Relentless Health Value

In this health care podcast, I speak with Dr. Marty Makary about his new book, which is entitled The Price We Pay: What Broke American Health Care—and How to Fix It. I could not recommend this book more highly. It’s a page turner for hospital execs trying to do the right thing, employers trying to do right by their employees, insurance carriers looking for better ways to actually drive health care value, and doctors and nurses who are feeling burnout because they see their organizations demanding them to do things misaligned with their mission to do the best they can by patients. Dr. Makary tells me in this interview that his intent with this book was to shine light on some of the issues, mainly around the price we—as patients, taxpayers, employers, basically all of us—pay. Dr. Makary says that understanding the situation is the first step toward navigating and redressing it. The Price We Pay gives multiple examples of egregious pricing. I’m going to split these examples into two categories: First, your basic price gouging, including surprise billing and what amounts to predatory pricing done at scale. The second category are high total prices because the services rendered were some shade of unnecessary. So high prices based on the price of the unit, and then high prices based on the number of units delivered. Dr. Makary and I talk about both challenges in this health care podcast. We also talk about the multiple instances where doctors and nurses and others are doing the right thing and really working hard to correct issues. Their efforts are glimmers of hope for all of us working hard to do right by patients. You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary. Martin “Marty” Makary, MD, is an American surgeon, New York Times best-selling author, and Johns Hopkins health policy expert. He has written for The Wall Street Journal, USA Today, Time, Newsweek, and CNN and appears on NBC and Fox News. He has written extensively on organizational culture, the science of measuring quality in medicine, and health care reform. Dr. Makary is the author of two best-selling books: Mama Maggie, a book about a Nobel Prize nominee, and Unaccountable, a book about health care transparency. He also just released a new book, The Price We Pay: What Broke American Health Care—and How to Fix It. This book offers a road map for everyday Americans and business leaders to get a better deal on their health care and profiles the disruptors who are innovating medical care. Dr. Makary is principal investigator of a Robert Wood Foundation grant to lower health care costs in the United States by creating physician-endorsed measures of appropriate medical care and directs the national “Improving Wisely” project to reduce waste in medicine. He speaks nationally on disruptive innovation in health care. Dr. Makary is a frequent medical commentator of NBC and Fox News, commenting on the health care cost crisis, the impact of new technology, and interpreting the latest medical research for everyday consumers. Dr. Makary is director of the Center for Opioid Research and Education and founder of solvethecrisis.org, a website that shares expert opioid prescribing recommendations for common medical procedures for clinicians and patients. At Johns Hopkins, he has served as the endowed chair of gastrointestinal surgery, director of surgical quality and safety, and founding director of the Johns Hopkins Center for Surgical Outcomes Research and Clinical Trials. Dr. Makary is a surgical oncologist specializing in minimally invasive surgery and teaches health policy and management at the Johns Hopkins University School of Medicine. He currently serves as the chief of the Johns Hopkins Center for Islet Transplantation and director of the appropriateness in medicine project. 02:11 Marty’s new book and its multiple examples of egregious pricing in health care. 02:41 The reason why hospital bills are often overinflated. 03:31 “Are Americans responsible for paying these marked-up, sticker-priced bills?” 04:58 Explaining the complexities of medicine, simplistically. 07:27 Balancing stories of price gouging with responsible billing. 07:59 “Hospitals were created in America as a safe haven for the sick and injured.” 09:29 How everyone can work toward changing this at the individual level. 11:23 “Have a conversation with your hospital.” 12:59 Marty’s advice to hospital administrators and board members. 16:56 “We can restore honesty in health care.” 17:01 How billing practices happen unbeknownst to hospital leaders. 17:35 Bad debt and mischaracterizing bad billing practices. 19:12 “Why don’t we call it ‘predatory billing’?” 22:12 “People are hungry for honesty in health care right now.” 22:55 A code of ethics pledge for hospitals on restoringmedicine.org. 23:25 “Large hospitals are on track for the largest profit margin in their history.” 24:50 Marty’s advice for how employers can help address these egregious prices. 25:47 “Billing quality is medical quality.” 27:03 Overtreatment as an element of overpricing in health care. 28:07 The “crisis of appropriateness.” 30:19 “How can we talk about the root drivers of poor health?” 31:18 The grassroots movement to start the health care system from scratch. 32:04 Relationship-based clinics. 37:08 Choosing wisely. 37:39 Improving wisely. 43:48 “People are willing to pay for quality, but they just want honesty.” You can learn more at martymd.com or connect with Dr. Makary on Twitter at @MartyMakary

There are 65,000 community pharmacies in the United States today, and the total cost to locate, staff, and operate these pharmacies is about 9% of our total national drug spending. That’s less than 1% of our national health expenditure—and falling. This is despite the fact that about 85% of our nation’s something like 6 billion prescription fills are unbranded generics, and unbranded generics are a staple of community pharmacy business. These stats are courtesy of Troy Trygstad, by the way. Bottom line, and pharmacy benefit managers pushing mail order may beg to differ, but many patients rely on walk-in pharmacies to get their meds filled timely (same day). They rely on the pharmacist for advice. They rely on the pharmacist to be an extension of the care team. This is even more stark in rural settings where there may be a pharmacist nearby but potentially not a doctor. It would kind of stink for a lot of patients if these pharmacies were pushed out of business by the elephants of the supply chain or, more accurately, on the demand chain. I’m referring to traditional PBMs (pharmacy benefit managers) and the pressures that they are increasingly putting on pharmacies, resulting in what’s beginning to amount to an existential threat for these community pharmacies. In this health care podcast I speak with Vinay Patel, who is the founder of Self Insured Pharmacy Networks. He’s also a pharmacist, and he’s also an expert in these matters. To clarify a couple things before we dive in, PBM stands for pharmacy benefit manager. There are three main pharmacy benefit managers that process the vast majority of prescriptions in this country today. These three traditional PBMs are ESI (Express Scripts), CVS Caremark, and OptumRx. Who hires and pays these PBMs? Employers, for one. And also some insurance carriers and sometimes the government, as in Medicare Part D. These PBMs, by the way … these three are vast, and they’re powerful. You can learn more at sipharmacynetwork.com. Vinay Patel, PharmD, is a pharmacist executive with a 12-year career focused on population health and community pharmacy operations. His background includes integrating pharmacy programs within multifaceted health care teams, engineering effective clinical operations to meet HEDIS program measures, and initiating a pharmacist-led hospital discharge medication reconciliation program.

Are patients consumers? Defining the terms patient and consumer will get us started here and also provide the insight and common understanding that we need to tackle this seemingly elusive question. Patient (adjective): able to accept or tolerate delays, problems, or suffering without becoming annoyed or anxious. Synonyms: forbearing, uncomplaining, tolerant, long-suffering, resigned, and stoical. Definition two (noun): a person receiving or registered to receive medical treatment. I’ll get to the number one adjective definition of patient soon enough—don’t you worry—but to start, let’s consider number two (noun) for about T minus 5 seconds. You’ll notice “a person receiving or registered to receive medical treatment” could mean pretty much any adult or child human with an appointment at any health care facility. Moving on. Consumer (noun): a person who purchases goods and services for personal use; a person or thing that eats or uses something. Similar to the term patient, a consumer could be anyone anywhere at any time who purchases anything or uses anything. The definition doesn’t separate informed consumers from ill-informed consumers and then postulate that ill-informed consumers are actually not consumers, and I can see why: This path would get dark really fast. If we’re looking at the literal answer here and I wanted to be obtuse, I could correctly say that the literal answer to the question, “Are patients consumers?” is yes. Consumers are people who use something, and they pay for something. Patients use health care and sometimes they pay for it, so literally patients are consumers as per Webster’s dictionary definitions. But let’s look at the not-literal answer. When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specializes in helping pharmaceutical, employer, pharmacy, and health system clients improve patient outcomes by creating and leveraging collaborations with other health care organizations. For more than 20 years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders and, most of all, the patient. 02:32 Why patients are not consumers. 02:41 A better way to define consumer. 03:15 When “patients are not consumers” is even more correct. 03:40 Where the definition of consumer starts to devolve or evolve. 04:17 The definition of consumer according to an article by The Hastings Center.05:01 The “consumer metaphor” and eroding physician professionalism. 05:26 The problematic points at demonizing the consumer patient. 06:36 EP205 with Maya Dusenbery.08:59 How “patient” may not be the best way to define our goals for the patient experience. 10:34 “It is tough to be a consumer when you don’t have the information that you need to be one.” 13:08 The paradox: Patients are not, and also are, consumers. 13:31 “The question itself is the answer.” 13:41 “Patients … are basically incapable of achieving health care consumer status in this country today.” 13:57 Things to consider for those who don’t think patients should try to be consumers. 15:21 “If you’re a patient … do the best you can to be a good health care consumer.” 15:59 Tips for being a good health care consumer. 16:30 Articles on how to be a good consumer online.17:00 “It pays to be suspicious.” 17:15 Get second, third, and fourth opinions from subspecialists.

“If operating on the wrong leg is called a ‘medical error,’ what do we call operating on someone who doesn’t need surgery?” That is a quote I have heard attributed to Jack Wennberg. It also crystalizes a theme I have been hearing a lot lately—the idea that quality metrics in this country today assess care from basically a patient safety standpoint but they don’t consider whether the patient actually needed the surgery or whatever in the first place. Or whether the outcome of the treatment matched an outcome the patient understood and had hoped for. I get into this in depth, by the way, with Dr. Suzanne Clough (EP235); and I’m going to get into it again in my upcoming interview with Dr. Marty Makary (EP242). In this health care podcast, I speak with Olivia Ross. Olivia has a reputation as a “rock star in the employer coalition world,” and I say this because it was a direct quote from an email I received after I mentioned that she was coming on the show. Olivia earned her rock star chops at the Pacific Business Group on Health (PBGH). Olivia is the associate director of the Employers Centers of Excellence Network, otherwise known as ECEN. What Olivia has worked on at ECEN is to put together a network of centers of excellence (COEs), meaning provider organizations that have committed to prospective bundled care payments for services like orthopedic surgeries, oncology, and bariatric surgery. Not only do these organizations … well, not only have they demonstrated excellence, but they also have demonstrated that they only treat patients who are appropriate to treat. Employers including Walmart, Lowes, and McKesson use this network. In my interview with her, Olivia discusses how the COEs are selected and exactly how employers intercept employees at the right waypoint along their patient journey, fly them or get them to travel to the COE, and then repatriate them back home with their local PCP (primary care provider) for follow-up care. I’m not sure if repatriate is the right word to use there, but I’m going to go with it. You can learn more at Pacific Business Group on Health.  Olivia Ross, MBA, MPH, is associate director of the Employers Centers of Excellence Network (ECEN) at the Pacific Business Group on Health (PBGH). Olivia oversees the ECEN program, a national, multi-employer initiative developed as part of PBGH’s commitment to value-based purchasing. 

I am working on a collaborative endeavor right now where the BAA (business associate agreement) signing has literally taken a year. The whole project will likely take 2 weeks. I know I’m likely not going to shock anyone listening, but the legal side of any sale or install or collaboration or proposed interoperability can be a serious impediment when every venture takes literally months or even years. That’s kind of the opposite of a fluid marketplace or fluid collaborative environment and one of the reasons why organizations can’t innovate, even incrementally, if that innovation involves any outside partners or alliances. This whole legal jumble can also be a big reason why organizations might stick with substandard vendors, even vendors who are clearly overcharging them in some cases—just because the hassle factor and expense of switching to a better option is real. So, what’s some practical advice to minimize the amount of time spent in BAA or contracting purgatory so that we can move forward with improving patient care and outcomes and being disciplined and efficient in the process in doing so? In this health care podcast, I speak with Bill Tanenbaum from Polsinelli. Bill is Polsinelli’s practice co-chair of health care technology and innovation. You can learn more by contacting Bill on LinkedIn and by visiting polsinelli.com. William A. Tanenbaum works closely with clients to provide actionable, industry-informed solutions for their business needs. Recognized as one of the Who’s Who Legal “Thought Leaders Global Elite,” Bill is also ranked in top tiers by Chambers: America’s Leading Lawyers for Business, Legal500, and Best Lawyers in technology, outsourcing, intellectual property (IP), and data law and as one of the Top 30 IT lawyers in the US (Who’s Who Legal). Chambers says Bill “brings extremely high integrity, a deep intellect, fearlessness and a practical, real-world mindset to every problem.”

We have gotten ourselves into this pickle: Americans—all of us as taxpayers, as patients, as employees, as employers—spend exorbitantly for highly variable results. Great work, great health care in some areas by some great physicians and their teams, and then voluminous other areas rife with overtreatment, errors, abysmal chronic care management, predatory pricing by entities owned by private equity or with billing departments gone wild. Who will be our knight in shining armor when it comes to fixing health care in the United States today? Will it be legislators? Will it be our current crop of large health care stakeholders? Will it be a self-proclaimed disrupter like Amazon or Haven Healthcare, that Amazon, Chase, and Berkshire Hathaway collaboration? In this health care podcast I speak with Brian Klepper, PhD. Brian has opinions on these questions. Spoiler alert: Some of the entities that Brian points to as intrinsic to the mission of fixing American health care are brokers who are not compensated in secret by insurance carriers. He also calls out primary care physicians and new primary care models as crucial. If you’re looking for brokers of this kind, go to healthrosetta.org for a list of them. You could also listen to my podcast with David Contorno (EP186). On the primary care side of the equation, listen to my chat with Jed Constantz (EP209) and also the one with Alex Lickerman (EP184). In case you haven’t heard of him, Brian is a health care analyst, commentator, and also an entrepreneur. He’s executive vice president at the Validation Institute, executive analyst and editor at the Health Value Institute, and principal of Healthcare Performance, Inc, a health care strategy and business development practice. He’s also principal of Worksite Health Advisors, a benefits consultancy. Formerly, Brian served as the CEO of the National Business Coalition on Health. You can learn more at careandcost.com, by emailing bklepper@gmail.com, and by visiting validationinstitute.com. 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.

Bad things have a propensity to occur in health care when patients are placed on a trajectory and then simply follow the yellow brick road—to an Oz potentially filled with unnecessary surgeries, MRIs that cost 10 times what they should, low-quality providers chasing RVUs (relative value units) like their paychecks depended on it … I could go on. Today I speak with Derek Winn, cofounder at Distilled Concepts and consultant at the Business Benefits Group. His distilled advice is to recognize that every transaction with the health care system is a waypoint on a larger journey—and also an opportunity to pause and ask questions. Payers of health care have a profound opportunity and perhaps growing obligation to help employees/members/patients, first of all, to recognize that a “look both ways before you cross the street” modus operandi is safer from both a monetary as well as an actual patient safety standpoint. Derek and I discuss the ways to make this happen, when/if it will become standard operating procedure, and the likely impact on providers and insurance carriers and Pharma if employers choose to take this route. By the way, BUCA stands for Blue Cross, United, Cigna, Aetna, and Anthem. We use this acronym in the interview. You can learn more by contacting Derek on LinkedIn atDerekWinn or by visiting distilled-concepts.com. Derek Winn is a lead consultant at the Business Benefits Group, where he has consulted clients regarding employer-sponsored benefit programs for nearly the past decade.

In this podcast, Liliana Petrova, CEO/Founder at The Petrova Experience, translates her experience as director of customer experience at JetBlue to the health care industry. Her advice is practical and designed to actually work in environments as complex and regulated and driven by safety concerns as the airline industry—and also, coincidentally, health care. In the past in health care, some have perhaps underestimated the impact of customer experience. But it’s hard to continue to do so in the face of Forrester research showing customer experience drives revenue growth by double digits compared to laggards in markets where there’s competition. Actually, this growth difference is true even in some markets where there’s not much competition. Why? Because when the customer experience is really bad, customers might choose to abandon the service/care altogether and just not return at all, anywhere. And Gartner touting facts such as 89% of companies these days are competing on a customer experience battleground. But back to today’s conversation. Somewhere in the middle of our chat, Liliana says, “When building to simplicity, it has to be perfect.” I loved it! This is a really simple, if you will, maxim with a lot packed into it that we spend some time unraveling. One spoiler: Good customer experience makes it easy for customers, makes it simple for customers. And second, perfect means perfect from the patient’s or customer’s point of view, not ours. One of the parts of the conversation I loved was Liliana’s dissection of just the physical space of a typical waiting room from a customer standpoint. I never thought about it before, but that desk that the front office staff usually is sequestered behind? That tall desk with the glass window? It resembles a payday loan place in a bad neighborhood. What’s the subliminal message there? Liliana wrote a few articles about lobby design, among other topics, by the way; and the links are in the show notes. I met Liliana at the Pharma CX conference hosted by PanAgora. Learn more at thepetrovaexperience.com. Liliana Petrova, CCXP, is a proven leader in the field of customer experience (CX) and innovation. She pioneered a new customer-centric culture, energizing the more than 15,000 JetBlue employees with her vision. She has been recognized for her JFK Lobby redesign and facial recognition program with awards from Future Travel Experience and Popular Science.

Here’s a vital question, “How do you make sure that the physicians your employees or members are seeing are high quality in a given area of focus?” Getting to the right doctor matters when you consider that something like 70% of back surgeries are unnecessary and medical errors are the third leading cause of death in this country. And also because, as Suzanne DelBanco put it in EP224, if a payer simply cuts out the bottom performing 10% of practices, the returns are outsized from a cost and quality perspective. The challenge is how to actually accomplish this. How to measure quality in a sea of dirty data and noise and whatever the opposite of interoperability and aggregated data sets is. With the confounding factor also that outcomes are rarely if ever included in data sets, especially when you consider that the outcomes that matter to patients are really the outcomes that count. Today I speak with Suzanne Clough, MD. In a former life, Suzanne was a co-founder of Welldoc, the first FDA-approved digital health platform and also featured on EP102 of this podcast. Now, Suzanne is the chief-medical officer over at ArmadaHealth, a company that aims to become a GPS for health care helping to get patients to the right doctor quicker. You can learn more at www.armadahealth.com Dr. Suzanne Sysko Clough, MD, is Chief Medical Officer of ArmadaHealth, a health and data science company that navigates consumers to quality health care providers using big data, AI, and proprietary quality algorithms that together produce 360-degree profiles of physicians. The platform enables precision matching of physicians with patients based on diagnosis/condition and nonclinical attributes. Before ArmadaHealth, Suzanne was a co-Founder and Chief Medical Officer of WellDoc, the first FDA-approved digital health platform. Dr. Clough completed her medical training in internal medicine and a fellowship in endocrinology at the University of Maryland Medical Systems and served as an assistant professor in the Division of Endocrinology as well as Medical Director and as the Founder and Medical Director of the Center for Weight Management and Wellness.

Today I speak with Claire Sporton. Claire is SVP of customer experience innovation over at Confirmit. Since we did this interview, the 2019 Edelman Trust Barometer came out. And it showed that trust in US hospitals has nose-dived 8 points. Pharma and biotech held steady since last year, or slight increases, but the bar is pretty low. Same with insurance. In this conversation, Claire and I discuss why this matters—why it matters to hospitals, to Pharma, to insurance carriers, and anyone else who is desirous of customers who come in once … and then they also return. And how do you get customers to come back? It’s by having an amazing customer experience that meets customer expectations, exceeds customer expectations, and at the same time creates a measure of trust. And trust breeds loyal customers. Here’s one maxim from Seth Godin that I particularly like. He said, “We all know someone who is transactional, and it makes us feel icky. What we strive for is to feel relational and to feel that we have a relationship with someone. We all know when we’re being manipulated.” The point is this: If we don’t have trust, we won’t have the right relationships within the health care industry involved in getting the right outcomes for patients. Entities won’t be able to work together (for example, Pharma and health systems, or insurance carriers and health systems, or health systems and patients … or any combination of the aforementioned). I saw a stat the other day that said if there’s an increase of customer retention of 5%, then business returns go up 25%. That wasn’t a health care reference, per se, so there was no contemplation of patient outcomes and how much they may improve as a result of trusted health care relationships and the interoperability that results from them and care coordination … all of the above. I think even at the transactional level there’s room for improvement. And I see this as an opportunity to differentiate. “Who will be the next—or the—JetBlue of the health care industry?” is my question. JetBlue did very well in relation to its competitors in the airline industry, and they did so by creating amazing customer experiences, which trust was derived from. For more information on the customer experience and the trust fronts, the following Relentless Health Value episodes might be of interest: INBW23, EP228, EP232, EP148, and EP188.  Claire Sporton is senior vice president of customer experience (CX) innovation at Confirmit. Claire has a passion for building truly customer-centric cultures that inspire change and deliver measurable business improvement. In her role, she focuses on driving forward the discipline of CX management and ensuring that Confirmit provides the technology and expertise that organizations need to empower and inspire everyone across the organization to do the right thing. Claire was a winner of the 2018 CX Impact Award, a prestigious award issued on CX Day by the Customer Experience Professionals Association. With a background in psychology and systemic management, Claire has over 20 years’ experience as a consultant and CX practitioner, leading companies to empower everyone to be accountable for improvement, motivate individuals to work differently, and predict and monitor real business impact.