Relentless Health Value

This episode is a tale of what happens when some employers decide to open up a few virtual front doors and when these virtual front doors lead only to referrals to providers who are willing to be accountable and offer financial predictability. That’s what these employers want, after all. They want accountability and financial predictability. Many employers now have access to all claims databases and other data like the RAND 3.0 report. Therefore, employers can and are using this information in a big way to steer their plan member populations. Given these goings-on, some slower-moving providers could easily find themselves on the outside looking in. So, who are those providers who are or will be getting shut out of referral flows? They’re definitely FFS-centric, but they could be a large health system, an urgent care center, or a hospital-owned PCP. In this health care podcast, I speak with Jeff Hogan, the northeast regional manager for Rogers Benefit Group and also president of Upside Health Advisors. We talk in this episode not about what might be theoretically possible but about what is happening right now. You can learn more at jhogan@rogersbenefit.com and connect with Jeff on LinkedIn. Jeffrey Hogan is the northeast regional manager for Rogers Benefit Group, a national benefits marketing and consulting firm. Jeff has been with Rogers Benefit Group for 30 years. Additionally, Jeff operates a consulting firm, Upside Health Advisors, where he provides expert witness services on health care–related litigation, is a consultant to payers and large provider groups for product development and launch, and is a resource to employers desirous of implementing strategies to manage their health spend. Jeff is focused on health care payment reform, health policy, care coordination, value-based health care, health care quality, and precision medicine. Jeff regularly appears on national forums focused on moving to value-based health care and is actively working to promote health care–related transparency measures in the market. He serves as the group’s liaison to the National Alliance of Healthcare Purchaser Coalitions. Jeff is the regional leader for The Leapfrog Group. He is also one of the coordinators of Connecticut’s Moving to Value Alliance. 01:43 What are self-insured employers doing right now to impact referral flows? 03:29 Are any virtual tech companies moving in on the local provider space? 07:46 “What we’re trying to do … is to help the member have the best outcome.” 10:32 “It’s a continuum, if you will.” 10:44 “There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence].” 11:13 “What is value for employers coming out of COVID? Accountability and predictability.” 13:40 What are second-order effects? 14:29 “People like and want better access.” 14:46 “Fee-for-service providers fear the informed health care consumer.” 22:19 “Many of the brick-and-mortar providers are realizing that they have to up their game.” 24:52 “Things will change.” 25:07 “People not only want convenience, but they want safety, they want data.” 26:11 “We are at an inflection point … After 35 years in the business, I really finally feel like we’ve broken through.” 27:31 “This requires people to really think; it requires employers to actually know what their biggest problems are.” 29:53 “We can’t go back to the fragmentation of fee for service.” 30:25 “Data is critical.” You can learn more at jhogan@rogersbenefit.com and connect with Jeff on LinkedIn. Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth What are self-insured employers doing right now to impact referral flows? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth Are any virtual tech companies moving in on the local provider space? Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “What we’re trying to do … is to help the member have the best outcome.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “There is a fairly significant gulf between providers … and, say, a COE [Center of Excellence]” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “What is value for employers coming out of COVID? Accountability and predictability.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “People like and want better access.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “Fee-for-service providers fear the informed health care consumer.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “People not only want convenience, but they want safety, they want data.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “We are at an inflection point … After 35 years in the business, I really finally feel like we’ve broken through.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “This requires people to really think; it requires employers to actually know what their biggest problems are.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “We can’t go back to the fragmentation of fee for service.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth “Data is critical.” Jeff Hogan of #UpsideHealthAdvisors and #RogersBenefitGroup discusses #FFS providers in our #healthcarepodcast. #healthcare #podcast #digitalhealth

And here I thought I knew a lot about value-based care. In this health care podcast, I am speaking with Mark Fendrick, MD, who is the director over at the University of Michigan Center for Value-Based Insurance Design. This conversation is for those of you who already know pretty much about value-based care concepts. If you do not, I’d go back and listen to, say, Encore! EP206, with Ashok Subramanian, before this one.   Dr. Fendrick talks in this health care podcast about what it takes for value-based care to happen in the real world. No kidding, it’s about making sure that reimbursement is aligned with good things (no great surprise there). Everybody is always talking about properly aligning provider incentives. And, although often discussed, it really matters. But two light bulb moments I had in this conversation with Dr. Fendrick: Here we are at the beginning of the year. How many doctors and nurses, inspired to do the right thing, have told their patients with diabetes, say, to go get an eye exam to check for diabetic retinopathy? No one would disagree that this is definitely a good idea. Diabetic retinopathy causes blindness. But here’s the reality of that conversation. Doc says, “Go get an eye exam.” And patient says, “I can’t. My deductible is huge, and I can’t afford it.” So, the patient doesn’t get the follow-up care and winds up in the hospital or blind. And the doctor gets dinged on his or her quality scores. Suboptimal outcomes all around, I’d say. This also happens on the pharmacy side of the equation, but I think a lot of us are a little bit more familiar with that scenario—like type 1 diabetics who can’t afford to pick up their insulin because of a Medicare Part D or commercial deductible that they haven’t met yet. I just never really connected the dots back to the provider getting black marks because their patient has a benefit design that’s not aligned with the quality measures. In a majority of benefit designs, consumer price sharing is based not on the value of the service but on how expensive the service just happens to be. Wow! Think about that. So, we’re trying to get our plan members to be consumers and use the power of their wallets to make good health care choices. And what we’re really doing is driving them toward cheap things or no care and discouraging them from indulging—and I say that sarcastically—in expensive things. But the expensive things might be the high-value care, and the relatively cheap things might be crap that’s fully unnecessary or harmful and, over a whole population, adds up to a lot of zeros. Health care is not like a consumer market where the expensive things are usually a better version of the cheap things. For all you economists out there, you don’t want the demand curve to be elastic when what’s cheap and what’s expensive has no correlation to quality or necessity. Nobody should be super flabbergasted when a $35 cure-all supplement peddled on YouTube makes some random influencer a millionaire. That’s how supply and demand works. Much to ponder in this episode. You can learn more at vbidcenter.org. There’s also a great newsletter you can sign up for there. A. Mark Fendrick, MD, is a professor of internal medicine in the School of Medicine and a professor of health management and policy in the School of Public Health at the University of Michigan. Dr. Fendrick received a bachelor’s degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School. He completed his residency in internal medicine at the University of Pennsylvania, where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Fendrick conceptualized and coined the term Value-Based Insurance Design (V-BID) and currently directs the V-BID Center at the University of Michigan (vbidcenter.org), the leading advocate for development, implementation, and evaluation of innovative health benefit plans. His research focuses on how clinician payment and consumer engagement initiatives impact access to care, quality of care, and health care costs. Dr. Fendrick has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design. His perspective and understanding of clinical and economic issues have fostered collaborations with numerous government agencies, health plans, professional societies, and health care companies. Dr. Fendrick is an elected member of the National Academy of Medicine (formerly IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the US Senate Committee on Health, Education, Labor and Pensions; the US House of Representatives Ways and Means Subcommittee on Health; and the US Senate Committee on Armed Services Subcommittee on Personnel. 03:53 Is back surgery high-value care? 04:46 If care is patient to patient, how is high-value care decided upon? 05:36 “Flintstones delivery: We have to move from the sledgehammer to the scalpel.” 10:19 “Almost all of the services that we recommend to reduce cost sharing … do not save money.” 11:36 “I didn’t go to medical school to learn how to save people money.” 16:14 “When a patient and their clinician agree … the patient should be able to get that [service] easily, and the clinician should be paid generously.” 17:14 “When patients and providers are aligned, they do much better.” 19:07 What services are deemed high value, and what services should be pre-deductible? 21:04 “Are primary care visits high value? … The answer is, it depends.” 25:13 What are V-BID’s core pillars to address value-based care? 27:24 How does Dr. Fendrick’s method of value-based care and reimbursement actually enable better consumerism? 29:11 What do providers think about changing reimbursement on low-value and high-value care? 30:21 “We have incentives that are run amok.” 31:34 EP176 with Dr. Robert Pearl. 32:12 “It’s all about incentives.” 33:05 “You do have the funding; you just have to have the courage.” You can learn more at vbidcenter.org. There’s also a great newsletter you can sign up for there.  Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth If care is patient to patient, how is high-value care decided upon? Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Flintstones delivery: We have to move from the sledgehammer to the scalpel.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Almost all of the services that we recommend to reduce cost sharing … do not save money.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “I didn’t go to medical school to learn how to save people money.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “When patients and providers are aligned, they do much better.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “Are primary care visits high value? … The answer is, it depends.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “We have incentives that are run amok.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth “You do have the funding; you just have to have the courage.” Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

In this health care podcast, I speak with Loren Adler, who is the associate director of USC-Brookings Schaeffer Initiative for Health Policy and has a particular focus on surprise billing. I wanted to talk to Loren about the surprise billing legislation that is going into effect on 1/1/22. I will let Loren explain, but, in short, this legislation removes the patient from the mix. If a provider decides to send a surprise bill, the patient will just pay the co-pay or coinsurance they normally would have if the provider had been in network. Then, it’s up to the provider who sent the bill and the insurer to duke it out on the back end. What this back end duking out consists of is the provider sending their big surprise bill to the insurer. The insurer may reply, with regrets, “Hey, we’re only gonna pay you … whatever … a fraction of the big bill.” The provider may at that point say, “Fine … whatever. I’ll take it.” Or the provider may say, “No can do. I’ll see you in arbitration.” This arbitration that then happens is a style called baseball arbitration, and Loren gets into the “why” there. Also, a provider cannot trigger an arbitration more than once every 90 days for the same service. So, there’s a wrinkle that will slow the roll of any provider with a plan to clog up the system by arbitrating every claim. I quiz Loren mercilessly about exactly what the provisions of this legislation are and the winners and the losers. But we also talk a lot about potential ramifications. For example, making surprise bills illegal will potentially accelerate bundled payments, if you think about it, because one of the reasons why bundles have stalled is because various parties who enjoy surprise billing refuse to be a part of the bundle—and then the whole thing just flies off the track. Also, premiums will go down approximately 1%, they say, for self-insured employer plans. And Loren and I get into the “why” of that—or, more accurately, Loren gets into the “why” of that. In listening to this recording, I realized we do sort of pick on anesthesiologists a bit here. So, apologies to those anesthesiologists who have been billing fairly this whole time, which is definitely the majority. You can learn more at brookings.edu. Loren Adler is associate director of the USC-Brookings Schaeffer Initiative for Health Policy. His research focuses on a range of topics in health care economics and policy, including provider payment and consolidation, insurance markets, Medicare, the Affordable Care Act, prescription drugs, and COVID-19 testing. Previously, he served as research director for the Committee for a Responsible Federal Budget and as a senior economic policy analyst for the Bipartisan Policy Center. Adler holds a bachelor’s degree in mathematical economics from Wesleyan University and a master’s degree in applied economics from Johns Hopkins University. 03:04 What is this surprise billing legislation? 04:27 What happens when a patient is sent a huge bill from the provider? 06:15 What is “the going rate”? 09:44 “If you weren’t leveraging surprise billing beforehand, this law has no effect on you.” 11:14 Will this legislation push the industry toward one hospital bill? 12:20 What will providers have to do if they don’t like what insurance wants to pay them? 15:26 What is benchmark pricing? 17:37 “Fundamentally … it’s really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other.” 18:19 Is this surprise billing legislation a compromise? 19:48 “Arbitration really isn’t meant to adjudicate every single claim.” 20:11 “The idea is really to kind of push the facility … to negotiate and figure this all out.” 20:50 Are hospitals being impacted by this bill? 24:56 What happens to providers who decide to send surprise bills anyway? 26:09 What are the implications of this legislation for self-insured employers? 28:48 Why have ground ambulances been left out of this surprise billing legislation? 32:23 “At the end of the day, I think this is a net positive for consumers and should be considered a win.” You can learn more at brookings.edu.   @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is this surprise billing legislation? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you weren’t leveraging surprise billing beforehand, this law has no effect on you.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Will this legislation push the industry toward one hospital bill? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What will providers have to do if they don’t like what insurance wants to pay them? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is benchmark pricing? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Fundamentally … it’s really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is this surprise billing legislation a compromise? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are hospitals being impacted by this bill? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the implications of this legislation for self-insured employers? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why have ground ambulances been left out of this surprise billing legislation? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “At the end of the day, I think this is a net positive for consumers and should be considered a win.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Here’s a trigger warning: This show gets pretty deep into some of the nether regions of PBM (pharmacy benefit manager) contractual terms with pharmacies. If you are not, I’m gonna say, pretty familiar with PBM goings-on, I’d suggest you listen to EP241 with Vinay Patel first or skip the first third of this show.   In this health care podcast, I am speaking with Ge Bai about Amazon’s pharmacy business. Ge Bai, PhD, CPA, is an associate professor of accounting at Johns Hopkins Carey School of Business. She is also associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. Ge trained as an accounting researcher who originally started looking into chargemasters for her dissertation. From there, she started checking out health care pricing and contracting issues. Who knew chargemasters were like a gateway drug into health care? I ask Ge questions such as, “Why the heck does Amazon need a PBM for cash pay patients?” and “What’s this Amazon Pharmacy model that some self-insured employers are talking about?” And then we get into rebates and the impact that Amazon will have on rebates. Right up front, I want to just say flat out, I learned a mind-blowing detail from Ge. There’s a contracting term that PBMs put in their contracts with pharmacies. Basically, a pharmacy cannot sell a drug to a cash pay patient for an amount that is less than the price a PBM pays the pharmacy for the drug or the pharmacy charges the PBM for the drug—I guess it depends how you perceive that relationship. So, the pharmacy’s list price paid by cash pay patients can’t be less than the contracted price that it has with any third-party payer. The PBMs will always have to get the better price than cash pay patients. There’s one exception, though: unless the cash pay patient wanders in with a coupon (like a GoodRx coupon, for example). There are a whole lot of implications to this if you start to think about it. Spoiler alert: There will be an “Ask an Expert” with Ge Bai coming out after the show, where Ge and I get deeply into GoodRx’s business model. So, stay tuned for that if you are interested. You might be subscribed to the show on iTunes, but I’d also encourage you to sign up for our newsletter on relentlesshealthvalue.com. Every week, you get a transcript of the introduction to the show that’s coming out that week, so you can prioritize your listening accordingly.   You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University. Ge Bai, PhD, CPA, is an associate professor of accounting at the Johns Hopkins Carey Business School and associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. She is an expert on health care pricing, policy, and management. Dr. Bai has testified before the House Ways and Means Committee, written for the Wall Street Journal, and published her studies in leading academic journals such as the New England Journal of Medicine, JAMA, JAMA Internal Medicine, Annals of Internal Medicine, and Health Affairs. Her work has been widely featured on ABC, CBS, NBC, Fox News, CNN, and NPR and in the Los Angeles Times, New York Times, Wall Street Journal, Washington Post, and other media outlets and used in government regulations and congressional testimonies. 03:27 Why is Amazon in the pharmacy space a big deal? 04:03 “I view Amazon Pharmacy as a combination of GoodRx and mail-order pharmacy.” 05:07 What’s the difference between Amazon and other pharmacies? 06:14 Why does the third-party payer health care system keep Amazon from cutting out the PBM? 07:49 “We don’t have insurance companies, we don’t have PBMs.” 09:21 “Who’s really using prescription drugs? The majority is Medicare patients.” 11:46 Is Amazon doing anything innovative in the pharmacy space? 12:37 What options do self-insured employers have now with Amazon? 14:42 Why employees and employers might choose to use Amazon Pharmacy over other mail-order pharmacies. 21:27 Will Amazon affect pharmacy rebates? 25:28 “Fundamentally, employers want to have more power in the whole process.” 27:41 What should you be doing as a self-insured employer? 28:58 “If we do not put out effort to make the private market work, then the next option would be single payer.” You can connect with Ge on LinkedIn and Twitter. You can also learn more on her Web site at Johns Hopkins University.   @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why is Amazon in the pharmacy space a big deal? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “I view Amazon Pharmacy as a combination of GoodRx and mail-order pharmacy.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What’s the difference between Amazon and other pharmacies? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Why does the third-party payer health care system keep Amazon from cutting out the PBM? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “We don’t have insurance companies, we don’t have PBMs.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Who’s really using prescription drugs? The majority is Medicare patients.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma Is Amazon doing anything innovative in the pharmacy space? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma What options do self-insured employers have now with Amazon? @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “Fundamentally, employers want to have more power in the whole process.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma “If we do not put out effort to make the private market work, then the next option would be single payer.” @GeBaiDC discusses the Amazon Pharmacy model on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pharma

My guest in this health care podcast is Darrell Moon, who is the CEO over at Orriant. I was super intrigued by some of the work that Darrell and his team are doing regarding high-cost claimants. Said a different and probably better way, certain people in need of care were identified because they were costing so much. Year after year after year, these individuals—I call them hyper-users during this episode, but it’s possible I made that term up myself—these hyper-users were getting all kinds of expensive health care, while at the same time, they were not getting any better. So, Darrell and his team realized that something was afoot here, and it turned out to be a combination of maybe loneliness, maybe low self-esteem and low self-efficacy. And no matter how many times you go to the cardiologist or the rheumatologist or the pulmonologist, none of those things will be cured. In fact, when someone’s identity becomes their myriad of health issues, they have a sort of perverse incentive, if you think about it, not to follow any of their doctor’s recommendations to take meds or make lifestyle changes. So, while their underlying condition—low self-esteem, low self-efficacy—remains untreated, their physical health tends to actually get worse, not better, despite all the medical attention. What’s necessary to help this type of patient is the best that behavioral science has to offer. A nuance I found really interesting and important in the work that Darrell is doing is that it’s pretty easy to identify a hyper-user from someone with a horrid chronic condition simply requiring a lot of care. The hyper-users will respond and appreciate the extra attention that a behavioral health coach/program has to offer. In contrast, those with other ailments will just merely get annoyed—usually on the quick—so they exclude themselves from the program. Sidebar: My guest Darrell Moon is organizing an Aspirational Healthcare Conference for July 14 and 15, 2021. In that virtual meeting, the intent will be to highlight Southcentral Foundation’s Nuka System of Care in Alaska and other similar health care models that achieve much better health care outcomes at half the cost. So, check that out if you are so inclined. Thanks so much also to Lee Lewis from the HTA (Health Transformation Alliance) for the introduction to Darrell and Orriant. You can learn more at orriant.com. Darrell Moon founded Orriant in 1996 to change the dynamics of health care and give employers some control over the ever-increasing costs of the health care benefits they offer their employees. Darrell believed that engaging individuals in the management of their own health was a key that had to be inserted back into the economic equation of health care. Darrell received both his bachelor’s degree in finance and his master’s degree in healthcare administration from Brigham Young University. As the CEO, COO, or CFO, Darrell managed medical and psychiatric hospitals throughout the country for over 10 years prior to creating Orriant. He also has more than a decade of experience managing insurance and managed care products. Darrell is a Forbes leadership contributor. 03:11 What do CEOs want out of the health care system? 04:52 Is it a good strategy to focus on high-cost claimants? 07:04 Who are the people year over year that wind up in the high-cost claimant pool? 07:50 “Really, you have to get to the crux of the problem, which is … they’ve become a victim … to the health care system.” 08:16 Who are these “hyper-users” and how do we define them? 11:35 “Getting that person to have a regular relationship with someone isn’t the hard part; the hard part is then helping them to build their self-esteem.” 13:20 “That’s the key to building self-esteem—is helping people accomplish what’s most important to them.” 14:57 Why helping a patient not to view themselves as a victim helps them manage their care better. 17:45 “It’s often less the training and the right personality of the person.” 18:54 Do health outcomes correlate with the self-esteem of the patient? 19:28 “If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience.” 21:21 “They’re the customer/owner of their own health.” 24:23 “How do you help not just the 1% but everybody [in health care]?” 27:16 “The ideal environment is to have a massively powerful primary care team.” 27:47 “Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right.” 29:34 “It’s not about just when [people] reach out … but [getting] people to reach out early.” You can learn more at orriant.com. Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth What do CEOs want out of the health care system? Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is it a good strategy to focus on high-cost claimants? Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Really, you have to get to the crux of the problem, which is … they’ve become a victim … to the health care system.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Getting that person to have a regular relationship with someone isn’t the hard part; the hard part is then helping them to build their self-esteem.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “That’s the key to building self-esteem—is helping people accomplish what’s most important to them.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It’s often less the training and the right personality of the person.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you want to identify future claims, ask people two questions: 1) Tell me about your health … and 2) Tell me about your social experience.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “They’re the customer/owner of their own health.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The ideal environment is to have a massively powerful primary care team.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Having an influence on that person and what they do and how they behave is more important than getting the diagnosis right.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth “It’s not about just when [people] reach out … but [getting] people to reach out early.” Darrell Moon of @Orriant discusses #ffs and #healthcarecosts on our #healthcarepodcast. #healthcare #podcast #digitalhealth

I had a vision for this inbetweenisode. I wanted to highlight the wisdom of our amazing guests this year. I really wanted to find some theme that might be a key to our health care transformation. To achieve maximum suspense, here’s the very short story of how I got from “Is there a common thread of wisdom throughout all the RHV episodes this year?” to “Why, yes, there is … and it’s a good one!” So, let’s start our journey of discovery with this. Here’s a fact: If you talk to patients, they will often tell you that they receive poor care or their needs are not met—when they fall between different providers, or their payer and their provider and their PBM (pharmacy benefit manager) are singing off of different sheets of music. For more information, go to aventriahealth.com.   When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specHumana recently came out with their Value-based Care Report. The subhead is Physician Progress and Patient Outcomes. It’s a very fancy report with a lot of pages and graphics, and this impressive format definitely caught the attention of some of our industry. I read one blog post really keying in on one sort of depressing aspect of the report, namely, that Humana’s value-based care (VBC) program saved a rounding error of 0.4% over their non-VBC program. I wanted to get an expert’s take on this report and the reaction to the report and could think of no better person than Steve Blumberg, who has worked in value-based care delivery on the provider and on the payer side. Steve Blumberg, MBA, is the VP of practice transformation for GuideWell Health, a subsidiary of GuideWell. This Humana report, if you’d like to see it for yourself, can be found at digital.humana.com/VBCReport.  You can learn more at guidewell.com. Steven Blumberg serves as vice president, practice transformation, for GuideWell Health. In this role, he is responsible for developing and implementing strategies for the further establishment of a high-quality, economically effective clinical system across Florida. He also provides guidance on value-based care and population health models. Prior to joining GuideWell in June 2019, Blumberg served as vice president for value-based care at Baptist Health South Florida, where he led the strategy and implementation for Baptist’s population health and value-based care efforts. Prior to that, he was senior vice president and executive director of AtlantiCare Health Solutions, the New Jersey division of the Geisinger Health System, where he was responsib

In this health care podcast, I speak with Steve Blumberg, VP of practice transformation for GuideWell Health, a subsidiary of GuideWell. How’s this for an interesting career trajectory? Steve spent the last decade working on population health and value-based care delivery ... on the provider side. Recently, he transferred over to the payer side, working for GuideWell Health, which is the health services arm of GuideWell, which is part of a family of companies including Florida Blue. So, a payer, in other words. I wanted to find out a bunch of things from Steve, but the main one is this: How do—if they, in fact, do—payviders improve care for patients? Or what does it take for an organizational structure to drive Triple Aim results? Going into this conversation, here is what I was thinking about: Payviders have access to longitudinal data (potentially) that siloed entities will certainly not. They also have a goal to keep care affordable in a really real way, especially if the patient/member/client is on the ACA (Affordable Care Act) marketplace and shopping for premiums. My big concern with payviders, though, is whether they’re an “HMO in drag,” as they say. On the other hand, payers and providers, in the most cynical sense, have wildly divergent goals. Search #medtwitter any day of the week—you will find a galaxy of tweets wherein doctors complain about payers—to just get a tiny sense of those wildly divergent goals. Do separate payers working with separate providers offer a kind of check and balance? A historical knock on this hypothesis is the inarguably crappy outcomes for chronic conditions that US patients have the privilege of paying comparatively ridiculous sums for. I couldn’t tell you whether those crappy outcomes are a result of the separateness of payers and providers or some other factor, but so it is. Here’s the short version of one of Steve’s main points: It’s not about control. It’s about connection. It’s about being able to connect with patients over their continuum of care. It’s also about how consumers and employers are increasingly trading out choice and broad networks for an assurance of quality. You can learn more at guidewell.com. Steven Blumberg serves as vice president, practice transformation, for GuideWell Health. In this role, he is responsible for developing and implementing strategies for the further establishment of a high-quality, economically effective clinical system across Florida. He also provides guidance on value-based care and population health models. Prior to joining GuideWell in June 2019, Blumberg served as vice president for value-based care at Baptist Health South Florida, where he led the strategy and implementation for Baptist’s population health and value-based care efforts. Prior to that, he was senior vice president and executive director of AtlantiCare Health Solutions, the New Jersey division of the Geisinger Health System, where he was responsible for population health, the organization’s provider physician group, and home care and hospice continuum services. Earlier in his career, he was chief planning and business development officer at UHealth–The University of Miami Health System. Blumberg also held leadership roles at UF Health–Shands Healthcare and Baptist Health Jacksonville. Blumberg has been active in community and professional organizations, including serving on the boards of the Ronald McDonald House, Community Hospice, and the Northeast Florida Health Planning Council. He has also served nationally on the Premier Population Health Steering Group and on the National Institute of Standards and Technology’s Baldrige Board of Examiners. Blumberg holds a bachelor’s degree in business administration and marketing from the University of Florida and a Master of Business Administration from Florida State University. He is a fellow of the American College of Healthcare Executives. 03:30 How does thinking like a payer change the way you build out a primary care provider practice? 04:37 “When I was on the provider side, I definitely worried about the total cost of care … but making the products affordable was … someone else’s concern.” 09:12 How would you define practice transformation? 13:29 “We’re curating networks.” 16:56 “If they come to the market, they’ll be hard to ignore.” 17:38 How integrated is the physicians network? 18:35 “Control isn’t the right word … it is the connection with the patient … that’s where we think the most effective primary care takes place.” 18:59 Where does attempting team-based care fall apart the most? 21:25 Are employers trading out for an assurance of quality? You can learn more at guidewell.com. Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth How does thinking like a payer change the way you build out a primary care provider practice? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “When I was on the provider side, I definitely worried about the total cost of care … but making the products affordable was … someone else’s concern.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth How would you define practice transformation? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “We’re curating networks.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “If they come to the market, they’ll be hard to ignore.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth How integrated is the physicians network? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth “Control isn’t the right word … it is the connection with the patient … that’s where we think the most effective primary care takes place.” Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth Where does attempting team-based care fall apart the most? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth Are employers trading out for an assurance of quality? Steve Blumberg of @_GuideWell discusses #healthcare transformation on our #podcast. #healthcarepodcast #healthcaretransformation #payer #pophealth

Alex Azar, who is the current Health and Human Services (HHS) secretary (until January 21 anyway), came out with a reboot of the proposal that effectively halts the practice of pharma manufacturers paying rebates to Part D plans. This reboot is supposed to go into effect on 1/1/2022. But this podcast is less about this may-or-may-not-actually-happen rule and is more about the actual impact of removing drug rebates within this unintuitively constructed health care system of ours. Should rebates go away, it’s actually a big deal that fundamentally could upend the heretofore-not-transparent messy middle of drug pricing. I’ll let Chris Sloan, associate principal over at Avalere Health, explain. Spoiler alert: The impact of killing pharma rebates to plans and PBMs (pharmacy benefit managers)? Bottom line, everybody’s insurance premiums go up in the current model when rebates go away. A few episodes from now, I’m talking with Ge Bai about why this is a suboptimal and not forgone conclusion. But this is what we’ve got going on right now. So, look for EP306 coming up for more on that. You can learn more at avalere.com.   Chris Sloan, associate principal at Avalere, advises a number of clients—including pharmaceutical manufacturers, health plans, providers, and patient groups—on key policy issues facing the health care industry. Chris’s economic analyses of key policy proposals and issues, including drug pricing and the repeal and replace efforts around the Affordable Care Act, have been featured in a wide range of publications, including the Wall Street Journal, the New York Times, the Washington Post, Politico, Axios, and Vox.

In November 2020, there was an Executive Order entitled “Lowering Prices for Patients by Eliminating Kickbacks to Middlemen.” And we had HHS (US Department of Health and Human Services) Secretary Alex Azar and the HHS Office of Inspector General finalizing a regulation to eliminate the current system of drug rebates in Med D (Medicare Part D). And what they were trying to do is create incentives to reduce out-of-pocket spending on prescription drugs by delivering discounts directly at the pharmacy counter to patients. Those discounts delivered at the pharmacy counter? Not insignificant. In 2019, Part D rebates totaled $39.8 billion. The new rule stipulates that federal spending can’t be increased as a result of this action. But in summary, it’s pretty much a reboot of the same ruling from earlier last year. Here’s a couple of points: The rule is only for Medicare (Med D)—Medicaid and commercial aren’t included—but … there’s a but, and we get into that in this episode. Also, the start date for this ruling is 1/1/22 if it continues to stand in the new administration, which is a big if. What was at stake the first time this rule was drawn up by HHS and is likely still at stake is the implementation flowchart. Who exactly is involved in adjudicating these “potential discounts for patients at the pharmacy counter”? Since any middleman who gets themselves involved in anything takes a buck, there is a massive land grab, if you think about it, that if any middleman can grab a buck, this could be a lot of money. So, the first time this HHS proposal was presented in 2019, I talked to AJ Loiacono, who’s the CEO over at Capital Rx. I have to say I was a little over-cocky relative to how well I really understood the hidden machinations behind pharmacy Rxs being adjudicated, and AJ does an amazing job explaining it. This is incredibly relevant as we contemplate potentially who gets a piece of the action moving forward. But regardless of, in some respects, what happens with this HHS rule, I found it interesting and valuable to understand what exactly happens in the dark messy middle, maybe underbelly, of a pharmacy adjudication. You can learn more at cap-rx.com. Anthony J. “AJ” Loiacono is a serial entrepreneur with over 20 years of experience in pharmacy benefits and software development. As the CEO of Capital Rx, a pharmacy benefit manager (PBM) that is bringing transparency and fair pricing into an otherwise opaque industry, his mission is to change the way prescriptions are priced and administered to create enduring social change. AJ spent his career studying the pharmaceutical supply chain and producing engineering solutions that have continually redefined the pharmacy benefit industry. At its core, Capital Rx is a technology-first company that has received multiple awards for the innovations that have propelled the company to record growth (Accenture Health Technology Champion, AMCP Gold Ribbon, EHIR Innovation Award, NYC Digital 100, etc).

I had a vision for this inbetweenisode. I wanted to highlight the wisdom of our amazing guests this year. I really wanted to find some theme that might be a key to our health care transformation. To achieve maximum suspense, here’s the very short story of how I got from “Is there a common thread of wisdom throughout all the RHV episodes this year?” to “Why, yes, there is … and it’s a good one!” So, let’s start our journey of discovery with this. Here’s a fact: If you talk to patients, they will often tell you that they receive poor care or their needs are not met—when they fall between different providers, or their payer and their provider and their PBM (pharmacy benefit manager) are singing off of different sheets of music. For more information, go to aventriahealth.com.   When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specializes in helping pharmaceutical, employer, pharmacy, and health system clients improve patient outcomes by creating and leveraging collaborations with other health care organizations. For more than 20 years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders and, most of all, the patient. For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses #collaboration as the common thread to transforming #healthcare in this week’s #healthcarepodcast. #podcast #digitalhealth