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Care management is crucial for adding value to value-based care, but gaining stakeholder buy-in on its significance can be challenging. While the return on investment for care management strategies is undeniable, the delayed realization of these returns can be daunting for financial leaders. In this episode of Value-Based Care Insights, Dan Marino sits down with Lisa Stockdale, the Director of Value Based Care, at Silver Cross Hospital, to look at challenges, as well as the benefits, in implementing successful care management programs. Gain insights into the importance of leadership buy-in, technology, and reinvestment in effective and cost-saving care management programs.

LISTEN TO THE EPISODE:

 

Daniel Marino:

 Welcome to value based care insights. I'm your host, Daniel Marino. When you think about value-based care, and in particular the performance of value-based contracts. Care management is absolutely essential to realizing any type of performance outcomes and really identifying the value that that we need to provide to our patients and frankly providing the support to our, to our physicians and our providers. Yet many organizations, many CINs, clinically integrate networks or ACOs, or just health systems, who are starting to engage in value based contracts. They really struggle with how to efficiently perform care management services, or to even invest in care management services. I can remember having conversations, even, you know couple of years back with CFOs relating to investing in care management. And it was tough, because care management doesn't provide that immediate ROI. Yet it is absolutely essential to realizing the results of any type of value based contracts.

Well, I'm really excited today to have as my guest Lisa Stockdale. Lisa is director of value, based care at Silver Cross Hospital. She has been in the care management world and has been instrumental in working with her physicians, her providers, her patients and her team in putting in place really effective care management programs. And frankly, the organization that she works for has really has realized some, some real nice shared savings and financial opportunities there. And it's a direct result of the care management that Lisa has put in place in her team. Lisa, welcome to the program.

 

Lisa Stockdale: Thank you, Dan. Happy to be here today.

 

Daniel Marino: So I know the work that you've done in care management has certainly not come without a lot of bruises and overcoming a lot of challenges when you think about what you've been able to put in place. And then you think about what other organizations struggle with, what are some of the biggest challenges related to implementing care management or putting in place an effective care management program?

 

Lisa Stockdale: Well, the 1st thing that we really had to tackle was getting like you mentioned finance to agree to invest in this program. So when we met our vendor we started working together in the fall of 2,019. So it was an 18 month project of really creating the storyboard for the leadership team here at our system to help them understand what the potential impact of a program like this would be. So we really approach the finance team, utilizing the study from Mathematica on care management, which was a very small cohort of population of patients. And looking at what our total spend and total cost of care was in our Medicare shared savings program, and forecasting what we might be able to save if we were to implement an effective care management program here. So that's really what got us over the hurdle. The way we look at the reimbursement for CCM, is it sort of keeps the lights on but the the shared savings and the impact to quality that we've seen is just a testament of the team. But that was really the 1st hurdle that we had to get over was changing the approach of, you know, care management. We're not just doing this for reimbursement. We're actually doing a community benefit with the reimbursement.

 

Daniel Marino: When you're investing in, you're investing in your teams, right? And you're investing in the future. You know the big challenge with any of these value-based care contracts is you may not see or receive the performance dollars until you know a best case is probably 14 or 15 months after you sign the contract. In some cases it's even longer than that. So you know, that's hard to build that into an ROI model. But it's absolutely essential in order for you to achieve those results. So when you, when you had worked with finance, I would assume really changing that mindset with your leadership, I mean, that had to be the biggest undertaking.

 

Lisa Stockdale: I would say, yes, I think you know, the culture of the organization you're in makes a big difference, and I'm very honored that that our culture here is built on quality, so that part was easy to get through right. Because the quality is there. So it was just really selling the potential opportunity. And you commented on investing in your team. I am just honestly so proud that we now have a way for clinicians to work remotely and care for patients. It's given us another vehicle, another opportunity to attract top talent in our market. Because the positions are attractive. And we have had 0 turnover in 3 years since we launched our program. So that's we're growing. We're hiring. My staff is referring friends and colleagues. So that just speaks volumes to me. About the program and their satisfaction at their job as well.

 

Daniel Marino: When you, when you think about the operations of your team. any, any strong care management program is really multi faceted. Right? So I mean, I'm assuming you have probably nurses who are managing the high risk population versus those that are moderate risk, and even doing navigation right? Patient navigation. Can you speak a little bit around say the operational effectiveness of your team, and maybe how you've structured it?

 

Lisa Stockdale: Sure. And I think that's a big, you know, testament to the partner that we have the technology really allows us to scale low cost, high value resources. So we do have pay medical assistance that have panels. They're supervised by RNs. So we do have sort of the day to day tasks that are occurring. And, like you, said, the navigation pieces are handled by a medical assistant, and then clinical escalation, or those higher risk, sicker patients can be managed by the RN. So it's really afforded us an opportunity to manage more patients and work with them, as they're sort of going through their care journey. There are points in their life where they need more support than others. So having that team based approach, and that, you know they're tethered to the physician or to the app, the advanced practice providers. It just has given the patient such a significant support system, and we've invited them to their care, and just seen tremendous results from that.

 

Daniel Marino: Well, you're really coming at this like you said from a team based perspective. So you have different levels of, let's say, clinical capability that you're bringing to the table to support, not just the clinician, as you mentioned, but to but to the patient as well. So care management obviously is expensive. In some cases there's been care management incentives that are part of the contract. I know Medicare has done that in the past. But one of the things that I'm particularly excited about was CMS released their new proposed reimbursement for advanced primary care management services, and for any of our audience members. If you're not aware of it, we'll include the link in in our notes. But it provides for a lot more codes around care management, and they've changed the rules a little bit in terms of how to better support the actual care management activities that's occurring between the clinician, between the patient and allowing more proper reimbursement for that. In your experience, Lisa, and I know you're just starting to get into this. What's your thoughts on the new releases from CMS?

 

Lisa Stockdale: I mean excited honestly. Nervous a little too, cause we have to figure out how to operationalize that.

 

Daniel Marino: Yeah.

 

Lisa Stockdale: But you know this is CMS’s gift, I would say to providers, and recognizing that these programs actually do deliver on an overall improved outcome for the patient, for the consumer and for all of us. Right? Because we're paying taxes to fund Medicare. So I take high responsibility for that in in our program. But APCM is really actually going to personalize the care management even further because not every patient needs 20 min every month. And so what happens is we deliver care 5, 7 min, 6 min here and there, and we're not able to actualize our reimbursement for that care. So with these new programs while they have a little bit of a lower reimbursement rate, we don't won't have to really drive that 20 min threshold if it's not necessary. So that's really exciting for me as I feel the patients are going to get a more personalized approach to their care management. And as far as the APCM program with the 3rd code that's released, kudos to CMS, there is higher levels of reimbursement or are qualified Medicare beneficiaries that are on the Medicare and Medicaid alignment programs, where we already know they have a financial social factor influencing the ability to manage their health. There's not going to be any concerns with patient cost sharing. And there's going to be higher reimbursement for the caregivers due to the fact that these folks have, you know, much further support needs than some of our other patients. So really, just aligning the reimbursement with the need of the patient population is really what I feel is very exciting to see coming from CMS.

 

Daniel Marino: Yeah, I agree with you. I'm excited for this, I think for a couple of reasons. One as you mentioned. You're really focusing the care management based on the patient's needs. Right? So the criteria obviously is important documentation always becomes important. But in care management we're really focused on the outcomes. Right? We're really focused on delivering the right level of care, the right level of service with the idea that we're advancing hopefully the quality and the outcomes of that patient to make them better, or whatever the case may be. I feel like the code set that CMS has come off come out with is really going to help. You're never going to get rich off care management, but you shouldn't be losing a lot of money either, and I think if this allows us to better align our financial elements with what is occurring within, for you know the needs of care management. I think that's absolutely key.

 

Lisa Stockdale: Yeah. And you make a great point there. Again, we talk about the reimbursement keeping the lights on and we're very conscientious with how we manage that. We know the labor is, you know, our largest cost factor. We're still realizing a profit of about $200 per patient per year in CCM. And what we've been able to do is reinvest that back into our primary care, clinics for additional support services. So just even a further way that we've been able to give back to the groups there. But sort of the icing on the cake is we are in the process of conducting a retrospective claims analysis for the patient population that we have enrolled in CCM. Versus our non-enrolled patients through our Medicare shared savings program, and we are starting to see, and we sliced our data 3 times 4 times to stress test it. And on average, we're generating approximately $1400 per patient per year in those risk, aligned populations. So we're comparing similar risk scores to similar risk scores and looking to see what we're finding massive changes in utilization patterns around part a utilization swinging back into the primary care setting, which is just really exciting. So another value add to the PCP is our patients are on average, seeing them 2 additional times per year, where that patient might have been delaying care and having that be more of a an acute condition, or they're selecting urgent care, or they're seeing their specialists when it's really something their primary care physician can handle. So building that tighter bond with the PCP and the patient has really also been just a phenomenal out, you know, improvement that we've see with the program as well.

 

Daniel Marino: If you're just tuning in, I'm Daniel Marino, and you're listening to value based care insights. I am here talking to Lisa Stockdale, and we're talking about innovations of care management, responding to a lot of the recent CMS changes and so forth. So the, I love your numbers, Lisa. I love the fact that you're you know you're identifying what the financial opportunities has been have been through integrating care management. You know you mentioned the $200 per patient per year as a as a net income. And then some of the other investment things that you've been able to do. What have been some of the maybe, if you can give us a few examples, what have been some of the concrete, let's say, operational challenges, using your data, that has been a bit of a game changer for you and for your team?

 

Lisa Stockdale: Really, we're teaching medical assistance how to care, manage, and proactively. Go find patients that are in need. I think, because the system itself is built in that reactionary model that it's a little foreign for staff to go nudge a patient, ask them something, trigger them the patient to respond to you. So we've spent a ton of time working with our employees and our care managers to, you know, really, redefine that experience for the patient and service the patient almost like a concierge type of program. So.

 

Daniel Marino: Yeah. And that's boy. That's a great point. Because I'll tell you. So many of us and healthcare for years have reacted to what's occurring with the patient. Right? So if a patient, and we know that ourselves, if we don't feel well, or if there's something going on, we we're not proactively, even in our own care of working with our providers, we react to something. And then, as physicians and as clinicians for the most part, you're reacting to what's occurring with the patient. So just the fact that you're using the data and changing that educational mindset with your MAs to start thinking about it a little bit more proactive, getting out in front of that absolutely the key, and being able to drive those results.

 

Lisa Stockdale: I agree with you. And I would say the last, you know, example really is the care planning process. And you know the beautiful thing about teamwork and healthcare is, you don't have to think of everything yourself, and you shouldn't. When you give clinicians tools they will go above and beyond your wildest imagination. Our nursing team got together and completely reconstructed our care planning process and put definitions around it. It's a Quarterly review, a Biannual update. It's a living, breathing document. The patient is shared. Their care plan through their text links on their phone as they participate with us. So as their care journey is changing their care, plan lives and breathes with them. And that is where we are also screening our patients for social determinants of health.

 

Daniel Marino: Oh!

 

Lisa Stockdale: I am so proud that they have tackled that

 

Daniel Marino: Absolutely.

 

Lisa Stockdale: Yes, and really, just being able to ask patients about, you know, do you feel safe in your home? Can you afford your lights and water and your food? And using those evidence-based screening questions. When we find those issues, those are notes going right to the physician or to the app saying, we've identified this. And then the, you know, sort of chain reaction occurs. The beauty of care management that 20 min can really be spent on whatever the patient needs at the time. So our team is now building relationships with our community based partners. We've been running a food bank program since 2021.

 

Daniel Marino: Oh, so socioeconomic and other health equity issues have really come into play. It sounds like within your care management approach.

 

Lisa Stockdale: Yes, and I believe that's 1 of the things that's impacting, you know the total cost of care performance where patients were not taking meds because they couldn't afford them, and things like that. So that that's really just been a beautiful thing to see unfold. And the clinical team has just taken that on and embedded it in our care planning process. And so that's really where we've seen successes with that.

 

Daniel Marino: How impactful or important has the technology support been to your care management team? I know you're doing a lot with data and you're really trying to understand from an analytic standpoint, what's occurring with your patients and your population. But how about the technology? How's that come into play?

 

Lisa Stockdale: Our program wouldn't be possible without our partner. And there's a couple of reasons why. The program is run off an SMS texting platform. Which step one. There is no barrier unless you can't text and there are those cases where folks don't have phones that text. But there's no apps to download. On the flip side the enhancements and the automation and scale that it gives to the clinical team is something I've never seen from another partner, another vendor being able to have an MA, you know, sort of run the day to day operations of that 500 patients and checking in regularly with folks, that that's really what's drove the majority of the ROI, because we are able to handle a lot more patients yeah, without adding additional labor.

 

Daniel Marino: Well, and I'll tell you it's the old adage, right? People processing technology.

 

Lisa Stockdale: Exactly.

 

Daniel Marino: Strong technology platform in order to support the care management that you want to deliver. You can only do so much. I mean, I could imagine your panel per care management, professional you know, and this probably varies depending upon risk level. But it's probably pretty high, and my guess is the only way that your staff is able to efficiently get through that and provide the care that they need is because you've got strong technology support behind you.

 

Lisa Stockdale: Yeah, it's exciting. We just crossed over the 3,000 mark plan for expansion for the rest of the year, just seeing the results that we're getting the organization is very excited to grow the providers are on board. So it's definitely been a good partnership, and, like I said, couldn't do that without a good partner, because EMRs are not set up like this. There's not many population health technologies out there that can accomplish something like this. So it's great for the patients, and also great for the clinician. And that's you know, where I see the sweet spot with the with the partners we have.

 

Daniel Marino: Well, and you have to have, as you said, you've got to have a strong care team that can work together, be able to and have it multifaceted from our ends all the way down to those that are handing patient navigation. But the technology is absolutely key. So one question that I do have, and maybe this focuses a little bit more on your growth. So I've been impressed with where CMS is going. They're certainly taking the lead in a lot of the care management work, and providing some incentives and support for those that are really, you know, around the Medicare patients if you will, but the commercials, it seems like to me, have been a little slower to react. Not necessarily providing the right level of financial incentives or care management support to organizations, to manage the commercial population. Is that true? What are you seeing around that that level of payer support?

 

Lisa Stockdale: 100% agree. I think the challenge for the commercial population is it all boils down to plan design and what is the consumer going to be responsible for after a service is rendered. So if you think about a family deductible at 3,500 or 5,000, and you have a 45, or 50 year old diabetic who definitely needs a care manager. That family is now paying out of pocket until their deductibles are met. And that's just unrealistic, right?

 

Daniel Marino: Unrealistic. Absolutely. Yeah.

 

Lisa Stockdale: Though this reduces their overall cost, it keeps their health outcomes in play. We, as providers, are really struggled by the constraints of the plan, design, and what the patient responsibility ends up being. And so, if I could implore anybody that might be listening on the payer side, that is something. We hope that you look at similar to how CMS is treating care management like a primary care service.

 

Daniel Marino: It should be a cost of doing business, and I'll tell you we've negotiated quite a few contracts, both fee for service and fee for value, and all of our fee for value contracts we incorporate care management services as an element of the plan design that should. It's a cost of doing business, it should not be costs that are shared with the patient. It should be as a result of you, providing more efficient care and reducing the overall cost of care, and I think you probably share the same philosophy.

 

Lisa Stockdale: Yes, you can never know go wrong investing in primary care, investing in care management. You're going to get the results that you need in the long run.

 

Daniel Marino: Yeah, yeah, that's it. That's absolutely true. So as we for any of our listeners who are who are tuning in and obviously care management, especially for those that are heavily involved in in population health and value-based care. Any piece of advice that you would give them, maybe from lessons learned, or things that have worked for you?

 

Lisa Stockdale: Don't give up. Yeah, you know. have a strong voice. If it's the right thing to do, you should keep fighting for it. There are patients and communities that need you out there. So you may be that you know, voice off to the side. But please keep going, partner with your finance teams, partner with your physicians. You know, this is not what problem that's going to be solved in silos and operational alignment because nothing is successful. Everything's an idea until it actually is put around operations is put around it. Having those partners is critical to the success that we have. My operations partner is really a dream, and I'm so grateful for her because she's taught me so much around running medical groups and making this program just what it is today. So it's really about having good partners.

 

Daniel Marino: Well. And I absolutely agree, as I've said in working with many organizations around the country, every care management program is unique. But there are foundations, foundational elements of care management that drive the results. And you don't have to reinvent the wheel. I think you've got there. There are lessons learned, the technology partner is important. The data is important. Educating your team is important. And I think, as any organization builds strong care, management and perfect examples with you the support that you provide to your physicians and clinicians. That's what drives the results.

 

Lisa Stockdale: I love it. I walk into my physician offices, and they hug me. We didn't have any of these programs until you got here, Lisa. And so it really is my love for the for primary care for the community here and for my physician partners that I've worked with for the last 10 years.

 

Daniel Marino: You’re definitely passionate about it, and that that comes that definitely comes through. So if any of our listeners are interested in connecting with you anything you share. I'm assuming you're on LinkedIn.

 

Lisa Stockdale: Yes, LinkedIn’s probably the best way to find me under Lisa Stockdale.

 

Daniel Marino: Good. Well, we will include your LinkedIn handle in our liner notes. And Lisa, this has been great conversation. Thank you for coming on and sharing your stories, and and your successes, and I wish you a lot of future successes as you continue to evolve your care management.

 

Lisa Stockdale: I appreciate you, Dan. Thank you for having me on today.

 

Daniel Marino: And a special thank you to you, our listeners for tuning in. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

Certain specialties, such as primary care, are generally better positioned to shift to value-based care. Specialists, particularly cardiologists, encounter challenges when transitioning from fee-for-service to fee-for-value. To succeed in this shift, they must rethink their approach to patient care. In this episode of Value-Based Care Insights, Dan Marino sits down with Dr. Sameer Sheth, a board-certified cardiologist who helps specialists transition to value-based care by focusing on a patient-centric approach to medicine. Gain insight into the healthcare provider ecosystem and how data and tools, patient engagement, and communication all support the shift from volume-based to value-based care.

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value-based care insights. I'm your host, Daniel Marino. As we've discussed on the program many times, shifting into value-based care is easier for some specialties more challenging than others. Some of the primary care areas have found it quite, I don't want to say easy, but the transition from fee for service to fee for value and value-based performance around the activities of primary care. It's been a smoother transition. For some specialties, they found it a little bit difficult. We worked with a number of specialty groups in either forming integrated networks, or maybe even a part of a larger ACO, and the common question that often comes up is for specialists and for specialties. What do we track? How do we transition into value based care? How do we make it something viable for our specialty providers. So we can continue that transition into value-based care. And it's no secret that it's going to happen in 2030, as Medicare has said, as CMS has said, you know, their goal is to move really as much as the healthcare community into value-based care. They want to get out of the or out of the framework of managing really patients Medicare patients in a in a fee for service structure, they want to move folks to value-based care under these commercial plans. So the transition for not only primary care, but particularly specialists, is really going to be important.

Well, I have a wonderful guest here today, that's going to help us talk through the transition for cardiology, for cardiovascular medicine from fee for service into fee for value. Dr. Sameer Sheth is joining us today, and he is a board-certified cardiologist practicing at a large health system. He's done a lot of work with not only in cardiovascular services, but with some other specialties helping specialist transition into value-based care. Looking forward to the discussion, Dr. Sheth, thank you for joining the program.

Sameer Sheth:

Thank you so much, Dan, for that warm introduction. It's pleasure to be here on on value-based insights. And I'm excited to discuss our topic today and share some insights with your listeners.

 

Daniel Marino:

Well, thank you. I appreciate that. Let's talk about cardiology and cardiovascular services again. As I said in my opening comments, for some specialties, it's been a little bit challenging to make that transition for fee, for service, to fee, for value. What have you seen within cardiology, within cardiovascular services? Has that transition been difficult? Are you seeing a little bit more momentum? What are you sort of seeing as you work with different providers around the country?

 

Sameer Sheth:

Yeah, historically, as you mentioned, cardiology has been really entrenched in fee for service. And really, what it means is, if you look at cardiology as a specialty. It's a wide range of subspecialties, and each focus on different aspects of heart health from general cardiology to structural health, to heart failure and transplants. And with modern technology, we've had so many advancements in the field of interventional cardiology or electrophysiology. And patients require more and more coordination between the cardiologists themselves. Yet our per our current payment models incentivize volume, they incentivize procedures, and they really don't really incentivize the quality of care for these patients. And so if we look at transitioning from a fee for service world where you're incentivized to do these things to a value-based world where requires a multi-faceted approach. It's a tough transition. And I think more and more realizing that it needs to happen. And really, to do this, you need a few things. You need to emphasize prevention. You need to emphasize coordination data. Utilization becomes a key aspect. How do you use the data that's available to identify patients, patient engagement becomes more important. And then, really, the last form is the innovative payment models that that we can get into and talk about, and the technology that can help that. So I think, really focusing on value over volume requires many steps along the way.

 

Daniel Marino:

Yeah, I agree with you. Good, good. Those are good points. And I, it's really a paradigm shift. But I think the interesting thing about cardiovascular medicine and cardiology, and you mentioned this one, there's numerous subspecialties. Second, is for cardiology, because it's internal medicine based, there's a lot of patients who see their cardiologists as their primary care physician. So when you look at the contracting opportunities there is attribution of lives to cardiologists that are different than other specialties. I think that provides an opportunity for cardiologists. I think it also provides a little bit of a challenge as well, too, because, although you may be focusing on the cardiology based chronic diseases. You may be missing some of the other ones. That and the coordination around that, I think, becomes really key. But other specialties are transactional, based right? Some of the interventional cardiologists. So in your experience, one of the things that you mentioned was alignment right? How do you align all of the sub specialty, cardiology or cardiovascular providers into an integrated network in such a way that they're working towards the same common goal?

 

Sameer Sheth:

That's a great question. And it's much easier in health systems that have all of the specialties in. In my experience as a general cardiologist, having the general cardiologist as a central point and responsible for that patient makes the most sense. They are doing the early diagnostic work, the medical management of these patients, and then referring to their colleagues who are helping with the procedural parts of the care. And so in independent practices where they may be more general cardiologists refer to colleagues that are at different practices, we still need to assign that attribution, and I think it starts with that general cardiologist.

 

Daniel Marino:

Yeah, really, just almost managing the case amongst your colleagues, right? And I, and I think similar to a PCP structure where you have that general colleague general cardiologist, being the quarterback of the of the care.

 

Sameer Sheth:

And I think you mentioned something very important for certain conditions, and as patients get sicker and chronic disease management becomes a big part of Medicare patients' lives. PCPs look to cardiologists for management of congestive heart failure for coronary artery disease. It's a team-based approach because these patients benefit from having their cardiologist intimately involved in their care. And we can't forget that comorbidities with cardiac disease are always existent diabetes, hypertension. And so, having that communication between the cardiologist who may act as that quote unquote PCP. And then their primary care provider, their internal medicine doctor, who is also addressing some of their needs. I think that's a big part of value-based care that we have not seen in the past, because everyone's really been in their silos, in the fee for service world, but that intimate communication is very important.

 

Daniel Marino:

So cardiology and cardiovascular services as a specialty is one of the areas that has been near and dear to my heart over the years. I had an opportunity early in my career, to manage a cardiovascular practice. And really enjoyed it really became engaged with the different subspecialties of cardiology and cardiovascular services. And there's been a lot of changes over the years. There's been a lot of changes from a focus, you know, 10-15 years ago a more interventional type work to less on interventions more on on therapies. In your opinion, you know. How does that come into play? I mean on the surface, you would think that it does help to reduce costs. You would help think that it does help to improve patient outcomes. But frankly, it's a mindset right? I mean that in and of itself depicts the transition from fee for service to fee for value. How is that received by a cardiology group, an integrated cardiology group that's really looking to kind of move or use that as a basis to move into value-based care?

 

Sameer Sheth:

That's a that's a great point. And I think you said it really. Well, it's a willingness to adopt that mindset a patient centered approach and shifting the mentality from volume to outcomes. And but it requires a lot of tools. And so what I say is, you know, a group that's looking to do this, you really need population health tools, you need data analytics, you need a a team based care approach because you can't do everything yourself. Cardiologists are very busy. They're seeing a lot of patients. There's a lot of wait times, but we want to move the care ahead. So I think the focus needs to be on a few things. One is data. Data analytics can really enhance the care provided to patients. So getting real time updates getting real time data from pharmacies. This allows us to treat the patient with the best medical therapies. As you mentioned, we're learning more and more through randomized clinical trials that medical management is the 1st step. Look at a condition like heart failure. Less than 10% of patients are on optimal doses of goal directed medical therapy. And we know that these medications can reduce the risk of hospitalization 40 to 50%, they improve mortality. So how do we leverage the data, knowing that, half of our patients are not on this one medication. Let's create a population health program where our nurses, our nurse practitioners, our pharmacists, can help get these patients on the right doses through trication.

 

Daniel Marino:

Right. Well, then. That's a great point. The data has to drive that because it drives it not only as an understanding of where you're providing the optimal level of care, but also what are the outcomes associated with it? And you know it was. It was interesting. I had the opportunity to work with a an academic cardiovascular, a very well world renowned cardiovascular program in the Northeast as part of an academic medical center. And I'll tell you many of the cardiologists, many of the faculty within cardiovascular services saw themselves as scientists versus even providers. And they love the data! The thing that I noticed was as they started to think about moving into more performance based care felt like they were looking at the wrong level of data. Right? They were looking at maybe more of the research data, but not the data that you just described.

 

Sameer Sheth:

Yeah, you said it exactly. Exactly right. Cardiologist love data. We've been using randomized control trials to show evidence for drugs and therapies. As you mentioned, these trials are very scientific, and look at the outcomes they look at clinical outcomes. But they don't really look at implementation. And so driving evidence based guidelines and reducing clinical variation are critical drivers of VBC and cardiology. We really need to standardize guideline-based therapy, and that requires implementation and workflow management. And so I see it as a need for cardiologists and cardiology practices to really understand, how can we in our existing workflows. Add these levers? How can we make sure that we prescribe the right medication? But how can we make sure the patient picks up that medication. How can we address side effects? How can we follow up in a timely manner? And you can't do everything alone, as I like to say so. There are huge opportunities to build those workflows around the cardiologist.

 

Daniel Marino:

So if you're just tuning in today, I am here talking to Dr. Sameer Sheth, and we're having a fascinating discussion around cardiovascular services and transitioning cardiology, cardiovascular services from fee for service to fee for value. Sameer, the data obviously is really important. But what you do with the data really becomes key. Let's talk a little bit about the governance structure. You know, a lot of cardiology groups obviously, have, you know, a lead physician there, and they, you know, they work with their providers, and so on, and so forth. How does governance? How does the you know the working with the different cardiology, physicians and providers, and so forth. How does that need to be different in a fee for service or fee for value world? How do we create that collective alignment, any thoughts?

 

Sameer Sheth:

I think, having a champion who believes in this is very important. And then having that champion who's willing to implement new programs that may be uncomfortable at first, but allow buy-in from the rest of the group. So for an example, if you look at ambulatory surgical centers, they're a growing field in cardiology, where diagnostics procedures can be performed as an outpatient. It creates better efficiencies lower wait times increase access to care, and they can be they can reduce cost by almost 30 to 40%. But that requires buy in from a champion and the group right? It takes capital. It takes time. You have to do a lot of legislative and processes to get that approved but it helps the group and the patients. And it's a large undertaking. But that's an example. Other things are creating a simple program like having urgent care in your cardiology office, having time to take patients who could otherwise go to the emergency room but bring them in for Iv treatments and therapies to get rid of excess fluid things like that. So there are new programs and having that champion who's willing to try these new programs that are outside the normal protocols and cardiology is a good start.

 

Daniel Marino:

Yeah, I agree with you really think you need to have that that physician champion, right? You have to have somebody in the group that's driving the change that's creating the vision of where the organization needs to go from a value-based perspective. And that could be that champion to activate the vision. And your example of moving from a queue to more of the ambulatory arena for cardiovascular services is spot on. We're seeing more and more of that with a lot of the transitions of care and payers are responding. Payers are asking for that. Many organizations in the contracting that we're doing for organization. They don't want to pay for some of these services that are being done in the Ecu arena. They want to do it in ambulatory. So which kind of leads us to my next question is, is, I was hearing you talk. you know, if we're if we want to build a contract right, get a deal at the end of the day. That's where the rubber hits the road right? You can do all of these great things, and we talk about this time and time again on the program. You could do all these great things around creating measures and aligning your group and being clinically integrated. But at the end of the day, if you don't have a value-based contract or some type of alignment with your payer partner, you know you, you're not going to create the right level of momentum that you that you need to.

 

Daniel Marino:

What are some of the important elements that cardiology, groups or cardiovascular groups should consider as they start to engage in value based contracts?

 

Sameer Sheth:

Yeah, as you start thinking about value based contracts, I think the one thing that cardiology groups need to get comfortable with is being responsible for the patient, not just their cardiology needs. And I think that starts as you mentioned, around attribution. Once you're responsible for that patient. That patient is attributed to you. You have to go beyond their needs for their cardiac episode. It may involve coordination to get them to see their nephrologist. It may require coordinating for them to pick up their medications. And so, as we think about attribution, there's different ways cardiologists should start thinking about it. 1st and is around diagnosis. Am I responsible for congestive heart failure patients? The second is, am I responsible for this patient that has multiple cardiac conditions that sees me more than they see their primary care doctor? Kind of what we call a plurality of claims, kind of, they're seeing this specific provider more than others, they should be responsible for the patient. Then, lastly, I think of cardiologists as kind of network attribution, where your network of cardiology or group or your health system, should be responsible for all the patients that they see. It's almost like an ACO an ACO model where the you know, a primary care organization is responsible or a group of patients. And this could be a multi-specialty group. This could be cardiologist. And I really think once you're attributed that patient. Then you create the programs around that group of patients to keep them healthy.

 

Daniel Marino:

Yeah, I agree with you. And as you're talking about this, you know, the an interesting thought came to mind for a cardiology group that has many of the subspecialties, and really moves towards clinical integration or clinically integrated within the group. You really have 2 contracting opportunities. You can contract direct with a payer around that attribution model right? The attributed lives to the general cardiologist. And probably can even, you know, second to that is come up with some episode based pricing models, right? That could be managed by the general cardiologist and then incorporated with a lot of the sub specialty. So I think that's an important contracting mechanism or an approach. But the second one is to be able to position yourself or position the Cardiology group as a preferred provider partner to ACOs, especially these primary, care-based ACOs. Not that you want to transition the attributed lives from primary care to cardiology, but the sub specialists working closely with the primary care groups, I mean, you want to talk about a way to bend the cost curve. That's it.

 

Sameer Sheth:

You nailed it on the head, I think, working closely with primary care. In my, in my view, is going to be the future of cardiology care because, there is an opportunity to show how cardiology care can improve outcomes. And then with that improve rewards for the cardiology group. So I think there's actually. And you mentioned, there's actually states that are far ahead on this. If you look at Maryland, they have a Maryland episode, quality improvement program. They call the equip program for cardiac episodes, such as heart failure, PCI, cabbage surgery. They have these bundles that look at cost and quality over 60 to 90 days. And that cardiologist can earn upside or earn shared savings from these episodes, and then with primary care it's a similar structure. If you can show value for episodes or through cardiac care, the primary care can subcapitate or give you some part of their shared savings because you also made an impact on that patient's life. So I think there's contracting opportunities with primary care with payers. And it's really new, but I think there's going to be a big uptick in the future with this model.

 

Daniel Marino:

Yeah, I agree with you. I'm a big proponent of episode-based pricing models. I think they really create some strong incentives. I think it really does align the providers. And if you do this well, you you're delivering really good care to those particular patients who are who are within that, that that episode of care, so to speak. But to your point earlier, you're only going to be successful. If you have the data right? You need to have the data to manage it. You need to understand what's occurring and identify some challenges that are potentially, negatively influencing patients who are considered in that episode. Without the data you're really limited.

 

Sameer Sheth:

And I think you're right. There's 2 kind of pieces of data that I see. One is the early real time data around where are your patients? Are they headed to the emergency room? Are they being discharged from the hospital? Because you need to attack the needs of the patient at the at as soon as you can, because that's really going to drive the downstream costs. And then, secondly, what we've been lacking for so many years is data around how am I performing? Am I doing the right things to be able to partake in the shared savings? I don't know where I where I am right now, and I think we've become more sophisticated. And payers have also to allow physicians to see how they're doing so that they can make adjustments quarterly or halfway through the year to say, Hey, I'm not doing so great on this metric. How can we improve as an organization? So data on both sides is very important to drive this behavioral change.

 

Daniel Marino:

So if any of our listeners that, you know, are either part of a cardiology or cardiovascular group, or maybe are part of a multi specialty group that has cardiology. If they're if they're really focusing on moving, wanting to move fast into value-based care. In your opinion, where do they need to start, or where should the predominant focus be?

 

Sameer Sheth:

Yeah, you said a cardiologist are busy enough and need to focus on the patient centered care and focus on prevention and focus on chronic disease. But they need to stay informed about the advancements in policies, in medical technology and really building those strong relationships. And it's really hard to do alone. So my opinion is that to really move into value-based care there are so many partners out there that can help with aspects of that transition. Whether it's contracting, whether it's the technology piece, whether it's helping you form a team-based approach. And I think navigating all those layers is hard enough alone, but with a partner it can be accomplished. So really, starting to shift and see how your practice can do that, it's exciting. Yeah.

 

Daniel Marino:

I think it's essential. And you know, we we've talked about a couple of things, I think, when we work with organizations that are considering either ramping up their work and value, based care, or maybe just starting to dip their toe in the water related to it. It comes down to 4 things. And you mentioned this. You need to have the strategy and the vision where you want to go with moving into value-based care. You need to invest in the infrastructure right? Because this is a different mindset moving from fee for service to fever value. Data is absolutely key right. And you would. You mentioned that, I think, if there was 1 point of our conversation that has really resonated with me, it's the fact that you need to have the data and re look at the right things in order to move that value based bar if you will. And then the last is, you need to create some contracting and alignment of incentives around that. So I agree with you. I know Sameer in in a lot of work that you do. Not only is seeing patients as a as a cardiologist, but you also do a lot of work with your own company. What are some of the things that that you can offer to different groups, or what are some of the things that you know you've brought to your colleagues who have been interested in in moving forward with value based care.

 

Sameer Sheth:

Yeah. And thanks for mentioning that, I think I saw it based on our discussion. We covered all the all the points that I saw the challenges it for cardiology practices. And so I wanted to create a solution. That's a 1 stop solution where they can get the data and analytics. They can get the contracting support. They can get the team to help them transition. And so we created Chamber cardio to do that and I'd encourage listeners to visit www.chambercardio.com if they're interested. We have a blog that really talks about a wide range of topics and value-based care. The upsides, the challenges. It can help cardiologists navigate these challenges themselves or contact us or contact me to help have some support. It's a great resource for anyone looking to implement or improve value-based care in their practice. So I really think this is the future for cardiology. And I really want thank you, Dan, for having me on the show. It's been a wonderful experience.

 

Daniel Marino:

Well, Sameer, this is great, and you obviously have a tremendous amount of knowledge. And I really appreciate you taking the time to share this with our listeners. Again, you know, if there is additional information that you need please look up Sameer's website. And Sameer, you want to share maybe your contact information real quick.

 

Sameer Sheth: Yeah, I'm happy to have anyone contact to me. My email is sameer.sheth@chambercardio.com. And or you can just find me on LinkedIn.

 

Daniel Marino: Yep, alright. Appreciate it, Sameer. Thank you again for joining the program. Really appreciate it. And again, keep driving forward with value-based care. It's something that we all believe in, and I'm a hundred percent behind you on this would love to have you back to hear the successes. I want to thank our listeners today for tuning in until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

Developing a strategic plan is crucial for the success of thriving healthcare organizations, but creating and adhering to the plan can be challenging. In this episode of Value-Based Care Insights, Dan Marino sits with Annette Kenney, a former healthcare Chief Strategy Officer and strategic planning consultant. Annette unlocks how healthcare organizations can develop a strategic planning process that includes input from all stakeholders, including the communities they serve. Uncover insights into how to transform a strategic plan into an actionable workplan that prioritizes activities and drives real success.

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. Over the last couple of years many organizations have started to ramp up their strategic planning process. If you recall back during the Covid years, it seems like strategy was kind of put on the back burner. Many organizations were forced to deal with many, put in place a lot of the tactical type initiatives just to accommodate and deal with many of the issues that we saw around Covid, around changes and reimbursement around some of the industry and political changes. So I think that area really from 2020 2021, up till maybe 2023 was really around the tactics to keep all of our healthcare organizations moving forward. And then over the last year, year and a half we've started to see strategic planning come in to come into play more for organizations and to really think about how they can position themselves in the market and really accommodate a lot of the of the needs of their of their patients in their communities. But the strategic planning process is difficult. It's difficult, from the standpoint of not necessarily creating the plan. Actually, that's the easy part. But activating the plan. Putting a document in place that becomes a living, breathing component of your organization that allows the all of the leaders, the team members to really rally around our common goal and to think about where we want to go as an organization and how we get there. That's really the key to that strategic plan. And it's really around that activation.  

 

Well, I'm excited today to have a strong colleague, somebody who's very knowledgeable in the strategic planning process. Annette Kenny. She's a former chief strategy officer for a large healthcare organization. She has put together numerous strategic plans both for the organization for clinical service lines for value-based care. And not only has she been successful in putting forth the plan, but has been very successful in helping to activate that plan. Annette, welcome to the program. 

Annette Kenney:

Well, thank you, and thank you for the kind introduction. Dan. 

 

Daniel Marino:

So when you think about the strategic planning process, why do you think organizations struggle so much with the activation of that plan? 

 

Annette Kenney:

You know it. It's interesting. And I appreciate your comments. Early on, because you know the bottom line, they struggle because healthcare is so complex, right? There are so many things we could be doing any given day. You're distracted by a number of operational challenges, financial challenges, local market challenges. It's, you know, you. You need to actively prioritize on an ongoing basis to make sure you're working on the right things. And you're allocating resources to the right things. And so that's where strategic planning comes in. It's a discipline that allows you to do that. Exactly how it's done in different organizations may be a little different, but it's always an opportunity to bring order to chaos. And I think organizations struggle because they're just distracted. And it's a little bit ironic, because the strategic planning process can help you from being distracted. But yet it often gets pushed aside. 

 

Daniel Marino:

Well, absolutely. And we've done a lot of strategic planning over the years. And one of the things that I often when I go into the strategic planning process. I often say to a lot of the leaders, what do you? Why do you want to do this? Right. What do you wanna accomplish? Is it that you want to grow into new markets? Are you doing this as a defensive measure to make sure you're competitive against you know your other market competitors? Are there some industry things that are changing? Are there other areas that help to say, motivate the team around strategic planning? What are those core things other than you know, what I had mentioned? What are the other core things that really need to be considered as you kind of define the why around strategic planning? 

 

Annette Kenney:

Yeah. Well, I think you know, some of the why will be a little bit different for every organization. But every organization is dealing with challenges and prioritization that can benefit and resource allocation quite frankly, that can benefit from a strategic planning process. So you don't have to wait for a seismic event to start thinking, “Oh, wow! Now we need a strategic plan.”  It needs to be, as you mentioned, a living, breathing process. Not that not a document, but a process. So that you're working on the right things. So I, I tend to think about people, process and data. It doesn't quite answer your question. I think your question is around what kinds of things will motivate an organization to do a strategic plan. Again, I'm advocating for it being built into your regular process. So you don't have to wait for something to trigger a strategic plan. But one experience I've had most recently was a merger so part of an organization that came together in pieces over the Covid period quite frankly between 2020 and end of 2022. And you can imagine doubling its size in that period of time, in that period of time of incredible chaos. And you know that was a trigger. We you know we thought hard about saying, Is this the right time to do strategic planning? Or should we wait until the dust settles? In retrospect it turned out to be exactly the right time to do strategic planning because it helped to form the basis of our culture. It helped to provide clarity for the organization. And it helped us really early on to align people and energize people around where we were going as a new organization. 

 

Daniel Marino:

Well, and that's such a that's such a great example. Because, you know you, a key component of a strategic plan is addressing the culture change and the and currently where we're at now and where we want to go. But I think another interesting point that you brought up is alignment. So when you're going through something as challenging and potentially as disruptive as a merger could be, I mean, it's exciting as it is, it's also very disruptive to the organization. 

 

Annette Kenney:

Okay. 

 

Daniel Marino:

Getting leaders getting the team getting employees getting. you know, even the community aligned around why you want to do this and what the end goal is, and how we're going to do it from a strategic standpoint. God! I can. Only I can only imagine. I mean that that's that has to be the biggest benefit coming out of it. 

 

Annette Kenney:

Yeah, in. In, in my experience, it has been. It almost feels hokey in a way to focus on mission vision values it, you know, it sounds like, just a lot of a lot of verbiage. But it's really meaningful what we did again, very early in the merger is engage community members, employees throughout the organization managers, of course, executive leadership as well in defining what's what is our mission? What is our vision? What does it? What are values? You know? How? How do we want to behave as an organization? What does success look like long term. What's important to the people who are our stakeholders, our community as well as our workforce. So we actually hit the ground running with focus groups with surveys. Just a lot of talking to people. I call it a listening tour. That's probably for 3 months or so. But we engage people throughout the organization and really kind of learned that there was common ground, even though we're all coming together with different perspectives, different experiences. Maybe even different goals. We have a lot of things in common, and that helped to inform again our mission vision values which in turn help to inform our executive leadership team around. Okay, what do we have to do to prioritize all things we have to do in order to achieve these results that are going to be so meaningful for our stakeholders. 

 

Daniel Marino:

Well, and I think I that's a that's a key part of it. There's so many, especially with a large organization, but even small organizations. There's so many competing priorities, and everybody has an opinion of where to go. I liked what you mentioned about trying to get the data and to listen and to understand where the different parts of the organization is. but also making sure that somebody has to help bring the group together to identify the strategic priorities. Otherwise, I think you just get wrapped in this. 

in this, this wheel of never ending movement without really identifying what direction we want to go. When you when you think about, then the success of that strategic plan defining priorities has to be key. I would also think the data. What are some other elements that you in your experience have been successful to the strategic planning process? 

 

Annette Kenney:

Well, I think you touched on it. You know, I mentioned people process data. People's all around alignment, right? And educating them in communicating to them the process right? And what's their role in that process? Because you mentioned as well, It's all about execution. I don't care what the plan is if we don't execute the plan, and you need the people who are doing the work to execute the plan. So aligning them through the process, getting engagement with them throughout the process and fundamentally educating them to the process. It's kind of a funny thing, because I've been doing this for so long, I take it for granted. But you bring teams together, and whether it's where people have been in the career or how their organization has functioned. You can't assume that everybody understands how a strategic planning process works or what their role is. It is in it. People don't necessarily connect the dots between strategic planning and operational budgeting and capital budgeting and incentive planning and business planning. They don't because they haven't been through that process. So having a process communicating that process and working with people to get them engaged and get them excited about it. So they understand their role. I think all those things are critical. 

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino. You're listening to value-based care insights. I'm talking today with Annette Kenny, former chief strategy officer of a of a large healthcare system. And we're talking about the strategic planning process. Annette, you know. I interesting comments in terms of being able to make sure that you're educating folks on what the strategic plan is, and then the process. How do you make sure in the strategic planning process? Maybe at the end of the plan that you're not taking on too much? 

 

Annette Kenney:

That is one of the biggest challenges. I have not been with an organization that hasn't complained that they have too many priorities. And they, you know. I wish I had the match exhausted to cut that down. The fact is, there's a lot of enthusiasm. There's a lot of really good ideas, right? And they're all good ideas. And there's a lot of competing forces that you know make the process very complex. I think it requires a certain level of discipline. You know I you, you go through a process, and as I mentioned, there are many ideas that are valid. But you can use data. You can weigh these opportunities against each other. You may not have the time to do a fully developed business plan, but you know enough. 

 

Daniel Marino:

Yeah. 

 

Annette Kenney:

Is this initiative weigh against that initiative, and does it? What? What is going to accelerate your achievement of the goals that you're setting out. So I think, having those goals, making sure they're measurable. helps a lot. 

 

Daniel Marino:

Yeah, I agree with you. And I think, having the goals of what you want to. What? What do you want to get out of this strategic plan, I think, is absolutely key and sort of having that North start right? So why do we want to do the plan? What are we helping to accomplish out of the planning process? What's our goal at the end of that planning process, I think, is really important. A colleague used to save. If you don't. If you don't have a goal, if you don't know where you're going, any road will any road will take you to, you know, to nowhere. Right? So you need to, you need to have that idea of where you're going. You keep on mentioning the data. Let's talk a little bit about that for a second. Obviously, data is important to the strategic planning process. But I also feel like you could have too much data. Right? So what's that balancing act between having enough data and what would be considered kind of that? Enough data versus data overload. 

 

Annette Kenney:

Yeah, well, I think you hit on a common challenge, too. Is that people say, Okay, we don't have the data. so we can't do our strategic planning process. You know enough. You probably know enough. I mean, certainly you need good baseline financial data. You know what your quality metrics are your patient experience. You kind of know where you are. You don't have to wait for perfect data to execute or develop a strategic planning process. It just needs to be good enough so that you establish some credibility with your stakeholders. Right? 

 

Daniel Marino:

The data, especially the market data. And this is where I see a lot of the challenge come in. The market data needs to inform your strategic planning process. It doesn't define your strategic planning initiatives. And I and I get the impression sometimes when I'm when we've done some strategic planning and worked with organizations, some leaders dive into the data because they think that's going to give them the answers when you can need to come up with the answers yourself. Right? The data needs to inform. It doesn't direct. 

 

Annette Kenney:

That's absolutely right, absolutely right. Again, it gives you a sense of what your baseline is. If you have a sense of what your vision is and the challenges in front of you. You know, you can use that data to say, Okay, we've got to get from A to B, and that helps you to find your initiatives right? And again, it does not have to be perfect. In fact, I would encourage organizations to resist too much data. Somebody needs to know all of this information, but your stakeholders don't need to know everything. 

 

Daniel Marino:

Yeah, it's true. 

 

Annette Kenney:

Right, they need to know what is going to be. The information is necessary to make an informed decision. 

 

Daniel Marino:

Yeah, right. 

 

Annette Kenney:

And that's all. So. 

 

Daniel Marino:

Sometimes I just I think folks just get too buried in that in the data. So Le let me switch gears just a little bit and talk about the activation component of the plan. Because again, I feel like. obviously, the plan is important, because that's the roadmap that tells you where you want to go. But if you don't, if you don't have the key elements that help you to activate, then all the plan is is a series of good meetings. in your experience. What are the activation steps, or what are the key things that have to come out of the plan that allows the organization that next day to begin rallying the troops and begin getting the activation components in place? 

 

Annette Kenney:

Yeah, I think it begins with something I alluded to earlier, which is communicating the process so people understand, you know, how a strategic plan connects to all of the other many processes we have in place in healthcare. You know the cat, you know, people don't necessarily associate budget process. But it's it needs to be very, very much aligned. Same with operating budget. I mean, this is where you make sure you have the resources to do what you said. Your strategic plan is so I think educating people to the process, how it links to other processes that they may be more familiar with is particularly operational leaders. Cascading the plan, you know, we talked about aligning people through engaging early process. So they get a taste of what this plan is. But then they need to say they play a role leaders at all levels, play a role in cascading that plan throughout the organization. So they can activate their teams and prioritize effectively with their teams so that they're, you know, focusing on the things that that the strategic plan is saying is our most foreign. 

 

Daniel Marino:

Right? Right? Right? Do in your experience when you've done strategic planning. And I guess it depends upon the type of strategic plan. Obviously, the leaders have been health care Leaders have been involved. How have you engaged the board in your strategic planning? 

 

Annette Kenney:

Yeah. Well, the board is critical. The board needs to. I mean, ultimately, they're responsible for approving the strategic plan. So I have engaged the Board early on as well. I think the Executive leadership team needs to really define the process lead this, but they need to engage the Board as critical stakeholders, so they need to stay educated. that doesn't happen to happen in just a strategic planning exercise. It can happen through regular board meetings. Just keeping a pulse on what are the forces that are impacting our ability to succeed as an organization? I think that active education of Board members, not just board members, but leaders throughout the organization is really critical. And they board members and other leaders need to understand the why. the why behind things, and you know, so you can engage them in a series of retreats, and but also in board agendas. Once the plan is approved. Keep it fresh, right? Structure, the agenda around the key elements of the strategic plan and bring the topics forward. You say, okay, we're making progress on this front. We're not making progress on this front, but keeping that ongoing engagement around what the strategic plan said, how we're proceeding against it, what forces might be getting in the way. 

 

Daniel Marino:

Sure. 

 

Annette Kenney:

Of us achieving these plans and then engaging them about. Hey? Sometimes you might have to pivot right? Best. Late plan. Sometimes things happen. You know. So board education ongoing board engagement is really critical. 

 

Daniel Marino:

Well, and I think defining the role of the board even during within the activation phase, right? Because the board should have some type of a role as well as providing strategic guidance. A lot of times board members have great relationships with their community leaders that allows you to position the organization differently or allow some level of activation, which certainly is key to the overall process. So if you're if you're thinking, I'm going to take us back. Then, you know, went over a number of a of elements. The data process, people, I think, is absolutely key communication education in the in the strategic planning process is really important. If you were to think through the 3 or 3, 4 5 elements of a strategic plan that really makes it effective, what would they be? 

 

Annette Kenney:

I think. really saying it's not about the plan. It's about the execution. And you know, keeping that execution in focus is key to actually getting it done. Yeah, so, but in terms of the key elements of the strategic plan. Yeah, I do think we touched on that? It's it's getting the right alignment. It's communicating with people getting them energized around that and doing that ongoing basis. Right? I mentioned with board meetings, setting agendas with the strategic plan in mind. Same with management team meetings, same with town halls, and that kind of thing. Touch on the strategic plan each time. So you make it living, breathing.  

 

Daniel Marino:

You typically in your, in a lot of your plans, do you include measures of success? In other words, how you track whether the plan is on is on pace, or whether you need to pivot. 

 

Annette Kenney:

Yes, absolutely and that's where data comes in. And also process as well. You look back and say, okay, we said we were going to accomplish these things. I mean, I like looking at them on a quarterly basis. Right? Are we. 

 

Daniel Marino:

Really having a scorecard right. 

 

Annette Kenney:

Yes. 

 

Daniel Marino:

You're going to track it! 

 

Annette Kenney:

So having a simple, simple, limited corporate scorecard. Where you can actually say, Hey, we're on base, or we're not on base. And then you can dive deeper into that. So I think that that is absolutely critical to it. And that is where data comes in. 

 

Daniel Marino:

Yeah. Well, I'll tell you. I you know I'm a big proponent of the strategic planning process I've said for years. If you don't have a plan, if you don't know what direction, then you're sort of, you know a boat without a rudder, just spinning in circles. So I think it's really, really key to have that if, and I know many of our audience members either are going through a strategic planning process, or maybe embarking in the strategic planning process, they enter into 2025, any final thoughts, or maybe suggestions on how some of our listeners can get a hold of you if they have some specific questions? 

 

Annette Kenney:

Sure, absolutely, you know. And I would encourage people say that you don't have this muscle in your organization, develop it because it is really effective and helping your workforce and helping you achieve your goals and achieving sustainable success. So I developed that that muscle. You can do it independently. But you could also work with consultants. you know, and  that brings a certain level of objectivity that that kind of helps along with the process so you can get a hold of me. At akenney@ahiconsulting.org and be happy to talk you through. If you have any questions. 

 

Daniel Marino:

Great. Well, thanks, Annette. I really appreciate your time. This, again is an is an important topic. Certainly, when you think about strategic planning either for the organization as a whole or even a clinical service line. The more that you can think strategically about your direction. I think it's really key for the organization. So I want to thank you for coming on the show. Really appreciate your thoughts and your comments. 

 

Annette Kenney:

Thank you. It's a real passion of mine, and I could go on and on, but I appreciate the opportunity. 

 

Daniel Marino:

And I want to thank you, our listeners, for tuning in until the next insight. I am Daniel Marino bringing you 30 min of value to your day. Take care. 

 

Academic medicine providers are increasingly depending on their clinical practices to fund their education and research divisions. How do academic medical providers balance financial performance with clinician and community needs amidst competing missions that challenge their business models? In this episode of Value-Based Care Insights, Daniel Marino sits down with Dr. Joseph Bosco, Vice Chairman of Clinical Affairs at NYU Langone Health, Department of Orthopedic Surgery and President of the AAOS, and Jeff Peters, a national expert in growth and service line strategies, to explore how academic medicine is addressing conflicting missions across their enterprise. Gain insight into growth models in academic medicine that prioritize clinician and geographic accessibility to keep patients in-network, while maintaining a strong focus on research, education, and quality care. 

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Dan Marino. On our program we've had a number of guests who've talked about or shared with us their insights on academic medicine. And as we discuss time and time again, the world of academics, as we think about productivity and supporting the different priorities within the academic mission, it is definitely different than community-based care. Mostly due to just the goals and the objectives of a lot of the providers that are within academic medicine. I mean many of the academic institutions. they have the clinical mission, they'll have their research mission, they'll have their academic mission. And many of them have worked through all 3 of those missions, which really provides a lot of competing priorities. But in the end of the day what we are starting to see and have seen for the last number of years, is there's continued pressure on the academics to provide the right level of financial performance. The right level of ability to expand and really supporting, or, let's say, connecting with their community based provider partners.

Well, I'm really excited today to have 2 wonderful guests who have an incredible amount of knowledge in this area. 1st is Doctor Joseph Bosco. Doctor Bosco is professor and Vice chair of NYU Langone health orthopedics. In his role he's led his department's transformation from a single specialty orthopedic hospital to a clinically integrated musculoskeletal delivery system. And then we also have Jeff Peters, Jeff is a frequent guest on the program. He and I have worked together for many, many years, is a national expert in strategy, helping organizations anywhere from health systems to individual hospitals, to medical groups, helping them with their financial improvements, strategic growth, and a lot of service line development as well. Dr. Bosco, Jeff, welcome to the program.

 

Joseph Bosco:

Thank you, Dan. Great to be here. Hi, Jeff!

 

Jeffry Peters:

Thank you. Yeah. It's an honor, Dan. Thank you.

 

Daniel Marino:

So, Doctor Bosco, maybe we could start with you as you. You think about some of the challenges that academic medicine has, particularly the financial challenges and things are changing. We're not seeing the level of reimbursement that we used to. We're not seeing the funding that we used to. And there's continued pressure on the academics to change their model. What are you seeing as you, as you talk to your peers around the country?

 

Joseph Bosco:

Well, WI think we're all experienced the same thing, you know. Traditionally, as you mentioned, academics had a academic medicine had 3 goals: clinical care, education and research. And it really that really hasn't changed as much. It's just that, you know, frankly, you know, in order to do your research mission and your education mission, you need to be a have a very politically relevant and make money clinically, frankly. You know no margin, no mission. And traditionally, and that even now education and research doesn't reimburse enough to keep a hospital and Medical school afloat. Frankly, so. It's the clinical. It's the clinical mission that funds much of the research and the education, especially.

 

Daniel Marino:

I agree there's that focus has really been over the last couple of years on more of the on the clinical mission. Has it changed the perspective of how some of your colleagues in in academics, their perspective on, on how they need to be productive? I mean, many of them have gone into academic medicine for the mission right? for to really be able to support maybe other areas. A lot of them see themselves as scientists as opposed to just providers. Are you seeing that change?

 

Joseph Bosco:

Yes, as really the pressure. Financial pressure is ratcheted up, and especially in orthopedics, frankly. Orthopedics is a little different, because most orthopedic surgeons a like what we do a lot clinically, and also even now get it gets reimbursed at a very high level. So when you hire a person that's going to be a half clinician, half scientist. Right? That's what they do. They are. They are making a sacrifice with the income they make. And that's just the way it is. And so what we see happening invariably is, they wanna be half clinician, half scientists, and that usually it evolves into 3 quarter clinician one quarter science. It's not just greed or wanna make a lot of money. Frankly, we see it. It's cause they enjoy doing the clinical part. So again, we really have to make an effort to make sure that the clinical activities drive and pay for the educational activities. And you know frankly, with the amount of consolidation that's happened in the healthcare industry today, right? Huge hospital networks. You know, we went from a single specialty Orthopedics hospital Manhattan to now a clinically integrated network with 4 community hospitals, 6 surgery centers and increasing accessibility. So that's, you have to go where the patients are, and so your physicians, your academic physicians, have to be able to move out to where the patients are, and sort of, If you will, get away from the mothership a little bit. If you don't do that, you'll be surrounded by a bunch of by a bunch of very adept surgeons or physicians giving high quality, clinical care, and guess what patients are going to drive past 4 or 5 of these doctors to see the academic doctor in the middle of the city, right? Or in somewhere in Iowa, where they have to drive 3 hours to get to Iowa City to see the doctor. They're not going to do that anymore.

 

Daniel Marino:

Yeah, it's going to, really. And it limits the growth right limits the opportunities. So, Jeff, you know, I know you've worked with numerous academic institutions across the country, academic medical centers. This is really a paradigm shift within their strategy, and you know you wrote a great article that came out in HFMA. I don't know 3 or 4 months ago on how you you've captured working with one academic Medical Center, and how you were able to help support their growth within the community, very similar to what Dr. Bosco just described. How difficult is it to have the leaders kind of make that paradigm shift dealing with either the pressures within our industry, or maybe even the culture that exists within the academic institution?

 

Jeffry Peters:

Yeah. So let me put the context. I think what Dan is referencing is the work that I've done over 45 years with the University of Chicago Medicine, which is a major academic medical center. Historically based in Hyde Park. And through an affiliation with what was once a community hospital, we built a network of family care centers in markets that they had less than 1% market share and put in free standing emergency rooms, primary care practices, specialty practices, supporting ancillaries, surgery center and treatment centers for cancer. And it's been very successful in growing their market share from 1% to 20% in the targeted areas. And it typically, it's been adding a hundred 1 million dollars incrementally to the enterprise. But what we're seeing is in academic medical centers. The physicians are very focused on their department. And just like bot Dr. Bosco references, how do we make orthopedics more accessible? How do we push it out? Unfortunately, as academic medical centers have built these integrated delivery systems, there's leakage. There's primary careers who are there, but don't necessarily refer to the specialist. A lot of the reason why is, you see a patient in in the emergency room, you wanna refer them to an orthopedic surgeon and the orthopedic surgeon only has hours one day a week at the Ambulatory Care Center. That patient wants to access that specialist right away, because in the market, there's other orthopedic centers that have instant access. So increasingly, what we're seeing academic medicals look at is a new model that is like the traditional multi specialty physician group practice. Where there's primary care, there's specialist. They have ancillaries, they have a surgery center, and they're not just linked on their productivity individually, or their contribution to the department. There are incentives so that they take good care of the patient, and if they prevent leakage and keep the patient within their multi-specialty group that's based there, and use the ancillaries and all of that, there's financial rewards.

 

Daniel Marino:

That are kind of tied into that that help to kind of drive where they wanna go and reward the physicians. I think, for that for that new model. So let me turn to you, Dr. Bosco, kind of building on what Jeff had mentioned, as you start to think about driving that care into the community, or even setting up different types of structures, you know, I've always said form follows function. You need to have the right incentives in place in order to drive the right level of behavior. What are you seeing on the on, on the types of compensation, modeling or the types of incentives that help some of the academic providers, the academic physicians kind of think about delivering care differently?

 

Joseph Bosco:

Sure. So I think you know, basically, there's no reason why you can't see patients and perform as like a community-based surgeon and ha be available, or have people that you work be available that does not necessarily have to impinge or impede your academic mission. You could be a researcher, you could teach and still have availability to see patients right? So what we try and align people's incentives, because we know that if we're not available, if we're not provide service right away to folks, they'll go somewhere else. They'll go to one of the residents that we've trained. That does a great job right? So we don't wanna lose those patience. No, you know we can't rely on this academic arrogance, I call it. That's been built over 30 years, saying, well, they'll wait to see Professor Bosco 3 weeks. No, they won't. They'll go somewhere else, probably just as qualified as me and do a good job. So in in many ways, we're in competition on a clinical basis for these patients, and we have to be available and affable.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino. You're listening to value based care insights. I'm talking with Dr. Joseph Bosco and Jeff Peters. Discussing the changes in academic medicine and some of the pressures and challenges that are associated with delivering care. Sorry, Jeff, you're gonna make a comment.

 

Jeffry Peters:

Yeah, thank you. Dan. I agree with Dr. Bosco that you've gotta be accessible. You've gotta you've gotta take care of that patient, and you've gotta take care of that patient where they live. That's still an evolving concept, Joe. I think in academics, because there are, the majority of academic physicians want the patient to come to them to come to the Mecca. And you know, for really rare problems, it makes sense. But for the majority of problems that an academic organization is taking care of, it can be taken care of just as well and more conveniently in a community setting. And I think organizations that evolve like Doctor Bosco has talked about and I know his big messages how do we improve our accessibility? Those are the ones that are really going to survive and thrive because they're responding to the needs of their patients.

 

Daniel Marino:

Yeah. And you have to. You have to think about it, you know. That's what I was kind of saying. It's a paradigm shift, right. You have to think about delivering that care differently which I think in in the academic setting, I mean, culturally, that could be really tough to overcome. You're used to doing it the same way within academic medicine. And really, that that has to change. So, as one example we've seen across the country over the last number of years certain specialties. That are, you know, these community-based physicians will partner with hospitals, with health systems to form these joint ventures either around surgery centers or some type of specialty hospitals, or what have you. And it's a way to really align those incentives, and to really be able to take it out to the community. What are you seeing Dr. Basco? How are you seeing that playing out in the academic world are you? Are you seeing some of the academic leaders, including that within their strategy where you're forming some of those joint ventures with either maybe the departments, if they will, if they can? or certainly with the community partners?

 

Joseph Bosco:

Well, so I think we have to take it back a step, you know, in order to be relevant clinically, you have to grow as an academic medical centers. Anyone. There's.

 

Daniel Marino:

Great Point.

 

Joseph Bosco:

You have to grow clinical basis right now. Traditionally, academics, you know, you have residents, so you have residents provide care well, resident work hours are decreasing, and it's very difficult to get additional residents. So you have a finite amount of resident work hours, right? And which is sort of decreasing. Then you have, you're increasing your clinical volume. So then, a higher percentage of your clinical care is gonna be provided by non resident physicians. So when we hire, you know, we bring a group in. They may not have any contact with our residents, with our teaching. They work, they work only with PAs. Some are full time academic faculty work with PAs in the office. or in the in the, or used to be. You had a resident in your office, and then, when you went to the or that resident went with you. Well, that worked, you know, 30, 40 years ago. It doesn't work.

 

Daniel Marino:

Yeah, it doesn't work now.

 

Joseph Bosco:

So you know, you have to get away from that resident thing. The other thing is I just wanted, you know, we talk about, you know, get increasing accessibility for financial reasons. We're forgetting the other thing is that when you add the Mecca, right, and you ask patients to access you. You're increasing socioeconomic disparities. We've done a lot of work on this. If you're poor and you don't have a car or and you live far away. You could have a hard time driving, you know, 2 hours to see someone. In New York we publish an article where we, the driving distance didn't make any difference. But if you live in queens you want to come to Manhattan and maybe 3 miles away. But you don't have a car. You can't take public transportation.

 

Daniel Marino:

Yeah, that's a great point. Great.

 

Joseph Bosco: You did. Your children. Who maybe work at an hourly wage at a Mcdonald's, or something like that. They can't afford to take off time, because they don't have permanent, you know, time off to take their parents the hospital. So they're hourly wage people, they're gonna lose money. So if when you do the whole thing where you have to drive to the Mecca, you're increasing socioeconomic disparities. So you get out in the communities and you see that.

 

Daniel Marino:

And I'd love that. And I and I think I mean, that makes so much sense. And I do a lot of research, and I work with a lot of organizations on improving kind of the or addressing some of the socioeconomic disparities. Do you think a lot of the academics take that into consideration with their strategies?

 

Joseph Bosco:

Well, listen. A couple of years ago I looked at the Bank of America. You know they had a 200 page state of the art of medicine. Right? And they said, Well, you know you have to look at, you know, high income zip codes and put your satellites in there, right?

 

Daniel Marino:

Yeah.

 

Joseph Bosco:

But what we've done at NYU we've gone to the poorest neighborhoods, and what we did was we elevated the quality care that the port that the lower socioeconomic groups get a lot of dual eligibles. That's been part of our mission. So when we look at our US News and we report rankings, we use one systems rankings, not just our hospital, but these, these safety net inner city hospitals that we've taken over as well. And we're proud of that fact. Now again, no margin, no mission. So you know we still keep our eye on the bottom line, but that doesn't prevent you from going out and putting satellites in low socioeconomic areas. So you could take good care of folks, because that's what we're supposed to do.

 

Daniel Marino:

Yeah, sure. Well, I know, Jeff, this has been a big area of focus for you as well, and you've incorporated this into a lot of the work that you've done with the academic institutions.

 

Jeffry Peters:

Yeah, I mean, I think Joe sort of represents how academic medicine needs to think about providing care. They've pushed their services out into the community, and they've provided access. So you have an ambulatory facility with an ER and somebody has a broken leg, they don't want the ER to stabilize it, and then go see the orthopedic surgeon at the Mecca, and it's gonna take you 2 weeks to get an appointment. You're gonna have to drive an hour. They want the ability to walk down the hall from the er that same day that at the very same hour, and have somebody who can take care of that broken leg or evaluate them to see if they need surgery. And the successful organizations are going to improve this access. It's the same thing when a primary care sees Mrs.Williams, who's a 95 year old, and says, you know, we've been dealing with this painting your hip long enough. I think you need to go see somebody, see if you need to have a hip replacement. We want to be able to go into our epic system and say, Mrs. Williams, when do you want to see the joint specialist who's in this building 5 days a week, and prevent that leakage.

 

Daniel Marino:

Them into that domestic network. I think that's really the key. But you have to. The only way that that's gonna happen is you need to make sure you have the access models and the community based facilities that would support it. So let me let me kind of address this or refocus our conversation. If any of our listeners right now, and there's a number of them that are within the academic setting, if they're thinking about changing their strategic focus, or some of them are really thinking about advancing their strategies right now to obviously enhance their financial performance, increase access, all of those things. You know. Let's start with you, Jeff. Anywhere that they would start, or what would you recommend as a starting point?

 

Jeffry Peters:

I think what they need to do is they need to really have a discussion as to sort of what is the goal. How can they take better care of the community that they wanna serve? And to look at that community in a broad geographical area, and then evaluate at the present time, are their services convenient to the populations they want to see? Is there immediate access to both primary care and specialist? Is there an integration between the specialist and the primary care? They need to look at it from the patient standpoint as opposed from being sort of institutionally focused.

 

Daniel Marino:

Yeah, that's a great, that's a great point. And I think a lot of times. you see, the focus being more inward facing as opposed to the outward facing. And then Dr. Bosco, is there any advice that you would give to some of the academic physician leaders? You know, if they're if you, if we have a medical director, or say a department chair or a section chief listening, that is thinking about expanding their service line. How do they create that right alignment to kind of change that focus? Maybe either in terms of balancing the different missions or improving the financial performance of their of their section or department.

 

Joseph Bosco:

Well, that's a great idea. And the way we look at it is, you know, a academic, medical, integrated musculoskeletal care delivery. It's a big tent right? And so you can, they have to think in terms, rethink about how they look at their providers, their physicians and surgeons. You need to welcome a clinically competent physician or surgeon that may have no interest in teaching, and has no interest in publishing, but they are, they are. They are contributing to the enterprise, as we say, by their clinical performance. They're providing excellent clinical care. And frankly, you know, if they see a lot of patients that those patients now can be research subjects of some of the research.

 

Daniel Marino:

Right.

 

Joseph Bosco:

They don't have the right answers this idea that if you don't.

 

Daniel Marino:

Right.

 

Joseph Bosco:

And 3, and you know, if you don't write 50 papers in 5 years, you're not gonna make 10 here. We're gonna let you go as long as they are contributing to the enterprise in in a meaningful way and performing within the standard that we set, then they're welcome. They can actually choose not to work with the residents if they want. And so but that's the only way that you can expand so you can have, I don't wanna say different tiers, but different. many of your physicians have different ways they wanna work, you know. Some people wanna work half time. Some people you know, wanna work 80 hours a week.

 

Daniel Marino:

Yeah.

 

Joseph Bosco:

You know, doesn't make any difference as long as they're as long as.

 

Daniel Marino:

That's a great point. I think if you can change that compliment and, like you said not having one physician that comes in with the pressures of being able to provide a certain level of research. Maybe they just wanna focus on that clinical support. You know. Then you build a strong complement of the faculty within that department. I think that's a great way of being able to ensure that the Department is supporting their strategy as well as the strategy of the organization.

Well, gentlemen, this was a great conversation. I really appreciate it. If if any of our listeners want to contact you, or maybe have some follow-up questions, Dr. Bosco, maybe we could start with you. Any information you can give on on how they can possibly contact you.

 

Joseph Bosco:

Sure they can. Email. Me is probably the best way at joseph.bosco@nyulangone.org

 

Daniel Marino:

Great. And how about you too.

 

Jeffry Peters:

Yeah, and feel free to email me. Jpeters@luminahp.com.

 

Daniel Marino:

Well, thank you, gentlemen, this is obviously a very important subject. I'd like to continue the conversation at some point down the road. Certainly, as we think about some specific initiatives as academics continue to align with their community based partners. But until then thank you again for joining me today, and a special thanks to our listeners for tuning in until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

 

The challenges posed by Medicare Advantage adoption have led numerous healthcare providers to exit the space altogether, despite the fact that 34 million Medicare patients are enrolled in Medicare Advantage plans. In this episode of Value-Based Care Insights, we sit down with Cliff Frank, a national expert on payer contracting, to delve into the complexities and hurdles healthcare providers face with Medicare Advantage plans, and explore how their responses impact both staff and patients. Gain insight into how geography and legislation influence the short- and long-term implementation of Medicare Advantage, and discover strategies for healthcare providers to safeguard patients from confusing plans and hidden costs.

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. In today's episode. We're going to dive into Medicare advantage, and in particular, the implications to hospitals, providers, health systems of leaving the Medicare Advantage space. Of course, there's been quite a bit of press over the last year and a half on all the challenges that hospitals, health system providers have had with Medicare advantage. 

Many very notable health systems. Chris Scripps, health being one of them and left met the Medicare advantage world last year. And it's interesting, because, you know, obviously, there's a big push for Medicare patients to move into Medicare advantage. The CMS. Is definitely creating incentives and has made it very clear by 2030 they really want to get out of the patient management claims adjudication. All of that good stuff get out of that space and really push it over to Medicare advantage. And yet we see Medicare advantage enrollment continuing to rise, 34 million people have enrolled in Medicare advantage plans into 2024. And yet, as we see the rise, there was an interesting report that came out at the beginning of the year from HFMA, that said 16% of the health systems were planning on stopping Medicare advantage, or stop accepting more plans, and in some cases leaving or dropping Medicare advantage. So it really creates a number of questions that we as an industry we're really, we're working towards. And I'd like to spend some time talking about them today. So those questions are, what's the impact to hospitals and health systems as they decide to not accept Medicare advantage within their payer space. What do the patients do? If you're switching from straight Medicare to Medicare advantage you're not familiar with what the alternatives are. So as a patient, it puts these patients at a at a pretty big disadvantage. And then what can hospitals do in the future? I know there's some legislation coming out, and we'll talk a little bit about that. But in the short term, what do you do to take care of patients in your community, especially if you're a rural health provider and have strong relationships with patients within your community.  

 

Well, I am pleased today to have a colleague of mine been on the show many times, Cliff Frank. Cliff is a national expert in payer contracting has worked with for many health systems, hospitals, providers around the country, and has done quite a bit of work in the payer community as well. Love to have him on the program. Cliff. Welcome.

 

Cliff Frank:

Thanks, Dan. Glad to be here. 

 

Daniel Marino:

So, Cliff, you know. In my opening remarks I kind of made a opened with a few questions related to the challenges hospitals are having as they consider leaving the Medicare advantage space. What are you seeing as that impact factor to hospitals as they're considering leaving Medicare advantage? 

 

Cliff Frank:

Well, it depends who, where, and how many.  So the who meaning which hospitals, in what geographic areas, and the how many is, how many plans are they thinking about walking away from? If they walk away from all of them. they could be putting their patience in a bit of a spot. Because if they want to go back to Medicare they can, but then they may not qualify for any Medicare sub, because the Medicare sups can medically underwrite and if you're sick, you know they don't have to take you so it's probably smarter and better to get rid of some of the abusive plans if you're going to trim them at all and stay with the plans that are more reasonable, and even make some have some conversations with the reasonable ones to get some, maybe some extra concessions, as you as you kind of narrow your field. On the other hand, if you're a rural facility and you're kind of it for the county  you, you know you can shut down a Medicare plan in a heartbeat by discontinuing your participation, and then they can't sell in the county at all. 

 

Daniel Marino:

Right. 

 

Cliff Frank:

Well, there's a lot of leverage there. If you're a more urban market where there's, let's say, 3 or 4 systems in play. you know it's really more about protecting yourself from an abusive plan as opposed to trying to kind of control the market cause you're not able to control it. 

 

Daniel Marino:

Well, it's no secret that probably the biggest area of frustration for hospitals for health systems is the administrative burden that come along with these Medicare advantage plans all the challenges around prior authorizations. Restricting care the costs to just get these services approved really does put some major burdens on these on these hospitals and health systems and yet at the same time, Medicare advantage, especially if you're maybe even in a rural or certainly in a metropolitan area, could be a significant portion of your revenue. Right? So as you think about that, hospital margins are slim to begin with, and in in some cases they're in the red. If you're all of a sudden cutting out the Medicare vend, you're impacting your top line revenue. Obviously it has a cost implication there. But how do you how do you manage through that? 

 

Cliff Frank:

So that I mean, that's that is the crux of the problem. And I have seen health plans. You know that that you contract as a pay as a provider, you contract with them 100% of Medicare for Medicare, 102, whatever you get. But then your actual yield is in the 80 s. Because of all these denials, and that doesn't speak to the friction costs that you're carrying on top of it. And then there's 1 other piece that's really important here, Dan, and that is, these patients come in, then they get treated, then they're ready to go to sniff. And there are no sniffs beds with that plan. So now you're stuck with that patient for a lot at, you know a thousand dollars a day, or whatever your costs are and you're not getting paid for it. Yeah. So that's a whole other problem where the providers down where the payers downstream network is skinny. And so all of these things. you know you look at you look as hospital CFO is going to look at it and say, well, you know, yeah, there's a cash flow hit. But frankly it's a lot less cash flow hit than is obvious, you know. So yeah, you're getting 82 cents on the on the on the Medicare dollar. But you're really getting about 70 or less by the time you add up the compliance costs the denials and the other friction costs. My sense is that you don't kick them all out at once, and you don't do it in February. 

 

Daniel Marino:

Yes. 

 

Cliff Frank:

You’ve got to do it close to the annual open enrollment period, which is October 15 through early December. So if you can cancel, you know, like September one, that's important. And be in communication with your local insurance brokers who deal with these Medicare patients and send communications out to your members. These are this plans we still participate in. 

 

Daniel Marino:

Yeah, giving them an giving them an option. I think the communication absolutely is key because you have to get. And it's tough, cause you're putting the patients in the middle. Patients don't understand the difference between Medicare and Medicare advantage. The only thing they understand is the Medicare advantage plans are cheaper, right? They offer a lower premium. So to be able to communicate with the patients is absolutely key. But I want to go back to something that you had mentioned working with some of the plans on some of these administrative burdens. It, you know, I think, for the larger national plans the humanas and United Health cares. I think that's a tough call, right? 

 

Cliff Frank:

They have one way of doing things, and that's their way, and that’s it. 

 

Daniel Marino:

Exactly. Is there more success that you can get with the regional plans? I mean, is that an alternative? 

 

Cliff Frank:

I think it is. And even some other large nationals that are fairly screwed up. But they are. they are. They have some local delegation of, or regional delegation to where the State executive has some power. But to make some administrative adjustments. So, for example, if you say to a plan, we're gonna shrink our network. I mean our participation from 17 Medicare advantage plans to 5. But one criteria is that we get gold carded. So, we don't have any more of this prior off. And if you want to do that, we'll consider you kind of in the inner circle. If you don't well, you're at risk to getting kicked out. You know something like that where there's some administrative non price concessions. Because, frankly, price is the least, you know, kind of the least important deal here. It's really Hassle. 

 

Daniel Marino:

Right?  

 

Cliff Frank:

Another piece  I wanna mention, though, is the connection to your medical staff. Because if your medical staff, for example, is deep in a humana deal, that's a risk deal. And now you're going to blow it up. and they're going to be forced over to the Academic Medical Center, which is higher cost, higher confusion, you know more friction all the rest of it. You know your medical staff may not be real happy with you as a hospital. So it's important to kind of figure out what some of these interconnected relationships are, and how pulling a lever over here may make something unexpected blow up 2 blocks over. 

 

Daniel Marino:

Yeah, the impact points, I think, are really, really key cause, it's not just a matter of thinking okay, we're not gonna accept it anymore. But it's really what you begin to. You know how you manage, how you manage through it. If you're just tuning in. I'm Daniel Marino, you're listening to Value-Based Care Insights. I'm here today talking with Cliff, Frank, and we are talking about the implications to hospitals, health system to providers from leaving the Medicare advantage space. Let's talk a little bit further Cliff about those impact factors. Because you're right. There's a lot of interconnectivity there. You know, as a hospital's thinking about maybe cancelling one of their plans, but yet, you know, the providers in the community may have their professional contracts right? You know again that puts the patient in the middle. What can the providers do? 

 

Cliff Frank:

Well, it's worse than that. Dan, because when the hospital does something. who are the patients going to call? They're going to call their doctor. 

 

Daniel Marino:

They're gonna call the doctor. 

 

Cliff Frank:

So now your medical staff is getting bombarded with hundreds of phone calls from anxious seniors who think that they're going to lose their doctor, because their hospital is, you know, a which may also be true.  So if you're going to do this as a hospital. set up a call center for people to call so that they don't jam up the doctors phone lines. If you jam up your doctor's phone lines, your revenue is going to take a hit because the patients can't get in to make an appointment. 

 

Daniel Marino:

Well, absolutely, and it continues to put that burden on the on the physicians. And it's just. 

 

Cliff Frank:

Wrong. Place. Yeah. 

 

Daniel Marino:

Never, never going to work. You know, there is a bill that's going to come out that everybody's kind of keeping an eye on for 2025. It's called the Improving Seniors. Timely access to Care act, and the goal with that is to help to streamline some of these administrative burdens. To create some type of electronic pro prior authorization to standardize what services do require pre authorizations versus those that don't. What do you feel the impact of this is going to be. Do you think it's going to have some, some positive implications, or is it still going to take a while for us to kind of work through all the pre off wrinkles that are out there. 

 

Cliff Frank:

Well, how long did it take to implement price transparency. 

 

Daniel Marino:

Exactly. And we're still going through that right. 

 

Cliff Frank:

Exactly so. 5 years after that legislation passes. It may be longer now with this new chevron doctrine, with the old chevron doctrine thrown out. So CMS's degree of free degrees of freedom in terms of administrative implementation is going to be more limited, and there'll be more lawsuits that come out of this over nits. So I. And this is what this bill is addressing is certainly important. But it is not, these aren't the only irritants. And so yeah. Might take an 82 yield up to an 87% yield. Okay? But still, you know, it's not regular Medicare. So, I think what we're talking about as a strategy for hospitals and other providers is still very, very relevant. Whether that bill exists or not. 

 

Daniel Marino:

I agree with you. I think it's a 1st step. I think it's going to take a long time for us to see the real, the impacts of that bill. and I really feel like, in order to work through these challenges with Medicare advantage. The hospitals, the health systems. You have to have a plan. We had an opportunity some time ago to create the payer strategy for an organization and within their payer strategy. Obviously, they were really focusing on what to do with Medicare advantage. And you know again there were some up and coming regional plans. That were starting to really take shape in the community for this particular hospital. A. Obviously the big market share was with the national plans. But it seemed like as we were having conversations with these regional plans that maybe steering patients or being able to create a stronger relationship with these Medicare advantage plan is really the way to go seems like these regional, these regional plans have stronger connections with the patients. There's a little bit there's more flexibility in terms of managing these administrative burdens, and I think you know, as you're starting to partner with the plans they understand, I think, a little better than some of the national plans what the hospitals and health systems are going through, especially in a rural setting. 

 

Cliff Frank:

Well, I think that's right. I think there are some limitations to that strategy that are significant. The 1st is that a lot of these regional plans can't handle a major uptick in membership because they don't have the risk based capital to slug away. And in Medicare at 12 to 15,000 bucks annually per member, you know, and risk-based capital is about 7 percent of that number. You pick up 30,000 lives, and suddenly you got to find, you know, a whole bunch of money fast. 

 

Daniel Marino:

Oh, yeah, yeah, yeah, absolutely. 

 

Cliff Frank: They don't have it. The second thing is, is the version 24 to a version 28 risk scoring conversion Is really a big challenge to these, to these smaller plans. I mean, just keeping up with their risk scores is tough. And now you know, because there's there are fewer things that risk adjust finding them and making sure you don't. Backslide on risk adjustment is really has to be a focus, which means, again, their administrative resources for finding and supporting new patients may be limited. And then the 3rd thing is that You know the and this may end up being a plus. But by being a local or regional plan. you know, you kind of know better how the system works in in a particular community. 

 

Daniel Marino:

Right. 

 

Cliff Frank:

And so you can make kind of more rational decisions that we providers might view as kind and reasonable. 

 

Daniel Marino:

Yeah. Well, and I can. 

 

Cliff Frank:

Cost more in in the short term. So I'm not sure kind of how all these things fit together. But if a regional plan is kind of not deep, financially. 

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

Moving, moving strongly in their direction, could kill them. 

 

Daniel Marino:

Well, it's a great point. So I think doing due diligence around that regional plan I think, is an important factor, right? Because, like you said there could be, although they want to grow, there could be a big shift. 

 

Cliff Frank:

Well, they could end up being a great risk partner. 

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

For some sort of shared risk or full risk deal. If you have a CIN that's set up to kind of do that. 

 

Daniel Marino:

Well, if you have the infrastructure, yeah, around the around, care management. 

 

Cliff Frank:

I mean, why do that with humana when you know they're going to screw you. 

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

So let's do it with somebody who's a reliable, who's at least local, so that if you have a problem, you can sit down and talk about it. 

 

Daniel Marino:

Yeah, yeah, absolutely. So with hospitals, though, you know, if they decide and a few of our clients, you know, they've been a lot of press around. Say, say, they're the regional hospitals regional. I'm sorry the rural hospitals leaving Medicare advantage. What alternatives do they have? Can they create some connectivity? You mentioned goal carding with, maybe creating some goal cards or some special arrangements directly with Medicare patients. In your experience, or what are you seeing around the country in terms of what other alternatives the hospitals have? How can they continue to provide services to Medicare patients when they do leave Medicare advantage? 

 

Cliff Frank:

Well, if they don't have, if they're just going back to regular Medicare. then, having some sort of easily accessible financial option for financing their deductible and coinsurance becomes really important. 

 

Daniel Marino:

Yes. 

 

Cliff Frank:

Because they're going to have. Those obligations. And they're probably not going to have a Medicare supp. 

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

That's going to step in So chip both financial support and charity care obligations will necessarily be higher. 

 

Daniel Marino:

Well in that financial support, even though it would cost the organization money, it might be less cost than the administrative burden they're assuming in the Medicare advantage world. 

 

Cliff Frank:

Well, now, this is going to sound harsh, but I do, and I don't mean it to. But if the administrative burden, if removing the administrative burden doesn't result in staffing reductions on the administrative side all you've done is move the administrative dollars around. 

 

Daniel Marino:

Yeah. Cost, shifting. 

 

Cliff Frank:

Yes, but you haven't. You haven't harvested the gains that could come from reducing your administrative friction. 

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

So. And it's really hard, you know, to kind of go through that process of saying, Well, who don't we? What don't we need to be doing anymore. And who's doing that? And now we need to help them exit the organization, because we don't need to be paying for that. 

 

Daniel Marino:

Yeah, absolutely, absolutely. But I think being able to provide those alternatives to the patient in one way or another, to kind of get over the hump. I don't feel like you know, not accepting Medicare advantage. I don't. I don't know if that's a necessarily a long term strategy. Good strategy for the organization, I think given where Medicare is moving and I mean, I think Medicare advantage is going to be part of our world for quite some time. Until we can figure out these administrative challenges. We have to come up with some short term alternatives. Right?  

 

Cliff Frank:

I think that's where the carrots and sticks come in. So if you're rural hospital, sole community provider in that county, you got you got some big sticks. Now, you may only have 5,000 Medicares in your market, but it's pretty disruptive to a plan to kind of have to carve out a county when they've been there. 

 

Daniel Marino:

Sure. 

 

Cliff Frank:

So the best thing would be to kind of. you know. Take a couple of them and say, Look, we're going to do this our way, or you're out. And our way is goal carding. Our way is a maximum number of denials. It means you're going to pay us for patients who are stuck here because your network is inadequate and it means you're going to pay our doctors fee schedule. That is at least 100 percent of Medicare. And not this 80% of Medicare stuff. 

 

Daniel Marino:

Right. So I guess when a hospital is thinking about what to do around Medicare advantage, it comes down to probably 3 things right? So if they're thinking about leaving, what's that implication to your physician partners, or your medical staff? Are there alternatives that you can provide, or at least align with some of the regional plans? And then setting up some alternatives with the patient. Right? So you don't. So you sort of as much as possible lessen the burden on the patient. Anything else you might add? 

 

Cliff Frank:

Yeah, there's 1 other thing that I would add, and that is advocacy with your State Hospital Association. 

 

Daniel Marino:

Good point yes. 

 

Cliff Frank:

If you're having these problems with the particular plan, so is everybody else. 

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

And you can't kind of organize a boycott that's not going. That's not legal. But you can turn to your hospital association, and they can organize. Some sit downs with particular plans or advocacy with the Federal Government. Around some of these issues. 

 

Daniel Marino:

Yeah, so. 

 

Cliff Frank:

So that you get some love and attention from some of these plans, who really otherwise won't pay attention. 

 

Daniel Marino:

Yeah, that's a great point. Great point. And hey, that's their job. Right? They should be able to advocate for the hospitals. Well, Cliff, thanks for your time. This is a great discussion, and not going to be the last time we're going to have it, that is, for sure. We're going to continue to see a lot of this activity and different decisions that are made for Medicare advantage. So thanks again for coming on. You know, I'm sure we're going to be having you back again sometime. Love to have you on the program. My friend. 

 

Cliff Frank:

It's always good man. 

 

Daniel Marino:

Yep, and to you our guests and listeners. Thank you for tuning in. We really appreciate it until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

 

After the Federal Trade Commission (FTC) announced a ban on non-compete clauses in April 2024, the healthcare sector experienced a major shift in physician employment contract negotiations. In this episode of Value-Based Care Insights, Hal Katz, a partner at Husch Blackwell specializing in healthcare life sciences, explores the consequences of this decision along with the resulting policy adjustments and legal appeals. Gain insights into the FTC ruling on physician employment agreements, the required alignment between single-specialty groups health systems, and more.  

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Daniel Marino:

Welcome to value based care insights. I am your host, Daniel Marino. Back in April of this year there was an interesting ruling that came out from the FTC. I'm sure many of our of you, many of our listeners have seen that. And the ruling was really around the FTC banning non-competes. And, boy, I'll tell you it really started a whole series kind of a tighter wave of discussions, if you will. On what is potentially is going to mean to physicians. Single specialty physicians, such as anesthesia as well as employed medical groups, large multi-specialty groups who have employment agreements that have non-competes included in there. It really it started a lot of chatter. And then, very soon after the FTC came out with their ban, of course there was a number of appeals, and it stuck in an appeal right now. But again, it has such a large implication to our provider community that I thought it would be really interesting for us to dive into what the potential ban means, and what are those implications to both physicians who maybe they're negotiating employment agreements with a non-compete, or our executive partners who may be negotiating with a medical group that you may or may not want to include a non-compete. 

 

Well, I'm really excited today to have a colleague that I've worked with for quite some time, Hal Katz. Hal is a partner with Hush Blackwell. And he leads the healthcare life sciences and education strategic business unit for Hush Blackwell, over 30 years of experience. Just a great knowledge of information. And just a great guy. Hal welcome to the program. 

 

Hal Katz:

Dan. You can introduce me anytime. Thank you for those kind words. Great to be with you today.

As healthcare providers grapple with the shortage of anesthesia providers and increasing financial constraints, leaders are redefining their relationships with anesthesia providers. In this episode of Value-Based Care Insights, Daniel Marino is joined by Tim Hanners and Dr. Dave Lebec where they address these challenges and explore best practice approaches in working with employed and independent anesthesia groups. The discussion explores ways to improve financial performance by enhancing anesthesia outcomes, optimizing staffing models, and managing reimbursement from payers.

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Daniel Marino:

Welcome to value based care insights. I am your host, Daniel Marino. In today's topic, we're going to spend some time talking about the changing anesthesia market and a lot of the pressures that we're seeing from our industry. Either. As a result of the anesthesia activities that are occurring. Maybe the shortage of the anesthesiologists and the sees of providers that are across the country, as well as the economic pressures. In many hospitals surgical services remains, if not the largest generator of revenue, It's certainly number 2. And yet anesthesia is such a critical component to providing that level of surgical services, not just in the hospital, but also in the surgery centers. So many hospitals are actually expanding their surgical services combining the services in the acute arena, but also in the ambulatory area.

Well, I'm really excited today to have 2 wonderful guests, 2 great colleagues, Tim Hanners, who is a former hospital executive, and has been working in the anesthesia space for a number of years, has helped, you know, quite a few organizations around the country help to improve and work through a lot of their anesthesia economic challenges as well as a lot of the operational challenges. I also have Dr. Dave Lebec and Dr. Lebec has been the chief medical officer for nationally, and the Seizure Service Company. Again, has worked with numerous organizations around the country from the provider perspective, just really helping to align the incentives and create a lot of clinical as well as operational efficiencies. Tim, Dave, welcome to the program.

 

With private equity's growing influence in healthcare systems, the significance of aligning healthcare providers has never been greater. In this episode of Value-Based Care Insights, we delve into the complexities of private equity interests and their profound impact on healthcare providers. Join Ericka Adler, a seasoned attorney at Roetzel & Andress, as she explores the current trends in private equity and their implications on physicians and healthcare systems. Gain insights into physician employment models, the regulatory landscape, and effective strategies for healthcare transactions.

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As Medicare Advantage enrollment rises and traditional Medicare enrollment declines, collaboration between payers and providers becomes essential. However, these relationships have historically been fraught with challenges and various administrative complexities. In this episode of Value-Based Care Insights, we explore the critical need for effective payer-provider partnerships with SueEllen Carroll, Managing Director at AArete, and Darren Ghanayem, a seasoned expert in healthcare and IT. SueEllen and Darren join us to share their insights on building trust between payers and providers, along with strategies for improving governance. Gain insights into fostering payer-provider contract collaboration, improving patient care, and reducing the administrative burden often associated with Medicare Advantage contracts.

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Transcript:

As healthcare providers engage in payer contract negotiations, understanding their contractual reimbursement rates compared to the market has never been more crucial. In this episode of Value-Based Care Insights, we sit down with Damon Morse, an expert in payer rate analyses, to discuss the challenges healthcare providers face with payer contract negotiations, and the strategies required to level discussions. Gain insights into how thorough analysis and strategic positioning can ensure fair reimbursement for provider organizations and support organizational growth.

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Transcript: