06 “We can see the day where … patients will get a prescription from mail order but still need us.”—Dan 25:46 “We would love to get paid to keep you healthy.”—Dan 27:15 Why are pharmacists wanting to get patients off prescriptions, and how are they involved? 27:36 “In some cases, we are misapplying expertise that’s sitting right in front of our face that can help us deliver a better patient outcome.”—Drew You can learn more at hometownrxpharmacy.com and avergent.com. Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We realized that we were missing out [on] … how … to leverage the experience and the expertise of the pharmacist in driving better patient care.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma Why would a pharmacy make it their goal to get their patients off their medications? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “Prescription medicine is the most expensive, most dangerous form of a plant.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We believe we can help people by giving up prescription medicines.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma Is a pharmacy equipped to create a personal relationship with their patients? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “Everyone is onboarded into the collaborative care model.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma How does this collaborative care model cross the spectrum? Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “Pharmacists are one of the unique professions that doesn’t get paid for time and knowledge [but rather] because of the product they dispense.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We can see the day where … patients will get a prescription from mail order but still need us.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “We would love to get paid to keep you healthy.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma “In some cases, we are misapplying expertise that’s sitting right in front of our face that can help us deliver a better patient outcome.” Dan Strause of @HometownRxWi and Drew Leatherberry from Avergent discuss #pharmacy partnerships on our #healthcarepodcast. #healthcare #podcast #pharma

This episode is a master class in raising health outcomes at lower costs from an award-winning health care system in … Alaska?! Who knew? In fact, I learned about the work of the Southcentral Foundation and the Nuka System of Care only because I happen to listen to Swedish health care podcasts and heard about them on one of those shows. Color me surprised when the interview suddenly switched to English and the guest was from Alaska. Here’s the short version of what’s happening with the Nuka System of Care, which serves Alaska Native and American Indian people. They have gone as close to the Triple Aim as I’ve seen in this country. Health outcomes are superior at costs about half the average. Patients—or, as they call them, customer owners—are happy. So are clinicians. How this was achieved (spoiler alert here) was not through incrementally trying to jigger the earlier and pretty much failing model of health care delivery that had been going on in Alaska for Alaska Natives at that time. No can do! The Nuka System of Care was rebuilt pretty much from the ground up to be, for reals, patient- and community-centric and to be relationship based, not transactional. Behavioral health is a built-in, not dangling off the back bumper. It’s also about assembling a multidisciplinary primary care team, one in which each clinician on the team really can work at the top level of their license. In this health care podcast, I had the honor and pleasure of speaking with Douglas Eby, MD, MPH, CPE. Dr. Eby is the physician executive/vice president of medical services, Southcentral Foundation Nuka System of Care. This episode is sort of two parts. There is the main episode, which you’re listening to now, that gets into the how to provide effective health care from the provider organization, clinician, and community standpoint. In a few days, we’ll release “An Expert Explains” episode, where Dr. Eby specifically goes over the lessons a self-insured employer might take away from all of this. If you are intrigued by what you hear in this episode, Dr. Eby will also be speaking on July 14, 2021, at the Aspirational Healthcare Conference, which will be virtual. Go to aspirationalhealthcare.com for more info. Yours truly will be there as well on July 15, and I’m very much looking forward to it.  For those of you into more immediate gratification, some of the themes that Dr. Eby covers in this health care podcast are expanded on in my interview with Greg Makoul (EP203) about listening to patients and Darrell Moon, who is the founder of the Aspirational Healthcare Conference. You can hear in EP305 talking about the 1% year over year most expensive claimants and the best way to help them and help your cost management at the same time.  You can learn more at southcentralfoundation.com. Douglas K. Eby, MD, MPH, CPE, is vice president of medical services for Southcentral Foundation’s Malcolm Baldrige Award–winning Nuka System of Care. Doug is a physician executive who has done extensive work with the Institute for Healthcare Improvement and other organizations around the Triple Aim, accountable care organizations (ACOs), patient-centered medical homes, whole system transformation, workforce, cultural competency, health disparities, and other topics. His speaking and consulting include work across the US, Canada, and portions of Europe and the South Pacific. Doug has spent more than 20 years working in support of Alaska Native leadership as they created a very innovative integrated system of care that has significantly improved health outcomes. Doug received his medical degree from the University of Cincinnati in Ohio and his master’s in public health degree from the University of Hawaii. 03:52 What’s the what and where of the Nuka System of Care? 04:49 What does the word Nuka mean? 05:25 “It’s all built around this idea that we’re raising … the ability for people to take control of their own health issues, and then we are just advisors … on that journey.” 06:39 “The reason why people do pay attention to us is … the proof in the pudding.” 09:09 What did the Southcentral Foundation do to create an ideal health system? 11:09 “It’s access, it’s relationship, it’s partnering, it’s being known … it’s getting at the whole family and the whole person.” 12:02 “There’s two huge problems with modern medicine all across the world. One is how money is handled … [and the other] is this blind acceptance of the medical model.” 14:14 “For 20 years, we’ve established a base of companionship and relationship.” 16:06 What does advanced primary care look like? 19:25 How does this new style of chronic management work, and why does it get better results than Centers of Excellence and other health system models? 23:25 “We refer out to specialists 65% less often than we used to.” 24:17 “It’s a ballet; it’s continual … all day, every day.” 25:33 How big are the patient panels in this system? 28:49 “I would say that 95% of what we do here is directly translatable to any location in the world.” 29:20 “Your workforce needs to look and feel like the community you’re trying to influence.” 32:12 “This is all designed and driven by the community that I am hired to support.” You can learn more at southcentralfoundation.com. @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth What’s the “what” and “where” of the Nuka System of Care? @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “It’s all built around this idea that we’re raising … the ability for people to take control of their own health issues, and then we are just advisors … on that journey.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “The reason why people do pay attention to us is … the proof in the pudding.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth What did the Southcentral Foundation do to create an ideal health system? @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “There’s two huge problems with modern medicine all across the world. One is how money is handled … [and the other] is this blind acceptance of the medical model.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “For 20 years, we’ve established a base of companionship and relationship.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth What does advanced primary care look like? @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “We refer out to specialists 65% less often than we used to.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “It’s a ballet; it’s continual … all day, every day.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth “Your workforce needs to look and feel like the community you’re trying to influence.” @deby59 of @SCFinsider discusses #populationhealth on our #healthcarepodcast. #healthcare #podcast #pophealth #digitalhealth

This episode might be about local providers getting disintermediated not by virtual front doors like I discussed with Jeff Hogan in EP309 but by entities providing virtual continuous care at home. Predictivae and proactive, the idea is to help reduce acute events requiring on-premises care. But if someone does wind up needing ramped-up care, they can get it hospital at home or SNF (skilled nursing facility) at home instead of them going anywhere. So, there’s a baseline level of home monitoring followed by periods where care is stepped up. The point is, everything is going down at home with the care coming to the person at the care level that they need, so it ramps up or down depending on what they’re going through or need at the time.  I’m talking in this health care podcast with Sumit Nagpal, CEO and founder over at Cherish Health. We talk about the goings-on in the whole aging in place or, as he calls it, living in place vertical. A couple of takeaways from our conversation I think are notable: First of all, who is going to drive first change here isn’t going to be, for example, hospital systems at scale suddenly deciding to work against their own perverse incentives to keep heads out of beds. Our first movers here—the ones who will push assisted living at home or SNF at home or CCRC at home or whatever you want to call it at home—is going to be consumers and their families who either can’t afford to or don’t want to send Grandma to an assisted living institution. So, this is how it’s gonna go down: Families across the country install technology to keep Grandma safe at home. A natural ally here, if you think about it, is Big Retail, by the way. Why wouldn’t Big Retail and Big Tech sell these solutions to grandmas’ families like they sell televisions today? But the second that grandmas everywhere have monitoring software in their homes is the second that FFS-dependent hospitals and other providers have a problem on their hands—a business problem, that is. And assisted living facilities and SNFs working a similar model are in the same boat. Here’s why. Actionable population heath data is now available, and once that data is available and looked at predictively and proactively, grandmas are not going to go to the ER like they once were for two reasons: (1) Proactive and predictive technology in the home will reduce acute events and (2) because if and when Grandma does have an acute event, she’s not calling an ambulance. The technology is notifying someone. Maybe it’s notifying the Medicare Advantage plan that Grandma’s on, who has realized the power of all this at-home stuff. And the Medicare Advantage plan maybe just hooked up with a forward-thinking hospital that built an ER at home service or a hospital at home service. Or maybe there’s some national technology player who is providing similar services. Sumit Nagpal and I talk through how this might look and also the essential factors for the health care industry to eventually adopt an at-home model. You can learn more at cherishhealth.com. Sumit Kumar Nagpal is the CEO and founder of Cherish Health, a consumer electronics company that develops advanced sensors and artificial intelligence combined with medical evidence and human touch. Cherish Health solutions improve the lives and enable the supported self-care of people aging or living with health challenges—our grandparents, parents, children, many of us. Sumit is a serial entrepreneur and has cofounded and grown five digital health companies over the past two and a half decades that have tackled progressively bolder challenges facing our health care economies. He serves on important industry boards, including HIMSS and Health eVillages. Prior to founding Cherish Health, Sumit was global lead for digital health strategy at Accenture. He is sought after for his expertise and unstoppable energy as an entrepreneur, change agent, strategist, and technology architect. 03:55 What does “health care is coming home” truly mean? 07:35 “It’s not like we’re cheese and we’re aging in place. We’re living. We’re living our lives.” 07:51 “Give us the ability to live where we want for as long as we want as safely as possible.” 10:31 “The challenge with wearables beyond the initial cost is … you have to remember to wear them.” 10:53 “The tech itself is not unreliable, but we as human beings are unreliable.” 13:34 “The conversation typically begins with privacy and goes into other kinds of risks.” 15:50 “Our health care economy is fundamentally misaligned.” 17:57 “The incentives … today don’t really enable this kind of proactive, preventive engagement.” 23:30 How do we solve this cost problem at scale? 23:44 How do you align incentives for those that will care to solve these problems? 26:47 “I don’t think that we’re going to have mass, large-scale change in health care moving home until people are starting to adopt … these kinds of services in their homes.” You can learn more at cherishhealth.com. @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth What does “health care is coming home” truly mean? @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It’s not like we’re cheese and we’re aging in place. We’re living. We’re living our lives.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Give us the ability to live where we want for as long as we want as safely as possible.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The challenge with wearables beyond the initial cost is … you have to remember to wear them.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The tech itself is not unreliable, but we as human beings are unreliable.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The conversation typically begins with privacy and goes into other kinds of risks.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Our health care economy is fundamentally misaligned.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The incentives … today don’t really enable this kind of proactive, preventive engagement.” @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do we solve this cost problem at scale? @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do you align incentives for those that will care to solve these problems? @sumitknagpal of @WeCherishHealth discusses #aginginplace and #ffs on our #healthcarepodcast. #healthcare #podcast #digitalhealt 

Ge Bai, Professor of Accounting and Health Policy at Johns Hopkins University, explains how GoodRx takes advantage of the dysfunction in the pharmacy supply chain and saves patients money. They negotiate the best prices with PBMs, offering more affordable cash prices to uninsured patients. This chapter explores the behind-the-scenes fees and partnerships that make the cash prices possible.

The Shkreli Awards have been published each year, for the past five years and counting, by the Lown Institute. The Shkreli Awards are a much-anticipated top 10 list of the worst examples of profiteering and dysfunction in health care. This year’s list, celebrating the most excellently egregious profiteering in 2020, are unique in the sense that everybody on this list this year—every one of them—decided, deliberately, that a pandemic might be a super opportunistic global stroke of luck to exploit fear and anguish to line their own pockets. The list is named for Martin Shkreli, the price-hiking “pharma bro” that is easy to point to as a model of pure, unadulterated health care profiteering. Here’s the point: Just because you can be clever and shifty enough to make a whole lot of money in health care doesn’t mean you should. Every dollar anyone earns without adding commensurate value back is just one more nail in the financially toxic coffin that patients and employers face in this country—and taxpayers. The Lown Institute is a nonpartisan think tank advocating bold ideas for a just and caring system for health. Their work is centered around four main topics: low-value or unnecessary care, accountability, health equity, and the human connection. In this health care podcast, I am looking so forward to speaking with Vikas Saini, MD, and Shannon Brownlee from the Lown Institute about this year’s Shkreli Award winners. (I wish I had a soundtrack of audience clapping. I’d cue it right now.) There are 10 winners, and we talk about most of them in this episode. You can learn more by connecting with Dr. Saini (@DrVikasSaini) and Shannon (@ShannonBrownlee) on Twitter.  Vikas Saini, MD, is president of the Lown Institute. He is a clinical cardiologist trained by Dr. Bernard Lown at Harvard, where he has taught and done research. He has also been an entrepreneur as scientific cofounder of Aspect Medical Systems, the pioneer in noninvasive consciousness monitoring in the operating room with the BIS device. He was in private practice in cardiology for over 15 years on Cape Cod, where he also founded a primary care physician network participating in global payment contracts. Dr. Saini is board certified in cardiovascular disease, internal medicine, and nuclear cardiology. He has served on the faculty of Harvard Medical School and the Harvard School of Public Health, where he initiated the first course focused on policy translation for cardiovascular disease prevention. Shannon Brownlee is senior vice president of the Lown Institute. She and Lown Institute President Dr. Vikas Saini are cofounders of the Right Care Alliance, a network of activist patients, clinicians, and community leaders devoted to organizing a broad-based movement for a radically better health care system. Before joining the Lown Institute, Brownlee served as acting director of the health policy program at the New America Foundation. As a senior fellow at New America, she published the groundbreaking book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, which was named the best economics book of 2007 by the New York Times.