EP449: For Clinical Leaders, Payers, and Plan Sponsors, Let’s Talk About Blind Spots for Getting Patients or Members Appropriate Care, With Marty Makary, MD, MPH

In this episode, Stacey Richter speaks with Rob Andrews, CEO of the Health Transformation Alliance (HTA) and former Congressman, about the strategic steps jumbo employers can take to achieve improved health outcomes while reducing cost. They delve into the importance of using data to discern effective practices, negotiate contracts, and hold intermediaries accountable. To Read The Show Notes With All Mentioned Links, Visit the Episode Page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. The discussion highlights maternal health as a critical area of focus, with successful interventions shown to reduce NICU admissions and overall healthcare costs. Andrews emphasizes the role of self-insured employers in driving systemic changes that align financial incentives with health outcomes. This encore is very relevant after the shows with Cora Opsahl (EP452), Claire Brockbank (EP453), and Marilyn Bartlett (EP450). Getting better health for the 160 million Americans covered by commercial insurance is all about rates, rights, and power. 07:34 How did Rob get to his current role? 09:08 The problem of maternal health and mortality rate, and how self-insured employers wind up directly and indirectly paying for this. 10:27 Why economic consequences move the needle, and why sometimes they don’t. 12:26 Why the best way to address costs isn’t to re-shift costs but to address them directly. 13:22 Why compensation that isn’t dependent on outcomes is a problem. 16:23 “Strategy’s not what people say; it’s what they do.” 18:21 How do you operationalize saving money with better outcomes? 26:26 How do employers turn conflict into collaboration? 28:20 What is the win-win-win structure among employers, payers, and providers in Rob’s eyes? 30:53 To whom should the task of risk adjustment fall? 34:43 “Better contracts do improve outcomes.”  

In this comprehensive episode host Stacey Richter sits down with Brian Reid to discuss pivotal aspects for the pharmaceutical industry. Key topics include understanding product value from the perspectives of plan sponsors, patients, and society, and the significance of benefit design in improving patient affordability. For the show notes with all links mentinoed, visit the episode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. The discussion delves into the complexities of drug pricing, the roles of Pharmacy Benefit Managers (PBMs) and brokers, and the impact of healthcare consolidation on costs. Reid emphasizes the importance of transparent communication among stakeholders, the detrimental effects of cost containment strategies, and the necessity of considering policy and reputational impacts. Throughout the conversation, examples such as the Hepatitis C drug illustrate the broader implications on drug access and affordability. Listeners are provided with critical insights into how pharmaceutical companies can better engage with ultimate purchasers to ensure patients receive necessary, cost-effective medications while navigating a changing healthcare landscape. For the show notes with all links mentinoed, visit the episode page. 08:29 Why is it important to understand the term “value” in respect to medicine? 10:07 Why is it important to consider all the players affected by the idea of this “value”? 11:06 Who are the ultimate purchasers in Pharma? 12:23 Findings of the Kaiser Employer Health Benefits Survey. 14:52 Why does it matter that we consider what value looks like to all players affected by Pharma? 16:46 EP300 with Bruce Rector, MD. 18:38 EP448 (Part 1) with Shawn Gremminger. 20:04 What does Pharma need to do to showcase their value when PBMs are often “locked in” at the moment? 23:11 Why Brian is celebrating companies that put their prices in their press releases. 32:31 Why does Pharma have an obligation to explain their value? 33:16 EP426 with Nina Lathia, RPh, MSc, PhD. 33:39 Why is it important for Pharma to keep an eye on hospital monopoly behavior? 35:55 EP370 with Erik Davis and Autumn Yongchu. 37:44 Why Pharma needs to capitalize on alignment.

In this conversation, Stacey Richter engages with healthcare leader Dr. Beau Raymond from Ochsner Health Network to explore the blueprint for better patient care through enlightened leadership, data-driven strategies, and localized health initiatives.  The discussion covers shifting from 'sick care' to preventative healthcare, integrating technology and data tools like glucometers for health coaching, and addressing health equity through accurate data and regional strategies. To Read the Show Notes with Mentioned Links and a Full Transcript, Visit the Episode Page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. The conversation explains the importance of stakeholder engagement, setting clear goals, financial incentives aligned with patient care, and continuous improvement through feedback loops. Practical steps such as weekly huddles for primary care teams and the role of digital health in managing chronic conditions like diabetes and hypertension are also highlighted to improve healthcare outcomes and operational excellence. A rate critical to attain better care for patients, I’m gonna say, is enlightened leadership—maybe dyad leadership—at a clinical organization. I am saying this because without enlightened leaders, it’d be harder to build from the blueprint that Beau Raymond, MD, talks about today on the show. 10:44 Why is it important to be flexible while keeping your goals in sight? 11:48 Dr. Eboni Price-Haywood’s article on disparities in COVID. 12:29 How is equity a data point to achieving overall care improvement? 15:01 “If you can’t measure it … accurately, you’re not going to be able to do anything differently.” 20:52 What strategies have been successful in using data to improve healthcare outcomes? 23:17 Why did Ochsner Health avoid looking at the individual physician standpoint in regard to an equity standpoint? 30:40 Why engaging patients in their healthcare actually improved patient visits and did not necessarily reduce patient visits. 34:49 “It’s really about engaging with the patient.”

In this episode, host Stacey Richter and guest Brendan Keeler dive deep into the significant legal clash between Epic and Particle over electronic health record (EHR) data access and market competition. To Read the Show Notes with Mentioned Links and a Full Transcript, Visit the Episode Page. This episode examines the broader repercussions on healthcare data exchange, including antitrust concerns, data liquidity, and the ethical considerations around secondary use of treatment data. The discussion brings to light how the outcome of such lawsuits could influence data transparency, interoperability, and the rules governing data sharing among plan sponsors, employers, and healthcare providers. Notable points include the shift to a judicial era impacting health tech companies and the potential for regulatory and judicial actions to improve data access and efficiency within healthcare networks. The episode emphasizes the critical need for clear pathways, accountability, and structured regulations to enhance patient care and reduce fraud in the healthcare data ecosystem. Consider Signing Up For Our Free Weekly Newsletter.  07:21 Who can gain access to EHR data? 10:31 Are there limits to how EHR data can be used secondarily? 11:36 Can EHR data be shared secondarily? 15:47 Part one and part two of Brendan’s comprehensive account of the Epic/Particle dustup. 15:57 What was the dispute that started Epic v Particle? 18:21 What are the two viewpoints in this dispute with Epic’s actions? 26:16 What progress has been seen since this lawsuit began? 28:00 Who else will be impacted by the likely rule cementing from this lawsuit?

In this episode, host Stacey Richter delves into the complexities of the Third Party Administrator (TPA) Request for Proposal (RFP) process with guest Claire Brockbank from 32BJUnion.  The discussion highlights the critical role of contracts in managing health plans effectively and the potential pitfalls of accepting contracts crafted by TPAs without thorough review. Drawing from Claire's experience, they explore tactics like starting with your own contract paper in RFP processes to gain negotiation leverage, and the benefits of employer coalitions in navigating health care complexities. To Read the full article which includes mentioned links visit the episode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to become a member of the Relentless Tribe. Real-world examples underscore the financial impacts of poorly negotiated contracts and highlight successful strategies for health plan sponsors to optimize costs and services. The episode aims to empower employers with tools and insights to negotiate effectively and ensure their health plan contracts align with their strategic goals, ultimately paving the way for better population health management and cost-effective care delivery. As but one example—and Cora Opshal spoke about this last week and Claire talked about this today—it’s about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent around $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200 on behalf of the plan sponsor. So now the plan sponsor is paying $200 for a $100 bill. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor? So it's understandable why the team at 32BJ pushed back and pushed back hard. We all can see why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today. For an open-source contract and some other free tools, please do head over to the 32BJ Insights Web site. 05:36 How does the initial contract writing affect how events in your healthcare plan will go? 06:56 What happens if a plan sponsor or employer doesn’t do the contracting right? 10:42 How much could be saved by doing contracting right? 11:01 EP433 with Justin Leader. 12:22 How do you start an RFP process with your own contract? 14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that’s best for you. 19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract? 21:11 Open-source contract available from 32BJ. 21:57 Why it’s important to really probe brokers, despite loyalty to your broker/consultant. 24:30 Who are the reliable agents and experts when carriers are looking to start this process? 26:24 EP428 with Julie Selesnick. 27:56 What’s the silver lining to this effort? 29:17 Why is it important to make it clear why you’re doing what you’re doing for your lawyers and any other support team you need? 31:39 What does “good” look like in this process? 34:15 Why is it important to continue to hold your ASO accountable?

In this episode I interview Cora Opsahl from the 32BJ Health Fund to examine the intricate dynamics between fiduciary duties and the entrenched status quo in healthcare. The discussion focuses on the challenges employers face when dealing with anti-competitive contracts and their responsibility to ensure plan expenses are reasonable.   Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members.   And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today.    Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available, in our show notes.   To Read the Full Show Notes with the Mentioned Links Visit the Episode Page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. 06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors? 09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design. 12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design? 14:12 How do these anticompetitive rights have quality implications as well as cost implications? 18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year? 19:46 What did the healthcare savings allow the unions and employers to do? 20:46 Study by Zack Cooper, PhD. 21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend. 24:15 Why 32BJ Health Fund wants to control the contracting process. 26:00 EP419 with Andreas Mang. 27:18 What are 32BJ Health Fund’s four non-negotiables? 33:17 Wall Street Journal article on health insurance contract. 35:30 Upcoming episode with Claire Brockbank. 36:14 What is the challenge that exists in our current healthcare environment? 37:43 Cora’s advice on how to get high-quality healthcare at an affordable price.

In this Spotlight Episode host Stacey Richter discusses the management of oncology side effects with Dan Nardi, CEO of Reimagine Care. Highlighting the challenges cancer patients face, especially following chemotherapy which often leads to nausea and readmissions, the conversation delves into how Reimagine Care facilitates at-home integrative cancer care.   Their services focus on proactive and reactive support via AI-driven tools like 'Remy' to assist patients outside of clinical environments. This approach aims to reduce emergency visits and improve patient outcomes while easing the workload on healthcare providers. The discussion underscores the role of patient reported outcomes and the integration of technology with human care to improve the quality of oncology treatment pathways.   To Read the Full Article Notes with Mentioned Links, Visit Our Episode Page . If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Note from Stacey Richter: Pulling off a show like this one is not cheap, and my Aventria business partner Dave Dierk and I are happy to fund the vast majority of it. But yeah, breath of fresh air, and thanks much to the team over at Reimagine Care for their sponsorship. My one disclaimer is that I have not personally vetted the solution, but there is a white paper available where you will also find some insights from Reimagine Care’s work with Memorial Hermann Health System. 03:38 Why is it really important to keep track of oncology patients and their side effects? 04:27 Why is cancer treatment such a complex care journey? 05:57 Are there outcome and financial issues that compound when an oncology patient is left to navigate their care journey on their own? 08:53 What is difficult in navigating cancer treatment care pathways, and what does Reimagine Care tackle within that? 09:55 EP157 with Ethan Basch, MD. 10:17 How does Reimagine Care proactively check in with oncology patients to help them navigate their care pathways? 12:41 How does Reimagine Care measure their performance, and how did their work affect patient outcomes? 13:28 The Reimagine Care white paper. 14:57 How do providers feel about Reimagine Care services? 17:37 Where can technology really make a difference in cancer care?

In Episode 451 of Relentless Health Value, host Stacey Richter converses with Dr. Spencer Dorn about the implications of AI in healthcare, referencing lessons learned from EHR implementations. They discuss Kranzberg's first law of technology, which advises against labeling a technology as inherently good, bad, or neutral, emphasizing instead the importance of its application, configuration, and the human decisions surrounding its use. Dorn and Richter explore both the potential benefits and drawbacks of AI, drawing parallels with past experiences in healthcare digitization. To read the full article with links mentioned or to sign up to the newsletter, visit our episode page. The first takeaway from this short show focused on artificial intelligence is gonna be the same, really, as it was in episode 446 about EHRs. Do not ascribe any given technology a label of, as good, bad, or even neutral. That is Kranzberg’s First Law of Technology; and it applies here, too. Second major takeaway—and again, this is the same as in that earlier show about EHRs, but today we’re talking about AI—if you’re thinking about the ultimate impact of the people and the processes that have some technology in their midst (technology, again, such as AI, artificial intelligence), the ultimate impact will not be a black-and-white binary. We talk about some of these nuanced not binaries in the 10 minutes that follow, but for more, I’ve put some links in the show notes on our epsiode page for some newsletters et cetera to check out. 05:23 What could happen with AI in healthcare if we aren’t thinking about how we’re deploying it? 05:58 How could the lessons from digitizing healthcare help us with employing AI? 08:25 How could artificial intelligence make things better and simultaneously worse? 10:55 Why is it important to look beyond the hype and pessimism and make a clear-eyed assessment?

In Episode 450 I speak with Marilyn Bartlett, a renowned CPA in the healthcare field, about her remarkable achievement of transforming the state of Montana’s employee health plan from $9 million in debt to a surplus of $112 million within three years. You can read the full show notes with mentioned links on the epsiode page. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. Marilyn discusses the steps she took, including identifying financial inefficiencies, targeting high-cost areas, and implementing data-driven strategies to produce quick wins and sustainable results. The conversation delves into the importance of having the right team, communicating effectively with stakeholders, and staying focused amidst challenges. Listeners will gain valuable insights into strategic change management and actionable advice for improving healthcare plans. Yeah, I made a meme for the show with Marilyn Bartlett. My very first meme ever. In this meme, I picture that Olympic silver medalist shooter from Turkey who showed up in a T-shirt and his hand in his pocket versus the others with all their fancy equipment that, turns out, may or may not be necessary, regardless of who might swear up and down that complexity requires even more complexity and plenty of expensive gear to shoot straight. Point being, it’s amazing what a dedicated CPA with a spreadsheet and their eye on the target can accomplish in the real world when they just do their thing and follow the dollar. And with that, Marilyn Bartlett has entered the chat. Marilyn Bartlett isn’t called the “Queen of Healthcare” for no good reason, and nobody is joking when they say this. She was probably the first person (or one of the first, at a minimum) to truly identify the amount of money getting sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the healthcare and insurance and consulting industries. She is a through and through numbers person but also deeply cares. She is truly a senior stateswoman in our field. To read the full article with mentioned links or the transcript, visit our epsiode page. 06:45 What gave Marilyn the confidence to fix Montana’s state health plan? 08:11 Why Marilyn knew she would have enough power to make the changes needed in Montana’s state health plan. 09:11 What Marilyn achieved in her time as the administrator of the Montana State Employee Health Plan. 10:38 What were the “quick wins” Marilyn was able to achieve when she first took over as administrator? 17:33 Stay tuned for an upcoming episode that covers RFP in detail. 17:50 How Marilyn structured her plan for the Montana State Employee Health Plan. 21:21 What’s the key to setting yourself up for success when doing what Marilyn was able to achieve? 25:02 Why putting together your own team is so important. 29:07 What happened when Marilyn left the Montana State Employee Health Plan? 31:08 Have the costs of the plan gone up since Marilyn’s time working on it?

So, I had a chance to read Dr. Marty Makary’s new book, which is called Blind Spots; and here’s why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. It’s because of something that he said on page 127 and which I’ve been mulling over for probably years, actually. 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. It’s this idea of what is appropriate care and how good are we at ensuring that patients/members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); Tom Lee, MD (EP445).  I mean, an estimated 21% of all medical care is potentially unnecessary. And unnecessary is, of course, one category of things that are not appropriate. This is according to a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary/inappropriate. This is billions of wasted dollars doing stuff that shouldn’t be done, and it’s not appropriate care. But think about this: How many visions for how to fix healthcare and how to reduce waste depend upon a broad-stroke assumption that we will materially ensure that patients are getting best-practice (ie, appropriate) care? That we cut down on over-medicalization and surgeries on the back end and add appropriate preventative stuff and optimal medical therapy to the front end? Dr. Makary and I delve into the challenges of ensuring patients receive appropriate care, touching on medical dogma, financial, business, and legal incentives, and the importance of measuring practice patterns. Dr. Makary provides practical advice for clinical leaders, payers, and plan sponsors on promoting transparency, improving health literacy, and steering members towards higher performing providers. To Read The Full Article Including Links Mentioned, click here. 07:32 What is appropriate care? 10:19 Why what we think might be appropriate care might not be appropriate care. 10:34 Why is medical dogma damaging to appropriate care? 12:45 Why we need less absolutism in medical practice. 13:37 How is groupthink prevalent in medicine? 14:02 Why do we resist new ideas? 17:43 How do providers figure out what to believe and what not to believe? 20:59 “If you leave it to the medical profession to fix itself … so far, it’s not going well.” 22:33 How does supporting health literacy affect appropriate care? 30:23 “People need to find their care based on quality and price.” 34:28 What proportion of medical care is deemed unnecessary right now?