Relentless Health Value

I cut this clip out of episode 407 with Vivek Garg, MD, MBA, from Humana; and it’s actually a really nice follow-on from the show last week with Scott Conard, MD, where we talked about the blowback that happened with clinicians at a clinic. This clinic had put into effect a bunch of the comprehensive primary care kinds of things that Dr. Garg talks about in this summer short. But what happened in Dr. Conard’s case is a new practice manager tried to go back to the olden days, and, spoiler alert, it was a kerfuffle. All the docs and the rest of the clinicians staged what sounded like a “mutiny on the bounty” moment from the way Dr. Conard described it. So, this summer short you’re about to hear and the one from last week again share one key point: Doctors, advanced practice clinicians, medical assistants, pretty much everybody on the team really likes a well-executed, operationally excellent transformed primary care model. And it produces better patient care. I was reading Dr. Robert Pearl’s book Uncaring the o

Back at the beginning of this year, I was so sad when I had to edit out the clip that follows from the original and extremely popular episode 391 with Scott Conard, MD. In the literally probably three minutes that follows in this clip with Dr. Conard after I finish my ramblings here, Dr. Conard introduces the impact that changing the practice model in a PCP practice in Queens, New York, had on the staff and patients alike. Spoiler alert: No way no how were they going back to the old way of doing things. The “Before” here was a clinic where the waiting room was filled to overflowing out into the hall with patients waiting to be seen, and this included a mix of really sick people who really needed to be seen and also … others. And thus they had, among a whole host of other bad things going on, the whole issue of suboptimal ER (emergency room) visits and urgent care usage. Anyone who couldn’t wait just headed elsewhere. Also, as it is so many places, care was pretty transactional. A patient who wasn’t in clinic

May I just take a moment and thank the Healthy economist for leaving a super nice review on iTunes? The title of the review is “Best podcast on the healthcare industry,” and the Healthy economist writes, “There’s no one simple fix [for the healthcare industry], but [Relentless Health Value] contains valuable insights on what actions can be taken to make things better for consumers and patients.” Thank you, Healthy economist. In this summer short, I am talking with Brennan Bilberry; and we’re talking about why everybody isn’t suing health systems for behaving badly in sometimes pretty egregious ways. Why isn’t anybody stepping in to prevent all of this consolidation that we all know, at this point, is pretty bad news? FTC, where are you? Brennan Bilberry cites three reasons for the way fewer antitrust lawsuits than you’d think would be going on: 1. A continuing lack of transparency. It’s tough to sue someone when you aren’t really sure what they’re up to, and, even if you do, it’s hard to prove because you can

Thanks for joining me as we kick off the summer season. Here’s what we’re gonna talk about today in our 10-ish-minute conversation. Keeping it short and sweet. First up, we got three super interesting voice messages left by your fellow members of the Relentless Tribe that I wanted to share with you. Next up, I will cover plans for the summer, because this summer, we have plans. And then after that, just wanted to chat a little bit about what I am up to right now. Agenda item #1: Episodes 399 and 400 of Relentless Health Value were me sharing my manifesto as it were. At the end of the show, I said that if you have a manifesto of your own, to share it by going to relentlesshealthvalue.com and hitting the orange leave a voice mail button. Doug Pohl, CEO of HealthTech Content, did so; and here is what he had to say: “My name is Doug Pohl. I’m the founder and CEO of HealthTech Content, and I'm pretty frustrated by the lack of progress toward making the improvements we need for healthcare. So, I put this out there

I hope you enjoy this encore episode of one of the most popular shows in the last 12 months. One of my mentors often said price is irrelevant. He said he would sell anything for any price as long as he could define the terms of the deal. During this conversation today with Scott Haas about PBMs (pharmacy benefit managers), that quote was playing in my head like an earworm. I’m henceforth gonna struggle with the term rebate to define dollars that the PBM gets back from Pharma, because, according to my guest in this healthcare podcast Scott Haas, it turns out “rebates” comprise only about 40% of those back-end dollars that some PBMs manage to score from pharma manufacturers. I don’t have any insight really into this, but Scott Haas certainly does—and this is the average that he has seen in his work and that we’re going to dig into today. But in sum … wow! Let me just repeat that a mere 40 cents on the dollar of the gross amount that PBMs take in “rebates” from Pharma these days winds up going back to plan spons

I couldn’t resist the “who’s suing who” because, yeah, you can’t go wrong with Aretha Franklin references. Back on the pod we have Chris Deacon, who is going to give us a rundown of the legal goings-on going on right now that impact self-insured employers, carriers, hospitals, and taxing authorities like cities. Chris breaks down the legal activity into three main categories, and then we discuss some examples of lawsuits in each category. So, here’s the outline of our upcoming conversation: 1. Breach of Fiduciary Line of Cases Against Carriers a.    Bricklayers vs Anthem Class Action b.    Mass Laborers vs Blue Cross Blue Shield c.     Member vs Cigna 2. Carrier vs Hospital (upcoding) and Hospital vs Carrier (underpayment) a.    United vs TeamHealth b.    TeamHealth vs United 3. Taxing Authority vs Nonprofit Hospitals a.    Tower Health line of cases in Pennsylvania b.    Pittsburgh vs UPMC This episode itself is a little on the longer side—and I didn’t want to edit too many of Chris’s words of wisdom—

Okay … let me get real here for a sec. For a few reasons, I wanted to chat with Vivek Garg, MD, MBA. Dr. Garg is CMO (chief medical officer) of primary care at Humana. Dr. Garg is an inspiring and incredibly articulate individual, and I like to both learn from and also be kept on my toes by the likes of such folks. But also, yeah, I’m suspicious of vertically consolidated payers. I mean, you listen to this podcast. I don’t need to recap what the financialization of the healthcare industry has done to patient care. But you heard my manifesto in episode 400. It’s about trying to find the right path forward and being open to exploring options here. It’s considering what doing well by doing good actually means. It’s contemplating whether to celebrate some good stuff going on in the industry even if there’s some not-so-good stuff going on in that same sector or even in that same company. Bottom line: We’re living in the real world here, and utopia is not on the table, at least anytime soon. So, that means there is

I’m gonna run through the five reasons Lauren Vela talks about in this healthcare podcast for the “why” with the inertia in benefits departments of self-insured employers. But before I do, let me report that, in sum, they add up to … in many cases, benefits folks sit between a rock and a hard place. You really can’t poke fingers at benefits teams who don’t have the bandwidth, the resources, the expertise, or the organizational power to, in essence, run a small insurance company in-house and also do the rest of their jobs. This is especially true when benefits teams get no help or air cover from the CFO or CEO of their companies. So, the bosses are, in effect, telling benefits teams to manage the second-biggest company expense—this uncontrolled thing growing at multiples of the rates of inflation. They say, “Go get a handle on that but also don’t make any noise, don’t disrupt anything.” And meanwhile, I don’t know, is the CFO under the impression that all he/she needs to do is pop by once or twice a year, issu

In this episode of Relentless Health Value, we delve into the perplexing state of healthcare legislation in North Carolina. Unlike the proactive measures taken by other states such as Texas, Indiana, and Wisconsin, North Carolina seems to be an outlier with its current legislative actions, despite its Republican majority legislature. Normally, a bit of divergence can be intriguing, but the current direction in North Carolina raises significant concerns for families and businesses struggling with healthcare costs. The situation here serves as both a case study and a cautionary tale for the rest of the country. We examine two key pieces of legislation moving through North Carolina's Senate and House. One involves Blue Cross Blue Shield (BCBS) pushing for the ability to create a holding company to invest policyholder payments into for-profit ventures, despite BCBS being a nonprofit. Historical precedents of similar actions suggest a likely increase in premiums, as discussed by Chris Deacon. The second bill invol

Let’s cut to the chase. You’ve gotten to the point where you have a gang of physicians/clinicians/physician practices who have expressed a desire to work together. What do you need to know right now? Eric Gallagher, CEO of the Ochsner Health Network, is my guest in this healthcare podcast; and I largely asked him the same question that I had asked Amy Scanlan, MD, from the UCHealth/Intermountain clinically integrated network in Colorado in episode 402 a couple of weeks ago. The question I asked both Eric and Dr. Scanlan is: What are you doing to help align physician practices into an integrated model? How are you going about that? Now, let me remind you, Ochsner Health Network is practically long in the tooth when it comes to clinically integrated networks; and it also exists in an environment that is unique, as are most local markets. But Ochsner’s local market is mostly Louisiana, which has an older population and a huge Medicare Advantage penetration. That is quite a different local market from what’s goin

So much of this episode (and this podcast as a whole, really) is about one consistent theme: How do we reset or redesign our healthcare industry, including hospital chains—mostly talking about the big consolidated ones that have a lot of money here—but how do we redesign these leviathans to be more consistent with our values as a country and the values of the doctors and other clinicians and others who work in these places and who went into the healthcare profession for a reason that had, you know, something to do with patients? And I mean something to do with patients that doesn’t involve dressing up for Halloween as a giant cardboard dollar sign, like some finance department guy did at one large nonprofit hospital in the spirit of shaking money out of poor patients (see article here). Or listen to previous episodes about hospitals raising prices way higher than the rates of inflation. Not to belabor this because we’ve already talked about it so very often, but you also have the whole thing with big, well-fu

This is a conversation about physician compensation, which is often oddly misaligned from the way that the whole physician or provider organization is getting paid. Now, first thing to point out: There are lots of different kinds of physicians doing all kinds of different things. As with most everything in healthcare, lumping everybody together and making general proclamations about what is best is a really cruddy idea. With that disclaimer, if you think about the main models of physician compensation, there are two; and this is oversimplified, but let’s call one fee for service (FFS), which is really getting paid for generating RVUs (relative value units)—in short, getting paid for volume. The more you do (especially the more expensive things you do), the more you get paid. And then we have getting some kind of capitation payment. A capitated payment is some kind of per member per month-ish flat payment to ideally keep patients healthy, and you will make the most money if you can figure out how to have the l

So, let me just cut to the chase here with very little preamble, and all of this is a setup to the interview that follows, although it is not really what the interview that follows is all about. A mentor of mine used to say, you can’t legislate the heart. Let me also suggest you can’t give someone in finance financial incentives and then expect them to not prioritize financial incentives. It stands to reason that if the healthcare industry is found to be quite attractive to those who are money focused, then do I need to say this? The money focused amongst us will, of course, do the whatever to the extent that they can make money. They aren’t gonna be throwing their backs into quality or cost effectiveness or taking care of patients. They are throwing their backs into making money. Is anyone shocked? Now, don’t get me wrong; I’m not a Pollyanna. And in this country, in order to run a healthcare business, you have to make money; otherwise, you’ll go out of business. So, do well by doing good and all of that. Bu

Somebody wrote on Twitter the other day that he was gonna give a talk on the use of evidence in drug policy, and Barrett Montgomery replied, “That’ll be a short talk then!” So, let’s talk about the IRA (Inflation Reduction Act) for a moment, specifically the “CMS can negotiate for drugs for Medicare patients” part of the IRA. There’s one topic I don’t hear discussed what I would consider maybe often enough. Will these negotiations result in pricing that is evidence based? Will good drugs that companies developed using less taxpayer money for R&D, drugs that positively impact the patient lives or have spillover benefits for society or save downstream medical costs, drugs that have solid comparative evidence data, drugs that are a meaningful therapeutic advancement over competitors ... will these drugs be priced in line with that value? Everything I just mentioned, by the way, are things that CMS is supposed to take into account during its negotiations. So, that’s what this show is all about. To have this c

I hope you listened to episode 399, which was Part 1 of this two-part exploration of my manifesto, meaning my aims and my path or framework to achieve those aims. Regarding the first part of my manifesto, episode 399 from two weeks ago, here’s the tl;dl (too long, didn’t listen) version; but please go back and listen to that show (Part 1) because it’s about you—and it’s a compliment and a thank you, and you deserve both. Just to quickly recap, Part 1 of my manifesto is that I started this show because I want to, and wanted to, provide information to those in the healthcare industry trying to do the right thing by patients, to get you the insights that you might need to pull that off, to create a Coalition of the Willing, as I’ve heard it called. When we get reviews like the one from Megan Aldridge, a self-proclaimed Relentless Health Value binge listener, I feel very gratified because it makes me feel like I’m chipping away at this mission and in a non-boring way. Thank you, Megan. Along these lines, th

Well, this episode became extremely relevant again after that Cigna case bubbled up in the news. Here’s the “too long, didn’t read” version: Attorneys filed a class action lawsuit against Cigna, alleging that the carrier is overcharging for lab services or did overcharge for lab services. The plaintiff is an individual member of a Cigna plan. The complaint tells a pretty wild story. On the Explanation of Benefits (EOB) that this member received for lab services, the amount billed was over $17,000. My understanding is, this member went to Labcorp to get those lab services. Cigna claimed it had negotiated a discount of over $14,000 for those lab services, meaning the remaining balance was something like $2700. OK … good news, I guess. Instead of the lab services costing $17,000, they cost $2700 to the plan and member. Except Cigna said to this member that they were only gonna pay $471 on the member’s behalf. This left the member with the responsibility to fork out over $2000 in deductible and coinsurance

This week and in episode 400 of Relentless Health Value, at the encouragement of the Relentless Health Value team, I’m gonna do two shows entitled “My Manifesto,” Part 1 and Part 2. In other words, why did I start Relentless Health Value and what’s the goal around here? I started contemplating this mission to define the mission thinking about how healthcare will ultimately be transformed and my role (if any) in all of this—or, more accurately, your role as a listener of this show and, often enough, someone who has the ability to take action. You there, listening right now, you are the alchemist who will transform the words that you hear here into something tangible. And that is how this show makes a difference. It is through the Relentless Health Value Tribe, and you, whether you realize it or not, are a very special person. But before I continue along this complimentary vein, let me back up for just one sec and talk about how I realized how special you are to begin with. It’s a funny thing because I get

Yeah, so while the commercial payer marketplace is completely boring, the reasons it’s boring are not. Let me walk you through this conversation I have in this healthcare podcast with Jacob Asher, MD. First, we establish that the relative number of each carrier’s commercial members in California don’t seem to change year over year … and this has been true for years. When you rank order carriers by member count, the song remains the same. It’s Groundhog Day. Here’s a link to the 2022 CHCF (California Health Care Foundation) enrollment almanac, which shows for the large group market, Kaiser has captured and retained just over half of enrollees. Anthem comes in next with 14%, Blue Shield gets 9%, and then bringing up the rear we have UHC, Aetna, Cigna, Centene, and all others in descending order splitting the remaining 21%. Hmmm … intriguing, the whole idea that these relative member counts remain so consistent. Then Dr. Asher and I dissect what is anybody actually doing to cut into the Kaiser market share o

If this were a video show, I would stare into the camera with steely eyeballs right now and say that I have a special message for employer CFOs. If you aren’t a CFO, pretend that you are so that you get the full effect here. So, now that we’re all CFOs, let’s pull up the company P&L (Profit and Loss) statement. This is what keeps us all up at night, right? Making sure that the net profit line at the bottom looks good. We could decide to lay off a few people. Reorg something or other. Beat up a vendor. Stop buying the gold paper clips. We also could go over and have a strident conversation with sales leadership about what they can do to jack up their sales revenue. Top line begets bottom line, after all. Or, here’s another idea: In this healthcare podcast, I am speaking with Paul Holmes, who is an ERISA (Employee Retirement Income Security Act) attorney with a specialty in PBM (pharmacy benefit manager) contracts, especially the PBM contracts from the big PBMs that get jammed in employer plan sponsor f

There are two facets of the Humira biosimilar market and launch that Anna Hyde, my guest in this healthcare podcast, talks about. One is market dynamics. The second is provider and patient confidence. These two concepts are tangled up together and cannot be separated. But let me back up a sec and explain, although Anna Hyde covers this really well and offers context in the interview that follows. So, first facet: market dynamics. This means fostering competition so the price of something goes down. That is the basis of capitalism. After all, you need competition to get in there and try to steal customers from each other by scuffling over price. In 2023, there’s supposed to be 12 biosimilar products for Humira that come out. So, we’ll see scuffling and lower prices? Hmmm … maybe not so fast. Second intertwined facet: provider and patient confidence that the biosimilars are as effective and have similar side effects (ie, there is confidence that the biosimilars are actually, for reals, interchangeable with