Relentless Health Value – Details, episodes & analysis

Maybe you’ve already caught Part 1 of my conversation with Shawn Gremminger, and if so, you're ahead of the game. But if not, no worries—here's the deal: I decided to split this deep dive into the 340B program with Shawn into two parts. So, feel free to jump into one or both—it’s totally up to you.

To Read The Full Article Including Links Mentioned, click here.

If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.

These episodes don’t have to be listened to in order, so you’re good to start here with Part 2. Let’s get into it!"

Right now, we are going to talk about how 340B impacts employers and commercial plans and other plan sponsors. So, if all you want to hear about is the why—as in, Why do employers care about what amounts to a program that is or was supposed to be for low-income Americans and Medicaid?—you are in the right place.

As just one example of the why should employers care if you are teetering on the edge of proceeding, did you know that if an employee or a member of a commercial plan gets a drug at a contract pharmacy participating in 340B, the employer does not get the rebate? The employer is gonna pay the list price for that med.

Wait, what? Yeah, details follow because Shawn Gremminger is gonna get into this and many other reasons why employers or anyone in the commercial market (or taxpayers, really) should care about this, as some may call it, Medicaid program. The fact is, 340B is currently so gargantuan that it creates market distortions that bleed into the prices and possibly the quality of healthcare for everybody, all Americans. And that could really matter to employer or Taft-Hartley plan sponsors.

After you listen to this show, if you want to drill in a little deeper on the “what the what” and the history of 340B, head back and take in Part 1 of this episode 448. Shawn Gremminger gives the skinny on how the program morphed over the years into a $53 billion juggernaut and is credited (or blamed) for all kinds of healthcare market consolidation and many other weird and unusual consequences that make me admire some of the folks who are truly gold medal winners in the sport of financial engineering.

If you want a summary of the points Shawn makes for why employers should care, it is your lucky day, because here you go. Here’s the four distortions in the market that Shawn talks about which impact employers:

To continue reading, please view our show notes/full article.

09:11 Why do employers care about 340B, which is a Medicaid program?

11:30 Why do I care as an employer, even if I’m not Pharma?

12:44 Why is 340B causing employers to pay significantly more for healthcare?

14:36 Study by Zack Cooper, PhD.

15:06 Why are there distorted pricing models at 340B hospitals?

21:22 Why do employers need to stop playing the blame game?

So, after some pondering, I decided to release this conversation with Shawn Gremminger about 340B in two parts. So, listen to one, listen to both, pick your poison. Shawn Gremminger came up with three really important takeaways relative to 340B, which is a feat unto itself, considering how sprawling this conversation can be. So, if you came here for some concise and actionable takeaways, you have come to the right place.

To Read The Full Article Including Links Mentioned, click here.

If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.

This first part you are listening to right now zeros in on Shawn’s first takeaway: whether or not the original intent, or the presumed original intent, of the 340B program has actually been met.

Many do not realize that 340B began life as a caterpillar. It originally, actually, was conceived as a lowly bureaucratic fix. But over the past 15 years, it has gone into a chrysalis and emerged into a 500-pound gorilla that sits in the corner of a lot of rooms, actually—probably more than many people realize. All of that being said, when you’re done listening to this first part of the convo, you should be able to competently assess whether or not 340B does, in fact, adequately help underserved communities get better healthcare—because 340B is supposed to help safety-net healthcare providers stretch scarce resources.

The second part of the show, which is a separate episode called Part 2, is how all of this impacts employers and commercial plans. And there’s two more takeaways there.

So, if you already have the gist of how we got from the beginnings of 340B to where we are in 2024 already and all you want to hear about is why do employers care about what amounts to a low-income program or was purported to be a low-income program, feel free to zip over to the second show and cut to that chase.

If you’re still with me for this Part 1—and I hope you are, because … wow, it’s a wild and tangled journey—here’s an outline of where this first part of the discussion is headed. So, for the sake of posterity and having this introduction transcribed in your inbox (be sure to sign up for the free newsletter), here you go. Here’s the outline.

Visit the full article to read more.

05:25 Shawn’s three takeaways from the 340B program.

06:04 What is the intent of the 340B program?

08:22 Read the full 32-page report of the Energy and Commerce Committee. 

09:17 Why does Medicaid have to get the best price?

13:26 Why was there a shift in how the 340B program looked starting in the mid-2000s?

15:11 Why do more than half of acute care hospitals now qualify for 340B?

18:18 How has hospital consolidation affected 340B?

20:37 What is the misalignment between how a hospital qualifies for 340B and how it benefits said hospitals?

24:11 How is a 340B designed for hospitals to make a profit?

28:45 Why isn’t there a real patient definition in 340B?

31:46 Why is 340B still popular among policymakers?

33:05 Are 340B dollars being used in underserved communities?

33:57 EP394 with Vikas Saini, MD, and Judith Garber, MPP.

To read the full show notes with links mentioned, be sure to visit our episode page and consider signing up for our free weekly newsletter.

Episode 443 of Relentless Health Value pays tribute to the late Marshall Allen, an investigative journalist dedicated to exposing injustices within the American healthcare system. Hosted by Stacey Richter, the episode features Dave Chase, founder of Health Rosetta, who shares memories and insights into Marshall's tireless work in investigative reporting.

The episode highlights Marshall's impact on healthcare legislation, his significant contributions to ProPublica, and his book 'Never Pay the First Bill,' which empowers patients and employers to fight back against corrupt billing practices.

The episode also includes an earlier interview with Marshall, focusing on his perspective as an investigative reporter, the exploitation within the healthcare system, and the importance of patients and employers demanding transparency and fairness. The episode encourages listeners to continue Marshall's legacy by subscribing to the Marshall Health Academy and purchasing access for employees.

09:28 What’s the point of view that Marshall is coming from with his investigative reporting?

09:57 “How does this affect the people who are paying for it and the people who are undergoing the care?”

10:49 “There’s a lot of good people working within this very messed up system.”

11:03 Why are patients considered outsiders in the healthcare system?

11:45 “What’s happened in healthcare is that the stakeholders treat each other more as the customer.”

13:45 What is upcoding?

17:18 “These are schemes that have been created within the industry to increase revenue.”

17:46 “This system is not set up for the benefit of the patient.”

18:13 “On the financial side, the industry is actually oppressing the American people.”

19:14 “We have been expected to pay whatever aggregate sum is thrown at us.”

20:21 Why have patients been so passive toward this crooked healthcare system so far?

22:05 What’s the difference between making a profit and profiteering?

29:45 What are the first-order and second-order consequences of what’s happening in health care right now, and which of these consequences will actually drive change?

30:45 “When you tell the truth about what’s going on … they become so ashamed … that they change their behavior.”

32:00 “The patient … is not their most important customer.”

32:50 “The sleeping giant is the employers.”

This show was one of the most popular episodes in the past 12 months, so enjoy this encore while I am in Chicago moderating a panel on pharmacy benefit management at the WTW Conference Board.

But while I have you, I just wanted to thank everyone for listening. You really are a part of our Relentless Tribe, and I could not thank you enough for your commitment to doing the right thing for patients and for this country—and that dedication is evidenced by you listening as often as you do to Relentless Health Value. Our show has the largest following of individuals who are truly pushing hard for patients over profits, and since, according to LinkedIn anyway, 40% of our listeners are at the “highest level of seniority in their organization,” I’m guessing that we have the muscle to do this thing. Thanks for being part of the Relentless Tribe and for all that you do.

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 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: 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 principal of Worksite Health Advisors and a nationally prominent healthcare analyst and commentator. He speaks, writes, and advises extensively on the management of clinical and financial risk, on high-performance healthcare, and on realizing the potential of primary care.

His current focus is on high-performing healthcare organizations that consistently deliver better health outcomes at lower cost than usual approaches in high-value niches and how, integrated with advanced primary care, they can be configured into turnkey comprehensive high-value health plans that can disrupt the status quo.

05:59 Is the HMO model of primary care a good model?

08:36 “Industrialized medicine is exciting.”

09:44 What does primary care have the opportunity to do?

10:06 “The problem that goes along with that is that now immense amounts of money are being infused into primary care organizations.”

11:00 Where does direct primary care and advanced primary care fit into this model?

14:19 “At the end of the day, what primary care really needs to be about is … the management of life issues as well.”

14:48 EP295 with Rebecca Etz, PhD.

15:03 “Better relationships quantifiably translate to better care.”

22:21 “Almost nobody in healthcare wants any of this to happen.”

24:30 Why the huge amounts of money being invested into primary care is actually a big problem.

28:43 “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!

Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert

I saw a Tweet from Farzad Mostashari, MD, the other day; and I’m gonna rewrite it in the context of today’s show:

This is why we can’t have nice things! As soon as someone comes up with something that might accomplish some good things when done in moderation and with good intent, it gets exploited for revenue maximization.

I have to admit, this conversation with Aaron Mitchell, MD, MPH, and actually the one with Mark Miller, PhD (EP380), from two episodes ago were both kind of painful for me—and let me tell you why. It’s the same reason I find conversations painful about hospitals or leading cancer centers or even some self-insured employers and EBCs (employee benefit consultants): It hurts my heart when some percentage of healthcare industry peeps who have the opportunity to produce so much good in the world instead choose to do stuff that is financially or otherwise toxic.

But let me get to the point of today’s show. Dr. Aaron Mitchell and I are talking about conflicts of interest (COI), and we’re talking about COI in the payments that are made from Pharma to physicians. COI might mean when physicians are paid in a way that skews their clinical decision-making. Nobody wants to be the patient of a physician with skewed decision-making, after all. That’s the “why” of this whole discourse.

Now, let’s get into two important points re: skewed decision-making. Any payment that skews decision-making is, in fact, considered no bueno by the current writing of the AKS, the anti-kickback statute. Second, almost any payment, direct or indirect, turns out, skews physician decision-making.

It’s not just getting paid the big bucks to make a speech or consult or whatever. Getting a modest free lunch can also have the same effect. Prescribing is affected. That’s what the data show and what the recent paper that Dr. Aaron Mitchell and his colleagues published in the Journal of Health Politics, Policy and Law articulates. Their paper is titled “Industry Payments to Physicians Are Kickbacks: How Should Stakeholders Respond?”

So, hmmm. Much to cogitate upon in what I just said, which is what the conversation with Dr. Aaron Mitchell that follows is all about. But let me offer up a few spoilers and maybe some additional thoughts.

First of all, some “Are payments COI and kickbacks?” contemplations are pretty black and white. We start out the conversation in this healthcare podcast talking about the recent Biogen incident, I guess I’ll call it, which is sadly not an outlier. Biogen never admitted any wrongdoing here. But if what they are accused of doing is true, this could be considered not a gray area. This is black-and-white COI—unquestionably should not happen.

But where things get a little bit more open to interpretation and require some consideration and thoughtfulness is if we’re trying to weigh the gray in the middle between black and white. Here, what needs to be thought through is the aggregate good versus the aggregate bad of Pharma paying physicians to do stuff or buying things for them. If Pharma needs help during its clinical trials to figure out a breakthrough therapy and they want to talk to leading experts in a specialty, that’s maybe a good thing so that they can get a drug that actually works well for patients.

So is—and this is me talking, not Dr. Mitchell—but I could see that Pharma helping to figure out ways to educate clinicians about the best ways to help patients suffering with real diseases that nobody else is making any effort to do anything about at a national scale … it could help humans live better lives if Pharma takes the advice of the right thought leaders and helps to disseminate their teachings.

Maybe physician societies could fill this role, but a lot of times, who needs educated are not the actual doctors in the society in question. It’s other doctors the patient is seeing who don’t realize the root cause is a GI problem or CKD (chronic kidney disease) until the patient needs a liver transplant or “crashes” into dialysis in the ER.

But irrespective of the validity of my musings here, the point is to quantify the in-aggregate “good” that might happen as a result of Pharma paying appropriate clinical experts appropriate amounts.

Contrast that aggregate good against some not so good. Study findings that Pharma can drive up not only Rx’s (prescriptions) for its own drugs but also drugs in general when they buy stuff for doctors or pay doctors. Patient populations get overmedicated when compared to a baseline as a result. Too many patients get diagnosed and treated for some condition that they may not actually have. Too many expensive me-too drugs get prescribed at big unnecessary costs to patients, taxpayers, and employers. When I say costs to patients, by the way, I also might be implying a clinical overtone here as much as a financial one, because there’s almost no drug that comes without side effects.

So, what are some solutions that Dr. Aaron Mitchell mentions in this episode, or I that bring up, if we are trying to steer physician payments into the aggregate good zone and out of the bad COI zone? Here we go, and these are not necessarily in the order in which they are discussed:

1. Keep an eye on practice patterns and overall costs. This might make physicians aware when their clinical decision-making is getting swayed, so to speak.
2. Get payers involved. Listen to this whole episode for the “how” and “why” here, but if anyone has a visceral reaction to this, here’s one possible positive from a physician standpoint: It could be a way to get rid of a lot of PAs (prior auths). If a doc’s practice pattern is average, on trend, and/or they do not take industry dollars, then they get what amounts to a PA gold card. With that carrot, a doc may have less inclination to let their prescribing decisions sway and/or take pharma dollars.
3. The federal government can get involved in a few ways that Dr. Mitchell talks about. One of them is a direct ban on all payments. Or maybe they could just clarify what is okay and what is not okay, since what is listed as COI in the current AKS is also currently considered an industry norm.
4. Asking providers themselves to pay attention and self-regulate and to, for example, not accept speaking gigs where they are paid to talk to an empty room or “consult” on topics that really they should know they’re not thought leaders in.

You can learn more at Dr. Mitchell’s personal profile on the Memorial Sloan Kettering Cancer Center Web site.

You can also connect with Dr. Mitchell on Twitter at @TheWonkologist.

Aaron Mitchell, MD, MPH, is a practicing medical oncologist and health services researcher. He is an assistant attending at Memorial Sloan Kettering Cancer Center in the department of epidemiology and biostatistics. His research focuses on understanding how the financial incentives in the healthcare system affect physician practice patterns and care delivery to cancer patients. He cares for patients with prostate and bladder cancer.

07:32 How does the recent whistleblower case serve as a good example of what shouldn’t be permissible in Pharma?

11:23 “There’s a little bit of a disconnect between what the law currently says and maybe the ideal world that we would want.”

11:56 Dr. Aaron Mitchell’s paper in the Journal of Health Politics, Policy and Law, titled “Industry Payments to Physicians Are Kickbacks: How Should Stakeholders Respond?”

14:37 How should stakeholders react to this new legislation?

17:56 What is the aggregate benefit versus risk of these payments to doctors?

19:53 BMJ paper by Tyler Greenway and Joseph Ross.

23:51 What should providers and the federal government be doing in light of this new legislation?

29:07 “It’s just always so much harder to get to the outcomes because there’s so much more that happens in between the clinical decision and then what the patient’s outcome is down the road.”

30:42 Will innovation be stifled with this new crackdown on kickbacks?

You can learn more at Dr. Mitchell’s personal profile on the Memorial Sloan Kettering Cancer Center Web site.

You can also connect with Dr. Mitchell on Twitter at @TheWonkologist.

@TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How does the recent whistleblower case serve as a good example of what shouldn’t be permissible in Pharma? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“There’s a little bit of a disconnect between what the law currently says and maybe the ideal world that we would want.” @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Dr. Aaron Mitchell’s paper in the Journal of Health Politics, Policy and Law, titled “Industry Payments to Physicians Are Kickbacks: How Should Stakeholders Respond?” @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How should stakeholders react to this new legislation? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What is the aggregate benefit versus risk of these payments to doctors? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What should providers and the federal government be doing in light of this new legislation? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“It’s just always so much harder to get to the outcomes because there’s so much more that happens in between the clinical decision and then what the patient’s outcome is down the road.” @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Will innovation be stifled with this new crackdown on kickbacks? @TheWonkologist discusses #pharma conflicts and kickbacks on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360)

I was at the PanAgora Pharma Customer Experience (CX) Summit earlier this summer. 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. You see manufacturers in the news getting fined, very publicly, by the OIG (Office of Inspector General) or the DOJ (Department of Justice) for doing stuff that is not really patient-centric by a long shot.

For those of you working at pharma companies looking to do the right thing by patients, looking to be patient- or customer-centric for reals, a couple of reality checks here which you might be able to use to spark transformation at your organization. You saw, for the first time ever, legislation allowing Medicare to negotiate for drugs to pass into law, as well as the inflation rebate. Listen to the show last week with Mark Miller, PhD (EP380), for the “why did that happen right now” full story, but the short version is this: People, voters, patients, physicians, taxpayers, policy makers … all of them are questioning the value that Pharma brings for the money being spent. I am being blunt, I know; but so is this here referendum that just happened. If you’re trying to spark change and you need a story arc that has a carrot and a stick to inspire transformation at your organization, I’m just dropping this here for you.  

In today’s environment, bottom line, being brand-centric instead of customer-centric diminishes trust. 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 motivations and goals. As we all know, for every early adopter, there are (it feels like) five laggards who will fight you tooth and nail because they do not want to transform. They like being brand-centric, and it’s been working out fine … well, up until this year, at least.

Karen Root is currently director of experience strategy at Boehringer Ingelheim, which is a pharma company. For many years prior to her current role, she was an enterprise head of brand and culture at WL Gore & Associates. What we talk about in this show is how to break down the historical “brand is king” mentality so that people want to follow with the awareness, courage, and determination to do so. Everything that we talk about in this episode can also be applied to pretty much any organizational transformation or the rollout of any innovation or new capability.

Here’s the key things that Karen talks about which are essential for an organization to transform, maybe (again) in a way that is customer-centric and/or to roll out new innovations or capabilities:

1. Leaders must communicate a compelling vision that also includes a realistic assessment of what it’s gonna take to reach that vision and offer hope and the promise that the hard work and inevitable problems will all be worth it.
2. Systems thinking—a consideration of the systems and the people who will need to be a part of the transformation, thinking through what is likely to go wrong and proactively planning for it
3. Identify the right entry point. This should be a micro-journey or a quick win so that the team can score a victory and get through the messy middle that exists in any transformation or rollout. Triple points if you can find a micro-moment that has some emotionality connected to it from your customers’ perspective or patient perspective. If you can fix a so-called moment that matters, it really matters. Consider starting by looking into call center logs, finding a common complaint, and fixing it. Do it this way and it’s harder for anybody to complain that the status quo is so super amazing and tell you to talk to the hand.
4. Determine how you are going to measure what your quick win accomplished, as well as your whole larger transformational effort.
5. Ensure you have a full story arc here that shows the before and the after that clearly articulates that the before (the status quo) is problematic and that we have to, with urgency, get to the after.
6. Never forget that we’re working with human beings here and not, as they say, rational economic actors.

One heads-up: In the conversation with Karen today, we talk a lot about the so-called J curve. As Karen says (and you can look this up), whenever you introduce a new anything into an organization, at some point, there’s gonna be a mess-up. And when something messes up, the whole team will spiral into a so-called “trough of disillusionment” or a “trough of despair,” sometimes it’s called. This is the rock-bottom hook of that J in the J curve. The thing is, if a leader’s vision isn’t sufficient or their will to continue isn’t sufficient, then the organization quits at this low point instead of working through it and coming out in a better place on the other side of the J.

And you know what happens then. From that point forward until eternity, everybody who brings up implementing an innovation or a transformation will definitely hear the lecture about the time we tried that and how it failed miserably. So, the J curve … Check it out. Don’t underestimate it.

One very last thing: If you are working for a large organization (like Fortune 500 large) and you have succeeded in moving a transformation forward (like being actually patient-centric or customer-centric, for example), hit me up. I would certainly love to hear your thoughts on how you did it and why you think you were successful and the impact that you had.

It’s been said that healthcare in this country will not be transformed because of some incremental government policy, nor will this industry transform because of some tech company who techs the crap out of healthcare.

It’s been said that the only way the healthcare industry in this country is going to fundamentally change is vis-à-vis a seismic shift in the way Americans view the healthcare industry in their understanding of what is going on and the extent to which it directly impacts lives. You and I, all of us, have heard pundits say every year for a decade (at least) that this revolution is a-comin’ and that this year … no más. Americans cannot afford to pay any more in premiums or out of pocket. We have reached the brink.

And year after year, we’ve discovered that, in fact, Americans as patients, members, and taxpayers can pay more and are willing to do so. Well, maybe right now we are actually cresting the chop. Medicare can now negotiate drug prices legislation. Maybe it’s a bit of a watershed moment here. In this healthcare podcast, I’m talking with Mark Miller, PhD, EVP of healthcare at Arnold Ventures; and this is what we talk about today: the why now—the why, all of a sudden, after years of talking and griping and nothing happening, how right now, what constellation of factors transpired that enabled Medicare drug price negotiation to become law.

You need to listen to the show to get the context, but here’s the seven main reasons by my counting that Mark Miller talks about in this episode:

1. The sensitivity of the public to just healthcare costs in general, Pharma being an easy-to-spot component of those healthcare costs
2. Sensitivity of policy makers to Pharma’s R&D claims, and non-industry-sponsored information coming out that tempers some of those research and development claims that Pharma has been making
3. Sensitivity that innovation isn’t a homogenous broad stroke when it comes to new drugs. There’s a difference between breakthrough innovations versus me-too-type drugs. Consider some new combination drug that’s, I don’t know, two generics and costs $2000 a month. There’s eyes on that kind of stuff, and if Pharma’s reputation travels in an industry-wide block, this compounds our #3 point here.
4. Sensitivity of innovation in the future versus people getting access right now to today’s innovations. If too many people (ie, voters) can’t get access to today’s meds, it’s a reach to expect them to worry too much about their future selves where, in all likelihood, they are thinking that they still wouldn’t have access to the drugs.
5. The landscape shifted, but pharma talking points did not—and the result was labeled “tone deaf” by some.
6. Voters wanted aggressive actions as a result of the aforementioned constellation of factors, and a majority of Congress people responded and either voted yes or didn’t protest overly hard, even if they didn’t.
7. Patient voices became more sophisticated. While they still might have issues with PBMs (pharmacy benefit managers) and/or insurance carriers, there’s a growing perception that the story here is more nuanced and Pharma is in that mix.

This is what we talk about in this episode: the why now, exactly and specifically. So thrilled to have had this conversation with Mark Miller, who has had, and continues to have, such a storied career.

In brief, Mark Miller ran MedPAC (Medicare Payment Advisory Commission) for 15 years. That’s a big deal. He also has held other roles at CMS and the Urban Institute. Now, Mark is at Arnold Ventures, as aforementioned, which is a philanthropic organization. He oversees Arnold’s work in healthcare.

One last thing: The legislation that just passed also includes a few other parts that impacts drugs. A big one is limiting the catastrophic Medicare Part D out-of-pockets to beneficiaries to $2000. And then there’s also an inflation rebate. So, there’s a rebate back to Medicare if Pharma raises its prices faster than the inflation rate.

Mark E. Miller, PhD, leads Arnold Ventures’ work to lower the cost and improve the value of healthcare. He has more than 30 years of experience developing and implementing health policy, including prior positions as the executive director of the Medicare Payment Advisory Commission, assistant director of Health and Human Resources at the Congressional Budget Office, deputy director of health plans at the Centers for Medicare and Medicaid Services, health financing branch chief at the Office of Management and Budget, and senior research associate at the Urban Institute.

04:45 Why did Medicare’s ability to negotiate on drug pricing happen now?
06:35 What’s different about the drug market today that allowed Medicare to gain the ability to negotiate drug pricing?
12:08 How has innovation played into drug price negotiations?
12:40 “If you limit profits, you can end up limiting innovation.”
14:03 Why was the distinction between more drugs and innovative drugs important to changing the landscape of the drug market?
15:49 More versus new and future versus now in the drug market.
19:59 “As the landscape was shifting, Pharma didn’t shift with it.”
23:00 How did voters change the landscape in drug pricing?
24:39 “Pharma did not have exclusive control over the patients’ voice.”
29:59 “The industry would largely like to just stick with the patents that they have.”
30:16 “Of course, it’s competition that ultimately drives innovation.”
31:30 “This is an exquisitely complicated market.”

@MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

Why did Medicare’s ability to negotiate on drug pricing happen now? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

What’s different about the drug market today that allowed Medicare to gain the ability to negotiate drug pricing? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

How has innovation played into drug price negotiations? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

“If you limit profits, you can end up limiting innovation.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

Why was the distinction between more drugs and innovative drugs important to changing the landscape of the drug market? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

More versus new and future versus now in the drug market. @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

“As the landscape was shifting, Pharma didn’t shift with it.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

How did voters change the landscape in drug pricing? @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

“Pharma did not have exclusive control over the patients’ voice.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

“The industry would largely like to just stick with the patents that they have.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

“Of course, it’s competition that ultimately drives innovation.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

“This is an exquisitely complicated market.” @MarkMiller_DC discusses #medicare #drugprices on our #healthcarepodcast. #healthcare #podcast

Recent past interviews:

Click a guest’s name for their latest RHV episode!

AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins

This show with AJ Loiacono is different than others you may have heard with him because in this healthcare podcast, we are not talking about PBMs (pharmacy benefit managers). We’re talking about brokers and EBCs (employee benefit consultants).

So, say I’m a self-insured employer. Here’s the big question: Is my broker or EBC helping me make the right decisions, or is he or she helping me make decisions that will make them the most money?

While there are some amazing and totally above-board EBCs and brokers out there, unfortunately, caveat emptor is a thing. Buyer beware, that is. Too many self-serving and I’m sure very charming sharks are out there circling plan sponsors.

It is currently a fact that some EBCs and brokers and even TPAs (third-party administrators) or PBMs or others take hidden kickbacks or fees or percentages. They make a lot of money, maybe the most money, in these secret ways. All this money, money paid in secret backroom deals—let’s not lose track, these dollars increase the total prices paid by plan sponsors and employees.

Now, I say this to say that my guest today, AJ Loiacono, calls 2022, right now, a “magical moment” for plan sponsors—and for straight-shooting EBCs and PBMs and all the others who are actually doing the right thing by their clients also. It’s because of the Consolidated Appropriations Act (CAA), which states quite clearly that plan sponsors can ask their healthcare and benefits service providers to disclose the money that they are making off of the plan—all of the money, not just the direct fees.

The CAA went into effect last December (December 2021), and contrary to what some people have said or may believe, it is in force right now. The field memo went out on 12/31/2021. So, the CAA is the rule right now.

And in fact, the CAA makes it imperative under ERISA (Employee Retirement Income Security Act) to do what I just said: Plan sponsors must disclose the monies that they are paying out on behalf of employees and ensure that those fees are reasonable and free from conflict. If you’re the fiduciary of the plan, you gotta disclose all these indirect and direct compensations of the people that you are paying or the people that you are paying who may be kicking back dollars to other people you are working with, unbeknownst to you. The Department of Labor is putting as much emphasis right now on healthcare as they put on 401(k) plans in the early 2000s, so this is a big deal—or it should be—for plan sponsors.

So obviously, in order to comply with the CAA, self-insured employers should be requesting from their EBCs and brokers or others that they disclose, in writing, how much money they are making off the plan. You can see why this disclosure would be necessary if the plan sponsor is responsible to determine if those payments are reasonable and seem to be free from conflict, right? You can’t evaluate something you do not know about, and if you don’t know about it, the plan sponsor is the one at risk. Ignorance is not an excuse here.

Here’s one example: What if the EBC or TPA is collecting a $40 payment per prescription from the PBM? Wait … what? Some plan sponsor is paying $40 per script in, I guess you’d call it, a commission? Yes, that is a rumored example—$40/Rx. It is basically full-on arbitrage, and if anyone disagrees, let me know why and how it’s not.

Or let’s say the EBC is making, say, $6 per script payable by the PBM, and this sum should be mailed quarterly to a PO box in another state. This was a condition, by the way, for a PBM to win an RFP (request for proposal) that the EBC wrote and picked the winner of. Yeah, you as the plan sponsor really probably want to know that this is going on because it’s your butt on the line. Maybe they are happening right now to you if you haven’t gotten the disclosures from your EBC or broker.

So, in sum, the CAA is in effect right now. Penalties can be levied right now against plan sponsors. For a deep dive into the CAA, listen to the show with Christin Deacon (EP342) from last year.  

What’s the process if I’m an employer plan sponsor? Step 1: Request in writing the dollars that your EBC or broker is making off of you. Similar to the advice that you’ll hear often on this show, ask for actual dollars, not a percentage of this or that. Ask for how much money did you (broker or EBC) make off each program that you recommended to us, and what did that total up to. Once you make that request, the EBC/broker/TPA (whoever you’re asking) has 30 or 90 days to respond, depending on who you ask. But if they do not respond, then you, the employer, should report them to the Department of Labor.

Keep this in mind: Once that EBC or broker is reported for failure to comply by anybody, meaning likely some other employer, it is only a matter of time before that information becomes public. And the second that info becomes public, I guarantee you that there’s some attorney out there just waiting to file a class action lawsuit against every other self-insured employer who uses that EBC/broker because everybody else out there is now out of compliance. Right? I’m not a lawyer and I am certainly not a class action ambulance chaser, but even I can figure out that strategy.

AJ Loiacono has been on this podcast before talking about PBMs, and in this episode he delivers, talking about the shenanigans of some brokers and how the jig is now up. AJ is the CEO of Capital Rx, which is a PBM 2.0, as they call it.

To see how the CAA is playing out, you can read about one real-life example of a school district’s lawsuit against an insurance consultant.  

Anthony J. “AJ” Loiacono is the co-founder and CEO of Capital Rx, one of the fastest-growing health technology companies in America. He has over 20 years of experience in pharmacy benefits, finance, and software development. AJ’s mission is to create the first efficient market for prescription prices and provide employer groups with the highest standard of patient care. AJ has spent his career studying the pharmaceutical supply chain and producing engineering solutions that have continually redefined the pharmacy benefit industry to achieve this goal.

Prior to Capital Rx, AJ was a co-founder of Truveris, where he served for eight years as CEO, CIO, and board member, leading the company to record growth (Deloitte FAST 500 and Crain’s Fast 50). Before Truveris, AJ co-founded SMS Partners, a joint venture with Realogy (RLGY), and in 2010 exited the partnership with a buyout. In his first venture, AJ started Victrix, a pharmaceutical supply chain consultancy, and successfully sold the company to Chrysalis Solutions in 2007. AJ is a graduate of Manhattanville College, where he studied finance while playing varsity soccer and rugby.

06:03 Who can get in trouble for mismanaging employee funds?
06:31 Who can begin the cycle for annual review?
07:53 “When you talk about conflicts of interest, they’re everywhere.”
13:17 “You’re paying for access.”
13:38 Why is it important to request that they disclose direct and indirect compensation?
14:08 What are the layers to these hidden fees and compensations?
18:17 What is a reasonable fee for a good plan admin?
19:32 “I think people need to step back and say, ‘How many different ways are they getting compensated?’”
24:57 “The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.”
25:13 “For every good broker consultant, there’s a horrible individual lurking out there and it’s easy to figure out: Ask for them to disclose their fees.”
28:14 “You can’t win if you can’t even pay the house fee to come in.”
31:42 Why do you need to ask for disclosure, and what do you need to ask specifically?
32:27 What are some of the characteristics of a good plan consultant?

AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Who can get in trouble for mismanaging employee funds? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Who can begin the cycle for annual review? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“When you talk about conflicts of interest, they’re everywhere.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“You’re paying for access.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Why is it important to request that they disclose direct and indirect compensation? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What are the layers to these hidden fees and compensations? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What is a reasonable fee for a good plan admin? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“I think people need to step back and say, ‘How many different ways are they getting compensated?’” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“For every good broker consultant, there’s a horrible individual lurking out there and it’s easy to figure out: Ask for them to disclose their fees.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

“You can’t win if you can’t even pay the house fee to come in.” AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Why do you need to ask for disclosure, and what do you need to ask specifically? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What are some of the characteristics of a good plan consultant? AJ Loiacono of @cap_rx discusses #ebcs, #brokers, and #plansponsors on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova

Okay, so … telehealth for Medicare patients. Currently, there’s payment parity, meaning a clinician gets paid the same amount for a Medicare patient visit regardless of whether that patient comes in the office or has a telehealth encounter. Right? Or did that end already? And if it didn’t end, how much longer will payment parity continue? Also, is it the same for commercial and Medicaid patients? Congress makes rules for Medicare patients, but is it Congress that makes the rules for commercial and/or Medicaid telehealth reimbursement rates? Or how do those reimbursement decisions get made?

What about the doing telehealth across state lines thing … the idea that if I’m a doc in New York, I can take a telehealth appointment with a patient in Arizona even though I am technically not licensed in Arizona? And who’s in charge of that?

Yeah, I went into today’s conversation with Josh LaRosa, VP at Wynne Health Group, with a lot of questions.

As you may suspect, this program is about telehealth. But just to level set on what we’re not talking about, this interview does not dissect the “should we use the telehealth or should we not” question; and it does not get into best practices or equity concerns. For that info, listen to the show with Christian Milaster (EP320) or Liliana Petrova (EP357) or Ali Ucar (EP362) or Ian Tong, MD (EP347). 

Also, we are not talking about the politics, per se, of who’s for telehealth and who’s against it. We also aren’t drilling too far into the telehealth fraud cases that are coming to light right now, but of course we cannot resist talking about them a little bit.

So, let me tell you what Josh LaRosa and I are, in fact, talking about in this healthcare podcast. We’re specifically discussing the near-term future of CMS reimbursement for telehealth and the allowed so-called “flexibilities” for telehealth. We talk about a few of the why’s behind why are policy makers doing some of the stuff that they are doing. And then we chat about the when, how long some of the new flexibilities and reimbursements that were permitted originally during the pandemic will continue. We touch on the Cerebral incident (I guess maybe you’d call it) and the potential DEA or legislative actions that may result from that as well.

An interesting point that we dig into for a couple minutes is this one: Do not forget that the whole telehealth reimbursement debate (do I wanna call it?)—Should we cover it? Should we not cover it? And for how much?—this whole debate is part of a bigger debate. A much bigger debate, actually: the fee-for-service vs the not-fee-for-service debate. That’s the larger context of all of this, and I think it’s often overlooked.

Nobody anywhere is limiting how often a practice who wants to use telehealth as part of some kind of risk-based or capitated thing can use telehealth. Why? Because in a capitated or bundle arrangement, from a Medicare trust fund perspective at least, telehealth visits are not equivalent to additional spend or additional volume. In a non-FFS environment, there’s little chance of fraud also, really. Also, patient safety—arguably, probably—becomes much more of a practice concern. It gets a lot less rewarding to do unsafe things over telehealth when you don’t get automatically paid to do them … and also paid to fix the problems that resulted from the unsafe things, which is the perverse beauty of FFS that we’re all so familiar with.

Acronym alert! PHE stands for public health emergency. A public health emergency is the thing the government declares, for example, during a pandemic.

Josh LaRosa, MPP, is a vice president at Wynne Health Group, focusing primarily on regulatory affairs with a focus on the US Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS). His interests lie in delivery reform and innovations in payment and care delivery models. Josh also supports the firm’s Public Option Institute, which studies the emergence of public option programs at the state level.

Prior to Wynne Health Group, Josh consulted for the CMS Innovation Center, where he worked to implement, monitor, and spread learning garnered from the center’s high-profile demonstration projects, most recently including the national primary care redesign effort, Comprehensive Primary Care Plus (CPC+).

Josh holds a Master of Public Policy from the University of Virginia’s Frank Batten School of Leadership and Public Policy. He also completed his undergraduate studies at the University of Virginia, graduating cum laude with a BA in political philosophy, policy, and law.

04:09 What is the story with telehealth policy right now?
06:08 What kind of flexibilities did HHS allow with telehealth after the pandemic?
09:46 Are we still under these pandemic flexibilities for telehealth?
12:15 Why isn’t the government just making greater access to telehealth permanent?
18:24 How does telehealth lend itself to the risk of overspending when dealing with an FFS model?
21:13 Does telehealth fit into the new CMS fee schedule?
22:55 How do states factor into the future of telehealth?
24:40 What is Arizona doing specifically to improve and ensure the future of telehealth?
30:56 What’s next in store for telehealth at the congressional level?

@josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What is the story with telehealth policy right now? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What kind of flexibilities did HHS allow with telehealth after the pandemic? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Are we still under these pandemic flexibilities for telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Why isn’t the government just making greater access to telehealth permanent? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How does telehealth lend itself to the risk of overspending when dealing with an FFS model? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Does telehealth fit into the new CMS fee schedule? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

How do states factor into the future of telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What is Arizona doing specifically to improve and ensure the future of telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

What’s next in store for telehealth at the congressional level? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai

Late in May of this year, three-ish months ago, I did an inbetweenisode that explores the “why with the no collaboration” amongst healthcare stakeholders and what the lack of collaboration signifies. That episode got a lot of traction and engagement.  

This episode that follows is a pretty good approximation of a presentation that I made at the MTVA (Moving to Value Alliance) symposium that happened in Connecticut this past June. If you listened to the earlier show about collaboration, this one is slightly different, shorter, and more to the point.

So, let’s start here: When you listen to any patient with a chronic condition talk about their challenges with the healthcare industry—and yes, if a patient has a chronic condition, more often than not, that is what they will talk about, their challenges …

I went on Twitter just now, and it took me literally 13 minutes to collect what I’m going to say are 300+ Tweets written by patients and their caregivers complaining about their chronic care journey. That’s the sad part. I don’t mean to kick this off talking about problems; however, if you’re gonna solve for something, it is important to understand what problem you are solving for. You do not want to be a solution looking around for a problem.

So, let’s fix this, this rampant problem problem that chronic care patients seem to have.

Many of the patient challenges in the 300 Tweets that I just collected can be grouped into two major categories. And these two major challenge groups can really only be solved for with collaboration amongst healthcare stakeholders. So, let’s dig in here.

The first major patient challenge is what I’m gonna call the care gap problem.

I was talking to someone at a provider organization the other day, and she had 8000 known care gaps with patients and [insert overwhelm here]. And these were just the care gaps that showed up on somebody’s radar because they added up to a quality metric, which is sometimes the definition people use for what is a care gap.

But if we think about all the other holes in patient care, the typical care gaps that are identified probably come not even close to the total number of actual care gaps: patients who can’t see their specialist because they can’t get ahold of their records from the local health system or no coordination of care. Coordination is probably another synonym for collaboration. This is a huge deal. People literally die because their clinician cannot get their biopsy results or whatever from somebody else. That’s a care gap as deep as a grave.

Or patients who keep showing up in the ER because they aren’t getting the help or the meds or the accurate diagnoses or the treatment plan that they need to stay out of the ER ... My grandfather had heart failure. At the end of his life, he was probably in the ER once a month. It was sad and painful and expensive and totally unnecessary. But his PCP didn’t seem to be collaborating with the specialists, and the ER I don’t think was telling anybody what was going on. Right? Or patients who can’t get a drug they need approved by their insurance, so they wind up in crisis. Crappy prior auth processes create care gaps. All of these things are gaps in care.

Carly Eckert, MD (EP361), was on the podcast; and she made a crucial point for me. In fact, I tried to get her to come on the podcast originally to talk about care gaps and closing care gaps; but she categorically refused. Chronic care management, she said, should not be a game of whack-a-mole. It may be better than nothing, a game of whack-a-mole; but it is certainly not ideal.  

Chronic care management by care gap is like cooking with a fire extinguisher. If we want to eliminate care gaps for reals, let’s just not have care gaps.

So, how do you go about not having care gaps, then? The goal should be to craft a non-fragmented patient journey. Let’s figure out what a great care journey looks like ahead of time and then try to keep the patient on it. That is the best way to eliminate care gaps: proactively. You don’t have them.

Immediately, because I am a person of action, I went into my filing cabinet; and I actually found an example of a patient journey map amongst my papers that I had worked on years ago. You have probably seen one of these and may have some of your own patient journey maps tucked away in a binder in your office somewhere. Most people have them. There are a few things that they all have in common, irrespective of the disease state or the organization or anything. The things that they have in common are they are complicated flowcharts with a lot going on. Besides just being complicated, the other thing that patient journey maps all have in common is that there are multiple parties mentioned with roles in that patient journey. You’re gonna have a PCP, a specialist or two, a hospital, a payer, a pharma company more than likely, a PBM maybe, maybe a community organization …

Here’s a quote that kinda sums that up from Dr. William Bestermann: “Improving chronic disease management is an enormous problem that requires multiple stakeholders coming together to combine new science, new systems, and new payment models in a comprehensive solution. No one person or organization can make progress that matters. The problem is too big.”  

Is this obvious? I think it’s pretty obvious. But yet, collaboration in general at the organizational level is less than common. With uncommon exceptions, you not only don’t have multiple providers working together but—heaven forbid!—you have payers and providers or other entities working together.

But just taking this back to the thrust of this conversation, the first major patient challenge can only be solved for with collaboration to create a non-fragmented patient journey, which reduces care gaps by avoiding care gaps in the first place. So, collaboration is a rate critical for a non-fragmented patient journey to eliminate care gaps that patients have big issues with.

So now, let’s move on now to the second big problem category that chronic care patients were Tweeting about in those Tweets that I collected: They can’t afford their care. This crisis of affordability is a huge patient challenge that, it’s not the only thing, but we can’t solve for it without being collaborative, without having collaborative relationships along the patient journey.

I don’t really want to get into how much healthcare prices have skyrocketed, but healthcare prices have been inflating at 4x the cost of everything else. This causes mental health issues; it causes stress. There’s a show with Wayne Jenkins from Centivo where we dig into this deeply. Listen to EP358.  

It is inarguable at this point that financial toxicity is clinical toxicity. I have a folder on my computer where I chuck references for this statement, and at this point, I probably have 400 studies and articles that all say the same thing in different ways with different patient populations. Most of these patients are insured. By the way, just because you have insurance doesn’t mean that you can afford to use it. And patients who cannot afford their care have worse clinical outcomes. Period. End of sentence.

Minor sidebar because I was really like head exploding emoji this morning: I saw somebody in a forum today lashing out at patients suffering with crippling medical debt saying that these people really should take some personal responsibility for the financial choices that they have made. WTH? The entity not taking responsibility for people losing their life savings and their homes simply because they had the fortune of getting sick or injured, the entity that should be taking some responsibility here is a broken, profit-driven healthcare industry.

Let me just add some fidelity to what I mean when I say “the healthcare industry,” which really should take some responsibility here for the financial toxicity that they themselves are creating. Consider that a lot of medical debt is of a balance bill nature and the people being pursued generally signed a contract which they did not understand the consequences of, because most of them had “insurance” and they certainly weren’t given a quote up-front so that they could make a rational economic choice.

So, let’s add some fidelity: How do we make healthcare more affordable? Or how do we make the charges not a complete surprise at a minimum? How do we do that?

Lots of ways, big and small, are required; but let’s talk about one of them: Navigate patients to high-quality providers charging a fair price. Navigate patients to providers who do not do low-value things and who have practice patterns that are aligned with evidence-based medicine (ie, get employers and providers to direct contract, especially in non-FFS ways, especially as it relates to primary care where there are measurable outcomes or quality). ACOs or CINs (clinically integrated networks) who know how to refer to high-value specialists or hospitals is another example of a collaboration that can help with affordability. Some health plans and TPAs (third-party administrators) are starting to get really data-driven about how they go about this. Point being, to coordinate care to or amongst high-value providers, multiple parties have to be involved (ie, collaboration).

So, in sum, we talked about two common and major patient problems, which are probably not a surprise to anyone listening. The two are a lack of coordinated care (patients falling into gigantic care gaps) and then also a lack of affordability.

We know how to solve for both of these issues. Defragment care and steer patients to high-quality provider organizations/hospitals/CoEs with competitive prices. Collaborate in these two ways. So, why are so few doing it, then?

You can always count on me to say the quiet part out loud, so here we go: The business model of most, many, lots of healthcare organizations, both for-profit and tax-exempt, is revenue maximization. As Kevin Schulman, MD, said on the podcast (EP366), it’s not A or B; we have a dysfunctional healthcare benefits system in this country.  

But nonetheless, if we want to identify a root cause for why with the no interoperability, why with the info blocking to prevent network leakage, why with the no collaboration … it’s not a technical problem at its core. It’s not a HIPAA concern, really, at its core. It’s a business case problem.

And I don’t say this as any sort of castigation. I say this because it’s actionable information. Tiptoeing around a thing that we all know just clutters our ability to come up with a solution that is actually going to work. Really understanding a pretty big root cause behind why needed collaborations don’t happen is necessary. This level of introspection is required for those who are mission driven to find others who are similarly mission driven to get a collaboration over the line.

But the good news is success stories abound. It’s my belief the healthcare industry won’t be transformed in one giant turn of some flywheel. It’s gonna be transformed one local market at a time. And there’s a lot of great stuff happening in local markets. Listen to the show with Dave Chase (EP374) for a bunch of examples. There’s a show with Cora Opsahl (EP372) that has some great examples of this. There’s the one with Doug Hetherington (EP367). We also have a show coming up in October with Nick Stefanizzi from Northwell Direct.  

All of these great examples are stakeholders harnessing the power of collaboration to defragment patient journeys and get patients into high-value care settings so that the overall cost of care is in range for employers, taxpayers, patients, and American families. I’m so excited, honestly, about that because the healthcare industry is a legacy that we will leave behind to children and grandchildren. I have a vision in my head about what I want the healthcare industry to look like in 25 years. Maybe you do, too. Listen to the show with David Muhlestein, PhD, JD (EP364), for more on that.

But the point is, if this vision is going to come true, we need to—like, right now—start building the roadmap to get to that goal. And a lot of this involves facilitating collaboration. Actually collaborating, for reals. There’s real momentum behind that in organizations such as the Moving to Value Alliance in Connecticut, where I originally gave a version of this same talk.

Thanks, by the way, to Steve Schutzer, MD, for moderating the collaboration panel that I was a part of at aforementioned MTVA symposium. Not only is he a great moderator, but he also has done a great service for patients through his ability to get a whole bunch of surgeons—who are pretty competitive as a general rule—to collaborate and form a Center of Excellence.

Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry.

In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.

01:41 What are the two major patient challenges in chronic patient care that can only be solved by collaboration?
01:56 What is the “care gap” problem?
03:19 “Crappy prior auth processes create care gaps.”
03:25 EP361 with Carly Eckert, MD.  
04:00 How do you eliminate care gaps proactively?
06:46 EP358 with Wayne Jenkins.  
08:21 What is one way to make healthcare more affordable?
09:49 Why aren’t more healthcare entities collaborating?
10:04 EP366 with Kevin Schulman, MD.  
11:13 EP374 with Dave Chase. 
11:18 EP372 with Cora Opsahl.  
11:22 EP367 with Doug Hetherington.  
11:25 Upcoming episode with Nick Stefanizzi.
12:00 EP364 with David Muhlestein, PhD, JD.  

Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast

What are the two major patient challenges in chronic patient care that can only be solved by collaboration? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast

What is the “care gap” problem? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast

“Crappy prior auth processes create care gaps.” Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast

How do you eliminate care gaps proactively? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast

What is one way to make healthcare more affordable? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast

Why aren’t more healthcare entities collaborating? Our host, Stacey Richter, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O’Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan