Relentless Health Value

Lately, several of the Relentless Health Value episodes have focused on digital health companies and their disruptive potential on referral flows of traditional provider organizations. We also talked about other goings-on with the potential to encroach on hospital systems and independent docs alike. For example, we’ve got Walmart getting, in a big way, into the health clinic business. We’ve got VillageMD and Walgreens teaming up. We’ve got mergers in the on-site clinic space. There’s just a lot of action. But let’s talk about what Dan O’Neill called “physician entrepreneurship” in EP287. Dan said that now is a fantastic time for entrepreneurial physicians to reinvent the practice model. This is true because many, including Dr. Matt Anderson in EP292, have said that it’s not an entirely safe bet if you’re a doc right now to hope that all the practice changes initiated by COVID (like telehealth, etc) go away like a bad hangover the second this pandemic gets stuffed back into Pandora’s box.   So, there’s risk mitigation strategies at play here, but there’s also a great opportunity for those who figure out how to legitimately improve patient outcomes in a way that consumers and patients love and that employers can easily contract for. Here’s the bottom line: Some, not all, of these new-fangled deliverers of health care have great marketing and maybe a great Net Promoter Score; but effectiveness is less than well validated. Don’t get me wrong. There’s a whole lot of providers who aren’t sure what kind of results they deliver and who aren’t exactly delivering amazing and sticky customer experiences. So, we certainly can’t forget that, as Bob Matthews has said, in the land of the blind, the one-eyed man is king. But what about a physician practice known in a local community that works together to create a Center of Excellence? Now, that’s interesting in this land of the blind. You get all the history and the advantage of being the “default care provider.” But you also are well poised for a post-COVID future, even in the face of all this disruptive activity. In this health care podcast, I speak with Steve Schutzer, MD. Dr. Schutzer is a physician executive for the orthopedic service line at Trinity Health of New England and medical director of Connecticut Joint Replacement. Dr. Schutzer knows a lot about setting up a COE, otherwise known as a Center of Excellence. He knows a lot about how to be a physician entrepreneur, and he knows how to compete in emerging market conditions. You can contact Dr. Schutzer at steve.schutzer@gmail.com.   Steven F. Schutzer, MD, graduated with honors from Union College and the University of Virginia School of Medicine. Following a surgical internship at the University of Rochester, he served as lieutenant in the Medical Corps of the United States Navy. After his tour of duty, Dr. Schutzer did his general surgical training at the University of Rochester and then completed his orthopedic residency at the University of Connecticut. He was then a fellow in adult hip and reconstructive surgery at the Massachusetts General Hospital, after which he entered practice with Orthopedic Associates of Hartford. He is currently on the staff of Saint Francis Hospital in Hartford, Connecticut. Dr. Schutzer is a founding member and medical director of the Connecticut Joint Replacement Institute (CJRI), a Center of Excellence at Saint Francis. He is also president of the management company overseeing the Institute, the Connecticut Joint Replacement Surgeons, LLC, as well as physician executive for the orthopedic service line at Trinity Health of New England. In 2014, Dr. Schutzer and two colleagues, Ms. Steph Kelly and Ms. Maureen Geary, launched a consulting company, Novel Healthcare Solutions, whose mission is to establish effective and trusting business relationships between physicians and hospital partners—and then create orthopedic Centers of Excellence. 03:22 Why would competitive physician groups gang together? 07:32 “Even if you never … bundle, going through the implementation process … will yield incredible unrecognized value.” 08:49 “It demands an end-to-end care redesign process.” 10:10 “The value of a COE is really unquestionable.” 10:18 “For every dollar saved [in a COE], two-thirds was in the quality side, and one-third was in the price point.” 13:08 Slide deck discussing the definition of a COE and its seven building blocks.14:05 “I’m talking about business relationships between the physicians … these are the most fundamental [relationships].” 15:23 “It is all about trust.” 15:48 What is the most central issue as to why a COE does well or fails? 16:25 “It’s not just data. It has to be actionable data because physicians naturally don’t trust data.” 21:54 “Employers are definitely taking note to patient-reported outcomes.” 22:37 What is the seventh element that is necessary for a COE, and what is fundamental to that element? 23:27 Where will fee-for-service doctors be in 2 to 3 years? 24:45 “The only way that we can accrue the value that we deserve is through these types of relationships.” 25:11 “The supreme motivator is opportunity.” 27:01 How do physicians and providers begin a transformation of the marketplace they’re in? 27:36 “What they need from us is product. They need products to disrupt the status quo.” 30:26 “The problem is that there are vendors who are working at the margin.” You can contact Dr. Schutzer at steve.schutzer@gmail.com.   @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech Why would competitive physician groups gang together? @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “It demands an end-to-end care redesign process.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “The value of a COE is really unquestionable.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “It’s not just data. It has to be actionable data because physicians naturally don’t trust data.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech “Employers are definitely taking note to patient-reported outcomes.” @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech Where will fee-for-service doctors be in 2 to 3 years? @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech How do physicians and providers begin a transformation of the marketplace they’re in? @SSchutzer of @THOfNewEngland discusses #centersofexcellence on this week’s #healthcarepodcast. #healthcare #podcast #digitalhealth #healthtech

Let’s cut to the chase here for our conversation about co-pay cards offered by pharma companies versus co-pay accumulators and co-pay maximizers deployed by health plans. This whole war of the co-pays started back in the day when PBMs (pharmacy benefit managers) began to shake down Pharma for higher discounts. The prize that PBMs offered Pharma was lower co-pays for patients. It’s a well-known fact that the higher the patient out of pocket, the lower the market share of the drug—the old supply-and-demand curve at work. So, the PBMs and health plans kind of had an ace up their sleeve because they control how much the patient pays out of pocket. And so, they use that ace to pull in higher discounts from Pharma. “You’ll make it up in volume,” they told Pharma. “We’ll make sure you get lots of patients by putting your drug on a lower formulary tier and giving patients who take your drug the lowest possible co-pays.” At a certain point, pharma companies started to get mad about their dwindling net prices. And they’re pretty smart. So, Pharma came up with a workaround to PBMs holding them hostage for lower net prices. Pharma decided to hand out co-pay discount cards. Then, they don’t have to pay the PBM. They can finesse lower patient co-pays all by themselves. Except now, the PBM sees this and they raise. Enter co-pay accumulators and co-pay maximizers. For this part of the extravaganza of game theory at its finest, I’ll let Dea Belazi, PharmD, MPH, explain. Dea is the president and CEO over at AscellaHealth. He’s a pharmacist by training who has worked for Pharma, then at a health plan, then spent lots of time in the PBM space. Now he’s working to create a different kind of pharmacy benefit at AscellaHealth. He has seen this tangled web from pretty much every angle. One thing to point out here before we begin: In the olden days, this whole war of who has leverage over who transpired in the context of small molecule drugs in competitive markets. So, like, Lipitor versus Crestor versus simvastatin—and they all cost, like, $100 a month. If the health plan made it untenable to get one of those drugs, they usually made another one in the same class financially attractive. So, the patient had options, and the stakes were a lot lower. Now this same war is being fought on the specialty side of the house, where drugs cost thousands or tens of thousands of dollars a month and the patient may have but one option. So, if it’s made financially toxic for a patient to get that one drug, then the patient has to choose between their family’s health and dipping into their 401(k). In these cases, Pharma can be, sort of authentically (and the “sort of” is an important qualifier), a hero who steps in and helps patients who are basically functionally uninsured because they can’t afford the co-pays and deductibles to actually use the insurance they’re paying handsome premiums to have. Pharma can step in and help via co-pay discount cards or through patient assistance programs to help those with lower incomes. But let me point out an obvious but rarely-mentioned-in-the-same-sentence connection. If the patient cost share is really high, there are at a minimum two parties responsible for that: the insurance company, who set the patient cost share and may have created functionally uninsured members in the process, and the pharma company, who may have set the price of the drug untenably high, maybe way over what the value of the product was. Neither is an innocent bystander, and the patient, sadly, is caught in the middle of this war. You can learn more at ascellahealth.com.   Dea Belazi, PharmD, MPH, has more than 20 years of experience in the health care industry, mostly developing and managing pharmacy benefit management companies. He is currently the president and CEO of AscellaHealth, a national specialty pharmacy benefit manager (SPBM™) serving commercial, Medicare, and Medicaid segments. He was part of the development of PerformRx, a PBM owned by Keystone First Health Plan, as well as another, FutureScripts, an Independence Blue Cross company that was sold to Catamaran a few years ago. Dea holds a PharmD from the University of Rhode Island and completed his dissertational work at Brown University. He later completed a Master of Public Health from Johns Hopkins University and a post-doc health outcomes research fellowship at Thomas Jefferson University. He is a reviewer for multiple medical journals and sits on multiple boards. 05:03 “The concept of co-pay accumulators wasn’t just a … PBM thought, but it also came from their customers, whether it was health plans or employer groups.” 10:00 “[This is] literally a math problem based on, ‘Do I spend it now? Do I spend it later?’” 11:31 What reason do employers and payers have for doing this? 15:26 “This is another mechanism for payers to push down additional cost to both the patient and now the pharma company.” 19:57 EP241 with Vinay Patel. 20:33 “I don’t think accumulators are really forcing Pharma to be more competitive.” 22:49 How co-pay maximizers are different from co-pay accumulators. 25:57 Who doesn’t like co-pay accumulators and maximizers? 28:03 How patient advocacy groups are a different model. 30:14 What is the biggest challenge facing employers right now? You can learn more at ascellahealth.com.   Check out our newest #healthcarepodcast with Dea Belazi of @AscellaHealth as he discusses #copayaccumulators and #copaymaximizers. #healthcare #podcast #digitalhealth #healthtech #copay “The concept of co-pay accumulators wasn’t just a … PBM thought, but it also came from their customers, whether it was health plans or employer groups.” Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers. #healthcare #podcast #digitalhealth #healthtech #copay #healthcarepodcast “[This is] literally a math problem based on, ‘Do I spend it now? Do I spend it later?’” Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers. #healthcare #podcast #digitalhealth #healthtech #copay #healthcarepodcast “This is another mechanism for payers to push down additional cost to both the patient and now the pharma company.” Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers. #healthcare #podcast #digitalhealth #healthtech #copay #healthcarepodcast “I don’t think accumulators are really forcing Pharma to be more competitive.” Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers. #healthcare #podcast #digitalhealth #healthtech #copay #healthcarepodcast What reason do employers and payers have for doing this? Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers. #healthcare #podcast #digitalhealth #healthtech #copay #healthcarepodcast What is the biggest challenge facing employers right now? Dea Belazi of @AscellaHealth discusses #copayaccumulators and #copaymaximizers. #healthcare #podcast #digitalhealth #healthtech #copay #healthcarepodcast

Welcome to Episode 292, Part 2. This is the second part of a two-part episode, but, in a way, you can listen to whichever part you want first. So, if you wound up here first, no worries. Just go back when you have a sec and listen to Part 1. There’s some good stuff there you don’t want to miss, including some background information that might be good to have.  This episode, as well as the last one, is about Teladoc buying Livongo. I am going to call the combined organization T&L because I heart acronyms as much as you do. Here’s the thing with T&L: They are not alone in their quest to disrupt the traditional health care delivery market. You also have Aetna making a plan design that advantages CVS clinics. You got Humana doing the home health thing. You got Walmart and Oak Street hooking up in Texas and risk contracting with managed Medicaid and Medicare Advantage. You have employers across the country direct contracting with Centers of Excellence and buy in perspective bundles. Also, speaking of employers, on the on-site clinic space, Premise Health just recently acquired CareHere. These two organizations will reach 11 million eligible lives at 2200 customers in 300 markets. All this being said, let me make a fairly obvious point: Increasingly, the competition is going to be about outcomes—or perceived outcomes. Competition is going to be around the value delivered (ie, quality divided by cost). This I like. To me, it’s a tragedy that the health care industry can get away with charging prices no one would consider fair and delivering subpar health care let alone health. I want some of these organizations that do a really nice job coordinating care and which patients really appreciate to do well by doing good. And I love that some of the payers out there—some of the employers and even some of the Medicare Advantage and other health plans—recognize the value that these organizations can deliver. But let’s consider the implications of this—notably, here’s one: Few, probably even the very best, for example, endocrinology practices or maybe even cardiology practices, have a bead on how well they ultimately attenuate downstream medical costs. They might not even know, outside of what they are required to report for quality incentives, how well they are consistently creating better patient outcomes. Livongo does—or at least claims they do—and lots of employers and plans buy the results they’re selling to the tune of something like $300 million in sales this year. Here’s what I don’t like: What is shaking out is a turf war, and the weapon of choice may or may not be authentically better patient outcomes. Some of the weaponry here is built on a marketing “chassis.” The one who has the best marketing shall triumph. People judge books by their covers, and that’s a cliché for a reason. You can read Al Lewis’s blog post on Livongo, where he dug into their purported results. Then listen with your left ear to some of the chatter on the street about how Livongo is more of an employee retention tool than, you know, a clinical tool. I don’t kn0w where these rumors started, but I keep hearing that because the Livongo NPS (Net Promoter Score) is high and employees, including executives, think it’s pretty cool as a service, that maybe, given this, that it’s okay if many of the Livongo charts and graphs don’t have labels on their Y axes. And it kind of, you know, makes sense if you actually sit there and stare at them as I have done.  All this I just said? Background noise. The games have begun, and the winners will be those who consumers/patients love. It’ll be the ones who know how to market to employers or Medicare Advantage plans. It’ll be the ones who can succeed in risk-based models. There you go. There are your three success factors. In this health care podcast, I speak with Matt Anderson, MD, MBA. Matt sees the ecosystem through the eyes of an innovation leader at a health system. And my finale interview of our two-part series here is Brian Klepper, PhD, principal over at Worksite Health Advisors. Brian will speak from the POV (point of view) of employers. You can learn more at bannerhealth.com and drmatthewanderson.com and connect with Dr. Anderson on Twitter at @DrAnderson19 and on LinkedIn. You can also learn more at careandcost.com, by emailing bklepper@gmail.com, and by visiting validationinstitute.com.  Matthew Anderson, MD, MBA, has a passion for finding unique solutions to difficult problems in health care. He focuses on creating environments that allow patients and physicians to have frictionless experiences. Through insights gained in private practice, leading physician groups, and embedding himself in the health care innovation landscape, he can empower those looking to improve the health of communities and the well-being of those that dedicated their lives to providing care. He has been a business owner, medical director, and chief medical officer and now leads clinical innovation projects for Banner Health and advises several health care start-ups and venture teams. Brian Klepper, PhD, is executive vice president of the Validation Institute, principal of Worksite Health Advisors, and a nationally prominent health care analyst and commentator. He speaks, writes, and advises extensively on high-performance health care, primary care clinics, and the management of clinical and financial risk. His current consulting focus is on health care organizations that consistently deliver better health outcomes at lower cost than conventional approaches in high-value niches. In his role at the Validation Institute, he spearheads programs that identify, validate, celebrate, and promote true high-performance health care programming. 05:06 What is the viewpoint about this merger from an MD, MBA in a health system? 06:30 “They’re really starting to become someone who can provide that continuity of care in a way that I don’t think anyone’s really done before.”—Matt 07:38 “When you are competing for patients, by definition you’re competing for revenue.”—Matt 10:09 “At baseline, their goal is to provide care but at the lowest cost possible.”—Matt 12:17 What is a forward-thinking provider organization doing right now? 12:31 “This is going to be a space race for health care innovation right now.”—Matt 15:43 “Sometimes it just comes down to the basics, and if you get the basics right, you can apply it in any situation.”—Matt 16:29 What’s forced the inertia in the industry to become action? 17:23 “Things are moving slowly but surely in the right direction, and that’s something I’ve never seen during the course of my career.”—Brian 19:56 “Everybody and his wooden-legged brother claims that they have a high-value service, but very few actually do.”—Brian 21:13 “I think that the stakes have just gotten much higher for health systems … and physicians … of all types.”—Brian 23:46 EP252 with Chad Gray.25:12 “High-performance organizations represent a new paradigm in their niche.”—Brian 25:35 “It speaks to the core problem of American health care, which is that we’ve developed a culture of excess.”—Brian 27:42 Where’s the top of the bell curve right now? 28:10 “A lot of this is driven by policy … and that has sort of rigged the game.”—Brian 29:46 “There’s a tipping point, and then everything really, really will change quickly.”—Brian You can learn more at bannerhealth.com and drmatthewanderson.com and connect with Dr. Anderson on Twitter at @DrAnderson19 and on LinkedIn. You can also learn more at careandcost.com, by emailing bklepper@gmail.com, and by visiting validationinstitute.com.  Check out our newest #healthcarepodcast with @DrAnderson19 and @bklepper1 as they discuss the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth “They’re really starting to become someone who can provide that continuity of care in a way that I don’t think anyone’s really done before.” @DrAnderson19 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “When you are competing for patients, by definition you’re competing for revenue.” @DrAnderson19 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “This is going to be a space race for health care innovation right now.” @DrAnderson19 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “Things are moving slowly but surely in the right direction, and that’s something I’ve never seen during the course of my career.” @bklepper1 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “Everybody and his wooden-legged brother claims that they have a high-value service, but very few actually do.” @bklepper1 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast “It speaks to the core problem of American health care, which is that we’ve developed a culture of excess.” @bklepper1 discusses the Teladoc-Livongo merger. #healthcare #podcast #digitalhealth #telehealth #healthcarepodcast

This is episode 1 of a two-part show about the potential impact of the Teladoc acquisition of Livongo. To get started here, in deference to the fact that we’re all in the health care industry, let’s agree on an acronym, shall we—because I can’t keep saying Teladoc-Livongo. So, I’m going to go with T&L heretofore that will refer to the Teladoc acquisition of Livongo. What is the general merged T&L pitch? Here it is (I looked at their investor deck): T&L is going to use technology to transform the experience of living with a chronic condition and provide a differentiated consumer experience. The merger will also create a consumer-first, data-driven digital health experience that puts the consumer in charge. T&L will also translate deep consumer data to improve member outcomes and cost savings. Here’s why I think that whole slide is the tip of a disruptive iceberg. First of all, we’re in the middle of a land grab for patients. For my full land grab observational analysis, you can read the show notes of the Labor Day 2020 encore episode with Dr. Joe Selby or listen to it. But consider these intertwined points from the T&L investor deck: 80% of large employers believe virtual care will significantly impact the delivery of health care in the future—80%! Also, implementing more virtual care solutions is the number one priority for large employer health initiatives. That’s something.  In the T&L investor slide deck, slide 14 shows the TAM—otherwise known as total available market—that T&L thinks they’re going to get. Spoiler alert: It’s a $121 billion market, and they’re coming for you. Anybody who thinks you’re going to continue to care for patients with chronic conditions all by yourselves, at a minimum, enter your new frenemy. Here’s another reason why I think the T&L merger is the tip of the iceberg of disruption: They talk about, again in their investor deck, how they’re going to be fully scalable across multiple conditions, including CHF (chronic heart failure) and CKD (chronic kidney disease), plus integrated behavioral health; and also, they’ve been rumored to be courting MSK (musculoskeletal) outfits like Hinge Health. So, it’s not just diabetes anymore. Here’s another point: the referral flow. T&L are looking to start to disrupt the referral flow of traditional models. I mean, think about this. If they intercept the patient at the PCP level with Teladoc, then they can refer to a provider in the cloud, like Hinge Health or Livongo or one of the many behavioral health/mental health services lighting up our skies right now. Or consider this: Say I'm in Pennsylvania. I might not want my prostate specialist to be a few hours away if I have to go there on the regular. But let’s just say the specialist offers telemedicine appointments and now I only have to go there, like, once a year. Here’s the point I’m making: Vertical integrations like the one that Teladoc created by acquiring Livongo is a model that has all the potential of vertical integrations in the traditional sphere. Captive populations are a goal for a reason. And having a digital front door could enable all kinds of very geographically dispersed competitors that traditional health systems may not have realized are competitive. Is this my hypothesis? Nope. T&L say it flat out in their investor deck. Their goal is to increase enrollment and utilization by referring individuals across Teladoc and Livongo products. Here’s some other facts to throw in the stew that I thought were interesting: You’ve got consolidated health systems right now who, some studies show, have raised their rates 23% higher than in markets with competition. And the outcomes of said consolidated health systems in patient satisfaction and quality—pick a measure—aren’t any better as a trend line than health systems in competitive marketplaces with a whole lot lower prices. So, you’ve got costs going up and up, meaning that, as an equation, value is going down and down. Employers are getting pissed. Consumers are just done. You have Medicare Advantage (MA) collecting data and worrying about social determinants of health and holding providers accountable to deliver. If I’m an employer or a managed Medicaid plan, maybe an MA plan, and if I’m in an area where the only games in town are wildly expensive (like 23% more expensive) with low patient satisfaction or whatever—even average—and half my star ratings are based on patient satisfaction, you can see where I’m going with this: that these virtual options that are springing up might be attractive to people paying the bills. In this health care podcast, our lineup includes Bob Matthews, who can offer an interesting perspective because he is the president and CEO of MediSync, an entity doing some neat stuff in the cardiology space, also managing chronic conditions. He’s also the VP of quality for PriMed Physicians in Ohio. So, he can kind of represent the entrepreneurial perspective but then also the PCP perspective. Then we’re also going to hear from Dan O’Neill, MA, MS. Dan is a consultant who spent most of 2019 working in the Senate on the professional staff of the health committee, and he tackled issues related to health costs. Now, he’s doing consulting with entrepreneurial physician leaders and also start-ups. You can always count on Dan for a great big-picture assessment of what’s up in the ecosystem. You can learn more at medisync.com and dponeill.com.  Bob Matthews is president and CEO of MediSync. Bob has led multiple medical groups over 20 years. He is Black Belt trained in the Six Sigma quality methods. The MediSync team creates sophisticated processes and AI technologies to enable physicians to achieve best-in-the-nation clinical outcomes, especially in chronic disease management. Daniel O’Neill, MA, MS, is an executive in the digital health and health care technology industry. He has a track record of building teams, executing successful go-to-market strategies for new and established solutions, and structuring effective partnerships to scale venture stage businesses, particularly in health care/digital health. Dan works as consultant with venture-backed firms to define, develop, commercialize, and scale new health care services and software solutions. His areas of focus include bundled payments in the commercial population; virtual networks for specialist consults; tools for Medicare Advantage, Managed Medicaid, and other quality-rated and risk-adjusted plans; interoperability and clinical data exchange infrastructure; and new approaches to streamline the revenue cycle. Prior to becoming a consultant, Dan spent a year in Washington, DC, as a Robert Wood Johnson Foundation Fellow at the National Academy of Medicine, working on health policy in the US Senate. Dan has assembled and managed teams in product, sales, professional services, and account management. He also led the launch and growth of several products to facilitate care coordination and population health initiatives for primary care practitioners, accountable care organizations, hospitals, health plans, and other clinicians. In addition, he has worked on the development and commercialization of decision support tools to implement clinical pathways and avoid medical errors, and on predictive analytics using early versions of artificial intelligence. Dan completed his undergraduate study at Claremont McKenna College. He earned a Master of Arts from Johns Hopkins University and a Master of Science from the Stanford School of Engineering, where he focused on health care operations management and clinical informatics. 07:06 Are providers recognizing that Livongo is their competition? 08:32 Is this the beginning of the health care system in America being disrupted in a major way? 10:05 Where does the major disruptive potential lie with Livongo? 11:56 “The truth is that the local delivery system isn’t doing a good job, and Livongo only has to do a better job.”—Bob 14:55 What is MediSync? 15:46 Dan O’Neil speaks about the Teladoc-Livongo merger and what’s going on right now. 16:08 “You have a blockbuster merger in the world of digital health or health tech.”—Dan 17:03 How does this evolve? 18:16 “A vertical integration play in the virtual care space.”—Dan 19:47 “They call it captive populations for a reason.”—Stacey 23:59 “What you’re seeing … is a different approach to … building, marketing, and delivering the service.”—Dan 29:37 “Big mergers are always risky … that said … that is potentially a very significant move.”—Dan You can learn more at medisync.com and dponeill.com.  Check out our latest #healthcarepodcast with @dp_oneill and Bob Matthews and they discuss the Teladoc acquisition of Livongo. #healthcare #podcast #digitalhealth #telemedicine Are providers recognizing that Livongo is their competition? Bob Matthews discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #telemedicine “The truth is that the local delivery system isn’t doing a good job, and Livongo only has to do a better job.” Bob Matthews discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #telemedicine “You have a blockbuster merger in the world of digital health or health tech.” @dp_oneill discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #telemedicine “A vertical integration play in the virtual care space.” @dp_oneill discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #telemedicine “What you’re seeing … is a different approach to … building, marketing, and delivering the service.” @dp_oneill discusses. #healthcarepodcast #healthcare #podcast #digitalhealth #telemedicine

Medicare Advantage (MA) enrollment has nearly doubled over the past decade. It grew 37% from 2016 to 2020. Right now, MA comprises nearly 40% of the Medicare population—and that number is only expected to grow. So, in case you’ve been out of the loop, at the beginning of 2020, CMS (Centers for Medicare & Medicaid Services) rolled out a third category of these “chronic supplemental benefits.” And these chronic supplemental benefits allow plans to offer basically services to attenuate social determinants of health to offer stuff like nonemergency transportation, meals, home modifications … that whole list. This is all, really, part of a broader bipartisan effort to move Medicare from an acute care to a chronic care program. Then … corona. So, the question I’m kind of wondering about at this juncture is, Were/Are MA beneficiaries able to maintain their health status better than, say, other plan designs, especially given some of these chronic supplemental benefits, which you’d think would be super helpful in the middle of a pandemic? This should make sense, and it should really be true. At its core, MA is, as John Gorman put it when he was on the show last year, the biggest value-based payment experiment in the universe. And patient outcomes have definitely improved for MA patients over traditional FFS (fee for service), especially in the south and in other areas rife with cardiovascular and metabolic disease. So, that sounds great. Now let’s talk about the cash money denominator in the value equation. Humana reported $1.8 billion in profit for the second quarter. That was nearly double its haul in Q2 2019. So far, 2020 has seen a profit that is a 94.5% increase year over year. Humana’s earnings are not an outlier. MA plans across the board did very well, thank you very much, in the middle of a pandemic. Given that MA hasn’t actually reduced PMPM (per member per month) costs last time I looked at it, you’d think and hope that the confluence of higher rates and less restrictions on extra benefits should definitely lead to greater scrutiny on the plans by CMS. We’ll see what happens. Anyway, it occurred to me that it might be interesting to get a bead on what MA plans themselves have been contemplating and thinking about relative to the supplemental benefits et cetera. In this health care podcast, I speak with Betsy Seals, cofounder of the Rebellis Group. Betsy spent many years working with and for Medicare Advantage plans. I thought Betsy would be the perfect person to talk to to get a bead on what’s happening on the MA front right now. You can learn more at rebellisgroup.com. Betsy Seals is a cofounder and chief operating officer at Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage organizations and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 18 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the Medicare landscape. Betsy’s expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that addresses social determinants of health, and health plan operations. Betsy got her start in managed care on the health plan side, where she held roles in compliance and operations. Betsy also spent many years as a managed care compliance and operations consultant with Gorman Health Group, where she exited as chief consulting officer in the fall of 2018. 03:45 What is a Medicare Advantage plan? 04:02 The core imperatives for leaders of Medicare Advantage plans. 04:31 “How is risk adjustment functioning?” 04:34 Making disenrollment rates and member complaints top of mind for MA leaders. 05:40 “We all want to know why members are leaving. Well, they’re telling you!” 05:50 Star rating measures. 07:33 “Will Medicare beneficiaries really have confidence … going into the doctor’s office … next year?” 09:11 “Now, it’s not just ‘Is your doctor in the network?’ It’s ‘Does your plan also offer telehealth?’” 12:13 “When you really look at Medicare beneficiaries aging into the program or … younger … beneficiaries, their shopping trends and their consumer expectations are very much the same as yours and mine.” 13:58 CMS’s adjustment in April that allows MA plans to make changes to their benefits midyear to provide to beneficiaries’ changing needs during the pandemic. 16:01 Supplemental benefits as a decision-making factor in enrollees’ Medicare Advantage plan selection. 16:28 “The decisions made during this time with how to increase benefits or how to address the issues going on with your membership will have a really great impact on [your] AEP [annual enrollment period].” 18:12 “I think that there’s a real lack of understanding … around what issues are impacting their actual membership … but really understanding the demographics and the social determinants of health that are impacting your local landscape.” 19:30 “Health care’s not always related to in-office doctor visits.” 19:40 “I really do think that CMS is headed … to understanding that federal dollars for the Medicare program should not just be spent on doctor’s visits or screenings.” 21:10 “I think that there’s been a real shift in … what we understand now and also what we’re able to predict.” 23:24 Where Medicare Advantage plans fall in addressing population health management, working with hospital organizations, and social determinants of health. 24:24 Betsy’s advice for providers dealing with MA plans. 24:46 “I … think that this is … a missed opportunity [for] provider and plan partnership in a lot of ways.” 26:07 “Really understanding that the market has shifted and the way the beneficiaries enroll this year is going to be very different than it ever has been before.” 29:25 “One thing that shouldn’t be overlooked is that we really have an opportunity to dig into the data.” You can learn more at rebellisgroup.com. Check out our latest #healthcarepodcast with @betsyseals of @GroupRebellis as she discusses #medicareadvantageplans. #healthcare #podcast #digitalhealth #MAplans What is a Medicare Advantage plan? @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “How is risk adjustment functioning?” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “We all want to know why members are leaving. Well, they’re telling you!” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “Now, it’s not just ‘Is your doctor in the network?’ It’s ‘Does your plan also offer telehealth?’” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “The decisions made during this time with how to increase benefits or how to address the issues going on with your membership will have a really great impact on [your] AEP [annual enrollment period].” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “I really do think that CMS is headed … to understanding that federal dollars for the Medicare program should not just be spent on doctor’s visits or screenings.” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans “I … think that this is … a missed opportunity [for] provider and plan partnership in a lot of ways.” @betsyseals of @GroupRebellis discusses #medicareadvantageplans. #healthcarepodcast #healthcare #podcast #digitalhealth #MAplans

There is a land grab going on right now, the likes of which the health care industry hasn’t seen before—at least in our generation. Spoiler alert: There’s a whole episode of Relentless Health Value coming up on the impact of the Teladoc-Livongo hookup. And that is totally relevant to the point I’m about to make. But let me just start with a little bit of background: American patients—let’s get real here—have no more money to spend on health care every year. Really. I mean, you look to employers. The government? Who knows? But let’s just say for the purposes of this discussion that what’s going on right now is a zero-sum game—that the dollars in the system every year are the dollars in the system, and if you want to increase your revenue as any given health care stakeholder, you’ve got to take those dollars from somebody else. Alright … now consider this: Previously, if a health system, say, were going to make a list of their competitors, they’d probably list the health system down the street, maybe the one in the next town over if there seems to be a lot of commuting. Oh, my, how we no longer live in that simple world! Enter the pandemic and patients not only accepting but kind of digging virtual care and its convenience and its accessibility. Now consider what happened to brick-and-mortar stores who didn’t add online retailers to their list of competitive threats. Virtual entities doing chronic care management, diabetes, musculoskeletal, other population health endeavors … these are now or will soon enough be head-to-head competitors to in-person care settings. My local health system, they may also decide to stand up to telehealth—and many of them did. But if the playing field is now in the Cloud, how’s the patient experience on their systems? Everybody accepted that, in the beginning, they were kind of buggy and calls dropped and all you could see was the doctor’s ear in a weirdly dark room or something. But six months later or a year later? Not exactly sure when patients’ patience will run out, especially when there are companies out there who built amazing virtual experiences from the ground up and who, by the way, are often hired by health plans, who, by the way, make it financially, let’s just say, attractive for patients to use those services that the plan is providing instead of the big expensive consolidated health plan that raised their rates 30-fold over the past couple of years like one of them anecdotally did. So, you start to see why, if I were a health system or a provider executive, I’d kind of shuffle the patient centricity, design thinking, patient experience—that whole bunch—to the first tab of my spreadsheet. Patients have, at this moment, unprecedented choice; and so do their employers, nothing for nothing. As Dr. Matt Anderson told me the other day, if a health system thinks that it’s going to make the difference by doing more specialty services and expensive procedures, that might be a risky bet. So, anyway, I thought it might be a good idea to replay my conversation with Dr. Joe Selby from early last year. Dr. Selby is the [now-retired] executive director of PCORI, otherwise known as the Patient-Centered Outcomes Research Institute. PCORI is an independent nonprofit organization in Washington, DC. Since December 2012, PCORI has funded hundreds of studies that compare health care options to learn which work best given patient circumstances and preference. So, it’s definitely good background information. Anyone driving for the best patient experience might want to have it at their fingertips. You can learn more at PCORI.org.

Here’s a couple of sentences ripped from the headlines recently: It is free to be tested for COVID-19 in the US, but the cost of treatment can be shocking. Even if you’re insured, the deductible and co-pay can add up to several thousand dollars. And if you’re uninsured, the financial toll is even uglier. That’s what Boston resident Danni Askini learned when she got a $34,927 bill after receiving treatment in a local emergency room for COVID. That’s from Time magazine. Episode 260 of the show was about the Shkreli Awards and the worst profiteering in health care. The judges of the Shkreli Awards bucketed the winners into a few categories. One of the categories of “winners” was called Schizophrenic Compartmentalization, and this schizophrenic behavior seemed super applicable to hospitals this past year. This schizophrenic compartmentalization happens when the person who wrote the mission statement and probably doctors and nurses are on a totally different planet than the billing department. So, I wanted to take a look at a couple of mission statements just as a reference point, including the mission statements of the hospitals that won Shkreli Awards in the Schizophrenic Compartmentalization category.  Luckily, there is a Web page where hospital mission statements are all collected in one place, so I did not need to travel far to confirm that they are all very, very similar—something along the lines of treat patients with compassion, be a productive member of the community, ease suffering, and give the highest value to all concerned. That’s very noble and what I would expect a hospital, honestly, to be striving toward.  Here’s the thing, though. This is what the whole hospital is supposed to be doing. I didn’t find one mission statement that said everybody except the finance team is subject to this mission statement. Those guys over there? They have their own. In this health care podcast, I speak with Doug Aldeen. Doug is an attorney. He is generally hired by self-insured employers. He has dealt with hospital finance teams for two decades, so he is the perfect person to dig into the delta between the hospital’s mission statement and the finance team’s mission statement. This is what we talk about in this podcast. Doug also offers up some solutions at the micro and the macro level. One vocabulary word before we get started: RBP is otherwise known as reference-based pricing. This means when a health plan, usually a self-insured employer’s health plan, says that they’re going to pay for health care services based on usually the Medicare rate. So, they’ll pay, like, 1.5 times or 2 times what Medicare pays, for example. Do I want to be a little bit sensitive right about now to some of the hospitals that are struggling under the weight of COVID and the shutdowns that have been transpiring across the country? Yeah, I do. At the same time, there is absolutely no excuse to take advantage of those that you claim to serve. There’s a big delta between charging a fair price and wrenching dollar bills out of the sweaty hands of hard-working Americans just because you can. You can learn more by emailing Doug at doug@health-attorney.net or following him on LinkedIn.  Doug Aldeen is an Austin, Texas–based health care and Employee Retirement Income Security Act (ERISA) attorney who recently served as ERISA counsel on behalf of the Berkeley Research Group in New York City to the $7.7 billion May 2016 acquisition of Multiplan and its medical bill repricing product Data iSight by the private equity firm Hellman and Friedman. Since 1997, he has represented reference-based pricing organizations, a bundled payment software platform, PPO networks, medium to small self-funded plans, third-party administrators, and provider-sponsored health maintenance organizations in various capacities, including Herdrich v. Pegram, which was argued before the US Supreme Court in 2001. Moreover, he serves as a resource to national news organizations regarding issues on health care and as a consultant with the Governmental Relations Committee at the Self-Insurance Institute of America in Washington, DC, and as an adviser to RIP Medical Debt, which has abolished over $1.2 billion in medical debt. Doug received his JD from the University of Illinois. 03:59 Exploitive hospital billing practices. 04:20 The impact these exploitive billing practices have on patients. 04:45 Why would a hospital exploit the patient with their billing practices? 09:31 “You could adversely affect 3 million people.” 10:53 The “scorched earth” policy. 11:33 EP242 with Marty Makary, MD.12:28 “I think the long-term plan … is preserving the network.” 13:08 EP186 with David Contorno. 16:03 A third exploitive billing process: hospital-owned insurance plans, or “payviders.” 20:35 MOOP: maximum out of pocket. 21:07 RBP: reference-based pricing. 21:58 Exploitive tactic #4. 26:03 The solution to changing exploitive billing strategies. 26:39 “You have to be willing to travel.” 28:34 EP240 with Olivia Ross.28:47 “It’s educating your employees and really having an honest conversation about ‘This is what it really costs.’” 30:28 Doug’s advice to hospital execs listening right now. You can learn more by emailing Doug at doug@health-attorney.net or following him on LinkedIn.  Check out our newest #healthcarepodcast with @AldeenDoug as he discusses exploitive #hospitalbilling practices. #healthcare #podcast #digitalhealth What is the impact of exploitive billing practices on patients? @AldeenDoug discusses exploitive #hospitalbilling practices. #healthcarepodcast #healthcare #podcast #digitalhealth “You could adversely affect 3 million people.” @AldeenDoug discusses exploitive #hospitalbilling practices. #healthcare #podcast #digitalhealth What is the “scorched earth” billing policy some hospitals use? @AldeenDoug discusses exploitive #hospitalbilling practices. #healthcare #podcast #digitalhealth “I think the long-term plan … is preserving the network.” @AldeenDoug discusses exploitive #hospitalbilling practices. #healthcare #podcast #digitalhealth “You have to be willing to travel.” @AldeenDoug discusses exploitive #hospitalbilling practices. #healthcare #podcast #digitalhealth “It’s educating your employees and really having an honest conversation about ‘This is what it really costs.’” @AldeenDoug discusses exploitive #hospitalbilling practices. #healthcare #podcast #digitalhealth

You may or may not know (I don’t know why you would, honestly), but I speak Swedish. I mention this because there’s this famous and really culturally emblematic Swedish word which is this: lagom. It means “the exact right amount.” In Swedish culture, the exact right amount deserves its own word. For example, “Did you have enough watermelon?” “Why, yes, I had half a slice. It was lagom.” Lagom has no direct translation in US English because, in the United States, we don’t need a word for “the exact right amount.” Why? Because the exact right amount already has a word: the most. More. More is always better. I think this shows up in health care in this country, and it definitely showed up in my conversation with Dr. Bishal Gyawali in this health care podcast. There’s this cultural bias in this country that more is better. The point I’m making is that there’s a sort of fundamental belief that aggressive therapy—the most aggressive therapy—is the best therapy and conservative therapy, or following the treatment pathway that works for the majority of patients, is kind of like a surrender. It’s not about being pro or anti anything. It’s about being data driven. It’s about finding the “lagom” amount of care that the data suggest is the best amount of care and not immediately assuming that if something isn’t done that it’s been a subpar outing. In this health care podcast, I’m talking with Bishal Gyawali, MD, PhD. Dr. Gyawali is a practicing oncologist; assistant professor at Queen’s University in Kingston, Canada; and he has studied and worked in Nepal, Japan, and the US, and now in Canada. He’s a thought leader in studying the data impartially and finding ways to help patients and oncologists systematically make the best decisions toward high-value oncology care that is not financially toxic. You can listen to Dr. Gyawali sum this up in his own words or read his paper on the topic, but here’s his top-line suggestions: Follow NCCN and ASCO guidelines. Payers: Negotiate drug prices based on clinical benefit—and this means you, too, Medicare. Hospitals: more price transparency up front but also for the doctors. Financial toxicity is a thing. It’s been shown that patients who are suffering from financial toxicity die earlier. So, this is definitely data that a doctor needs to know as much as some kind of clinical decision-making factor. Hospitals: Have a financial advisory desk. Correct the misincentives at the physician/patient level (ie, all that’s going on with “buy and bill”). You can read Dr. Gyawali's published paper in JAMA and connect with him on Twitter at @oncology_bg.  Bishal Gyawali, MD, PhD, is a medical oncologist with work experience in various low- and high-income countries. He graduated medical school in Nepal with seven gold medals and received his PhD from Nagoya University, Japan, as a MEXT scholar. He then practiced as a medical oncologist at Civil Service Hospital, Kathmandu, Nepal. He currently works as a medical oncologist and scientist in the Division of Cancer Care and Epidemiology at the Queen’s University Cancer Research Institute in Kingston, Ontario, Canada, where he is also an assistant professor of public health sciences. He was a research fellow at PORTAL (Program On Regulation, Therapeutics And Law) from 2018-2019. He also serves as a medical consultant for the not-for-profit Anticancer Fund, Belgium, and as editorial board member for the Journal of Global Oncology and ecancer. His clinical and research interests include cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. Dr. Gyawali is an advocate of the “cancer groundshot,” a term he coined to imply that research investment should be made on known high-value interventions in cancer care that are affordable and easy to implement globally. Dr. Gyawali is active in the oncology and clinical research communities on Twitter. 03:18 Oncology decisions on the individual level and oncology policy decision making. 05:10 Reverting to the mean. 06:29 “We’re assuming … more care is good care, which is not necessarily true.” 06:49 “What we need to focus on is above-average level of health outcomes.” 07:55 “Sometimes we forget the goal, and we get so entangled in the path itself that we forget the destination.”11:19 Cutting out low-value care during the pandemic. 12:09 Reevaluating cancer screens and looking at the evidence for appropriate use cases. 13:24 Distinguishing the term “survival” from “mortality.” 16:34 “If a person dies, it does not matter what the person died of.” 17:26 “A lot of the things that we do routinely in medical practice need to be reevaluated.” 18:53 The FDA approval of oncology agents and things that make a difference. 20:37 “What exactly are we gaining from these drugs?” 20:53 EP282 with Aaron Mitchell, MD, MPH.23:15 Dr. Gyawali’s advice to policy decision makers. 23:42 Policy decision-making interventions that are possible. 24:50 “The problem with these guidelines … is that a lot of these people who are on these guidelines, they have huge conflicts of interest to the industry.” 26:58 How to pay less for low-value care. 27:42 A better path forward to pay for value. 31:02 Ways to help on the individual level. 32:07 “At the end of the day, the ultimate use of an intervention happens in the clinic.” 34:24 “We should never be pro or anti anything; we should just be pro-data.” You can read Dr. Gyawali's published paper in JAMA and connect with him on Twitter at @oncology_bg.  Check out our newest #healthcarepodcast with @oncology_bg as he discusses #oncologyscreening and #oncologycare. #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy “We’re assuming … more care is good care, which is not necessarily true.” @oncology_bg discusses #oncologyscreening and #oncologycare. #healthcarepodcast #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy “What we need to focus on is above-average level of health outcomes.” @oncology_bg discusses #oncologyscreening and #oncologycare. #healthcarepodcast #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy What’s the difference between “survival” and “mortality”? @oncology_bg discusses #oncologyscreening and #oncologycare. #healthcarepodcast #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy “If a person dies, it does not matter what the person died of.” @oncology_bg discusses #oncologyscreening and #oncologycare. #healthcarepodcast #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy “A lot of the things that we do routinely in medical practice need to be reevaluated.” @oncology_bg discusses #oncologyscreening and #oncologycare. #healthcarepodcast #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy “At the end of the day, the ultimate use of an intervention happens in the clinic.” @oncology_bg discusses #oncologyscreening and #oncologycare. #healthcarepodcast #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy “We should never be pro or anti anything; we should just be pro-data.” @oncology_bg discusses #oncologyscreening and #oncologycare. #healthcarepodcast #healthcare #podcast #oncology #digitalhealth #healthcarepolicy #oncologypolicy  

Disclaimer before we get started here: This show is probably a 300-level class in pharmaceutical/PBM relations. If you are tuning in for the first time and you aren’t pretty familiar with the role of PBMs, I would go back and listen to, say, episode 241 with Vinay Patel or episode 166 with Tim Thomas from Crystal Clear Rx.  OK, now that that’s out of the way, if you’re still with me, this episode is like a ride on a roller coaster. In this health care podcast, I talk with Mike Schneider, who’s a principal over at Avalere Health. And we get into, you know, kinda deeply, the what and the why behind the "Big Three" traditional PBMs deciding that now might be a fantastic time to set up GPOs. PBMs are pharmacy benefit managers—there’s three huge ones. GPO stands for group purchasing organization. Traditionally, these GPOs have purchased drugs and supplies for hospitals and other providers at, according to their marketing materials, volume discounts. So, the unfolding story here, in a nutshell, is that ESI (Express Scripts) set up a GPO called Ascent in Switzerland. Optum has had an Ireland operation going in full swing for a while. And now we have CVS Caremark setting up a GPO called Zinc. These GPOs are not like normal GPOs working with hospitals, but instead, these GPOs are the entity which is now going to negotiate with pharma companies. In the past, it was the PBM that was negotiating with the pharma company to get rebates. Now it’s this GPO entity. “But wait,” you may say. “Wasn’t there an executive order the other day requiring PBMs to, for example, pass through all of the rebates that they’re collecting to patients?” Indeed, there was. And that rule doesn’t say anything about GPOs having to do the same, especially GPOs in, let’s just say, Switzerland. It’s a tangled web we weave. You can learn more at avalere.com. You can also connect with Mike on LinkedIn.  Mike Schneider is an experienced health care executive with over 20 years of experience in the pharmaceutical manufacturer, pharmacy benefit manager, and payer side of health care. He previously spent 9 years at CVS Caremark, where he was a director of industry relations with responsibility for trade strategy development, rebate negotiations, and contract execution for CVS Caremark’s own Medicare Part D plans and that of its clients. He held a similar position at Universal American (UA) before it was acquired by CVS Health, where he also negotiated UA’s commercial business. Mike has held various sales and market access roles with pharmaceutical manufacturers with increasing responsibility. Before entering health care, Mike began his career as a researcher at the Procter & Gamble Company in Cincinnati, where he worked on hair care product formulation development focusing on the key markets of China and Japan, and then moved on to work in drug development. Mike holds a BS degree from the University of Illinois and an MBA from the University of Akron. 02:30 What does a GPO add to a PBM? 05:05 Rebates vs driving more revenue. 10:20 PBMs vs safe harbors. 12:07 The net impact on the commercial side. 13:48 PBMs vs pharmaceutical manufacturers. 14:35 How the "Big Three" PBMs compete with each other, and how employers would choose between them. 15:37 What the net-net is here. 17:48 How PBMs are shifting their models. 20:23 How GPOs may be making things even less transparent. 21:11 “The PBM world as a whole is not very transparent.” 24:40 “One of the biggest beneficiaries of this whole rebate [system] is the government.” 25:25 “The question is, ‘Who’s paying those costs?’” 25:40 EP216 with Chris Sloan.26:40 A better way to move money from Pharma to employers and plan sponsors. 27:43 “Put your money where your mouth is.” You can learn more at avalere.com. You can also connect with Mike on LinkedIn.  Check out our newest #healthcarepodcast with Mike Schneider of @avalerehealth as he discusses #PBMs and #GPOs. #healthcare #podcast #digitalhealth #healthcarefinance #pharma What does a GPO add to a PBM? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma Rebates vs driving more revenue. Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs safe harbors. Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma What is the net impact on the commercial side? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma PBMs vs pharmaceutical manufacturers. Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How do the "Big Three" PBMs compete with each other? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How do #employers choose between the "Big Three" PBMs? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma What’s the net-net here? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How are PBMs shifting their revenue models? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma How are GPOs making things even less transparent? Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “The PBM world as a whole is not very transparent.” Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “One of the biggest beneficiaries of this whole rebate [system] is the government.” Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “The question is, ‘Who’s paying those costs?’” Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma A better way to move money from Pharma to employers and plan sponsors. Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma “Put your money where your mouth is.” Mike Schneider of @avalerehealth discusses #PBMs and #GPOs. #healthcarepodcast #healthcare #podcast #digitalhealth #healthcarefinance #pharma

In this health care podcast, I’m speaking with Dan O’Neill, MA, MS. Dan says that, in many ways, this is a fantastic time to be an entrepreneurial physician leader. We are in a place to reinvent the practice model, meaning finding ways to increase value while losing bloated business practices in labor and capital. It’s more possible than ever to make a medical practice more efficient and effective with less overhead and, at the same time, meet the needs of patients in ways that are, you know, were impossible in the business model of five years ago and earlier. It’s just a new world, and I don’t just mean because of COVID. I mean in all the ways that everybody—including me—has been squawking about for years: consumerism, the rise of technology and its attendant expectations, Medicare running out of money, and employers who have cried uncle on rising health care costs and/or gone out of business. The silver lining in everyone getting used to telehealth and aggregated FFS (fee-for-service) revenue tanking for a couple of months is that suddenly some of the cushy cha-ching reasons to keep the old model don’t feel quite as much of a sure thing for the risk averse any longer. On the flip side, it’s also a fine time for you insurers to step up. Consider what some of the plans are doing right now to help PCPs (primary care providers), for example, transition to value and help independent docs stay in practice at the same time. I could say the same for some of the self-funded employers. It’s gonna suck for you all if the PCPs not connected to consolidated health systems go belly-up. Now is the time that you really can help them help you, and everybody wins from a quality and cost standpoint now and down the line. My guest on this health care podcast is Dan O’Neill, MA, MS. Dan’s a consultant who spent most of 2019 working in the Senate on the professional staff of the health committee focused on issues related to health care cost mainly. Now he’s doing consulting with entrepreneurial physician leaders and also start-ups. You can learn more at dponeill.com. Daniel O’Neill, MA, MS, is an executive in the digital health and health care technology industry. He has a track record of building teams, executing successful go-to-market strategies for new and established solutions, and structuring effective partnerships to scale venture stage businesses, particularly in health care/digital health. Dan works as consultant with venture-backed firms to define, develop, commercialize, and scale new health care services and software solutions. His areas of focus include bundled payments in the commercial population; virtual networks for specialist consults; tools for Medicare Advantage, Managed Medicaid, and other quality-rated and risk-adjusted plans; interoperability and clinical data exchange infrastructure; and new approaches to streamline the revenue cycle. Prior to becoming a consultant, Dan spent a year in Washington, DC, as a Robert Wood Johnson Foundation Fellow at the National Academy of Medicine, working on health policy in the US Senate. Dan has assembled and managed teams in product, sales, professional services, and account management. He also led the launch and growth of several products to facilitate care coordination and population health initiatives for primary care practitioners, accountable care organizations, hospitals, health plans, and other clinicians. In addition, he has worked on the development and commercialization of decision support tools to implement clinical pathways and avoid medical errors, and on predictive analytics using early versions of artificial intelligence. Dan completed his undergraduate study at Claremont McKenna College. He earned a Master of Arts from Johns Hopkins University and a Master of Science from the Stanford School of Engineering, where he focused on health care operations management and clinical informatics. 02:37 Why switching revenues to a different model isn’t simple. 03:45 The segmentation approach we need to focus on. 04:15 The straightforward answer for PCPs. 04:27 The path forward for specialists. 05:21 Moving away from “buy and bill” economics. 05:31 EP282 with Aaron Mitchell, MD, MPH. 07:36 Are health systems buying more practices, or are more practices becoming independent? 09:22 “It starts from why are they making the investment and what is the thesis?” 11:01 Separating the venture-/growth-oriented approach from the financial engineering approach. 12:47 Opportunities for physicians with an entrepreneurial mind-set. 15:55 “What services am I currently delivering?” 21:37 The opportunity to do well by doing good. 24:00 Health insurers as a barrier to change. 24:54 “This is a good opportunity to affect real change.” 25:40 “If you’re just waiting around for change, it’s probably not gonna walk in the door.” 27:43 The attempt to reinvent care delivery. You can learn more at dponeill.com. Check out this week’s #healthcarepodcast with @dp_oneill as he discusses #entrepreneurial #physicianleadership. #healthcare #podcast #digitalhealth #healthtech Why switching revenues to a different model isn’t simple. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech The segmentation approach we need to focus on. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech The straightforward answer for PCPs. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech The path forward for specialists. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech Moving away from “buy and bill” economics. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech Are health systems buying more practices, or are more practices becoming independent? @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech “It starts from why are they making the investment and what is the thesis?” @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech Separating the venture-/growth-oriented approach from the financial engineering approach. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech Opportunities for physicians with an entrepreneurial mind-set. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech “What services am I currently delivering?” @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech “This is a good opportunity to affect real change.” @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech “If you’re just waiting around for change, it’s probably not gonna walk in the door.” @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech The attempt to reinvent care delivery. @dp_oneill discusses #entrepreneurial #physicianleadership. #healthcarepodcast #healthcare #podcast #digitalhealth #healthtech