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Relentless Health Value™


American Healthcare Entrepreneurs and Execs you might want to know. Talking. Relentless Health Value is a weekly interview podcast hosted by Stacey Richter, a healthcare entrepreneur celebrating fifteen years in the business side of healthcare. This show is for leaders in pharma, devices, payers, providers, patient advocacy and healthcare business. It's for health industry innovators, entrepreneurs or wantrepreneurs or intrapreneurs. Relentless Healthcare Value is the show for you if you want to connect with others trying to manage the triple play: to provide healthcare value while being personally and professionally fulfilled.


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American Healthcare Entrepreneurs and Execs you might want to know. Talking. Relentless Health Value is a weekly interview podcast hosted by Stacey Richter, a healthcare entrepreneur celebrating fifteen years in the business side of healthcare. This show is for leaders in pharma, devices, payers, providers, patient advocacy and healthcare business. It's for health industry innovators, entrepreneurs or wantrepreneurs or intrapreneurs. Relentless Healthcare Value is the show for you if you want to connect with others trying to manage the triple play: to provide healthcare value while being personally and professionally fulfilled.




EP419: The Financialization of Health Benefits for Boards of Directors and C-Suites of Self-Insured Employers, With Andreas Mang

For a full transcript of this episode, click here. Are you on the board of directors of a company? Or are you a shareholder of a publicly traded company? Or are you a CEO or a CFO who reports to a board of directors or these shareholders? Well, this show is for you. And it’s about how the healthcare industry has become financialized at the same time that providing health benefits has become the second-biggest line item after payroll for most companies. We talked about that with Mark Cuban (EP418) also. So, this show isn’t really about health benefits; it’s about the business that these health benefits have become and how, if the CEO or CFO of an employer is not intimately involved in the financial layer wrapping around health benefits, then the company is getting really taken advantage of by those entities who are intimately familiar with the financial layer surrounding those healthcare benefits. And the employees of that company also are getting equally taken advantage of. This is not a case where paying more or less results in better or worse employee health or healthcare. It is a case where not minding the shop in the C-suite means that financial actors just take more of the pie and nobody wins but them. Employer loses; employee loses. Andreas Mang, my guest today, kicks off this interview talking about the conversation that will go down between himself and any CEO whose company gets bought by Blackstone. So, if you’re a CEO and you’re aspiring for this to happen, yeah … heads up. But he says it’s kind of an unnatural act to dig into anything that smells like health benefits or health insurance. Some may not even realize that this whole financial layer has developed that sits above the healthcare benefits themselves. And they also may not think that there’s anything that’s possible that can be done. As far as both of these points are concerned, Andreas Mang gives a list of, as he calls them, easy things a C-suite can do to save 10% while improving employee satisfaction and health. Saving 10% or more, this can be a really big number. A lot of this is just enforcing purchasing discipline that is being used elsewhere. Here’s Andreas’s list recapped: 1. Have CFO engagement throughout the year. (We talked about that with Mark Cuban also.) 2. Be self-insured once you have reached a certain size. (Andreas gets into this in more detail during the show itself.) 3. Be very, very careful who you hire as your broker or benefits consultant. There are five things that need to be true: · They have the experience to do the job. · Flat-fee model compensation · No product pushing · Fees at risk (30% or more) · Simple termination provisions 4. Do carrier/ASO/TPA RFPs once every three years or thereabouts. 5. Do dependent eligibility audits. (Cora Opsahl talked a lot about this also in an episode [EP372] last summer.) 6. Leverage pharmacy coalitions and stop-loss collectives. (In the show itself, Andreas offers some warnings because some of these coalitions and collectives are great and some are not.) But bottom line, just keep in mind, as Mark Cuban said two weeks ago (EP418), those that are taking your money, your company’s money, are advantaged when you are confused. Where there’s mystery, there’s margin. If you can’t convince ’em, confuse ’em and all that. This is a business strategy. Healthcare should not be this complicated. But yet, it has become so; and anyone who doesn’t realize that is letting themselves and their employees really get taken advantage of. Unknown unknowns are not benign. As I have said several times already, Andreas Mang is my guest today. He is a partner at Blackstone, the private equity and alternative asset manager. His job is helping portfolio companies manage their US healthcare benefits for their employees. You can learn more at Blackstone and by connecting with Andreas on LinkedIn. Andreas Mang is senior managing director, portfolio operations, and chief executive officer of...


Encore! EP381: For Reals, Becoming Customer-centric, Transforming, or Innovating at a Very Large Organization, With Karen Root

Why did I decide to encore this show about being customer-centric and transforming or innovating at a very large organization? Well, two main reasons. First reason can be neatly summed up by this recent Tweet from Rik Renard, which I have edited slightly to suit my own purposes. Here’s the Tweet: “The Achilles’ heel for most healthcare [innovators] is overlooking the role of change management. The deal isn’t sealed until the whole team is raving. Adoption doesn’t [automatically follow innovative thoughts no matter how good they are or how much it cost to build or buy anything]. Take change mgmt seriously.” This is relevant to pharma companies, to big provider organizations, to SaaS vendors, to payers … pretty much anyone. So, yeah. This show … still relevant. But also there’s a #2 reason for this encore. It’s coming at ya smack in the middle of an ongoing series for boards of directors, CEOs, and CFOs of self-insured employers. As discussed last week in the show with Mark Cuban and Ferrin Williams, PharmD, MBA (EP418), healthcare has become financialized. There is a whole financial layer sitting in between health benefits and the employer, and dealing with that requires customer centricity, transformation, and innovation at the employer level—a little change management, if you will. And with that, here is your encore. I was at the PanAgora Pharma Customer Experience (CX) Summit. Let me tell you one of my big takeaways. Many at pharma companies who are trying to convince their organizations of the need to be provider- and/or patient-centric are having a tough go of it. Heard that coming from every direction. Seems there are quite a few pharma organizations out there who are not actually customer/patient-centric. Say it isn’t so. Turns out, they continue to be pretty darn brand-centric whether or not anyone besides the CX team and the most successful KAMs (key account managers) realize this hard truth. This matters because, from a provider organization, physician, or patient standpoint, it’s not what’s written on the walls … it’s what goes on in the halls. It’s what a company actually does in their interactions with the rest of the healthcare ecosystem that matters and that builds their reputation. You see this lack of customer centricity and, et cetera et cetera, there are certainly other things going on here; but you see the lack of customer centricity manifesting, right? You see the pharma reps that get kicked out of hospital systems because the perception is they add little if any value and “waste doctors’ time; all they do is shove detail aids in our faces.” Heard that recently. Look, this doesn’t just pertain to Pharma; this is a message for the whole industry. But there is certainly a way to do well by doing good, and how that starts is helping provider organizations and patients improve patient outcomes as the primary goal. Being innovative to that end. It’s about supporting the best-practice standard of care and bringing resources to bear that are truly helpful. That is how more of the right patients can get the right treatment/drug at the right time or take their meds as per the A1A clinical guideline. It’s probably also the way to sustainable business success. I’ve said it here a thousand times: People trying to do the right thing by patients all need to work together. If there’s a party in the mix that nobody else wants to deal with because they are deemed not a team player or they don’t listen … yeah, that’s what I call a competitive disadvantage, beyond just squandering their ability to achieve their mission statement and improve patient care and lives, that is. Today’s conversation is with Karen Root, who was a speaker at the aforementioned PanAgora conference. In this healthcare podcast, we are talking about how to make transformation and innovation actionable at a large organization—maybe a pharma company but pretty much any large organization with lots of people, lots of human beings with different...


EP418: Mark Cuban With Some Advice for CEOs and CFOs of Self-insured Employers, With Mark Cuban and Ferrin Williams, PharmD, MBA, From Scripta

CEOs and CFOs … hey, this show is for you. Let’s start here: What do all of these numbers have in common: $140,000, $3 million, $35 million, and $3 billion? These are all actual examples of how much employers, unions, and some public entities saved on healthcare benefits for themselves and their employees. The roadmap to saving 25% on pharmacy spend and/or 15% on total cost of care in ways that improve employee health and satisfaction always begins when one thing happens. There’s one vital first step. That first step is CEOs and/or CFOs or their equivalents roll up their sleeves and get involved in healthcare benefits. Why can’t much happen without you, CEOs and CFOs? Here’s the IRL: In 2023, the healthcare industry has been financialized. There is a whole financial layer in between your company and its healthcare benefits. And unless the C-suite is involved here and bringing their financial acumen and organizational willpower to the equation, your company and your employees are currently paying hundreds of thousands, maybe millions, of dollars too much and doing so within a business model that deeply exacerbates inequities. There are people out there who are very strategically taking wild advantage of a situation where CEOs/CFOs fear anything to do with healthcare in the title and don’t do their normal level of due diligence. You think it’s an accident that this whole space got so “complicated”? HR needs your help. Bottom line, if you are a CEO or CFO and you do not know everything that Mark Cuban and Ferrin Williams talk about on the pod today … wow, are you getting shellacked. Mark Cuban uses a different word. Healthcare benefits are, after all, for most companies the second biggest line-item expense after payroll. But don’t despair here, because all of this information is really and truly actionable. Others out there are cutting zeros off of their spend and actually doing it in ways that are a total win for employees as well. My guest today, Mark Cuban, is a CEO, after all; and when he looked into it, it took him T-minus ten minutes to figure out just the order of magnitude that his “trusted” benefits consultants and PBM (pharmacy benefit manager) and ASOs (administrative services only) and others were extracting from his business. He pushed back. So can you. But just another reason to dig into that financial layer wrapping around your employee health benefits right now, you might get sued by your employees. Below is an ad currently being sent around on LinkedIn by class action attorneys recruiting employee plan members to sue their employers for ERISA (Employee Retirement Income Security Act of 1974) violations. It’s the same attorneys, by the way, from those 401(k) class action lawsuits. I’ve talked to a few CEOs and CFOs who are scrambling to get ahead of that. You might want to consider doing so as well. Now, for my HR professional listeners, considering that some of what Mark Cuban says in the pod that follows is indeed a little spicy, let me just recognize that the struggle is real. There are multiple competing priorities out there in the real world, for sure. And bottom line, because of those multiple competing priorities out there in the real world, it’s really vital that everybody work together up and down the organization in alignment. Lauren Vela talks a lot about these realities here in episode 406. This is a longer show than normal, but it’s also like a show and a half. Mark Cuban talks not only about his work with Mark Cuban Cost Plus Drugs, which is a company that buys drugs direct from manufacturers and sells them for cost plus 15%, a dispensing fee, and shipping. It’s kind of crazy how so often that price is cheaper, sometimes considerably cheaper, than the price that plan members would have paid using their insurance—and the price that the plan is currently paying the PBM. Most Relentless Health Value Tribe members (ie, regular listeners of this show) will already know all that, but...


Encore! EP385: Morgan Health and the 5 Things Self-insured Employers Should Do Right Now, With Dan Mendelson

There are two big reasons why I decided to encore this show with Dan Mendelson from Morgan Health at this exact moment in time. 1. It’s a great show (one of our most popular shows in the last year, actually) with lots of keen insights for self-insured employers—and by self-insured employers, I mean HR folks, of course, but also CEOs and CFOs. That was foreshadowing for my second reason. 2. It’s gonna be an employer CEO/CFO triple play here on Relentless Health Value. Next week on the pod, my guest is Mark Cuban, along with Ferrin Williams from Scripta. And Mark Cuban, spoiler alert, has his own message for CEOs and CFOs of self-insured employers. Then the week after that, we hear from Andreas Mang from Blackstone who shares, among other things, what happens when some company gets bought by Blackstone and that CEO shows up for a meeting with Andreas and that CEO happens to know nothing about their vast, inefficient, and wildly wasteful healthcare spend. And with that, here is your encore. For a physician practice to transform itself from an FFS (fee-for-service) machine cranking out volume but not necessarily health or care, the office has to have a high enough percentage of their patients in value-based arrangements to make it actually feasible to transform. It is only when they hit a tipping point of enough patients in risk-based contracts that they can afford to be accountable for their results. At that point, yeah, everybody wins—doctors, patients, actually the entire community wins because when a local practice transforms, all of their patients tend to benefit at some level from the new processes and procedures and standardizations and pop health systems that get put in place. So, let’s move forward with this with all haste, shall we? Why aren’t we? What’s the problem here? Well, there are lots of problems, don’t get me wrong. But a big one is self-insured employers on the whole are not offering any sort of accountable care arrangements to the providers in their community. This is 150 million patient lives we’re talking about here—a huge chunk of many providers’ patient panels. Self-insured employers have a really big opportunity to level up the care in their whole community due to the spillover effect when a provider practice transforms itself because it has enough patients to do so. But these employers are stuck. They are paralyzed. They are doing the same thing this year that they’ve done last year, and therefore their whole community is equally stuck in a smorgasbord of suboptimal FFS goings-on. So, offering accountable care contracts is one thing (a very big consequential thing) that is also one of the five things self-insured employers can do to improve employee health that I talk about in this healthcare podcast with Dan Mendelson. Dan Mendelson, my guest today, also wrote a Forbes article listing out these five things. Here are all five things that Dan mentions in one handy list: 1. Expand availability of accountable care models to improve the care experience, quality, and affordability at a local level. For a deep dive on this, listen to the show with Dave Chase (EP374). 2. Invest in the data access needed to assess health outcomes. For a deep dive on this, listen to the show with Cora Opsahl (EP372). 3. Align employees’ health benefits with pop health outcomes. For a deep dive on this, listen to the show with Mark Fendrick, MD (Encore! EP308). 4. Prioritize care models that can meet employees wherever they are. For a deep dive on the DEI (diversity, equity, and inclusion) aspect of this, listen to the show with Monica Lypson, MD, MHPE (EP322). 5. Make care navigation a central part of the benefits package and experience. My guest today, Dan Mendelson, is CEO of Morgan Health at JPMorgan Chase. He previously founded Avalere Health. Before that, Dan served as associate director for health at the Office of Management and Budget. Besides exploring the why and the what for each of the five things...


EP417: 5 Kinds of Payer and Provider Collaborations and 5 Must-Haves for Said Collaborations to Work, With Josh Berlin, JD

Yeah, it’s a fact that the vast majority of past and present provider and payer relationships are not exactly collaborative. They may better be described as fairly adversarial, actually—especially when viewed through the lens of provider organizations trying really hard to find a payment model that will enable them to do better by their patients and deliver better outcomes. We’ve had Justina Lehman (EP414), Ali Ucar (EP362), Dan O’Neill (EP359) talking about this from the provider organization standpoint. We also had Dan Serrano (EP410) and Will Shrank, MD (EP413) corroborating here. But after each of these earlier episodes, many comments and conversations ensued about said potential (or not) payer/provider collaborations. And there was a theme of many of these online exchanges. The theme was wondering if we’d all get laughed at for even talking about these rare and elusive Shangri-la scenarios. Like expending words and energy thinking about payers and providers working together was as crazy as being seen earnestly discussing, I don’t know, whether mermaids know about pants or something. And that’s why I wanted to get Josh Berlin on the podcast today: to talk about the why, the what, and the how of collaboration. I wanted to know if there really is a solid why here for the why collaborate, especially from a payer point of view. And when I say payer, I mean a payer kind of payer like a Blue Cross, United, Cigna, Aetna plan kind of payer. And I’m calling that out because payers are intermediaries in all cases except for their fully insured members. Except for that one book of business, entities actually taking the risk are taxpayers or self-insured employers. So, saving money on its face is not a super compelling value proposition. Listen to the show with David Contorno (EP339) for the why there. As we talk about in the interview that follows, though, what might be compelling is predictable spend, possibly—or even more compelling could be a competitive differentiation for that payer that leads to higher market share. Payer/provider collaborations can also lead to a more resilient market foothold that can stand up to threats from upstart competitors or big tech and big retail swooping in looking for a tasty slice of this $3 trillion industry. There’s also the potential for a higher profit margin. And, oh, one additional reason to collaborate if you’re a payer that we don’t get into super heavily but I’d be remiss to not mention is the whole Star Ratings thing for Medicare Advantage plans, because stars equal big money. But a payer is not gonna get that Star Rating shekel if providers aren’t delivering high enough quality care. Also, of course, we have HEDIS (Healthcare Effectiveness Data and Information Set) and other quality measures that have financial value ascribed to them. In the conversation that follows, Josh talks about different types of collaborations. Collaboration is a really very vague term, so what exactly is this collaboration, what does it entail, and how do you do it? Josh told me that there are five kinds of collaboration, and here they are in order of their depth of entanglement, I guess you could call it. 1. Sharing data back and forth 2. Use that data to identify areas of need and then do something programmatic together, like create clinical pathways or work on one very specific type of quality program. 3. A joint venture (JV)—you JV and work together on some sort of narrow network kind of product 4. Become capital partners in some way. 5. Having a risk-bearing kind of relationship—the provider gets a piece of the premium dollar So, that’s the five types of collaboration. But here’s the things you’ve got to tick through, that you have to really go through and make sure you’ve got all these things before you start. Otherwise, it’ll be a monumental waste of time. 1. Complementary capabilities that enable scalability 2. A desire for sustainability in a market, and both have common goals and...


EP416: Why Should Med Schools Teach the Business of Medicine? With Adam Brown, MD, MBA

Now, I’m being pretty careful here because med schools are super sensitive about their curriculums. And I am sensitive to the fact there’s much to teach in four years. So, throwing no shade here, what do I know from the Krebs cycle? Choices of what to teach are tough. With that disclaimer, in this healthcare podcast I am speaking with Adam Brown MD, MBA, about an article he wrote entitled “Dear Medical Schools, Educate Students on the Business of Medicine—Without it, you are doing your students a disservice.” Let me give you Dr. Brown’s list for the “why teach the business of medicine.” He says: 1. The role of physicians in medicine has changed, and we dig into this in the episode. 2. There’s an expectation mismatch. Docs are investing 10 years and, on average, $200K to $300K in real dollars to get that MD or DO. You don’t want those new physicians quitting on the quick because the reality is so different from what they thought it would be. Not being up front about the business of medicine is like hiding the reality of the situation instead of preparing them. 3. If you don’t understand the business of medicine, you do not know how to advocate for yourself or the profession or even patients in a way that is compelling to the current set of decision-makers. As maybe a corroboration here, may I just report that I probably have gotten (conservatively) 100, 150 emails and LinkedIn notes from physicians who say basically some version of the same thing: Thanks so much for Relentless Health Value. I wish I would have learned even the basics of what you cover in med school. If I had, I would have been able to help myself and help myself help patients far better. 4. Docs are the ones with the prescription pads. Docs are just functionally the gang who are driving costs that patients and employers and taxpayers ultimately incur. Not knowing the how much or just the whole story here can inadvertently contribute to clinical morbidity, because patients who fear they cannot afford care do not follow doctors’ orders. We should get real about that. Or if they do follow doctors’ orders and go into debt … I mean, there’s just study after study in oncology and otherwise that shows patients who cannot afford their care have worse outcomes. We cannot hide from this any longer. 5. The last reason is that there’s lots of things that docs can do besides just be at the bedside. Not giving insight into these alternative paths seems unfortunate for any doc who maybe wants to mix it up some because they’re feeling burned out or in a different season of their life looking for something more aligned with where they are as a person. So, now let’s think about this whole question from the standpoint of the system itself—from the standpoint of doing better by patients. Why is it important to teach docs the business of medicine? Let’s start here. When physicians do not understand the business of medicine, it’s harder for docs to get into boardrooms and have their voices heard. Not teaching the business of medicine in med school might be one reason why there is such a shockingly small percentage of doctors on the boards of directors at major nonprofit hospitals (listen to the show with Suhas Gondi, MD, MBA [EP404]) and why there’s so little “dyad leadership” in the ranks of both clinical and payer organizations, etc. And even fewer nurses are in organizational decision-making roles, by the way, despite nurses actually being the most trusted profession—even more trusted than doctors by 14 percentage points, according to Gallup. One way to interpret this lack of docs and other clinicians in the boardroom is simple cause and effect. Doctors are losing control and ownership—and I mean this in literal terms—of the organizations that run the business of medicine, which controls the medicine of medicine. Chad Erickson wrote a comment about this on LinkedIn that I thought was great. He wrote, “Opportunities for physicians to really control or even impact the...


EP415: Some Jumbo Employers Buying Better Healthcare Outcomes While Saving 15% on Total Cost of Care, With Rob Andrews

I just want to stop here and have a gratitude moment. I wanted to thank the Pittsburgh Business Group on Health for inviting me to do the keynote at their annual symposium. It was a big honor. But in doing so, I had the opportunity to play clips from both the podcast and also from people who helped out and gave me a custom clip special for the occasion. So, thanks to Matt Ohrt; Jodilyn Owen; Justina Lehman (who provided a clinical pathway example); Andreas Mang; Larry Bauer; Rob Andrews (my guest in this episode); Nicole Bradberry; Amy Scanlan, MD; Rebecca Etz, PhD; David Muhlestein, PhD, JD; Lisa Trumble; and Doug Eby, MD, MPH, CPE. If you’d like a copy of that presentation, which is all about care gaps and the impact of care gaps especially as it might relate to self-insured employers, click here to request it. I also again want to thank Havarti Risk Services and Keith Passwater for a super nice donation to support the show, as well as Employees First. Please support these organizations who have supported us and help us keep the lights on over here. I am so looking forward to the show today. It is with Rob Andrews, who is the CEO of the Health Transformation Alliance (HTA), which is a group made up of jumbo employers. I had wanted to get Rob on the show ever since I heard him say at the thINc360 conference in DC earlier this summer, “Morally abhorrent doesn’t move the needle. What moves the needle is financial implications.” This interview was my chance to ask Rob Andrews, what are these financial implications of which you speak that move needles? Financial implications to whom? What kinds of financial implications are we talking about? And when that needle moves, what happens? In the show that follows, Rob says that when you improve the health of employees and dependents and actually just the health of the community, you as an employer improve your financials directly and also indirectly, which Rob talks about relative to maternal health outcomes as his exemplar because, as a case study, it’s undeniably superb. It’s really interesting how employers in a geography wind up footing indirectly a rather shockingly large bill for babies and uninsured or underinsured moms or moms on Medicaid avoidably going to the ICU and the NICU, which the hospitals tally up as hundreds of thousands of dollars in billed charges. The term million-dollar baby is a term, after all. Listen to the episode that follows for more on these indirect costs and how they happen, but let me focus on the direct bucks out of pocket right now because … yeah, study after study shows that, for self-insured employers, if you pay for the right things and you steer to the right providers in the right care settings known to actually improve health, a self-insured employer and the member do a whole lot better than if the employer kind of laissez-faire pays for any manner of things provided by anybody who can manage to submit a billing code—even if that billing code comes with a too-good-to-be-true discount. Rob talks about how the HTA has data to suggest that if you, as a self-insured employer, lean in on paying for the right things, readmissions go down 29%. Total cost of care is 15% lower. Drugs cost 25% less. So, none of this is theoretical, as we talk about how employers can create a win-win—better health, lower costs. There are jumbo employers in the HTA right now who are doing this. I love how Will Shrank, MD, has put it; and I’m paraphrasing, but it’s a point that keeps getting reiterated in episode after episode here on Relentless Health Value: There’s a difference between paying for what you want and just negotiating allegedly cheaper prices. Buying things is not a strategy. And that is true no matter what price you think you’re paying. Also not a strategy is buying things and then cost shifting to plan members, by the way. I love how Josh Butler uses a grocery analogy to describe but one possible flashpoint. Strategy, on the other hand, means...


EP414: An IRL How-To for Delivering Better Care and Getting Paid for It—A Value-Based Case Study, With Justina Lehman

Here’s why I think this interview with Justina Lehman is different. We get into the actual whys and how-tos of trying to be specialists, like an OB/GYN or an orthopedic practice that offers coordinated care … AND gets paid to do so. There’s so many conversations that transpire at the 50,000-foot level. This one is far closer to the ground. And if you want an even deeper dive on this topic, go back and listen to the episode with Steve Schutzer, MD (EP294). There are so many who put financial growth and doing “value-based” coordinating care kinds of things at a counterpoint. Like, “Oh, boy … we need to make some money this quarter, so let’s put all the VBC [value-based care] stuff on the back burner.” The point that Justina Lehman makes, both implicitly and also explicitly, is that doing the right things for patients, things we know are going to improve patient outcomes … doing these right things can also be a growth strategy. And I don’t just mean offering access and convenience. I mean also doing things that defragment care and coordinating it—things that will truly drive better chronic disease outcomes. This is what we talk about exactly and specifically in this healthcare podcast: How do practices work alone or band together into a kind of “value alliance,” I’ll call it, to both improve patient care AND make money? Alright, so here’s the absolute simplest possible business upside that taking really good care of patients can achieve: higher patient volumes at the practice. Patients, who I guess could be called consumers in this example, want to go to such a practice. The practice is differentiated. Your marketing has to be good for that to happen, but yeah … turns out patients really like nonfragmented care with a physician, a nurse navigator, and the rest of their clinical team who patients know, like, and trust. Also, turns out clinicians, ones who are purpose driven, like to work at places where they can be part of a team providing great care. So, you wind up with growth—you got your demand from patients who want to come to your practice; you got supply of clinicians who want to work there. Who would have thought? So, as long as practice leadership is also purpose driven, this can all be very opportunistic. But there’s also some risk exposure for those who don’t consider models like this. Will Shrank, MD, said on the pod last week (EP413) that any specialists who aren’t figuring out how to work with capitated primary care docs are gonna have some referral problems coming up here. And how do you work with capitated, advanced primary care docs? You demonstrate you have better patient outcomes. You cannot do that unless you do all the things that Justina Lehman talks about in this healthcare podcast. So, there’s risk in not doing some of this stuff. I’m gonna summarize the process that Justina uses to level up care and also get paid for it. 1. Assemble a committee of purpose-driven, committed physicians who want to improve care. Committee should self-select. No one should be there who doesn’t want to be there. 2. Define the situation analysis. What is care as usual? And then, what’s ideal care? And then, determine what the delta is between where we are now and where we want to go. 3. Design ideal care and the plan for how you’re gonna get from where you are now to where you want to be. What does ideal care look like? I actually gave the keynote at the PBGH (Pittsburgh Business Group on Health) symposium a few weeks ago, and I showed a slide that Justina Lehman had put together showing the ideal care pathway for a patient with gestational diabetes. If you weren’t there, here’s the aha: Ideal care includes multiple physicians. It includes working with payers and PBMs (pharmacy benefit managers) and how you’re gonna do that. There’s also gonna be a nurse navigator involved. It includes standardizing certain care flows and choices and making sure that patients have the right information so that they can get to the...


EP413: The Intersection of Healthcare Waste, Value-Based Care, and the Potential Rising Power of PCPs, With Will Shrank, MD

My conversation today is with Will Shrank, MD. Dr. Shrank led the evaluation group at CMMI (Center for Medicare and Medicaid Innovation). He has spent time in the private sector, first at CVS Health and UPMC (University of Pittsburgh Medical Center) as chief medical officer of the health plan in Pittsburgh, and then as the chief medical officer for Humana. Now he is a venture partner at Andreessen Horowitz and doing some consulting for CMMI. We start out this conversation talking about waste in healthcare. In fact, Dr. Shrank was on a team who did a study about waste in the US healthcare system. (The article is, unfortunately, firewalled.) In that study, it says estimates suggest we have upwards of a trillion dollars of waste a year. There’s two main groupings of said waste, turns out. The first is in administrative failures. There’s three subcategories here: fraud, waste, and abuse; administrative complexity; and pricing failures. Then there’s the clinical failures side of the waste house. There’s three subcategories here as well, and they are failures in care coordination, failure in care delivery, and then low-value care. Dr. Shrank digs in a bit on each of these in the interview that follows, but I have to say, I go in fast for the now what. Great that we know where the waste is coming from, because gotta know the problems to solve for them. But really, what’s the best way to solve for this waste? You know me by now, so I, of course, point out immediately that someone’s waste is someone else’s profit. So, that’s a wrinkle. And it’s a really rough wrinkle, because now you have groups lobbying to basically protect the waste. As just one example, what are pricing failures, after all, if not someone else’s margin? Major spoiler alert here, but Dr. Shrank says one sort of broad-stroke solution is aligning incentives with higher-quality care, paying for the longitudinal patient journey, and paying for outcomes. If you do this, then at least the clinical failures side of the equation could improve. The implication here is that if the incentive is to be accountable for value—which is, you know, numerator quality denominator cost—then the supply chain has an incentive to reduce its own waste because effectively, at that point, it’s coming out of their pocket as opposed to somebody else’s. Will this resetting of the financial model happen overnight? That was a rhetorical question that we all know the answer to. Commercial payers are slow to change, and all but the best employers have been (historically, at least) busy making extremely lateral moves and going nowhere fast. Few seem super inclined to reward and pay for what they care about rather than just negotiating a price. I sort of say this to Dr. Shrank, and he says, yeah, true enough. I’m paraphrasing with a lot of creative license right now, but he says, let’s reset our expectations with reality. We’ve actually come a pretty long way, baby, in not a particularly long time if you consider the whole value-based thing really only started not that long ago, relatively speaking. So, there will be problems to overcome and bumps in the road. We should expect that, and we haven’t had the time to work them all out yet. I think a couple of other interesting insights for me, one was a little sidebar we go off on about the power that PCPs might find themselves wielding if they can gang up and harness it. And this is kind of starting. We’ll see if it goes anywhere. I recently heard a story about a bunch of employed PCPs who went to their health system bosses and asked to stand up an APCP (advanced primary care practice) able to coordinate care, etc, do all the things that at this juncture we know are the right things to do for patients. Now they got shot down—bam!—with the backhands from above. I hope those engaged and activated PCPs quit and start up their own thing. Maybe they will. PCPs getting together here could be a way to solve for waste if they can gang up and harness...


EP411: Getting Paid (or Paying) for New Innovations Used in Hospitals as Part of a Procedure or a DRG—Also Bloodstream Infections and Dialysis, With Secretary David Shulkin, MD, and Erin Mistry

Just taking a moment here to thank our Relentless Tribe for really getting yourselves involved in the work that I had originally kicked off to improve the outcomes for CKD (chronic kidney disease) patients in this country. With the momentum that we have so far, this Relentless Tribe of ours, we are really (for reals) going to produce measurable improvements for patients with CKD—so many of you, not just talking but actually out there, actively doing what you need to do so that patients do better, and it’s making a difference. I have talked to doctors, other clinicians, administrators, IPAs, other provider organizations big and small, payers, societies, a great data company, a number of you who are consultants. It’s crazy what we have been able to build so far, and we’ve been doing this for less than a year. The Relentless Tribe … let me tell you, we move mountains. We get patients properly diagnosed. We get them into appropriate treatment plans. What restores my faith in these rough times, we have encountered one PCP, one clinician after another; and the second that we show them the “as per the guidelines” way to accurately diagnose and stage chronic kidney disease (which is not just using eGFR for those clinicians who might be listening), yeah, that’s it! These are great doctors, and they switch it up. They switch up what they are doing, and that makes my heart warm. These are doctors across the board, from ones in independent practices to ones maybe employed by academic medical centers. And once they have the right information, they use it. And it’s a wonderful thing, and I cannot thank everybody who has contributed enough. We are making real differences in patients’ lives. If what I am doing speaks to you in any way, please hit me up, because we’re cooking with gas and I could not be prouder of this community of change agents that we have built here. You’re amazing. You know what needs to be done, and you’re not afraid to do it. Now, back to our regularly scheduled programming. In this healthcare podcast, I am talking with Secretary David Shulkin, MD, and Erin Mistry. Here’s the first reason why I was interested in taking this interview after their public relations firm contacted me. We were at the thINc360 conference in DC earlier this summer, and I heard them talking about patients on dialysis dying from infections, which … didn’t realize how common that was and it seemed like a nice adjacency to our ongoing CKD work. I also thought this might be an opportunity to learn a little bit more about what’s going on with hospital-acquired infections and infection control. Superbugs are hella scary, but one thing I’m just gonna point out—and, small sidebar here, but listen to the show with Bruce Rector, MD (EP300) for more on this—in recent times, I don’t think there has been a pharma company who has managed to launch an antibiotic and achieve commercial success. So, what can easily wind up happening under the current payment model is that instead of just using the new antibiotic to treat resistant cases, there’s this perverse incentive to push for the drug’s use more broadly because more prescriptions, more money. But when the new antibiotic is used more broadly, that actually reduces its effectiveness against those resistant infections that it is here to treat. Okay … back to bloodstream infections now, which is the topic of the conversation today. If a patient has a central line infection and then gets sepsis, their chances of readmission within 30 days is almost 99%. This is not a little cohort. It’s not small potatoes we’re talking about here either. As Secretary Shulkin says during this interview that follows, if you’re gonna make a preventative care economic case study, do it on hospital-acquired infections and, most particularly, those with central lines that lead to sepsis. Even with very short time horizons, you can make that case. So, that was two reasons for this interview. The third: I’ve been extremely...


Encore! EP361: The Gap in Closing Care Gaps, With Carly Eckert, MD, PhD(c), MPH

I decided to encore this episode with Carly Eckert, MD, PhD(c), MPH, because I keep finding myself quoting Dr. Eckert in conversations, even a year later. First off, if you’re not familiar, a care gap is what happens when there is a bad transition of care. Patient has no idea what their discharge instructions actually mean, so they wind up back in the hospital. Patient didn’t pick up their prescription, so they wind up in the hospital or back in the hospital. Patient still has uncontrolled hypertension long after being diagnosed with uncontrolled hypertension or uncontrolled diabetes. It’s crazy how many patients keep going to their doctor and being told they have high blood pressure or high blood sugar and their care plans are not adjusted. Or they don’t take their meds due to cost or a lack of trust or whatever other reason. Or care gaps exist because the patients don’t go to their doctor in the first place. So, they settle right into a care gap that no doctor can fix because down there in the bottom of that care gap, there’s no medical professionals. So, a year later and the year after that, their blood sugar or their blood pressure is still high. These are patients in care gaps. I mean, consider that heart failure … I heard it called the “a little too late disease” by William Bestermann, MD, the other day. You don’t just spontaneously develop heart failure, after all. If you have uncontrolled hypertension and/or uncontrolled diabetes for too long, you will get heart failure and you’ll also probably get chronic kidney disease. Chronic kidney disease, by the way, is often the cause of most heart failure readmissions, so think about the entire impact of heart failure and most kidney disease when you think about the cost of care gaps. This is what we talk about today. And with that, here’s your encore. In this healthcare podcast, I’m speaking with Carly Eckert, MD. It’s kinda funny, actually. I originally wanted to get Dr. Eckert on the show to talk about care gaps and how to close them, but this show did not wind up going how I thought it was going to go because Carly Eckert is a physician by training who got really interested in the upstream causes of what she was seeing in clinical practice. Despite my best efforts, she refused to be lured into my closing care gaps conversation. So, instead, this conversation is about the construct of care gaps and thinking about them in context. Closing care gaps is a model of care and maybe not a particularly great one, relatively speaking. In fact, here’s another name for the model of care called closing care gaps: care gap whack-a-mole. Care gap pops up … we whack it. Care gap pops up … we try to close it. Another care gap pops up … we try to close it. Another care gap … you get the idea. Carly Eckert has worked in epidemiology and public health and also clinical informatics for health systems and payers. I recorded this show with Dr. Eckert prior to EP359 with Dan O’Neill. In that interview, which you should go back and listen to when you have a sec, Dan O’Neill cleared up a couple of things that I struggled with during this interview. Here’s the big one that I could not figure out: Why with the whack-a-mole? Why do we still insist as a nation on waiting for someone to show up in clinic to retroactively and reactively address a missed preventative care opportunity? Why don’t so many more provider organizations create pop health programs that consider the whole person proactively? Why don’t they take the time to operationalize whole-person care in a meaningful way? Ah, yes … to the surprise of exactly no one, it’s all about the Benjamins. As Dan O’Neill put it, if all a provider organization is doing is slapping a sheet on a doc’s desk every morning with a list of care gaps for all the patients that he/she will see that day, it’s highly likely that incentives, or penalties to do anything else, are very weak. It’s a sign that, from a paying for value perspective, we’re not...


EP412: Leadership of the Art and Science of Medicine, With Robert Pearl, MD

One of the questions I often get asked is this (actually, it’s more of a comment usually than a question): Someone says, “Seems like this whole transformative primary care thing is pretty much just, let’s go back to the old country doctor. Let’s just have a single doctor out there taking care of patients like a Norman Rockwell painting.” To which I reply (and I’m channeling many experts, including my guest Robert Pearl, MD, when I do), “Yeah … except no.” In the golden olden days of the “ye olde country doctor,” there was a lot of art in medicine and a lot less science. If someone got cancer or even heart disease, what was required, fairly exclusively, was comfort and compassion. Now, first and foremost so there’s no confusion, am I dismissing the importance of bedside manner and of providing comfort and compassion? Hell no. Would rather have that any day of the week than deal with a “drive-by PCP” or “drive-by specialist” with the throughput of a freeway who has no idea what I may befall the second I step out of his or her exam room. But in the olden days, medicine was fundamentally art with a lot less science … because there wasn’t much science. For the most part, we didn’t have data. Or MRIs. This was before the whole pharma industry for the most part. We had weird heroin-infused tinctures, but we didn’t have oncology meds or biomarkers or even statins for Pete’s sake. Consider all the new diabetes meds and biologics and artificial joints and sub-subspecialists who have, through data and advanced analytics by looking at patients across the country, proven out some best practices that might be fairly unintuitive—or disproven some conventional wisdom. It’s a different and much more complicated world today, and what’s required now is a healthy appreciation for not only the art of medicine but also the science. And science inherently means that, yeah, there are standards of care to be adhered to. That’s what science means. There are rules and better ways to do things as proven by looking at the data and not relying primarily on personal recollections of what may or may not have worked in the past. Listen to the shows with Bob Matthews (EP315) or Alex Akers (EP154) for more on this topic, but this all leads me to the interview with Dr. Robert Pearl in this healthcare podcast where we get into some concepts that he covers in his new book, Uncaring. In this episode, we’re talking about some how-tos for being a leader of doctors, going about that against the backdrop of this evolving art and science of medicine dynamic, and the impact of this evolving art and science dynamic on physician culture and self-esteem. Because (spoiler alert) if a doc is following evidence-based guidelines, not relying solely on their own personal experience, does that make said doc feel like they are being devalued and that they are but a cog in the wheel and practicing so-called “cookie cutter” medicine? So many nuances, so little time. But, yeah, there’s a lot going on which, at its core, is this tension that can play out in some big bad ways. I asked Dr Pearl for some advice for today’s healthcare leaders, and he did not disappoint. He suggested using a model that he calls the A to G model, and, in short, you’ve got to have: A: an aspirational vision B: behaviors C: context D: data E: engagement (throughout the organization and also with the patient) F: faculty G: governance You’ll have to listen to the episode for the why and how of each of these. My guest today, as aforementioned, is Dr. Robert Pearl. I am sure that most of our Relentless Tribe who are listening to the show today already know Dr. Pearl, but in short, he was the CEO of Kaiser Permanente for 18 years. Now he hosts a podcast called Fixing Healthcare. He teaches at the Stanford Graduate School of Medicine and Business. He writes articles for Forbes and elsewhere. He’s also an author. He wrote a great book called Mistreated, and now there’s a new one called Uncaring. I...


Are Physicians (and the Rest of Us, Nothing for Nothing) Knights, Knaves, and/or Pawns? With Larry Bauer, MSW, MEd—Summer Shorts 8

During the recording of episode 409, where Larry Bauer was explaining some really cool and innovative bright spots in the healthcare industry created by physicians, we somehow got off on a tangent about an article in JAMA from 2010—and I was all in. Unfortunately, going all in on a topic that has nothing to do with the actual topic of the currently in progress podcast means one thing; and you probably know by now what that one thing is. Yep … summer short. So, let me unveil for you our last summer short of 2023. In this healthcare podcast, we’re gonna talk about doctors and the societal perception of them as being a knight, a knave, or a pawn. All of this is from a JAMA article that is entitled, surprisingly enough, “Societal Perceptions of Physicians: Knights, Knaves, or Pawns?” and it’s by Sachin Jain, MD, MBA, and Christine Cassel, MD, and is unfortunately firewalled (but I’ve linked to it anyway). To get us started here, this is the first sentence of that JAMA article: “The British economist Julian Le Grand suggested that public policy is grounded in a conception of humans as ‘knights,’ ‘knaves,’ or ‘pawns.’ Human beings are motivated by virtue (knights) or rigid self-interest (knaves) or are passive victims of their circumstances (pawns).” And, yeah, that plays out. Why can’t physicians own hospitals? Well, in somebody’s eyes, docs got a knave rap. How’d that happen? I don’t know. I can make some guesses. Even if it’s a small percentage of docs doing knave-y money grabs or power-hungry things, there is spillover. We societal humans, after all, like black and white, not gray. So, everybody gets painted with the same brush in the same color, and policy gets created to control the lowest common denominators. I loved this conversation with Larry Bauer that follows because it explains a lot of sequelae, if you will, that I couldn’t quite put my finger on the root cause of. So, in the brief but fast-moving clip of the conversation that follows, Larry Bauer and I chat about docs as knaves or knights. But we don’t get around to pawns, so I did just want to chuck in my two cents here about this third category. I also will say that since I’ve got these three new classifications, I find myself using it to predict actions—to some effect, I might add. I was chatting with someone recently, and I said something about doing well by doing good and he replied, “Well, how about this? You can do the good, and I’ll focus on doing well by doing well.” Okay … so, that’s a predictive layup. The harder ones are where people with a lot of press training and social capital do talks about doing good and being knightly, but then you listen to the minutes of their board meetings and, wow, are they focused on revenue maximization … at the expense of patients and their fellow doctors. This happens more often than I would like to see, but then again, I would like to see this happen never. As I mentioned about eight sentences ago, the category we don’t talk about in this conversation with Larry Bauer that follows—which has also occupied a chunk of my mind space lately—are pawns. As with all of these categories, it’s not just docs who fall into them but everybody else, too. Pawns are super interesting. You might be way ahead of me here and have been thinking about this for years because, on its face, this is obvious. But sometimes there’s truth hiding in plain sight, so I’m not embarrassed to keep talking about this in case it helps you connect the same dots I’ve recently started to connect. I will state at the outset here that those who I would chuck in the pawn category do not listen to this podcast (neither do knaves). They do not like this show at all. This show forces a level of self-reflection and awareness and, to some degree, accountability about the net net of some of the goings-on that those who don’t want to hear it don’t like at all. I was reading an article the other day about the “tragedy of organizational decision-making.” Kind...


Why Do Actuarial Risk Horizons Really Matter for Anybody Trying to Improve Patient Outcomes? With Keith Passwater and JR Clark—Summer Shorts 7

On our Web site,, there is a little orange button that says send us a voice message. If you have a question, feel free to click on that button and we’ll try to round up a posse to answer your question if we can. So, let’s do this thing. “Hey, Stacey! Really big fan. Really loved the last episode. I had a question. Could you provide more clarity on what the key takeaway was about the actuaries and the different timelines that they’re working on versus physicians? I would greatly appreciate it. Thanks.” Great question. And yes, I did kind of drop in an episode something about risk horizons with no explanation. Instead of trying to answer that question myself, I reached out to a couple of actual actuaries, Keith Passwater and JR Clark. I’m gonna play their answers and give a little color commentary before and after to kind of knit together this whole thing into a few succinct takeaways for you. Keith Passwater is former senior vice president and chief actuary over at Anthem. Keith founded Havarti Risk Services. He brings better risk products and services to healthcare clients. Keith is also a Fellow of the Society of Actuaries, a member of the American Academy of Actuaries, and he serves on the General Committee of the Actuarial Standards Board. JR Clark is SVP of health plan product and strategy at Paytient Technologies, where he partners with thoughtful employers, insurers, and health systems to help people better access and afford healthcare. JR is known for his public exchange marketplace strategies (and that’s relevant for today) and the creation of alternative products in the individual and small group segments. So, our panel here is strong is the bottom line. I do want to take a moment to underscore five times that if any healthcare transformation is going to happen, whomever is transforming pretty much anything must—and this is mandatory—they are going to have to be hip to hip with an actuary. But a special kind of actuary—one who applies their considerable smarts to factor in the patient or member as an actual stakeholder in their equations, because what now? Came to discover that in most actuaries’ current models, the impact on the patient or member is not part of their equation. Yeah, yes, you heard that right. Despite the fact that study after study shows that once co-pays or coinsurance reaches a certain dollar amount, patients will start abandoning care, as just one example. And despite financial toxicity being clinical toxicity, and how the cost of care can be a comorbidity, as Cody Coonradt has put it, you only have a small percentage of actuaries who are factoring this in when adding and subtracting and toting up the benefit design. So crazy, especially because even if you forget about the human aspect here (just ignore it), I’d suspect the math is actually wrong if you ignore the patient as a stakeholder. There are financial consequences when patients abandon meds and care, and some of them manifest fairly quickly—and not in a way that is revenue positive for the plan: Diabetes patients who don’t take their insulin. Guy sees a spot on his arm. Is it melanoma? I don’t know, but I do know I’ll be $600 in the hole if I go see the doctor, so he doesn’t go until it’s really big. I mean, unless the patient dies on the quick, you’d think that there’d be some statistical contemplations about this (ie, how much does it cost plans in the short/medium term when patients who need care fail to seek it). Actually, Alex Sommers, MD, wrote a post on this the other day. In this post about how much it actually costs when patients abandon care, he references the Four Horsemen of the Apocalypse, which is probably why I remember it. Any actuaries out there who are taking the patient into account—or health equity is another thing—let me personally give you a round of applause. It’s really easy to feel powerless inside a big machine where everybody is a cog in the wheel, and therefore it’s really...


Should You Not Give Employees the Benefit Design They Think They Want? With Lauren Vela—Summer Shorts 6

Lauren Vela is back on the pod today with a summer short that originally was a section of episode 406 that, unfortunately, I had to cut. It was a little bit tangential to the “why with the employer inertia” theme that the original episode was about. But tangential does not mean unimportant. This clip has some really critical insights on a different topic that may or may not to a greater or lesser degree contribute to inertia. And I’m gonna call this other topic the benefit design that most employees might ultimately be the most satisfied with might not be the one that they are explicitly asking for. Let’s start with three kinds of market research insights that Lauren Vela, my guest in this healthcare podcast, uncovered when interviewing friends and neighbors not in the healthcare industry about their benefits: 1. Nobody reads their benefit information. 2. They are unhappy with their benefits. 3. The most important thing for them is to have choice. They want to avoid the notion of “managed care.” In thinking about this, I was reminded of a Henry Ford quote: “If I asked my customers what they wanted, they would have told me a faster horse.” Or Steve Jobs famously said, “Some people say, ‘Give the customers what they want.’ But that’s not my approach. Our job is to figure out what they’re going to want before they do.” Jobs’s whole thing, after all, was that true innovation often comes from anticipating customer needs and desires before they can articulate them themselves. So, let me reconcile Lauren’s findings when she interviewed people about what they want in their benefits and what Henry Ford and Steve Jobs have to say about the matter. First of all, patients/plan members—most people have never experienced a comprehensive primary care situation where they are assisted in finding the highest-quality specialists or sub-specialists and have their care coordinated. They have never had someone worrying about them in their “in-between spaces,” as Amy Scanlan, MD (EP402), put it, between appointments. This is all just a fantasy. It is a reputed Shangri-la that almost no one has ever seen with their own two eyes. But what many have seen—I have; you have—are narrow networks in which cost containment is wielded like a brute-force weapon, where, for example, the NCI-designated cancer centers are out of network as a way to make sure that people with cancer don’t sign up for your plan … or don’t last long on your plan if they do. (Did I say that out loud?) Do I sound like I suffer from a brutal lack of trust? Yes, I do—and I was just role-playing there an employee probably pretty accurately. Most of us remember the HMO a-go-go years when your PCP was an administrative gatekeeper and you had to see them to get a specialist appointment—except you never could see them. Wait times were weeks or months, obviously by design, right? But this way-too-expensive PPO model is the devil I know because, even if it totally sucks, it’s better than the conspiracy theories and/or accurate or exaggerated recollections of other options. Here are my recommended next steps. Listen to the shows with Vivek Garg, MD, MBA (EP407), and Scott Conard, MD (EP391), and Douglas Eby, MD (EP312), as a start. All three make it really clear that advanced primary care—maybe even direct primary care—can not only save money, but it also can produce better health and patients are super happy and usually clinicians, too. It’s like a quadruple aim home run. But none of this can happen if we say “integrated care or advanced primary care and you have to go there to get a referral” and then leave whatever that means up to employees’ or plan members’ imaginations. Communication is really required here, as it is when rolling out most new things—not just cars or cellular telephones. You can learn more about Lauren’s work by connecting with her on LinkedIn. Lauren Vela is a passionate advocate for a more rational and sustainable healthcare system and recognizes the...


Payers Trying to Differentiate Themselves by Working With Provider Organizations … or Not, With Jacob Asher, MD—Summer Shorts 5

This summer short is about the dynamic between payers and providers. An opening point that Jacob Asher, MD, my guest in this healthcare podcast, makes in the interview that follows is that, for a payer, it’s super hard to competitively differentiate from both a cost and/or a quality perspective when you and all of your payer competition use the exact same PPO (preferred provider organization) networks. I mean, what? Are these same exact doctors gonna somehow do a better job with your members than with the rest of their patients? This is even more true if you think about this from a physician or a practice point of view. Will clinical teams in their clinical workflow figure out who your members are, first of all, which is a thing, and then switch up what they choose to do for your members that is special? Even theoretically, that sounds like an executional fandango, which is exacerbated in markets with lots of payers. I guess I am not shocked when I hear stories like Dr. Asher was talking about: Doctor sits down at desk after a long day and sees 27 “Dear Doctor” letters from all of the payers in his or her payer mix. “Hey, Doc. Let me tell you about our amazing new thing.” And Doc’s like, “Pajama time awaits.” And—boom!—the letters, unopened, right in the recycle bin. From a payer’s standpoint, back to square one, I guess. Now, I will chuck in the mix here—and this has nothing to do with the conversation with Dr. Asher that follows—but one thing I’ve spent my entire career doing is helping organizations set up programs to collaborate with other organizations. If I authentically solve an actual, authentic, prioritized problem, I usually can find many people who seem pretty pleased to work with me. Now, is this easy to do? No. It takes strategic thinking and executional competence and/or grit to see it through. You really have to understand and account for vested interests and all the weird perverse incentives. Personally, I gotta work with a whole team of others coming at this from all different directions to untie this Gordian knot. But anyone who really wants to or needs to reach across the aisle and engage with other stakeholders or customers, even in any sort of systemic way, it’s just not possible to phone it in. Anyway, I just want everyone to succeed in working together. It is impossible to have a longitudinal patient journey if everybody is all up in their own silos fragmenting care. You can learn more by connecting with Dr. Asher on LinkedIn. Jacob Asher, MD, completed a residency in otolaryngology–head and neck surgery at the University of California, San Francisco, after receiving degrees from Brown University and the Boston University School of Medicine. Dr. Asher then practiced as an ENT (ear, nose, and throat) surgeon with Kaiser Permanente in Northern California and also served on the board of directors of The Permanente Medical Group, where he focused on physician compensation reform, member satisfaction initiatives, and retirement benefits. After transitioning to full-time health plan management, Dr. Asher served as a California commercial market medical director between 2008 and 2022 for Anthem Blue Cross, Cigna, and UnitedHealthcare. In those roles, he supported membership growth and retention in both fully insured and self-funded product lines and promoted value-based reimbursement, including capitation. He has led utilization management teams, collaborated with internal and external population healthcare advocates, and worked to develop clinical initiatives that sought to achieve the Triple Aim. In his role as the clinical face of the health plan to the local market, he worked with network colleagues on accountable care organization partnerships and hospital and physician contract renewals with integrated pay for performance, supported Obamacare exchange participation, engaged in quality improvement collaboratives, and supported regulatory compliance efforts. Currently, Dr. Asher is serving...


Supergroups, Super ACOs, and Ochsner’s Value-Based Care Journey, With Eric Gallagher—Summer Shorts 4

Here’s a quote from Rolling Stone magazine: “A supergroup is a very fragile thing. Rock bands are always about balancing huge egos, but when those egos are oversized from the get-go it can lead to huge problems. That’s why supergroups like Blind Faith often fail to go beyond a single album, and why long-lasting ones like CSNY had drama that never seemed to end.” Hmmm … that’s apropos because, turns out, super ACOs (accountable care organizations) may have some similar issues. A super ACO means multiple ACOs or CINs (clinically integrated networks) which are each comprised of multiple practices or provider organizations, and it’s all under different ownership. Said another way, there are multiple levels of competitors—frenemies, if you will—trying to work together or not work together as the case may be. There’s a lot of infrastructure complexity and process complexity and, frankly, inefficiency. There’s trust issues. There’s the problem that rule #1 of change management is to create “quick wins” so that everyone can smell potential success and realize it’s possible, so momentum happens. But if doing anything is hyper-complicated, then it’s really tough to have a quick win. Today in this summer short, this is what I am chatting about with Eric Gallagher. We talk about how Ochsner evolved from a super ACO or super CIN into its current form. This summer short is a 13-minute clip that went a little far afield from the main topic of episode 405, which was the full episode with Eric Gallagher, and therefore, I cut it. But as I always do when I cut an actually pretty great section from a show for reasons of time, I have been on the edge of my seat to share it with you. This show is actually a very nice follow-on to the one with Dan Serrano (EP410) from last week. As Eric describes Ochsner’s history and its path forward, it is a case study of some of the recommendations that Dan mentioned. This summer short also really echoes some of the themes in episode 409, which was the one with Larry Bauer, and also one upcoming with Jodilyn Owen. What will work in one local market, don’t count on it working elsewhere—or not work as well at a minimum. Healthcare is local. This is a lesson many investors and entrepreneurs looking for rapid scaling prototypes have learned the hard way, and listening to Eric, it’s really easy to catch the why for that. If this topic intrigues you, also listen to the show with Dr. Amy Scanlan (EP402). Also episode 349 with Lisa Trumble. And lastly, I would recommend the show with David Carmouche, MD (EP343). Dr. Carmouche was talking about Ochsner’s work improving patient outcomes with a Medicare Advantage plan. One final note/point to ponder: scale. To really get value-based contracts, you need it. You need it to afford the infrastructure, and you need it to demand a seat at the table. But yeah with that … everything in moderation, I guess, because any scale that starts to approach monopoly proportions seems to invite bad behavior. You have to get big enough to matter in the market but not so big that your big footprint squashes market dynamics, because it seems like many succumb to the siren song at that point of putting profits over patients. You can learn more at Ochsner Health Network. Eric Gallagher, chief executive officer for Ochsner Health Network (OHN), is responsible for directing network and population health strategy and operations, including oversight of performance management operations, population health and care management programs, value-based analytics, OHN network development and administration, strategic program management, and marketing and communications. Prior to joining Ochsner in 2016, Eric held leadership positions in healthcare strategy and execution—including roles at Accenture, Tulane University Health System, and Vanderbilt University and Medical Center. A New Orleans native, Eric earned a bachelor’s degree in human and organizational development from Vanderbilt University...


EP410: The Imperative and a 201-Level Financial How-To for Payers and Provider Organizations to Collaborate to Help CKD Patients and Others With Chronic Conditions, With Dan Serrano

In this healthcare podcast, I am talking with Dan Serrano; and we’re talking about payer/provider collaboration—blocking and tackling, I’m gonna say—from primarily a financial and revenue point of view. I’d classify this as, say, a 201-level discussion (ie, not entry level, but it’s also not super deep in the weeds). We mainly cover the ins and outs of why a provider organization should probably be looking to get paid to better take care of patients with chronic disease and drive better patient outcomes at lower downstream costs and, to some degree, also why payers should be helping provider organizations in their local communities to do so by providing some help and shelter on the journey from here to a capitated payment. The focus today is really, I’d have to say, on the messy middle, where a provider organization does not have capitated contracts nor access to any premium dollars, which, by all accounts, is the holy grail here. The premium is where it’s at, and provider organizations might want to be aiming to get a piece of that action. The why for this “get the premium dollar” prime directive is pretty self-evident when you look at the big bucks rolling around in the coffers of those who are collecting said premium dollars. So, this “get the premium” endgame is, for sure, a big piece of the why—why, if I am a provider organization, I might want to take the time and energy and spend the money to embark on a path that might lead me to be able to get compensated for the stuff that patients really want and need to do better, which includes all of the things that I spoke about with Eric Gallagher in episode 405. Also, Vivek Garg, MD, MBA, in episode 407 and Amy Scanlan, MD, in episode 402. Spoiler alert: It’s not easy. Now, I asked Dan Serrano, as aforementioned my guest today, to offer up his advice here in the context of CKD (chronic kidney disease) patients. Why did I ask Dan to use the CKD case study, as a touchstone? Well, first of all, talking about this topic in totally theoretical terms is not ideal. We need an actual example for a lot of this to kind of make sense, combined with the first step for most outcomes improvement programs, which is to study your data and pick a patient population to focus on where the data suggests that you can have a big impact. And speaking of impact, did you know that an underlying reason why heart failure patients get hospitalized and rehospitalized is because of underlying CKD? So, impact in the short term and longer term, which I’ll get to in a sec. Another reason is—and I’m quoting John Rodis, MD, MBA, here, who is the independent medical director of QC-Health—Dr. Rodis said the other day, “I sure as heck hope I don’t get CKD, because if I do, chances are I’m not going to be diagnosed. And even if I am diagnosed, I won’t be treated properly.” So, there’s that. And I can see why he’s saying that. Two out of five patients with ESRD (end-stage renal disease) don’t even know they have kidney disease at all. And the number of patients with progressing CKD on any kind of evidence-based treatment plan is stunningly low. But also, here’s another reason I asked Dan Serrano to talk about CKD patient populations specifically as his example: I and Dr. Rodis and the team at QC-Health are not the only ones who have figured out that CKD patients are notoriously expensive and way underdiagnosed. You know who else has figured this out? Payers. Also, private equity. In fact, I was in a meeting with a payer recently, and they stated they had to get CKD patients into point solutions. This payer—and I’ve heard of others, too—none of these entities are waiting around. And I guess, fair enough, if you look at some of the population health data, that I’m sure these payers and others are looking at. But if you work for a payer and you’re listening right now, what I would say, “Okay, with the point solutions, one that you have carefully vetted, of course, because we have patients suffering right now...


EP409: 3 Really Cool Innovative Primary Care Bright Spots and a Few Notes for Policymakers and Payers, With Larry Bauer, MSW, MEd

In this healthcare podcast, we are talking about innovative primary care teams and, by way of Larry Bauer, my guest today, bringing you three inspiring case studies. Much can be inferred from these case studies, as much from how they are alike as how they are different. It is wildly important at the same time that it is wildly underappreciated how different local markets are. I love how Cody Coonradt put it on LinkedIn the other day. He wrote: “Healthcare is not a $4T market—it’s 500 some-odd interconnected markets ranging in size from $1-50B. [It is] not a singular problem … each market [is driven] by unique third party payer incentives with unique patient cohorts. … “Before you figure out the next great idea—seek to understand the underlying health economic, revenue cycle, service provider contracting, and cash conversion processes that undergird it all. [That] is how to truly disrupt healthcare.” Or, said another way, if you’re part of the community, if you are already caring for patients in that community because you’re a doctor or another clinician, you probably have the best shot at truly—and in meaningful ways—helping patients in that community. This whole statement is a really uncomfortable truth for many in private equity and anybody else who wants to find the easy button to fix healthcare with some big-ass, scalable, rapid-fire bulldozer approach. It’s also a very uncomfortable truth for any national payer looking for one model or one point solution to roll out in a broad stroke to every one of these 500 some-odd interconnected markets that Cody mentioned. One size does not fit all here, and leveling up patient outcomes and care is hard grueling work that requires local market knowledge, being rooted in the community with relationships to succeed. You gotta get a little closer to the ground. Policymakers, please take some notes here. And you, too, self-insured employers, payers. So many universal lessons are embedded in these three examples that Larry Bauer, my guest, shares today. But bottom line—and round of applause required—you go, all you doctors and nurses and other clinicians or mission-oriented teams who take it upon yourselves to find ways to address the problem of human suffering in your local area. Stay tuned for an upcoming show with Jodilyn Owen, where we dig into this whole dynamic hard. I’m talking about the dynamic where some barbarian at the gate (ie, some venture-funded start-up) has gotten money—in some cases, lots of money—while there are community-based organizations out there who are doing amazing work really helping patients in the community improving outcomes and cutting costs and struggling, scrambling for every penny they can manage to get their hands on. So, that’s in the future. Talking about today, though, we’re gonna cover the bright spots when you get a really creative and committed PCP (primary care) team who is part of their own community and who wants to do better by patients locally and got some money to attain that goal. Today, as I said earlier, I am talking with Larry Bauer, who has been working with innovative PCPs and other docs for decades. All three of these case studies that Larry describes on the show today concern frail elderly adults, and this is on purpose (this using of the same patient population) for a couple of reasons. One of them is just to highlight that the same population in different geographies is not the same population and, therefore, the solution set is going to be different if we’re gonna reach out and care for them. The second reason for selecting three solutions that all pertain to frail elders is that this group is notoriously expensive and care is notoriously poor. Everybody has a story about how their frail elderly family member or friend died a bad death or did not “finish well,” as Larry Bauer puts it. It’s a patient population at the mercy of this industry and unable, a lot of times, to advocate for themselves. So, solutions here solve,...


Does Advanced Primary Care Reduce Access for Patients? With Vivek Garg, MD, MBA—Summer Shorts 3

I cut this clip out of episode 407 with Vivek Garg, MD, MBA, from Humana; and it’s actually a really nice follow-on from the show last week with Scott Conard, MD, where we talked about the blowback that happened with clinicians at a clinic. This clinic had put into effect a bunch of the comprehensive primary care kinds of things that Dr. Garg talks about in this summer short. But what happened in Dr. Conard’s case is a new practice manager tried to go back to the olden days, and, spoiler alert, it was a kerfuffle. All the docs and the rest of the clinicians staged what sounded like a “mutiny on the bounty” moment from the way Dr. Conard described it. So, this summer short you’re about to hear and the one from last week again share one key point: Doctors, advanced practice clinicians, medical assistants, pretty much everybody on the team really likes a well-executed, operationally excellent transformed primary care model. And it produces better patient care. I was reading Dr. Robert Pearl’s book Uncaring the other day, and he summed up the reason why, I think, these transformed primary care practices do better. He was quoting Atul Gawande, and here’s the quoted quote: “The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.” I interviewed Dr. Pearl, by the way, so stay tuned for that show coming up. In this summer short, Dr. Garg digs into one common objection to more comprehensively comprehensive primary care, and that is that by improving care, we decrease throughput and, therefore, access to primary care, especially in areas where there are not enough primary care doctors. You can learn more at,, and the Humana report. Vivek Garg, MD, MBA, is a physician and executive dedicated to building the models and cultures of care we need for loved ones and healthcare professionals to thrive. He leads national clinical strategy and excellence, care model development and innovation, and the clinical teams for Humana’s Primary Care Organization, CenterWell and Conviva, as chief medical officer (CMO), where they serve approximately 250,000 seniors across the country as their community-based primary care home, with a physician-led team of practitioners, including advanced practice clinicians, nurses, social workers, pharmacists, and therapists. Dr. Garg is the former chief medical officer of CareMore and Aspire Health, innovative integrated healthcare delivery organizations with over 180,000 patients in over 30 states. He also previously led CareMore’s growth and product functions as chief product officer, including expansion into Medicaid primary care and home-based complex care. Earlier in his career, Dr. Garg joined Oscar Health during its first year of operations as medical director and led care management, utilization management, pharmacy, and quality, leading to Oscar’s initial NCQA accreditation. He was medical director at One Medical Group, focusing on primary care quality and virtual care, and worked at the Medicare Payment Advisory Commission, a Congressional advisory body on payment innovation in Medicare. Dr. Garg graduated summa cum laude from Yale University with a bachelor’s degree in biology and earned his MD from Harvard Medical School and MBA from Harvard Business School. He trained in internal medicine at Brigham and Women’s Hospital, received board certification, and resides in New Jersey. 02:31 Does advanced primary care reduce access to patients? 03:01 Are five-minute visits with patients really access? 04:17 Will advanced primary care provide outcomes that make certain PCP responsibilities unnecessary? You can learn more at,, and the Humana report. @vgargMD discusses #advancedprimarycare on our...