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Relentless Health Value™

By: Stacey Richter
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  • Summary

  • American Healthcare Entrepreneurs and Execs you might want to know. Talking. Relentless Health Value is a weekly interview podcast hosted by Stacey Richter, a healthcare entrepreneur celebrating fifteen years in the business side of healthcare. This show is for leaders in pharma, devices, payers, providers, patient advocacy and healthcare business. It's for health industry innovators, entrepreneurs or wantrepreneurs or intrapreneurs. Relentless Healthcare Value is the show for you if you want to connect with others trying to manage the triple play: to provide healthcare value while being personally and professionally fulfilled.
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Episodes
  • EP435: Optimized Pharmacy Benefits Are Required if You Want to Do or Buy Value-Based Care, With Dan Mendelson

    EP435: Optimized Pharmacy Benefits Are Required if You Want to Do or Buy Value-Based Care, With Dan Mendelson
    May 2 2024
    For a full transcript of this episode, click here. This conversation I am having with Dan Mendelson, my guest today, all started with a post that he had written on LinkedIn considering how pharmacy benefits can or should be optimized within the broader context of value-based care. Total cost of care, value-based medical care, and pharmacy benefits—these worlds have to collide. There is just so much intertwined into all of this, which is why I pretty much immediately invited him to come back on the pod to discuss in greater detail. A few years ago, I heard a doctor say that practicing medicine without considering pharmacy is like getting to the 90 yard line, putting down the ball, and walking off the field. And, yeah … when a patient gets to a certain point in a whole lot of disease progressions, optimal medical therapy includes pharmacy. It’s a thing. Adherence is a thing. In fact, I saw a stat the other day that patients not taking their meds costs an estimated $3874 PEPY (per employee per year). Also, half of all hospital admits are caused by nonadherence. Those two stats, by the way, are from a post on LinkedIn by Brian Bellware, who was recapping a video from Eric Bricker, MD. But also, as Barbara Wachsman (EP430) said on the show, half, I think she said, of all ER visits are due to patients not taking their meds right. Olivia Webb (EP337) was on the pod, if you want to go back and listen to that one, talking about how she spends hours every month trying to figure out how to navigate access issues to manage to get her Crohn’s disease drug. So, yeah … one underlying reason why a lot of this stuff happens is that pharmacy benefits are purchased and siloed a lot of times. In fact, I have yet to see, really, any mainstream contract wherein a PBM (pharmacy benefit manager) is held accountable in any way for downstream medical costs, which may be incurred because of suboptimal pharmacy benefit design, right? And there are so many examples of bad downstream medical impacts. I really like how Mark Fendrick, MD, put it in episode 308. He said benefits, including pharmacy benefits, are like peanut butter and jelly relative to enabling high-quality care. You gotta have both working in concert, like CMS or a plan sponsor just paid a ton of money to get a patient an organ transplant, and then the patient can’t afford their transplant meds, which aren’t on formulary and are really expensive, and therefore there’s organ rejection. This happens. Or a patient with uncontrolled diabetes with a huge co-pay for insulin. Doctor says, “Hey, you gotta take your insulin.” Patient says, “Can’t afford it.” Right? This makes no sense, and it’s shockingly common. I’m thinking right now of that young man who died in the Midwest because he could not get his asthma inhaler. It wasn’t on formulary. So, here’s the game plan. I talk with Dan about the five kind of vital considerations he had brought up in that aforementioned LinkedIn post when considering how pharmacy benefits can or should be optimized within the broader context of value-based care. Dan’s advice for the pharma industry is woven in here as much as his advice for EBCs (employee benefit consultants) and employers. I am sure that most of our listeners are going to be very familiar with Dan Mendelson, my guest today, and his work; but the quick background here is that he runs Morgan Health. The mission over there at Morgan Health is to drive innovation in employer-sponsored healthcare, and they do that by investing and working with their portfolio companies in the context of the 300,000 or so employees over at JPMorgan Chase. At the same time, Morgan Health also engages in policy discussions because, as Dan says, no one employer is going to control public policy. As a footnote here, I just will say that I actively seek out opportunities to listen to Dan Mendelson’s thoughts. He has spoken a lot and really eloquently and with great insight about setting up the economic models for healthcare, not sick care. Recently, actually, he was on a panel at the Milken conference along with Natalie Davis; Yele Aluko, MD, MBA; and Henry Ting, MD. There are definitely insights to be gleaned. Also mentioned in this episode are Brian Bellware, CIC, CHVP; Eric Bricker, MD; Barbara Wachsman; Olivia Webb; Mark Fendrick, MD; Natalie Davis; Yele Aluko, MD, MBA, FACC, FSCAI; Henry Ting, MD; Ashok Subramanian; Rik Renard; Nina Lathia, RPh, MSc, PhD; Don Berwick, MD; Kenny Cole, MD; Steve Pearson, MD, MSc; Sarah Emond; Alex Sommers, MD, ABEM, DipABLM; and Jodilyn Owen. You can learn more at the Morgan Health Web site and follow Dan on LinkedIn.
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    35 mins
  • EP434: 4 Surprises About Bundled Payments, With Benjamin Schwartz, MD, MBA

    EP434: 4 Surprises About Bundled Payments, With Benjamin Schwartz, MD, MBA
    Apr 25 2024
    For a full transcript of this episode, click here. I’ve been in a couple of meetings lately. In one case, a healthcare company came up with a strategy and deployed it; and the strategy didn’t go as planned. The other one, it did go as planned—it worked great. Of course, I’m coming in on the back end like a Monday morning quarterback here; but the plan that failed, I have to say, I wasn’t surprised. Had they asked me ahead of time, I would have told them to save their money because the plan was never gonna work, even though the strategy looked like kind of a straight line from here to there. Nor was I shocked by the success of the other plan, even though this one that triumphed had what looked like five extra steps and was slightly counterintuitive if you looked at it cold, without understanding the way the healthcare industry actually works. Here’s my point: It might feel like the healthcare industry is chaos monkey central and impossible to predict actions and reactions—and, for sure, there’s always unknowns and intersecting variables—but it’s not a complete black box. The trick is, as you know and I know, you gotta understand what other stakeholders are up to. You gotta get a bead on what they’re doing and what their incentives are because then you can better predict actions and potentially reactions. So, let me state the obvious (that’s why listeners tune in to this show as I just said, and it’s what we aim to shine a light on here at Relentless Health Value): the pushes and the pulls and the forces. What’s going on outside of the organizations or the silos that we work within day-to-day. Because if you’re looking to sell to, partner with, not be obstructed by [insert some stakeholder here], then it’s very vital to be keyed in on what they’re doing or what their customers are doing or what their customers’ vendors are doing. This show should feel like it gives you a measure of control (or at least that’s my hope) or a method to find the measure of control. And I hope you succeed. That’s why I continue to put out these shows. The RHV tribe members want the same thing I want—to fix the healthcare industry for patients and for members—so, thanks for being here and for making actionable the insights that you might find here. I have been so looking forward to doing a show with Ben Schwartz, MD, MBA, orthopedic surgeon and prolific writer of deeply thoughtful and insightful posts on LinkedIn. In this healthcare podcast, we are talking about bundled payments. And today’s your lucky day if you think you know a lot about bundles, because most people who listen to this show at least know enough to be dangerous. So, that’s our starting point, which is why I asked Dr. Schwartz to talk to me about what most people find surprising about bundles and bundled payments. There are four surprises that we go through in the show today. Listen to the show or read the transcript to find out exactly what they are. So, no spoiler alert alert. But relative to these surprises, we get into the four types of bundles that may or may not be available. And those four types of bundles are: 1. CMS bundles such as the BPCI (Bundled Payments for Care Improvement) and the CJR (Comprehensive Care for Joint Replacement) bundles, and we talk about the current state of said BPCI bundles, which are being sunsetted probably because so many efficient clinical teams are being penalized for getting too efficient. They become victims of their own success the way the program is currently designed, wherein the goalposts keep shifting. 2. Commercial bundles—ie, a bundle that is offered by a commercial carrier such as a BUCA (ie, Blue Cross Blue Shield/UnitedHealthcare/Cigna/Aetna/Anthem) carrier 3. Direct bundle—a bundle that is paid for directly by a plan sponsor such as a self-insured employer 4. Condition- or diagnosis-specific bundle. These types of bundles do not spiral around a surgical intervention at their core, which most of the current bundles do. This may describe CMS’s recently announced “Making Care Primary” initiative, but we’ll have to see about that. Speaking about the #3 kind of bundle, the employer-direct bundles, especially for musculoskeletal (MSK), let me share a post by Moby Parsons, MD, that I thought captured the entrepreneurial spirit of some of these orthopedic surgeons who are seeking employers to direct contract with and cut out the middleman, etc (which, by the way, is the main topic of an entire show upcoming with Elizabeth Mitchell from the Purchaser Business Group on Health). But Dr. Parsons wrote: “When our bundle business has sufficient growth to ensure the absolute sustainability of our practice against declining reimbursements … in a fee-for-service system, I am getting this tattoo. Don’t tell my wife. [And the tattoo is ‘Free Yourself.’]” My guest today, aforementioned, is Dr. Ben Schwartz. He’s an orthopedic surgeon in the Boston area ...
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    40 mins
  • EP433: The Mystery of the Weekly Claims Wire: What Are Plan Sponsors Actually Paying For Each Week? With Justin Leader

    EP433: The Mystery of the Weekly Claims Wire: What Are Plan Sponsors Actually Paying For Each Week? With Justin Leader
    Apr 18 2024
    For a full transcript of this episode, click here. On the show today, I am going to use the term TPA (third-party administrator) and ASO (administrative services only) vendor kind of interchangeably here. But these are the entities that a plan sponsor—for example, a self-insured employer is a plan sponsor—but these plan sponsors will use to administer their plan. And one of the things that TPAs and ASOs administer is this so-called weekly claims wire. Every week, self-funded employers get a weekly claims run charge so they can pay expenses related to their plan in weekly increments. The claims run usually comes with a register or an invoice. This invoice might be just kind of a total (“Hey, plan. Pay this amount.”). Or there might be a breakdown like, “Here’s your medical claims, and here’s your pharmacy claims.” Maybe there’s another level down from that of detail if the plan or their advisor is sophisticated enough and/or concerned enough about the fiduciary risk to dig in hard about what the charges are actually for. I was talking about this topic earlier with Dana Erdfarb, who happens to be executive director of HR at a large financial services organization. Dana I’m definitely gonna credit for inspiring this conversation that I’m having today with Justin Leader. Dana was the first one to really bring to my attention just the level of hidden fees that are buried (many times) in these claims wires … because when I say buried in the claims wire, I mean not charged for via an administrative invoice. These hidden fees are also not called out in the ASO finance exhibit in the contract, by the way. So, yeah … hidden. I don’t know … if you have to hide your charges, in my mind that’s a pretty big tell that your charges are worth hiding. Now the one thing I will point out is that just because the charges are worth hiding doesn’t necessarily mean that the services those charges are for are unwarranted. Some of these services are actually pretty worthwhile to do. There’s just a really big difference from a plan sponsor knowingly contracting at a known rate with a third party to do something versus paying for a service knowingly or unknowingly via fees hidden in a claims wire wherein the amount paid is not in the control of the one paying the bill. Anyway, I was talking about all of this earlier, as I mentioned, with Dana Erdfarb. That conversation was exactly the framework that I needed to snag Justin Leader, my guest today, to come on the pod and really dig into the detail level of what’s going on with this claims wire. So, in this healthcare podcast, we’re gonna talk about the five fees that tend to be tucked in to many claims wires. We also talk about one bonus—not sure if it’s a fee—one bonus way that plan sponsors give money to vendors in ways the plan sponsor might be unaware of. Here are the five hidden fees that we talk about at length in the show today, and then I’ll cover the bonus: 1. Shared Savings Fees. This is where a member of a plan goes out of network, and the TPA/ASO goes and negotiates a discount from the out-of-network provider and then shares the savings. Get it? Shared savings? This category also might include BlueCard Access fees, which we talk about in the show. But there also could be overpayment recoupment fees lumped in here. This is where the TPA messes up, overpays, and then charges the plan sponsor a percentage of the money they just got back when they corrected their own mistake. I’m just gonna pause here while everyone contemplates how we’ve all gone so wrong in life to not have figured out a way to charge others when we correct our own mistakes. Here’s a link to a great LinkedIn post by Chris Deacon and a deep dive article on this topic. 2. Prior Auth Fees. Lots to unpack with this one, which Justin does in the pod. 3. Prepayment Integrity Fees. This is evaluation of the claim before it’s being paid. Listen to the show for how this may (or may not) differ from what the TPA/ASO is supposed to be doing (ie, it’s the TPA that’s supposed to be [yeah, right] adjudicating and paying claims). 4. Pay and Chase Fees. This is where a bill was paid wrong, and it’s not immediately the TPA/ASO’s mistake. This is where something like a provider double billed or overcharged or something, and the TPA/ASO later figures this out and then chases the pay to get the money back. 5. TPA Claims Review Fees. Sort of self-explanatory but also not. Again, please listen to the show for more. When I’d been talking about all of this with Dana Erdfarb, as I mentioned earlier, just about this whole thing, she said something that Justin Leader echoes today: Many of these fees are structured as a percentage of savings. This is challenging for a plan sponsor because the savings is vendor reported and not validated. But it also means that if the savings increase annually with trend (as they, generally speaking, do), then the fees will increase ...
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    40 mins
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