Relentless Health Value

There's a next generation of digital front doors being created that open up to a patient/member experience that folds in payer, provider, and employer data—plus behavioral data the patient themselves generates when they browse through content in there. Because that's what it takes for a so-called personalized experience or patient journey to ensue. This is what I'm talking about in this healthcare podcast with Kristin Begley, PharmD. In an ideal world, you'd have, for example, a member/patient/customer who goes to their doctor and is handed a tablet to fill out an intake form. When they hit submit, they get access to a digital front door that leads to a vast Web portal inhabited by the doctor as well as the patient's payer and their employer. This personalized Web portal then knows this patient has asthma and is nonadherent to their maintenance medication and is using their rescue med a lot, because it's in the payer PBM (pharmacy benefit manager) data. The portal also knows the patient is searching a lot on content like what to do when you have a terrible asthma attack. Further, the portal knows that the patient's current doctor visit, the one where they're filling out the intake form, is about a respiratory chief complaint, because it's in the doctor data and also on that intake form, which, by the way, was immediately uploaded with structured insights available to all parties sharing the portal data. Now, everybody who needs to know knows this patient is at obvious rising risk. What can happen now? Lots of things. Because the portal knows what's included in the patient's benefit plan, there can be a proactive reach-out to get that patient into an available whole longitudinal program before they wind up in the ER. Maybe that's a point solution. Maybe that's a high-quality doctor offering a bundle. Which leads me to the whole value-based care part of this. Front doors are not only for patients to get steered to the best provider—maybe one with a value-based arrangement—but also, in a way, a front door for providers and payers to work together. A portal can be the "hub," if you will, the shared neutral interoperable space for all the parties who need to share space for their value-based arrangement to work out. In fact, some of these portals are taking on risk themselves. Like, you guys all use our portal for your value-based arrangements, and we'll guarantee this level of performance in those arrangements. Portals sharing risk and taking upside becomes even more relevant when the portal comes with its own network of existing provider users, for example—provider users who want to be paid for value and also with EHR (electronic health record) data and direct access and influence over patient care. It's the old network effect. But besides helping make sure the patient gets the right care at the right time, digital front doors also have the potential to ease patient administrative burden. While there's lots of well-placed attention on affordability, patient administrative burden means delayed or foregone care. That's as per a new study by Michael Anne Kyle, PhD, and Austin Frakt, PhD. Kristin Begley is chief commercial officer at Wildflower Health right now, but she started out as a pharmacist before she defected to the business world. She has spent time in the pharmacy space with big companies and small companies before transitioning into the value-based, risk-based world. She's now at Wildflower leading sales and account management, and she knows a whole lot about digital front doors. You can learn more at wildflowerhealth.com. Kristin Begley, PharmD, is a proven leader in the healthcare space with 20 years of experience in health information technology and the pharmaceutical supply chain, focusing on innovative solutions and software. She currently serves as the chief commercial officer of Wildflower Health, a modular digital-enablement care company that activates women and their families within the healthcare ecosystem. Wildflower's software, hardware, and humanware amplify and personalize available resources to women, breaking down silos of care between payers and clinicians while fueling the shift from fee-for-service to value-based care. Wildflower supports the whole person by helping clinicians address both clinical and social determinants of health needs and empowering women to confidently navigate and access care for the family. Kristin is a founding member of All Tru Health, a consulting organization dedicated to improving quality and lowering healthcare costs for Americans, with an emphasis on emerging technology and high-value clinical care. She also served as the chief commercial officer at EmpiRx Health, a pharmacy care manager with a model rooted in payer alignment through at-risk management and concierge service. Prior to that, Kristin was the chief pharmacy officer of Truveris, a healthcare technology company that sheds light on the inner workings of the pharmaceutical supply chain, serving all segments, including consumers. She also led Hewitt's national pharmacy practice, where she managed Rx benefit strategy for Fortune 500 employers. Kristin holds a doctor of pharmacy degree from Samford University. 04:20 What do we mean by "digital front door" in healthcare? 05:27 "In healthcare, the next generation of digital front door is connecting all those stakeholders that try to help patients stay healthier." 06:20 "What we're trying to migrate to is … walk into any front door." 07:24 Why is engagement the hardest part? 10:24 "Are they digital providers … or are they healthcare providers?" 12:25 "When we live in a capitalistic healthcare system, we all have a price tag on our head." 14:01 "How will providers and payers ever be successful in value-based care if we don't have activated, educated, motivated patients?" 16:36 "I don't know how … we succeed in value-based care without having … personalized content for everyone." 18:24 "What does a consumer want?" 26:52 How does Wildflower Health achieve their value-based care network effect? 29:54 What do stakeholders want relative to value-based care? You can learn more at wildflowerhealth.com. Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare What do we mean by "digital front door" in healthcare? Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare "In healthcare, the next generation of digital front door is connecting all those stakeholders that try to help patients stay healthier." Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare "What we're trying to migrate to is … walk into any front door." Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare Why is engagement the hardest part? Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare "Are they digital providers … or are they healthcare providers?" Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare "When we live in a capitalistic healthcare system, we all have a price tag on our head." Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare "How will providers and payers ever be successful in value-based care if we don't have activated, educated, motivated patients?" Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare "I don't know how … we succeed in value-based care without having … personalized content for everyone." Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare "What does a consumer want?" Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare What do stakeholders want relative to value-based care? Kristin Begley of @wildflowerhlth discusses #digitalhealth and #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedcare Recent past interviews: Click a guest's name for their latest RHV episode! David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard

Reference-based pricing, the way that most employee benefit consultants use the term anyway, refers to a methodology used by employers to pay providers for services. Usually we're talking within a fee-for-service (FFS) environment here. The way it typically works ... there are different flavors, but how it typically works is this: Reference-based pricing (RBP) means that an employer starts with some reference-based price. Many times, it's the Medicare rate. Medicare will pay X dollars for something. The employer—and when I say employer, I mean the vendor/company the employer is using to run this whole thing mainly—but the employer will decide that they're willing to pay some percent over the Medicare rate to providers who render that service to the employee. Maybe it's 10% over the Medicare rate or 20% to 50% as David Contorno talks about in this healthcare podcast. One of the biggest pushbacks against RBP schemes has been that it results in balance bills for employees, meaning that an employee goes to the hospital, the employer decides to pay some RBP amount for that service to the hospital, but the hospital hasn't necessarily agreed to accept that amount. There's no contract in place. So, the hospital decides to bill whatever their chargemaster rate is—which, as we all know, is redonkulous—and the employee gets a giant out-of-network balance bill. For the most part, this doesn't have to happen if you do it right; and David Contorno discusses all of this and more on this An Expert Explains. You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn. David Contorno is founder of E Powered Benefits. As a native of New York, David began his career in the insurance industry at the age of 14 and has since become a leading expert in the realm of employee benefits over the last 22 years. David was Benefits Selling magazine's 2015 Broker of the Year, and in March 2016, Forbes deemed him "one of America's most innovative benefits leaders." More recently, he received the 2017 Leadership Award at ASCEND, the annual conference of The Association for Insurance Leadership, which recognizes those whose leadership in support of improving the value and performance of employee benefits has significantly advanced the industry. David is a member of the board of directors for both the Charlotte Association of Health Underwriters and HealthReach Community Clinic. He served on the NC Insurance Commissioners Life and Health Agent Advisory Committee, as well as participated in the Technical Advisory Group that helped with the market reforms required under the Affordable Care Act in North Carolina. He is a longtime member of the Lake Norman and South Iredell Chambers of Commerce as well as the National, North Carolina, New York, and Long Island Associations of Health Underwriters. David contributes to numerous publications, including Forbes, Benefits Selling magazine, Business Leader magazine, and Insurance Thought Leadership. David is committed to giving back to his community and actively participates in the membership drive for the United Way, assisting the local chapter of Habitat for Humanity, and supporting The Dove House Child Advocacy Center. When he is not working, he enjoys boating and traveling. 01:37 What does good reference-based pricing look like? 01:57 What is the pricing methodology that 97% of healthcare is using? 04:25 How has E Powered Benefits minimized the noise around reference-based pricing? 04:55 "You're getting what we view as balance bills all the time." 06:47 "What very few people really recognize is that hospitals have multiple revenue streams." 07:36 "Which is the highest price? The answer is, commercial." You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn. @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast What does good reference-based pricing look like? @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast What is the pricing methodology that 97% of healthcare is using? @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast How has E Powered Benefits minimized the noise around reference-based pricing? @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast "You're getting what we view as balance bills all the time." @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast "What very few people really recognize is that hospitals have multiple revenue streams." @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast "Which is the highest price? The answer is, commercial." @dcontorno discusses #employers and #referencebasedpricing on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa

Let's just start here: As a general construct, insurance carriers have every incentive for health insurance premiums to go up every year. If you're an employer, that is a material fact. Is it counterintuitive? Maybe. Except if you're an employer and your premiums are going up year after year, it begs the question why, every single year, the already-extravagant amount you pay continues to go up way more than the inflation rate. You'd think that if your broker and your plan administrator were so great at their fiduciary responsibility over your self-insured plan that this wouldn't be happening. Oh right, whosever PPO network you're using, they don't have any fiduciary responsibility over your self-insured plan. You do, all you CFOs and CEOs and benefit professionals out there. Wait, I misspoke. Plan administrators do have fiduciary responsibility—to their shareholders. The CEO of CVS/Aetna made $36 million in 2019. He's clearly very good at that job. The rest of them are, too. I'm not singling anyone out here. And also, this podcast is not investment advice. In short, as previously stated, most major insurance carriers and the brokers they pay commissions to have every incentive for your premiums to go up every single year. That's where we're at, folks. It's an open secret, yet so many are just getting so wildly taken advantage of by carriers and brokers whom they have really put their trust in. If you work for a self-insured employer, tell your CFO/CEO to listen to this show. Or if you are a CEO/CFO or a benefits professional in charge of healthcare benefits, welcome. I hope this information is helpful. My guest in this healthcare podcast, David Contorno, has been in the benefits industry longer than he hasn't been in the benefits industry. I think he started working in a benefits brokerage when he was 17 or something. Currently, he's the founder of E Powered Benefits. In this episode, we talk about the keys for self-insured employers that lead to better health for their employees at something like 20% or more lower costs. Here's some of the imperatives for employers that David digs into in this episode: Advanced primary care—really valuing primary care providers who do not work for hospital systems and, therefore, are not subjected to the ball and chain of perverse incentives that David talks about at some length. Getting cost and quality data so you can make prospective choices and not get hit in the back of the head with an after-the-fact "gotcha" in the form of an overpriced bill that you are now obligated to pay. Let me bring up all the articles lately in the New York Times and elsewhere … people paying hundreds of thousands of dollars for something that should cost a fraction of that. Most of them have "good" insurance (keep that in mind) from their employer. Also keep in mind that most of these stories that hit the news are the ones where some poor employee got stuck with a bill—not the metric ton of other examples where the self-insured employer was on the hook. If you're an employer, you can get ahead of these "gotcha" moments. It's textbook risk mitigation if nothing else. Create benefit designs to help employees find and incent them to use the highest-quality providers charging a fair price. Listen to EP334 with Sunita Desai for more on the topic of incenting consumerism. Know how your broker gets paid. If someone is paying your broker a commission and it isn't you, then your broker makes more money when your premiums and rates go up. They are a sales rep getting paid to make someone else money off of you. Get a handle on your pharmacy spend. David gets into some nuances here which are super interesting. You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn. David Contorno is founder of E Powered Benefits. As a native of New York, David began his career in the insurance industry at the age of 14 and has since become a leading expert in the realm of employee benefits over the last 22 years. David was Benefits Selling magazine's 2015 Broker of the Year, and in March 2016, Forbes deemed him "one of America's most innovative benefits leaders." More recently, he received the 2017 Leadership Award at ASCEND, the annual conference of The Association for Insurance Leadership, which recognizes those whose leadership in support of improving the value and performance of employee benefits has significantly advanced the industry. David is a member of the board of directors for both the Charlotte Association of Health Underwriters and HealthReach Community Clinic. He served on the NC Insurance Commissioners Life and Health Agent Advisory Committee, as well as participated in the Technical Advisory Group that helped with the market reforms required under the Affordable Care Act in North Carolina. He is a longtime member of the Lake Norman and South Iredell Chambers of Commerce as well as the National, North Carolina, New York, and Long Island Associations of Health Underwriters. David contributes to numerous publications, including Forbes, Benefits Selling magazine, Business Leader magazine, and Insurance Thought Leadership. David is committed to giving back to his community and actively participates in the membership drive for the United Way, assisting the local chapter of Habitat for Humanity, and supporting The Dove House Child Advocacy Center. When he is not working, he enjoys boating and traveling. 04:20 How do you ensure better care for patients? 05:10 "What's required to correct those things is not really a massive degree of intellect or even innovation." 05:38 What's the road map for self-insured employers who want to take control of their healthcare costs? 10:06 "Higher costs equal more profit and more revenue." 14:03 "The problem with devalued primary care is … that most people pass over the primary care provider and go right to the specialist." 19:41 "Every employer should have every broker sign a compensation disclosure form." 20:06 "If you think there's perverse incentives on the medical side … it gets even worse on the pharmacy side." 21:01 What changes do employers find when they follow the road map to taking control of their healthcare costs? 21:44 "It's not uncommon for us to reduce total healthcare spend for an employer by between 20% and 40% at the end of the first year." 22:09 "I can't change [the] outcome without changing the path you walked to get there." 22:41 "Going self-funded is where the journey starts, not where it ends." 24:47 "If most employers truly understood how badly these carriers and health systems are taking advantage of them … [it's almost like] Stockholm syndrome." 27:09 "The only legitimate fear that employers should have is, How do they message these changes … to the employees?" 29:21 "This has to happen, and if it doesn't happen, the system's going to break and … be picked up by entities that are, I think, only going to make the situation worse." You can learn more at epoweredbenefits.com. You can also connect with David on LinkedIn. @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits How do you ensure better care for patients? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "What's required to correct those things is not really a massive degree of intellect or even innovation." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits What's the road map for self-insured employers who want to take control of their healthcare costs? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "Higher costs equal more profit and more revenue." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "The problem with devalued primary care is … that most people pass over the primary care provider and go right to the specialist." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "Every employer should have every broker sign a compensation disclosure form." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "If you think there's perverse incentives on the medical side … it gets even worse on the pharmacy side." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits What changes do employers find when they follow the road map to taking control of their healthcare costs? @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "It's not uncommon for us to reduce total healthcare spend for an employer by between 20% and 40% at the end of the first year." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "I can't change [the] outcome without changing the path you walked to get there." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "Going self-funded is where the journey starts, not where it ends." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "If most employers truly understood how badly these carriers and health systems are taking advantage of them … [it's almost like] Stockholm syndrome." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "The only legitimate fear that employers should have is, How do they message these changes … to the employees?" @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits "This has to happen, and if it doesn't happen, the system's going to break and … be picked up by entities that are, I think, only going to make the situation worse." @dcontorno discusses #employers and the #medicalindustrialcomplex on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthbenefits Recent past interviews: Click a guest's name for their latest RHV episode! Nikki King, Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316)

My overarching thought throughout a lot of this interview was that improving rural health will take everyone remembering to not let perfect be the enemy of the good. If I live in rural America, there's no subspecialists. Forget about even seeing a garden-variety kind of specialist. I might have to drive hours to even get to a PCP. There are NPs (nurse practitioners) in a lot of these remote communities, but everybody's fighting over whether to let them practice independently, even in places where there's zero PCPs for hundreds of miles, effectively leaving everyone in the vicinity with basically zero access to any care. Or here's another issue: Maternal mortality in this country is not only heartbreaking—a mother dying in what should be a precious moment—it's also embarrassing as an industrialized nation to be so far in last place. I don't know this for a fact, really, but women who have to drive literally hours to see a provider during their pregnancy or—God forbid!—they go into labor unexpectedly … is that a factor in our horrific maternal mortality rates? Consider that in Canada, which has, by the way, substantially better maternal mortality rates than the USA, PCPs and NPs deliver babies in low-risk pregnancies even in areas that have access to ob-gyns, unlike a lot of rural America. When do we start wondering if we're letting perfect be the enemy of the good? When do we start considering if no access to care is worse than some access, even if the "some" access is not with, perhaps, the ideal type of provider? These are not questions with easy answers, so we need data. We need to think in shades of gray—not in binary terms where good and bad have static definitions unaltered by wildly different circumstances. That said, one way to potentially make many parties happy might be to do something like the Nuka system has done for Native Americans in rural Alaska. Listen to EP312 for more info on that. It's pretty cool. But let's just back up a sec with a little situation analysis: The thing with rural hospitals closing—and they are surely running in the red and closing—is the very pernicious cycle that develops. A hospital closing is kind of a bellwether for a community caught in a downward spiral in ways I did not realize until my conversation with Nikki King in this healthcare podcast. The main industry shuts its doors—maybe coal, or I grew up in a steel town when they were "closing all the factories down." That was a Billy Joel quote there, and I spent a few years as a kid in the very same Allentown that song is about. Community trauma is no joke. Oh, and also, now there's no commercial lives. So, say the hospital in that town isn't prepared for this new payer mix reality and it closes. Then maybe a few hundred doctors and nurses move away, along with their spending habits, so other jobs go away. Then the more affluent senior citizens don't move back to their hometown to retire because who wants to live in a town with no hospital? Also, young families who have a choice might choose to go elsewhere. Former population centers start to disperse, and now there's not even a population big enough to support a hospital even if one would decide to go there. And when that hospital goes, so does its maternity department—and likely, even OB/GYN practices. Forget about a laborist. You then will have local PCPs leave town because, right, a PCP connected to a hospital can make twice as much as an indie. Reference the huge number of PCPs in this country who are employed by a health system. Most of these employed PCPs will not work in rural communities where their employer health system has no facilities to refer to. There's no jobs there for an employed physician. Obviously, no specialists can stay in business in this environment either. Things go from bad to worse: Child abuse rises, and multigenerational diseases of despair start to set in. And there's no healthcare to treat these diseases or prevent them. Things go from bad to worse to even more worse. In this healthcare podcast, I am honored and thrilled to talk with Nikki King, DHA, who offers up three community-centric ideas around solving the crisis of access that people in rural communities face. In short, these ideas include: Freestanding ERs (ERs that have the financial discipline to not take advantage of the communities they claim to serve, that is) Telehealth that recognizes broadband issues, which is possible Expanding nurse practitioner rights and maybe even the scope of PCP practices to, for example, include maternity care for low-risk pregnancies in areas that have zero or very minimal access to healthcare otherwise Here's the shorter-than-short version: Perfect can't be the enemy of the good when we're talking about some of these communities that have no healthcare options. Nikki King grew up in Kentucky in the coalfields of central Appalachia. She managed a behavioral health and addictions unit at a critical access hospital and also worked in biostatistics. She is on the board of directors of the Indiana Rural Health Association and has developed policies as a member of the National Rural Health Association, among a whole list of other achievements. Nikki is innovative and compassionate, and she understands the culture of those she serves. She talks about a few things that she worked on during the pandemic that are truly inspirational. You can learn more by emailing Nikki at king.nikki2014@gmail.com. You can also connect with her on LinkedIn and follow her on Twitter. Nikki King, MHSA, DHA, was born and raised in the coalfields of Southeastern Kentucky. Prior to working in the healthcare industry, she worked for the Center of Business and Economic Research studying models of sustainability in rural communities with a single economic engine. She has been working at Margaret Mary Health since 2015, occupying roles in clinical statistics, as well as currently managing the behavioral health and addiction services department. In addition to her role at Margaret Mary, Nikki completed her DHA at the Medical University of South Carolina and her MHSA from Xavier University. She currently serves on the Indiana Rural Health Association's Board of Directors, the American Hospital Association's Opioid Stewardship Advisory Group, and the National Rural Health Association's Policy Congress and Government Action Committee, and as the Board Chair of Rural Health Leadership Radio Board of Directors. 05:57 How dire is the rural hospital situation right now? 06:18 How could freestanding ERs be a potential solution for rural hospitals? 08:21 What are other potential rural health access solutions? 09:25 Why is broadband a roadblock to telehealth as a solution for rural health access? 14:06 The "hot potato" of nurse practitioners in the healthcare world. 15:05 "The number of residencies for physicians each year is not increasing, but the population … is increasing." 19:06 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care. 20:41 What's the issue with maternity care in rural America? 22:53 "As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse." 26:50 How is mental health care affected in rural communities? 27:23 "Rural communities are trying very hard to hang on to what they have." 28:49 "When you look at the one market plan that's available in a rural community, you probably can't afford it." 30:39 What's the single biggest challenge to moving to a model that incentivizes keeping people healthy? 31:33 "The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare." You can learn more by emailing Nikki at king.nikki2014@gmail.com. You can also connect with her on LinkedIn and follow her on Twitter. @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth How dire is the rural hospital situation right now? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth How could freestanding ERs be a potential solution for rural hospitals? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth What are other potential rural health access solutions? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth Why is broadband a roadblock to telehealth as a solution for rural health access? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth The "hot potato" of nurse practitioners in the healthcare world. @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth "The number of residencies for physicians each year is not increasing, but the population … is increasing." @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth What's the issue with maternity care in rural America? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth "As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse." @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth How is mental health care affected in rural communities? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth "Rural communities are trying very hard to hang on to what they have." @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth "When you look at the one market plan that's available in a rural community, you probably can't afford it." @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth What's the single biggest challenge to moving to a model that incentivizes keeping people healthy? @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth "The easiest low-hanging fruit … is having national Medicaid and have that put under the same hood as Medicare." @NikkiKing0911, DHA, discusses #ruralhealthcare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #ruralhealth Recent past interviews: Click a guest's name for their latest RHV episode! Olivia Webb, Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews

Here's the cold hard truth: The whole specialty pharmacy operational model is not built to serve patients, a fact that becomes crystal clear when you're a patient. Instead, the specialty pharmacy model is, rather, pretty blatantly dedicated to the power struggle for revenue and captive patient populations. It's war between providers and the whole PBM/insurer/specialty pharmacy vertical consolidations. Employers and pharma manufacturers are, of course, on the battlefield as well. The patient, meanwhile, gets to be more the product than the customer if you think about. It's probably more similar than anyone would like to admit to the way that Facebook or Twitter users are the product, not the customer. This analog is not entirely parallel, but there's unsettling similarities if you think about it. What is a drug that qualifies to be a specialty pharmacy drug? Usually, these drugs are complicated to store, dispense, to use, and/or they're expensive—generally, really expensive. Lots of zeros, completely unaffordable to pay cash for them as an individual. No one is using a GoodRx card and not using their insurance to pay for these puppies. They can cost as much as a house. Biologics, for example, usually considered specialty drugs—lots of cancer and immunology therapies, injectable medications, IV/infused medications—all these are usually considered specialty drugs. There's no one definition of a specialty drug. It's more that someone somewhere decided to not run the drug through your traditional retail pharmacy for any number of reasons. The problem with the current status quo, wherein the patient gets tossed around while everybody fights over them, is that some basic needs are not being met—like if a patient asks the person administering the drug maybe even a pretty simple question about the drug or its side effects. It's way more likely than it should be that the nurse or whomever doesn't know the answer. Not knocking nurses here at all but definitely knocking a system that allows that to happen. I mean, really now. We're injecting a six-figure therapy in someone's arm that will impact their body in a myriad of maybe frightening ways, some of which are a problem and some of which are not. Said another way, there's a really good financial and clinical use case for making sure that we're patient-centric at a specialty pharmacy point of service—if you care about the patient and cost efficiency, that is. But I guess therein lies the root cause of the trouble. In this healthcare podcast, I'm talking with Olivia Webb about what it would take and be like to create a "patient-first specialty pharmacy," as she has coined the term—a specialty pharmacy dedicated to patients not only having a half-decent experience but also one that might actually create better patient outcomes. Olivia Webb is author of the Acute Condition newsletter. I would certainly recommend subscribing. Coming up, we're doing a few more shows on this topic wherein we cover the whole brown bagging, white bagging, clear bagging extravaganza. Also, hospitals opening up their own PBMs, which is a fascinating wrinkle. One last thing: If you're following the whole PBM/insurer/specialty pharmacy vertical integration skullduggery, keep an eye on a bunch of lawsuits against these combined entities (three examples here, here, and here) alleging that they are doing some not super upright and honest things with their massive market power. (Say it isn't so!) You can learn more at acutecondition.com. Olivia Webb, PharmD, is a healthcare strategist and writer. She publishes the weekly healthcare newsletter Acute Condition, in addition to writing freelance pieces. She also works as a senior communications manager at the specialty care start-up Thirty Madison. In the past, Olivia has worked on healthcare policy and hospital consulting at Economic Liberties, Massachusetts General Hospital, and Advisory Board Company. 04:11 Why did Olivia start thinking about a patient-centric specialty pharmacy? 05:33 "There's really no layer on top of it to make it look nice." 06:23 "You're kind of dealing with this vertical stack that doesn't really deal with patients frequently." 06:35 Is the specialty model more patient friendly or less? 07:08 What would a patient-centric specialty pharmacy look like? 07:58 "There's a lot of fragmentation; there's a lot of friction." 08:11 What's unique to specialty pharmacy prescriptions? 10:38 Why can infusion centers be a high-drama place? 12:15 What's "the question" around specialty pharmacy? 12:42 Who has the vested interest in ensuring patients take their medications correctly in specialty pharmacy? 14:39 "It's really just a unique area of healthcare where the people that I think of as the good guys and the bad guys completely flips." 16:05 Why might the time be ripe for disruption in the specialty pharmacy area? 19:56 "There's no one with a clear incentive to cap the prices." 20:09 What are the barriers in specialty pharmacy? 20:31 "The patient just isn't at the center, the financial incentive, in any direction." 29:22 "I think people who are designing these things need to see how patients are actually doing it." 29:50 "I think there's a lot of money here; I think this market is going to only increase in size." 30:10 "I think you need scale." 30:20 AEE15 with David Carmouche, MD, of Ochsner. You can learn more at acutecondition.com. @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why did Olivia start thinking about a patient-centric specialty pharmacy? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth "There's really no layer on top of it to make it look nice." @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth "You're kind of dealing with this vertical stack that doesn't really deal with patients frequently." @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is the specialty model more patient friendly or less? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What would a patient-centric specialty pharmacy look like? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth "There's a lot of fragmentation; there's a lot of friction." @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's unique to specialty pharmacy prescriptions? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why can infusion centers be a high-drama place? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's "the question" around specialty pharmacy? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why might the time be ripe for disruption in the specialty pharmacy area? @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth "It's really just a unique area of healthcare where the people that I think of as the good guys and the bad guys completely flips." @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth "The patient just isn't at the center, the financial incentive, in any direction." @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth "I think people who are designing these things need to see how patients are actually doing it." @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth "I think there's a lot of money here; I think this market is going to only increase in size." @OliviaWebbC of @thirtymadison and the #acutecondition newsletter discusses #patientfirst #specialty on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Brandon Weber, Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14)

I was listening to a panel discussion and heard Brandon Weber use the phrase the "barbarians at the gate" of the healthcare industry. I think I reached out to invite him to come on the podcast before the end of the segment. But at risk of spoiler alerts, let me sum up what I think is so interesting about Brandon's insights, which he talks about on the show. First of all, it isn't an "oh, heavens, some companies out there are trying to disrupt the status quo," like this is some sort of news flash that hasn't been tossed out with police lights and sirens however many times already over however many years. Brandon gets into the sheer magnitude of what's going on, right now, from a capital investment standpoint but also from a human capital standpoint. How many crazy smart proven disrupter-type people have come along with that capital? Brandon also touches on something I've been thinking about lately: coalition building, for lack of a better word for it. If we have status quo behemoths with market caps of a third of a trillion dollars out there, some start-up who is super happy to have scored a however-many-million-dollar seed round is not a threat in and of themselves. But if many of these littles are aligned and working together in win-win ways that ultimately take market share from the big dogs, now things get interesting. So, while much attention is focused on point solutions that disrupt some aspect of care delivery, we might want to take another look at the less visible entities that are putting platforms underneath: the companies that are building out services that offer economies of scale, that create "pipes" helping patients connect with appropriate solutions that make this emerging market just work better. It's these platform companies, combined with a general willingness to collaborate, that make ganging up a sort of natural strategy to build a really flourishing ecosystem. And it's that whole ecosystem that I would consider the most likely disrupter within an industry very much designed for the big to get bigger. Anecdotally, I see both of these ecosystem-building factors happening (ie, the platforms and then also a really unprecedented level of collaborative, all-boats-rise kind of thinking). There are communities like the one that Brian Klepper runs for benefits professionals or Health Tech Nerds or outofpocket.health. But based on what I see in these groups and elsewhere, the sharing and helpfulness is really encouraging and heartwarming if you're not an incumbent, I guess. My guest in this podcast, as mentioned, is Brandon Weber, who is the CEO and founder of Nava. This is one of those foundational-type upstarts. Brandon's company Nava is a benefits brokerage but one that's built on a platform that crochets together everything it takes to support a best-practice employer health plan. For example, point solutions have to be easy to buy and fold in, while on the back end, all of those point solutions and others need access to the right data so that appropriate employees can be engaged and make the most of the benefits offered. If you think about it, it's easy to see how having a really strong foundation here amplifies the value that can be delivered and accelerates change management. Coming up also, stay tuned because I'm interviewing Kristin Begley about optimal digital front doors, which is sort of an extension of the conversation that you'll hear in this episode. You can learn more at nava.io or by visiting their LinkedIn page. Brandon Weber is the cofounder and CEO at Nava, a modern benefits brokerage on a mission to provide high-quality, affordable access to healthcare to all Americans. By melding cutting-edge tech solutions with deep industry expertise, Nava aims to fix healthcare, one benefits plan at a time. Prior to Nava, Brandon cofounded VTS, a tech-driven leasing and asset management platform that transformed the commercial real estate marketplace. Trusted by over 45,000 brokers and asset managers around the globe, it's now used in over 50% of all office buildings in the United States and is consistently ranked one of New York's best places to work. Outside of work, he enjoys retreating into nature and is passionate about backcountry skiing, mountaineering, and trail running. 04:13 What does it mean to have "barbarians at the gate" of healthcare? 05:32 What is the overly complex gate to healthcare? 07:28 "No one can make the argument that we've seen this before." 08:37 Are the "barbarians" in healthcare going to expand the system that already exists? 09:25 What is the number one pain point in healthcare? 13:25 "Typically, the innovation doesn't come from the incumbents." 17:16 "We were actually just blown away by the amount of innovation that is already happening … [in] care delivery." 17:58 "The future is actually here; it's just not evenly distributed." 18:08 Why is there a need for a distribution layer in healthcare? 20:57 "Everyone is vying to be that one app in the pocket that acts as the aggregator, the hub, the steering point." 26:32 "If you build it, they will come … that is absolutely not true in [healthcare]." 29:46 "The benefits broker is likely the most underappreciated stakeholder in the healthcare industry." You can learn more at nava.io or by visiting their LinkedIn page. @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation What does it mean to have "barbarians at the gate" of healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation What is the overly complex gate to healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation "No one can make the argument that we've seen this before." @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation Are the "barbarians" in healthcare going to expand the system that already exists? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation "Typically, the innovation doesn't come from the incumbents." @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation What is the number one pain point in healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation "We were actually just blown away by the amount of innovation that is already happening … [in] care delivery." @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation "The future is actually here; it's just not evenly distributed." @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation Why is there a need for a distribution layer in healthcare? @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation "Everyone is vying to be that one app in the pocket that acts as the aggregator, the hub, the steering point." @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation "If you build it, they will come … that is absolutely not true in [healthcare]." @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation "The benefits broker is likely the most underappreciated stakeholder in the healthcare industry." @BrandonGWeber, CEO and founder of @NavaBenefits, discusses the gatekeepers of #healthcare on our #podcast. #healthcarepodcast #digitalhealth #healthinnovation Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW30), Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss

Here's a hot take for you. I just learned what a hot take was last week, so, of course, I needed to get me one on the quick. The thing with hot takes, from what I understand, is that they are open for discussion. What I'm talking about today is something I've been thinking about for a while, and I would be interested in your thoughts, since probably some finesse is needed here. I want to talk about the imperative of collaborating with organizations across the care continuum, even the ones you may have a problem with. Let us begin by discussing why collaboration is so vital if the intention is to improve patient care, quality, and lower costs. The story really begins with fragmentation. Turns out, the US ranks last among 10 other countries in a recent study on healthcare systems. One of the reasons why is the fragmentation of professionals and patients and siloed health information. This is from a Commonwealth Fund study. In fact, according to an AJMC article I found the other day—or do a Google search for any number of others—fragmentation is associated with increased costs of care, a higher chance of having a departure from clinical best practice, higher rates of preventable hospitalizations … Even among patients with the same chronic condition, lower quality happened and costs were higher in patients who received more fragmented care. So, nothing for nothing, but it's kinda self-evident that to fix American healthcare, we need to fix fragmentation. But to fix fragmentation, stakeholders along the care continuum have to—God forbid!—collaborate and work with each other. For more information, go to aventriahealth.com. When not hosting the show, Stacey is co-president of Aventria Health Group, a marketing agency and consultancy. Aventria specializes in helping pharmaceutical, employer, pharmacy, and health system clients improve patient outcomes by creating and leveraging collaborations with other health care organizations. For more than 20 years, Stacey has innovated better-coordinated health solutions benefiting all stakeholders and, most of all, the patient. 00:12 What's Stacey's hot take on collaboration in healthcare? 00:43 Why is collaboration so vital, and how does fragmentation play into that? 01:38 "To fix American healthcare, we need to fix fragmentation." 03:23 "Nobody gets to be holier than thou." 04:38 What is the bottom line on collaboration in healthcare? 05:20 What's the difference between collaboration and collusion? 05:35 "More is not usually better." For more information, go to aventriahealth.com. Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth Why is collaboration so vital, and how does fragmentation play into that? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth "To fix American healthcare, we need to fix fragmentation." Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth "Nobody gets to be holier than thou." Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth What is the bottom line on collaboration in healthcare? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth What's the difference between collaboration and collusion? Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth "More is not usually better." Our host, Stacey Richter, discusses her hot take on #healthcarecollaboration in our #healthcarepodcast. #healthcare #podcast #collaboration #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Brian Klepper (AEE16), Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry

This conversation starts out talking about the RUC, which is a committee run by the AMA, who has the sole source contract with CMS to figure out how many RVUs any given procedure or service is worth. There are roughly four times as many specialists on this RUC committee as PCPs. You might be able to see where this is going, but let me let our guest in this healthcare podcast, Brian Klepper, explain how primary care got trampled by the goings-on. Brian Klepper is a longtime healthcare analyst and former CEO of the National Business Coalition on Health. You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Advisors, a benefits consultancy focused on linking high-performance/high-impact healthcare organizations with purchasers. He founded and moderates a popular professional healthcare Listserv, Healthcare Hackers, which is a discussion forum on healthcare high performance and value and which has about 850 participating benefits managers, benefits advisors, and innovative vendors. An active author and speaker, Dr. Klepper has provided healthcare commentary to CBS Evening News, the Wall Street Journal, the New York Times, and the Washington Post. He has published widely in healthcare trade and academic publications and in newspapers nationally. Brian is a regular contributor to Employee Benefit News, the Health Affairs Blog, The Health Care Blog, The Doctor Weighs In, Kevin MD, and other expert healthcare blogs. He is a reviewer for Health Affairs and The Journal of Ambulatory Care Management. He is an advisor to the Lundberg Institute and to several for-profit healthcare organizations. In his spare time, Brian is an offshore sailor. 01:00 What is the RUC? 03:18 What is the goal of the specialists in the RUC? 04:32 Why health plans and not health systems? 06:55 "All this time, the hospital community was waging war against the HMO community." 07:59 "The incentives that have been at play have been very formidable." 08:23 "Primary care has developed a reputation for being the easy specialty … and it's just not so." You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What is the RUC? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What is the goal of the specialists in the RUC? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Why health plans and not health systems? @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "All this time, the hospital community was waging war against the HMO community." @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "The incentives that have been at play have been very formidable." @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "Primary care has developed a reputation for being the easy specialty … and it's just not so." @bklepper1 discusses #primarycare on our #anexpertexplains #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Recent past interviews: Click a guest's name for their latest RHV episode! Brian Klepper (EP335), Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312)

In this healthcare podcast, I'm talking with Brian Klepper. If you haven't heard of him, Brian's a longtime healthcare analyst and former CEO of the National Business Coalition on Health. This interview takes off like a shot, as most of my conversations with Brian Klepper do. We're talking about primary care and its various iterations. We start out with Exhibit A—the HMO version of primary care from the '90s. This is a great comparator to really get a handle on what's going on today. During the heyday of HMOs (back in the '90s), primary care was basically a glorified gatekeeper kind of doing two things. On one hand, they were restricting access. It wasn't an accident that it was really hard to get an appointment with a PCP. On the other hand, it also wasn't an accident that, once you got there, the PCP only had 7 minutes to spend with you, which basically meant that you left with an appointment to see a specialist at, of course, the health system that probably had just bought that PCP practice. Everybody's happy then, right? Specialist volume goes up, they make a ton of money for the health system, plans make a ton of money because they make a percentage of total healthcare spend … Oh right, everybody's happy except the patient who can't get care and the PCP who can't do their job. By the way, for more information on why the '90s version of the HMO industry crashed and burned, listen to my conversation with Alex Jung on this exact topic. A big part of the "why" really actually took me by surprise. But back to primary care … Today, in broad strokes, we have three kinds of PCPs. And when I say three kinds of PCPs, we're not really counting urgent cares or what amounts to urgent cares in that mix—meaning, not counting a lot of the retail clinics because they don't really manage patient care like you'd hope a PCP would manage care. Last I checked, none of them were managing much more than an episodic visit. You can't manage a chronic condition in 15 minutes. So, like I said, there's three kinds of PCPs that are around today; and let's call the first kind the OPCP, the original PCP. This version of the PCP office is primarily fee for service (FFS). Maybe they have a couple of capitated contracts. But the distinguishing factor isn't really what their payer mix is. It's that they're not taking on much risk or any risk of real consequence. Second, we have direct primary care doctors. This group tends to cut out insurers and work directly with either employers or patients themselves. They take a monthly fee, and, in general, a patient can see them however much they need to. Again, no risk or little risk is assumed here beyond the primary care services themselves that are rendered. Third, we have what Brian calls industrialized primary care—or some people call it advanced primary care, or APC—but I'd probably call it something different. I'd call it "taking risk for the full continuum of care" primary care. Maybe I wouldn't even call it primary care at all because this third category really is starting to color outside of the lines of primary care. This third iteration requires many things to accomplish. It requires an unimpeachable relationship with the patient; you cannot be successful with this otherwise. It requires great virtual/digital capabilities. It also requires data—data to help ensure that care gaps are filled but also to make sure that patients are referred to high-quality, high-value specialists downstream who will actually create outcomes. It also includes optimizing specialty pharmaceutical usage, for example. Brian gets into this and how a state employee health plan is on track to save $1.3 billion in this fashion. Brian believes that this third iteration of primary care—this APC industrialized primary care—is the third leg of a three-legged stool that is needed to transform healthcare. If you must know, the second leg is identification and the use of high-performing specialty services; and the third is value-based reimbursement environment. Most of the second half of this conversation with Brian is about why there's just a flurry of investment into various forms of these advanced or just maybe even regular primary care models and how they might evolve moving forward. I ask Brian about Carbon Health and their recent claim that they can do primary care with about 25% to 30% EBITA, even at Medicare FFS rates. So, there's that. One last thing: Next week, we'll be posting an "Ask an Expert" with Brian Klepper, where he gives the backstory about how the RUC—that AMA committee—basically killed primary care. So, come back for that show after you're done with this one. It's a plot full of intrigue, that's for sure. You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. Brian Klepper, PhD, is a healthcare analyst, commentator, and entrepreneur. He is a Principal of Healthcare Performance Inc, a healthcare strategy and business development practice, and CEO/Principal of Worksite Health Advisors, a benefits consultancy focused on linking high-performance/high-impact healthcare organizations with purchasers. He founded and moderates a popular professional healthcare Listserv, Healthcare Hackers, which is a discussion forum on healthcare high performance and value and which has about 850 participating benefits managers, benefits advisors, and innovative vendors. An active author and speaker, Dr. Klepper has provided healthcare commentary to CBS Evening News, the Wall Street Journal, the New York Times, and the Washington Post. He has published widely in healthcare trade and academic publications and in newspapers nationally. Brian is a regular contributor to Employee Benefit News, the Health Affairs Blog, The Health Care Blog, The Doctor Weighs In, Kevin MD, and other expert healthcare blogs. He is a reviewer for Health Affairs and The Journal of Ambulatory Care Management. He is an advisor to the Lundberg Institute and to several for-profit healthcare organizations. In his spare time, Brian is an offshore sailor. 05:10 Is the HMO model of primary care a good model? 07:48 "Industrialized medicine is exciting." 08:59 What does primary care have the opportunity to do? 09:21 "The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations." 10:15 Where does direct primary care and advanced primary care fit into this model? 13:35 "At the end of the day, what primary care really needs to be about is … the management of life issues as well." 14:05 EP295 with Rebecca Etz, PhD.14:19 "Better relationships quantifiably translate to better care." 21:48 "Almost nobody in healthcare wants any of this to happen." 23:58 Why the huge amounts of money being invested into primary care is actually a big problem. 28:11 "We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending." You can learn more by emailing Brian at bklepper@worksitehealthadvisors.com. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Is the HMO model of primary care a good model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "Industrialized medicine is exciting." @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp What does primary care have the opportunity to do? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations." @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Where does direct primary care and advanced primary care fit into this model? @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "At the end of the day, what primary care really needs to be about is … the management of life issues as well." @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "Better relationships quantifiably translate to better care." @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "Almost nobody in healthcare wants any of this to happen." @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Why the huge amounts of money being invested into primary care is actually a big problem. @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp "We should be able to get wildly better health outcomes for about 40% to 45% of the money that we're currently spending." @bklepper1 discusses #primarycare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #pcp Recent past interviews: Click a guest's name for their latest RHV episode! Sunita Desai, Care Plans vs Real World (EP333), Dr Tony DiGioia, Al Lewis, John Marchica, Joe Connolly, Marshall Allen, Andrew Eye, Naomi Fried, Dr Rishi Wadhera, Dr Mai Pham, Nicole Bradberry and Kelly Conroy, Lee Lewis, Dr Arshad Rahim, Dr Monica Lypson, Dr Rich Klasco, Dr David Carmouche (AEE15), Christian Milaster, Dr Grace Terrell, Troy Larsgard, Josh LaRosa, Dr David Carmouche (EP316), Bob Matthews, Dr. Douglas Eby (AEE14), Dr Sheldon Weiss, Dan Strause and Drew Leatherberry, Dr Douglas Eby (EP312), Ge Bai

In this episode, host Stacey Richter speaks with Sunita Desai, PhD, a health economist and assistant professor at NYU Grossman School of Medicine, about the real-world impact of price transparency in healthcare. They break down the intended progression from transparency to consumerism to lower costs and higher quality care—and why, in practice, that progression often stalls. Sunita shares key research on the barriers consumers face when trying to act on price information, and they discuss what it will take to make consumerism an effective force in healthcare. === LINKS === 🔗 Show Notes with all mentioned links: https://relentlesshealthvalue.com/episode/ep334 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe 🫙 Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue 🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b === CONNECT WITH THE RHV TEAM === ✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/ 06:23 Why is everyone so interested in price transparency right now? 07:30 How does price transparency enable consumerism? 08:05 What are the two aspects to consumerism in order to enable it in health care? 11:01 Does access to price transparency tools lower costs and spending? 15:19 Why is there such low utilization of price transparency tools? 16:13 What's the first barrier to using price transparency tools? 17:10 Why bypassing the physician at the point of care limits the use of price transparency tools. 17:53 EP284 with Carm Huntress.23:20 EP308 with Mark Fendrick, MD.23:31 How does reducing spending with high-deductible health plans negatively affect high-value health care? 25:23 "There is not a strong correlation between prices of providers and quality." 28:48 How does a reduction in physician choices undermine price transparency? 29:30 "We owe that information to patients … it's useful for patients to know what out-of-pocket costs they should expect."