Relentless Health Value

In this podcast originally published early last year, Alex Akers and I had a chance to speak with Dr. Robert Pearl about his book Mistreated: Why We Think We’re Getting Good Health Care—And Why We’re Usually Wrong. Besides being an author, Dr. Pearl is former CEO of the Permanente Medical Group; he’s a frequent keynote speaker; and he is also the host of a podcast called Fixing Healthcare.  Here’s what Dr. Pearl said at the recent HLTH conference in Vegas, and I’m editorializing a little bit here. Dr. Pearl said day after day, patients and their families experience the unnecessary frustrations and heartaches that are so rife in American health care. Mistreatment is certainly a continuum, but in all of its manifestations, it’s pretty much nothing less than rampant. I mean, how else do Americans manage to pay more than twice as much per patient for a health system that ranks 37th in the world? There are definitely bright spots, and there are definitely great men and women working within health care. So, I do not—and I’m certain Dr. Pearl does not—mean to be all doom and gloom. But we’ve got some realities to deal with here. There’s a simple answer to the question, “What happens if we fail to change?” Disruption will happen. While the pace of health care disruption in many sectors hasn’t exactly set world speed records, it’s inevitable. And, according to Dr. Pearl, status quo health care providers will lament their decision not to have embraced change sooner. To wrap our heads around this, Dr. Pearl suggests that there are four must-haves, four pillars to get the American health care industry back on track. Spoiler alert: Those four pillars are (1) integration, (2) pay-for-value, (3) modernize our approach to technology, and (4) clinician- and physician-led organizations. You can learn more by connecting with Dr. Pearl on Twitter at @RobertPearlMD. 

There are four pillars that contribute to readmissions: ensuring patients are equipped to self-manage and properly take their medications; follow-up (usually by PCPs); managing transitions of care and care coordination, which might be known as interoperability; plus avoiding medical errors. Dr. Kim Noel and I discuss each of these pillars and how telehealth and other digital tools can close gaps and help patients do what they need to do to stay out of the hospital. Dr. Noel is a clinical researcher, physician, and telehealth specialist. She is an appointee to the New York State Department of Health Regulatory Modernization Initiative Telehealth Advisory Committee and serves as the director of Stony Brook Medicine Telehealth and the deputy chief medical information officer there as well. Kimberly Noel, MD, MPH, is a board-certified, preventive medicine physician. She serves as the telehealth director and deputy chief medical information officer of Stony Brook Medicine, where she provides leadership to all telehealth activities of the health system. Dr. Noel is also the chief quality officer of the patient-centered medical home (PCMH) for the family medicine department, working on quality improvement and population health management for National Committee for Quality Assurance (NCQA) designation. She practices occupational medicine clinically and provides digital solutions for employee wellness programs. She is an appointee the New York State Department of Health Regulatory Modernization Initiative Telehealth Advisory Committee and has won many service and innovation awards for health care. In academia, her research areas are in machine learning, risk models, and remote patient monitoring. Dr. Noel has developed several educational curriculums, including a 40-hour telehealth curriculum for the School of Medicine, as well as interprofessional educational curriculums with the School of Health Technology and Management, Nursing, Dentistry, and Social Work. Dr. Noel is a graduate of Duke, George Washington, and Johns Hopkins Universities. She is a proud graduate of the Stony Brook Preventive Medicine program, whereby she is now working collaboratively with the residency program leadership on development of a telehealth preventive medicine service. You can learn more by connecting with Dr. Noel on Twitter at @DrKimNoel

Patients, families, caregivers are generating data outside of the health care setting. They are tracking exercise, symptoms, blood pressure. And they’re coming in for their appointments bearing stacks of printouts or their username and password on a little piece of paper and asking their clinicians to log in to their accounts and check out the goings on. Clinicians, meanwhile, struggle to understand how to bring these data elements into provider environments so that the data can improve engagement and can improve care and outcomes. How can all this data be used to help patients better self-manage? In this health care podcast, I speak with Vicky Tiase, a nurse informaticist and director of informatics strategy over at NewYork-Presbyterian Hospital. We talk about the opportunities to use patient-collected data, but mostly we discuss the barriers and how to overcome them. We also consider the flip side to this: a new CMS (Centers for Medicare and Medicaid Services) rule that mandates that providers must make provider-collected data available back to patients in a form of the patient’s choosing. How does that fit into this picture? It’s interesting to observe that there’s at least two schools of thought emerging relative to which apps patients use. Or maybe a better way to put it: It’s less about two schools of thought and maybe more like two phases to a larger goal. One might come before the other. One school of thought concludes that provider organizations should prescribe apps, since it makes it easier on the back end to assimilate the data into clinical workflows and also hearkening back to the patriarchal origins of medicine—Doctor knows best and should tell the patient what to do. The other school of thought concludes that patients should be able to pick their own apps that appeal to them. The place that these two priorities merge is if apps are part of a trusted framework so that no one winds up with anything developed by Russian hackers, but yet the choice can still be left up to patients but within, like I said, this trusted framework. Vicky will be speaking at the Digital Medicine Conference sponsored by NODE.Health. That event is coming up on December 9 in New York City. NODE.Health, by the way, stands for the Network of Digital Evidence. Look it up on the Web if you have questions. I will be at the Digital Health Conference. If you’re going to be there, too, let me know! You can learn more by connecting with Vicky on Twitter at @vtiase, or join her at the NODE.Health Digital Medicine Conference on December 9, 2019.  Victoria (Vicky) Tiase, MSN, RN, is the director of research science at NewYork-Presbyterian (NYP) Hospital. She has over 13 years of experience of giving clinical input to technology projects in all areas, especially regarding the implementation of the NYP electronic medical record. Vicky is responsible for supporting a range of clinical information technology projects related to patient engagement, alarm management, and care coordination. She was the nursing lead for the design, implementation, and rollout of an institution-developed personal health record (PHR), myNYP.org. She is passionate about finding data-driven, information technology (IT) solutions for increased patient and provider engagement in health care and leads research efforts to ensure the capture and presentation of data for the use and benefit of clinicians. Vicky serves on the steering committee for the Alliance for Nursing Informatics (ANI) and recently completed a fellowship in the ANI Emerging Leaders Program assessing nurse readiness to use health IT tools for patient engagement. She completed her master’s in nursing informatics at Columbia University and is currently pursuing a PhD from the University of Utah with a focus on the integration of patient-generated health data into clinical workflows. 

The North Carolina State Employees Health Plan (SEHP) crafted a proposal called the Clear Pricing Project. The Clear Pricing Project proposed to pay network hospitals based on a transparent price schedule. Considering that SEHP purchases benefits for something like 720,000 people in North Carolina at a cost to taxpayers of billions of dollars, this seems reasonable. When you’re the fiduciary for thousands of dollars, let alone add six more zeros, it would seem to be non-negotiable to actually see the numbers and not write a check to a black box. Nonetheless, a few of North Carolina’s largest hospital chains disagreed. They want to bill whatever they want and to do so shrouded by a cloak of secrecy. I don’t want to put words in anyone’s mouth, but it appears that the CFOs and CEOs of these hospital systems don’t believe that the treasurer of the state has a right to see what he’s spending taxpayer money on. And these CFOs and CEOs have expressed their position with a brutal onslaught of personal attacks against the North Carolina Treasurer’s office. I feel like this episode needs a trigger warning. As David Contorno, also from North Carolina, has said on this podcast (EP186), the only way to pay less for health care is to pay less for health care. It’s hard to do that if you don’t know how much you’re paying. It just blows my mind when all across this country, financial toxicity is reducing health outcomes while nonprofit health systems—excluding some of the rural ones—are yanking in record profits, and employers and public entities are not messing around when they say that health care prices are an existential threat. Let’s all get on the same side of this issue, please. Ultimately, it’s everyone’s responsibility to do the right thing right now. In this health care podcast, I am speaking with North Carolina State Treasurer Dale Folwell. You can learn more at nctreasurer.com.  You can also connect with Treasurer Folwell on Twitter at @DaleFolwell or on Facebook at Dale Folwell. Dale R. Folwell, CPA, was sworn in as State Treasurer of North Carolina in January 2017. As the keeper of the public purse, Treasurer Folwell is responsible for a $100 billion state pension fund that provides retirement benefits for more than 900,000 teachers, law enforcement officers, and other public workers.

In this health care podcast, I speak with Mark Blum from America’s Agenda. When I was talking with Mark, I kind of pictured him bearing a flag with a peace sign on it. His point for unions and employers alike is this: Instead of ripping each other into shreds at the bargaining table over health care, maybe work together proactively. Clip the reasons for rising health care costs in the first place. These reasons include, but certainly are not limited to, excess middleman profits that do not contribute to patient value, private equity earning profits on the backs of patients and payers, a health care system that rewards volume over value … I could go on and on. But here’s a way out of this tangled web we’ve been forced into: Instead of bowing and scraping at the boots of special interests driving up the costs of health care for Americans—and when I say Americans, I mean bosses or labor alike—instead of flailing at the mercy of these forces, change the game. Gang up together and proactively demand to get what you pay for. Mark and I talk about two very concrete examples on how to do this. Mark and the team at America’s Agenda, for example, saved New Jersey $1.6 billion (that’s billion with a B) over the past three years on pharmacy benefits alone. That’s a whole lot more shekel than could have been generated by haggling over who pays for what of a pharmacy bill that is $1.6 billion too high. We also talk about direct primary care and how much direct primary care—not owned by a private equity, by the way—how much direct primary care can improve patient outcomes while, at the same time, reducing costs. Mark has some learnings here, too. You can learn more at americasagenda.org and solidaritus.net.  Mark Blum is executive director of America’s Agenda, an alliance of labor unions, businesses, health care providers, and government leaders with a common mission of guaranteeing access to affordable, high-quality health care for every American. Under Mark’s direction, America’s Agenda has defined widely adopted principles of high-value care delivery design and achieved an unrivaled record of success in building winning statewide health care reform campaigns. Managed Care magazine recently featured an America’s Agenda–designed strategy that netted more than $1 billion in prescription drug savings for New Jersey’s public workers during 2018 and 2019 and is projected to save the state nearly $2.5 billion over five years without cutting public employee prescription benefits. Mark serves also as president and CEO of SolidaritUS Health, a leading-edge, labor-owned direct primary care provider whose innovative approaches to relationship-based care delivery were featured recently in Modern Healthcare magazine. SolidaritUS Health has revolutionized patient experience and improved quality of care while reducing employer health costs substantially and helping save thousands of US industrial jobs from being offshored. Mark, who has served as a special adviser on hospital finances to leadership of the California legislature, serves currently as an appointee of Governor Phil Murphy to the New Jersey State Health Benefits Value and Quality Task Force. Mark was the first male ever elected to the board of directors of the American Medical Women’s Association. Internationally, he has served as adviser to Cambodian textile workers organizing the first labor unions in their country’s history.

In this health care podcast, I speak with John Gorman, who is a government-sponsored health programs guru. He’s also the founder of a newly minted organization called Nightingale that (spoiler alert) we discuss toward the end of our conversation. I just want to interject right here that I, for one—but I’m sure John would agree—do not believe that Medicare Advantage (MA) is, as is, perfectly terrific and devoid of problems. There are, of course, well-known issues with coding, the whole exaggerated diagnoses for higher reimbursements thing … then there’s the whole potentially wasteful quotas payments and the restrictive networks of doctors cited issues. We don’t get into these during our conversation, focusing instead on comparing MA to FFS (fee-for-service) Medicare. From there, we get into advice for independent physicians in rural hospitals and then we wind up at price gouging by nonprofit hospitals. John’s points are insightful as always, and I guarantee he will give you a lot to think about. You can learn more and connect with John on LinkedIn. John Gorman is the founder and former executive chairman at Gorman Health Group (GHG). For 22 years he led the development of the industry’s leading consulting practice and several entrepreneurial ventures in government health programs. John’s work focuses on Medicare Advantage, Medicaid, and Accountable Care Act strategy, governance, and social determinants of health. John considers himself a defender and fixer of health insurance coverage, especially Medicare, Medicaid, and subsidized individuals served by health plans. He has strong opinions and relies on evidence and sound policy. Prior to founding GHG in 1996, he was appointed by President Clinton as the first assistant to the director of the Health Care Financing Administration’s (now Centers for Medicare and Medicaid Services) Office of Managed Care.

In this health care podcast, Pam Arora, SVP and CIO at Children’s Health in Dallas, talks about the work she and her team are doing. Spoiler alert: It’s pretty visionary. They have integrated telemedicine solutions in schools and in patients’ homes. They’ve also been monitoring adherence to vital transplant meds by putting chips on the capsules. They have initiatives happening with voice and GPS technology. I asked Pam what it takes to get all of this done while, at the same time, balancing the usual suspects—the EHR upgrades, the security patches, the virtual desktops, the inevitable panic of the month. Pam explains her answer far more eloquently than I’m going to be able to recap here, but in a nutshell, she says it’s all about getting the fundamentals right. A hospital, a health system, needs a capable, robust EHR infrastructure that really works. She further adds that attaining that infrastructure takes a lot of things, but one of them is a relentless attention to the details, particularly the details around what exactly and specifically patients and their families want and need. I met Pam at the NODE.Health conference earlier this year in New York City. You can learn more at childrens.com or onTwitter at @ChildrensTheOne.  You can also connect with Pam on Twitter at @pkarora. Pamela Arora serves as senior vice president, information services, and chief information officer (CIO) and is responsible for directing all efforts of the information services groups in the organization. Her oversight encompasses systems and technology, health information management, and health care technology management and support.

I want to talk about the wellness industry today. In the parlance of the famous (or infamous, depending on where your revenue is coming from) Al Lewis, traditional “to employee” types of wellness programs are health care done to employees, not for employees. They’re like forced health care. Generally, these programs tout cost savings to the employer. And also generally, these programs aren’t optional; they may include sticks as well as carrots and sometimes sticks that are dressed up as carrots but are actually still sticks. The wellness industry is big business—like, regulated by the SEC big in some cases. That’s why this Clay Christensen quote is so apropos. Despite the fact that your average wellness program is often, let’s just say, heartily suboptimal from a cost, quality, and satisfaction standpoint, most employers continue to basically force employees into them. Many brokers continue to offer these ineffective programs as well. I mean, why wouldn’t they? Everybody in the supply chain is making money. Besides, it’s time consuming and maybe even risky to try to re-educate an employer organization who might not know any better. It’s one of those great examples where doing the right thing isn’t as profitable or safe as exploiting outdated thinking as long as the market will bear. Employers are getting wise to a lot of things right now. I’d suggest a fast follow-on is going to be their view of these wellness programs. It will be interesting to see if current vendors are able to compete with the newer solutions that actually work and which employees actually appreciate. It will also be interesting to see if there’s any backlash against the supply chain that continues to offer up these solutions, especially given some of the lawsuits that are currently under way and all the research which is eminently available. After about ten people wrote in looking to hear an interview with him, in this health care podcast I’m honored and pleased to speak with the one and only Al Lewis. Al is basically synonymous with wellness programs’ analysis and evaluation. One of my favorite things about Al is that he is as controversial as he is respected. He’s been called both “the founding father” of disease management, and he’s also been called the “troublemaker-in-chief” of the wellness industry. Regardless of your opinion of Al’s views, his integrity and commitment and rigorous analytical approach is open and shut. Al is the author of two books, which you can find in the show notes. He’s also the CEO of Quizzify. Quizzify is a company and an approach that teaches employees how to get the care they need while avoiding the “care” they don’t. Quizzify’s claims have been validated, by the way, by the Validation Institute. You can learn more at quizzify.com. Al Lewis wears multiple professional hats. As an author, his critically acclaimed category-best-selling book on outcomes measurement, Why Nobody Believes the Numbers, chronicling and exposing the innumeracy of the health management field, was named 2012 health care book of the year in Forbes. Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, released in 2013, was also a trade bestseller. His 2014 book Surviving Workplace Wellness has also received great accolades, and excerpts appeared in Harvard Business Review and elsewhere.

In this health care podcast, I speak with Lee Lewis, who is the newly minted chief strategy officer at the Health Transformation Alliance, otherwise known as the HTA. The HTA is a group of 50 major corporations that have come together in an alliance to do one thing: fix our broken health care system. Anyone who knows Lee knows he knows a lot about how to improve health care benefits for large employers. He’s pretty much the perfect guy to be the chief strategic officer at the HTA. The most amazing thing that I always find about improving health care, the structure of health care benefits, and health care benefits for an employer is that it’s like having your cake and eating it, too. On one hand, both the employer and the employee save money. On the other hand, employees get better care and they spend less time away from work struggling to navigate the health care jungle all by themselves. Lee has a playbook for improving the structure of health care benefits or health care benefits for large employers, and this playbook consists of three chapters, which we get into in this podcast. The first chapter covers the “how” of health benefits, including what Lee calls the “administrative superstructure.” The second chapter in Lee’s playbook is the “what,” which usually comprises drug spend and then, on the medical side, how care is delivered for specific clinical conditions like musculoskeletal, cardiometabolic, etc. There are a few conditions that tend to rack up the most costs categorically, and those are the ones that Lee focuses on. The last chapter in Lee’s playbook is the “who,” meaning where employees are steered to for care—and that also includes an emphasis on PCPs (primary care providers). You can learn more by visiting htahealth.com and by connecting with Lee on LinkedIn.  Lee Lewis is an innovator and strategist helping large, national, self-funded employers save millions on health care through leading practices, vendor partnerships, and member engagement. He pioneers methods around the convergence of digital health, medical consumerism, biomedical supercomputing, and system reengineering.

Here’s one fact of life that’s always true: It will always be the desire of big vested interests to maintain and stick with the status quo. This applies to all of the various parties in the drug supply chain as much as it does to any other industry. So, here’s the $106-billion-a-year question: In 2019 or 2020, will all of the drug pricing proposals and legislature popping up all over the place in Washington and in some states right now—will they all just simply blow over? Is it the case that Big Pharma and pharmacy benefit managers (PBMs) and insurance carriers are well girded enough to withstand these various efforts to undermine their revenue streams—at least at some level? But let’s start at the beginning. You may be wondering what exactly is going on right now legislatively and with various proposals. It’s very difficult to keep track of it all. And what are pharma companies and PBMs and insurers mulling over as they contemplate their strategies to maintain their current level of control and keep their shareholders happy? Never fear. In this health care podcast, I speak with Josh LaRosa from Wynne Health Group. He sets us straight and gets us up to speed. You can learn more at wynnehealth.com. Josh LaRosa, MPP, joined the Wynne Health Group in November 2018, bringing with him over three years of federal health care policy consulting experience. The majority of his experience in the federal consulting space has been with the Centers for Medicare and Medicaid Services (CMS), and he in particular has worked heavily with the agency’s Center for Medicare and Medicaid Innovation (CMMI). With CMMI, Josh worked to implement, monitor, and spread learning garnered from the center’s high-profile demonstration projects, most recently including the national primary care redesign effort, Comprehensive Primary Care Plus (CPC+). Josh has also assisted a multitude of provider organizations participating in CMMI’s Health Care Innovation Awards Round One and Two to implement their innovative health care delivery and payment models. Through such experiences, Josh has been exposed to a wide array of innovations in health care delivery and is deeply interested in how changing provider, patient, and payer incentives can result in a higher-quality and more cost-effective health care delivery system. Josh holds a Master of Public Policy from the University of Virginia’s Frank Batten School of Leadership and Public Policy, where he had the opportunity to work with a DC-based nonprofit and explore policy options for addressing the behavioral health needs of military and veteran families. Josh also completed his undergraduate studies at the University of Virginia, graduating cum laude with a BA degree in political philosophy, policy, and law. 01:48 This conversation happened at the end of August 2019. 02:32 Are we at an inflection point with health care legislation? 05:10 What obstacles stand in the way of seeing any legislation passed by Congress? 05:51 EP231 with AJ Loicano.06:14 Most likely to happen and most disruptive among the health care measures being proposed. 09:03 The catastrophic benefit and how it works. 16:34 International Pricing Index Model. 20:12 The two areas that would have the greatest impact on the industry, if they transpire. 21:07 Federal Trade Commission (FTC), PBMs, and drug pricing. 21:46 Mandating PBM contracts, and what it would take at the FTC. 22:27 Bringing transparency to the forefront of PBM contracting. 27:10 Brand manufacturers vs generic manufacturers. 28:05 Breaking down barriers in generic reform. You can learn more at wynnehealth.com.