LUMINA Podcasts

In this episode of Value-Based Care Insights, host Daniel Marino explores one of the most pressing issues in healthcare today—workforce engagement and retention. Since the COVID-19 pandemic, healthcare organizations have faced unprecedented levels of burnout, turnover, and staffing shortages. Daniel is joined by Tanya Allee, Vice President of Patient Experience at Campbell County Health, a rural health system that is making meaningful strides in workforce development. Tanya shares practical strategies and initiatives to boost staff satisfaction, improve retention, and create a healthy culture of support and engagement. Tune in for valuable insights on how health systems can navigate workforce challenges and create a healthy organizational culture resulting in better patient care. 

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. Across many of our healthcare organizations, whether it's a hospital or a medical group, health system. Focusing on workforce culture, workforce alignment and just the experience of the of the workforce has been top of mind for organizations, really, since the pandemic. And maybe even before the pandemic. What we saw was after Covid, a lot of high turnover with staff just getting burned out, particularly in nursing. And we talked about that on this program before, where you know the burnout factor is really high. The stress level is really high. There's been challenges with working remote and then hybrid. And now there's a big push to get everybody back into the office. It's not really affected healthcare too much, because at the end of the day we need to be in the clinic or in the hospital in order to take care of patients. But this this drive to improve our workforce experience, and making really our staff and our physicians, our providers, happier and more engaged in the work that we're doing is still a major focus. And still is a major challenge for a lot of organizations. And if you think about it, it's a challenge for all. But it's particularly a large challenge for rural health providers. Rural health providers find it difficult to recruit staff. So oftentimes what they do is they'll put in place some good training programs and group development programs. And if folks get frustrated and then they leave again, major disruption major cost, human capital is always difficult to replace.  

Well, I'm really excited today to have a great guest. A lady who's been working in this space for some time. Tanya Allee, Vice president of Patient Experience at Campbell County Health. It's a rural health care provider. Tanya has been leading the workforce improvement initiatives at Campbell for some time, and just has a great amount of knowledge as well as I think, some, some wonderful wins and suggestions for us as we think about tackling the workforce challenges and improving our overall experience of our staff. Tanya, welcome to the program. 

 

Tanya Allee:  

Thanks, Dan. I'm very excited to be here today and visiting with you. 

 

Daniel Marino:  

So, Tanya, when you look across the country and you hear about many of the challenges that organizations have. Healthcare organizations have. What do you see, as really, you know, some of the largest challenges that we're facing these days? 

 

Tanya Allee:  

I think you did a great job on hitting on a few of them right off the top. We've got significant turnover. We've got competition pulling because we don't have a huge, vast staffing resources to pull from. And so we're competing with other organizations. And certainly, as you mentioned before, our rural health care is also very difficult to get people out here in some of the cold weather and lack of some of the opportunities that they would have in some of the bigger locations. So I think that that does make a big difference in what we can pull in and what we can keep, and so managing our staffing, managing our turnover, managing that engagement within, and really creating a culture where people want to thrive and work in, come to and stay in is really our big focus. 

 

Daniel Marino:  

Well, and it's a I sort of describe it as a slippery slope of challenges right? That sort of feed off one another. For the staff, if you're short staff, then the staff that are there become even more challenged and more burned out. And then, if they leave, or they don't see some progress, or maybe we're putting pressure on them to fill in for the staff that has already left right? It just exacerbates the problem. So you know, as we think about this, it's almost difficult, really, to get ahead of this. If you're going to put in any type of improvements. 

 

Tanya Allee:  

Yeah, I think the slippery slope was a perfect analogy. And I think that's exactly what we've been up against. And assuring that we can still provide high compassionate care with teams that are overwhelmed and burdened and burnt out, and pulling extra shifts and managing extra responsibilities and duties. It's a lot to ask. 

 

Daniel Marino:  

Do you see differences in some of the challenges that staff are facing? Is there differences in the challenges with the clinical or the nursing personnel versus the administrative or non clinical personnel? Or is it really that same frustration, level? 

 

Tanya Allee:  

I  think the frustration level is probably pretty comparable. However, I think, on the clinical side it's certainly more intense in the fact that we don't have a lot of capabilities to backfill. And the clinical needs in our community, and I'm sure in many others are rising, our patient volumes are increasing, the acuity is increasing, and so the need for adequate qualified staffing is also increasing. 

 

Daniel Marino:  

Right? Yeah, absolutely. You know, when, when we've when we've spent some time working with organizations, and we've done a little bit of work here and there with trying to improve workforce, and particularly around, you know, like the OR improvement, and so forth. Oftentimes staff look to leadership that says, well, leadership isn't doing this or administration isn't doing that. I don't really see that as the case. I think it's really an organizational change that has to occur now. It probably starts with the leadership, but at the end of the day, if we're really going to improve the whole workforce experience, in my opinion, it needs to be an organizational commitment. What are you seeing as you started to make some changes in your organization? 

 

Tanya Allee:  

I love that analogy, because that was a huge part of the conversation when we initiated our culture PIT team. Where does this really need to lie? Where's the responsibility at? And there was a lot of back and forth within our champions of it absolutely needs to be from the top down, and others would say, Nope, definitively, it needs to come from the bottom up. We have to have that engagement infused. And really to your point, what we came to an agreement on is ultimately everyone needs to be engaged. Everyone needs to have that ownership. Everyone needs to be empowered to create the desired outcomes and results, and the culture that we want to work and live and thrive and serve in. 

 

Daniel Marino:  

Yeah. And I don't think anybody will argue with that. I mean theoretically, that makes really sense, I think, where the rubber hits the road is where you start right? Because it's overwhelmed right when you think about it, that you know, if you, if you come to the realization that this needs to be an organizational based initiative, you know, where do you start? So where did you start as you started to have that conversation, you know, with your colleagues, and with the with the staff, and so forth? 

 

Tanya Allee:  

Well, you're exactly right. And we initially started with a small group of leaders or champions that we knew were very strong outside of the box thinkers and really started plugging into where are we at? What are the issues or concerns? And then looking at what are the desired outcomes? What are we trying to achieve? What are we trying to accomplish? What kind of environment do we want to come to work in every day? Part of our mission vision is to be the 1st choice in healthcare. And that's not just for our patients and residents, but it's also for the people that we employ, the people that work to serve those patients and residents. And so we had a lot of very detailed, quite frankly, raw conversations. There was a lot of back and forth. There was not always agreement. And I think ultimately that's what catapulted us into some of the initiatives that we ended up going live with. I think those ideas, and challenging each other, and being open and willing to have some of those more difficult conversations amongst the team really helped move us forward. And ironically we went back and forth, and we had tapped into multiple resources and multiple different ideas. And everyone brought something to the table. And really, in the end, after all of those discussions, we came back to framework that we had actually initiated over a decade ago. 

 

Daniel Marino:  

Wow! That's great. 

 

Tanya Allee:  

It wasn’t new, and that's what was the best thing about it. 

 

Daniel Marino:  

Yeah, yeah. Well, those you know clearly, I mean, that was the value, the values that were inherent in your organization. But I love that approach because, you know, againpulling people together and aligning around the vision of where we want to go. You know it's an old adage,if if you don't know where you're going, any road will take you there right? And I think to be able to get folks together and align around what that future vision is. Your billing consensus, your billing alignment, your billing building, the realization of what it's going to take for us to get there. But you know, at the end of the day I mean, it sounds like it really came back to what was what was the initial value drivers of the organization. 

 

Tanya Allee:  

Yeah, yeah, it was. And I do think that gave us a little bit more solid ground to reopen this initiative or this movement, if you will. Because it wasn't the next new flavor of the month. It wasn't something that we were going to dive in and then lose steam on. It was something we'd already committed to like, I said over a decade ago. And so it was much easier to get buy in and get people to participate. And again, basically, we just need to figure out we've got the basics. We've got the bare bones. How do we recommit? How do we reconnect? How do we reinforce the accountability around the things that we already stand behind. 

 

Daniel Marino:  

If you're just tuning in, I'm Daniel Marino. You're listening to value-based care insights. Having a wonderful discussion with Tanya Allee, Vice President of Patient Experience at Campbell County Health. And we're talking about improving the workforce and some of the initiatives that Tanya's deployed as she's been able to tackle this within her organization. Tanya, when you when you started this though did you form a task force? How did you get? How did what was this the structure you put in place to get input right? Because I mean, frankly, I'm assuming you went out there. And if staff are frustrated, I mean, Heck, you could walk down the hall, and you can probably get a ton of opinions. How do you? How do you create some type of a structured approach to not only get the opinions, but kind of coordinate those opinions until some into some type of an output? 

 

Tanya Allee:  

And really it was we very strategically aligned culture champions that we knew would be willing to be raw and forthright with what's going on, and what we have some opportunities for. But would equally be solution seekers and be willing to say, and here's what we can do. And here's how we can tackle this. And here's how we get to move forward. And so it was, it was very intentional, and I have to say I feel personally, we knocked it out of the park. The group that we pulled together for this were just absolutely beyond exceptional. And I said, tough conversations, but the outcome was phenomenal. 

 

Daniel Marino:  

That's great. That's great. Well it sounds like this is what you did. You want to have those formal leaders. But you also want to have the informal leaders right? The informal leaders who are the influencers. And you know, as I've said, for many, many years, even when I used to manage a lot of my medical practices, the informal leaders were more influential than even the formal leaders, right? Because they were the ones that were involved in kind of managing the conversations around the grapevine. So that that sounded like, you know, a lot of what you've been able to do. Talk a little bit about some of your initiatives. What were some of the things that came out of that group that all of a sudden started to propel you forward. 

 

Tanya Allee:  

Well, I think the biggest thing, and that taps in completely to those champions throughout the entire organization. But one of the big movements, the big focus was the “We are CCH.” So we were trying to break down silos. We were trying to get people collaborating together and reinforcing that we're all here on the same ship, trying to accomplish the same thing. Which is to provide the best compassionate, patient care. And so the “We are CCH” became our phrase our go to phrase, that's what represents all of our standards. It kind of summarizes everything, and everyone is used to that now. And so we hear that regularly throughout the halls and within meetings, and sometimes when behaviors or things aren't aligned with what we are, what we're doing, we'll hear people say, hey, “We are CCH” and this is how we're going to move forward with this, and it reinforces the solution seeking opportunities versus the problem presenters. 

 

Daniel Marino: 

Right? Well, it sounds like that mantra was probably, or that phrase was probably the element that really allowed you to kind of get past the challenges or currently getting past the challenges, but leading you to what the vision is going to look like, right? Because it's just early on, I mean, at the end of the day. We all have to collaborate around what a future vision is going to look like. And that phrase probably helped you get past some of the challenges and keeps you on that right path. 

 

Tanya Allee:

Exactly right. And we refer back to that very frequently. 

 

Daniel Marino:  

So when you started this, you know again the staff, both clinical, non-clinical, I mean, critical to the organization. But you can't forget the physicians right? And the physicians are extremely influential, you know they drive the patient care right? How did you communicate with the physicians? Were they part of the process? Did they provide that input? Where did they fit in? 

 

Tanya Allee:  

Well, we initially rolled this out with just our department leads, managers, directors, supervisors. Then we started to infuse that into all staff. And so our culture champions, with all of their enthusiasm and energy, went to all of the staff meetings and shared the initiative and the movement, and where we were going where we were headed, and excitement behind that. And then the final step has been to start, including those providers in those conversations inviting them to the staff meetings. To be part of our challenges every month and making sure they're well informed of the initiatives that we're rolling out, and eventually we'll be taking some additional steps to continue to engage them to become additional champions for us.  

 

Daniel Marino:  

Well, I would. I mean I would assume that your physicians have to be pretty excited about this, because typically physicians and providers, if there's challenges with the workforce, if there's high turnover, you know, they're the ones mostly impacted and affected. So I would assume that they would be excited. And for the most part pretty supportive of the direction you want to go. 

 

Tanya Allee:  

Yeah, we have not seen where we're getting any significant pushback. I would completely agree with you on that. I would like to make that assumption as well. And I know we've got some just like we did with the leaders. We've got some phenomenal physician champions that we'll be tapping into more and more to help kind of spread that eagerness and that enthusiasm for where we're going. 

 

Daniel Marino:  

Yeah, that's great. So why don't you share with us? Maybe a few of your successes? What are some of the things that I guess maybe you're particularly proud of with you and your team. And you know, as you kind of look back, what were some of those good success stories. 

 

Tanya Allee:  

Well, we with a few of the initiatives that we've rolled out, and “We are CCH” being a huge piece of that. We've had so many success stories. I was just in a meeting yesterday, and people were sharing that we've created this environment we are creating. It's still an active process.  

 

Daniel Marino:  

And it always will be right. This is a journey. 

 

Tanya Allee:  

Right. And so we were really creating this environment where it's safe to have these conversations, it's safe to hold each other accountable. It's safe to redirect and coach people back to our framework, and our standards of behavior, and leaders and staff alike are seeing that actively happening, and where people again, are being more solution oriented versus problem dumping. And so I think a lot of that has aligned with you know, this isn't just this department, or this person, or this leader or executives issue. This is our issue as CCH. And so how are we going to work to resolve that? And I think that's a critical piece. 

 

Daniel Marino:  

Wow! That's great. And I'll tell you, creating a safe place within the work environment is huge. Because, you know, as we see oftentimes when we go into different organizations and we do a lot of work around process improvements both clinical and non-clinical. We often see Staff really scared to voice their opinion right? They don't feel that there's a comfortable place to do that. And I think and it's you probably see this. And you know it sounds like you have that in one of your stories, the staff have great ideas in terms of how to improve and put in place new solutions. But oftentimes they're scared to voice those opinions. And creating that safe space, I mean, that's where you really pick up a lot of the momentum. 

 

Tanya Allee:  

Absolutely. And one of the initiatives that we rolled out we're calling our quarterly career conversations. That's really the full intent of those conversations all leaders are meeting with their staff quarterly, and we have a hodgepodge of various formats that we've put together in one. So we get an opportunity to round with the employees, we get to harvest ideas and suggestions and get some additional momentum from them. We also get to provide feedback and assessing how they're aligned with our standards and their day-to-day interactions. And then we also get to align that with our strategic goals and our mission. And then finally, they get an opportunity to establish a personal goal where they feel like they're really engaged in part of where we're headed. 

 

Daniel Marino:  

Yeah, well, that's wonderful. And that engagement is, I think it's critical, you know, just being able to empower folks. It probably was a breath of fresh air, I would think to a lot of folks, and especially those young up and comers within the organization. I mean, they want that right? They want to be able to be with an organization where they can grow, they can contribute. They feel like they're a part of something. 

 

Tanya Allee: 

Absolutely. 

 

Daniel Marino:  

Have you? Have you seen any? Has there been any responses or feedback from patients? Have patients noticed the difference? 

 

Tanya Allee:  

You know we have had some feedback. We take in a lot of feedback in a lot of different capacities, good, bad, or indifferent, and we've noted that there's been comments from patients or calls from patients where they're saying, Hey, we've seen a significant difference. We were there a couple of years ago, and now we're seeing that the staff seem happier, they seem more engaged. They're very enthusiastic about the work they're doing. And so I do think it's getting observed on multiple levels, not just internally amongst our peers, but also for the people that we're so privileged to be able to serve and take care of. 

 

Daniel Marino:  

Yeah, well, and you know, you're part of the community, and especially for a small rural organization, you know, integration with the community and with the patients is so critical. And not only are they patients that we serve, but they're our neighbors. So everybody talks right. And you know what's going on there. So I would think a lot of those positive vibes that you're getting through the organization based on some of the improvements. I mean, it has to be funneled out through the community. 

 

Tanya Allee:  

Yes, yep, absolutely, and said, we we've had our hard knocks, and we've had our obstacles had to overcome, and the community is not afraid to reinforce those and remind of those, but I think we have plenty of opportunities to celebrate the key things that our hard, hardworking staff are doing, and that our team and our executives and our board are very committed to, and it's all worth celebrating. 

 

Daniel Marino:  

Yeah, that's great. That's great nice job. So when you think about where you're at now and where you want to go, a few goals come to mind? What are you looking to? Maybe accomplish immediate, say over this next year? 

 

Tanya Allee:  

Really, we want to keep the foot on the gas pedal with the initiative rolled out over the last 12 months. We want to make sure that people don't think this is just a flash in the pan, and so I think that's absolutely critical, and then continue to build on those. And so we've got some great momentum with that continuing to infuse in our providers. Certainly our new employees. We're doing a significant amount of leader onboarding and training to assure that everyone is aligned and providing the same type of interaction and communication. I think that's going to be a critical piece moving forward. 

 

Daniel Marino:  

Yeah. Well, it sounds like as you put those things in place. You're going to see some great outcomes from it, right? I'm sure it's going to decrease some of your turnover. And you're just going to have happier employees. And I'm sure the providers, as you start to integrate them more. The physicians and the staff certainly are going to come together. If  you were to think about for any of our listeners who are interested in kind of tackling these same things within their own workforce, any recommendations you can give to our listeners? Where do they start? 

 

Tanya Allee:  

As I said earlier, I think, starting with finding your internal champions. 1st and foremost, find your thought leaders. Find your galvanizers, find the people that have the energy and the enthusiasm, and that ability to see the reality and the things we have to work on. But, more importantly, the ability to figure out. Then how do we bridge that gap? How do we get to the next step versus focusing on what's not working as well as we'd like to see it. And I think by pulling those people together in a room and having some tough conversations, and then figuring out what that ultimate goal and outcome is that's going to give you the framework and the purpose to get where you need to go. 

 

Daniel Marino:  

Well, you're I couldn't agree with you more. The champions are key. I also like what you did about setting the vision, and I think if I think back on how, what organizations have done, and at least the work that we've done with organizations thinking about some of the workforce challenges and the changes that they've made, those that have been able to define the vision of where they want to go have made the greatest progress. So I think that, combined with the champions. And then, you know, celebrating the wins right? Those are the other things that I've seen that are big success elements. 

 

Tanya Allee:  

Absolutely. And we're really trying to dive into that and remind people. It's so easy, I think, especially in healthcare, where we know where we're wanting to go, and we're high achievers. And so, as you accomplish things, you lose the excitement. And so we don't. We don't want to let go of that. We want to recognize all the small little wins. 

 

Daniel Marino:

Yeah, that's great. Well, if any of our listeners have questions or they just want to connect with you, I know you're on LinkedIn. Would you mind sharing your LinkedIn? 

 

Tanya Allee:  

No, not at all. Please feel free to reach out to me. It's Tanya Allee on LinkedIn, and I'm happy to continue to engage in these conversations and brainstorm with other leaders, and what they're doing, and how we can maybe collaborate to continue to make healthcare a wonderful place to work and serve. 

 

Daniel Marino: 

 Well, I agree, and sharing the stories and sharing ideas, I mean no sense reinventing the wheel. I think the more that we can collaborate as a network, you know. That's really key. Well, Tanya, thanks so much for coming on and sharing your story. I wish the best of luck to you and to Campbell, and to your organization and to the staff. It sounds like everybody's working really hard, and I'm so happy to hear that you all are making great progress. 

 

Tanya Allee:  

Thank you. Thanks so much for having me on today, and we're very excited to see what the future holds for us. 

 

Daniel Marino:  

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

In today’s episode of Value-Based Care Insights, host Daniel J. Marino Marino sits down with Dr. Amit Jain, MD MBA, Associate Professor of Orthopedic Surgery and Neurosurgery, Chief of Minimally Invasive Spine Surgery at Johns Hopkins, and Director of Value-Based Care for Johns Hopkins Health System. Together, they unpack how organizations can reduce costs while improving performance outcomes such as length of stay and readmission rates—ultimately advancing their value-based care strategy. Explore expert insights on aligning surgical services with cost-effective, high-quality care delivery.

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. Organizations that are focused on value-based care performance continue to think about how they could influence total cost of care for a lot of their services. And let's spend a second talking about cost of care. When we talk about that, it's not necessarily the accounting cost of what it takes to produce the service, although obviously that's important. But total cost of care really focuses on what we let's say, charge the insurance companies for, or what the patient is responsible for. It's that cost to provide the service to the industry. And there's a lot of influences around that total cost of care number. So, in other words, if you're inefficient in providing the service, if you're not anticipating some of the challenges that occur with the patient. It's going to increase your total cost of care. There's also performance outcomes that are associated with that total cost of care. So, for instance, length of stay within the hospital. Readmission rates, all of those performance indicators, again, directly related to your efficiency and your ability to create the right level of cost of care. So, some of the biggest influencers, maybe the biggest influencer of total cost of care, is how we perform our perioperative and surgical services. It's no secret that surgical services for a hospital or health system could make up anywhere between 65 to 70% of their total revenue. So, you know, again, it's very impactful when you think about what it means to that organization. Yet the inefficiencies that occur out of within the OR could really drive, or, let's say negatively, influence a lot of your performance outcomes.  

 Well, I'm really excited today to have a guest who is really an expert in this area, Dr. Amit Jain. He is the associate professor of orthopedic surgery and neurosurgery, and chief of minimally invasive spine surgery at Johns Hopkins. Dr. Jain also serves as the director of value-based care for Johns Hopkins. Health system. Dr. Jain. Welcome to the program 

 

Amit Jain:

Thanks so much, Dan. It's really a pleasure to be here and talk about this topic that's near and dear to my heart. I think value-based care and perioperative services, and where the 2 meet is exactly the space where a lot of innovation can happen, and a lot of great conversations can take place. So thanks for having me on the program 

 

Daniel Marino:

Yeah, my pleasure. Glad you're here. So let's jump into that. When you think about perioperative services or surgical services. What do you see as the biggest challenges that are impacting total cost of care? 

 

Amit Jain:

Yeah, as a practicing spine surgeon, I can tell you, surgery is not cheap. And it's certainly a big ticket item for any revenue of a hospital. It's also an opportunity to think about value for the patient. And how do we improve outcomes and try to control costs in a manner that's appropriate and efficient. I think there's a lot of factors that allow perioperative services to be an interesting area for value-based care. Starting with the fact that we don't always know how to define the episode itself. So, for instance, we don't know where to start counting the cost. Is it before surgery? Is it at the time of when the patient steps into the hospital? Is it a time of discharge? What about the post? Acute phase? What about all the various aspects to who should be getting surgery like the appropriateness of selection, patient optimization. So there are so many factors that go into it. And all of these things really drive up the cost of care, and individually can modify the outcomes and value. 

 

Daniel Marino:  

Yeah, I would agree with you. And I think a lot of folks. You know, a lot of organizations approach this by kind of each of the areas as you mentioned that go into the perioperative surgical episode. Right? So they. So when you really think about it, the surgical episode, there's 4 key areas there. It's the preoperative component of the episode. It's actually the surgical episode. It's the post-operative recovery. And then it's the recovery of the home. So why do you think that it's been difficult for organizations to think about those 4 episodes in its entirety, or even really to think about each of those episodes individually? 

 

Amit Jain:  

I think a lot of it has to do with our traditional setup of where the boundaries of the hospital start, and where the clinicians who are bringing these patients to the hospital for a given procedure or surgery live. And having that coordination between the 2 groups is of prime importance. So there are somewhat different challenges in terms of scheduling efficiencies, resource, utilization. There's high variability in processes and practices among patients that are being signed up for surgery. There's lack of data, driven decision making oftentimes. And you know, ultimately, I think there's siloing of communications and collaboration which are all areas that really influence how these patients come to the hospital, who's going to manage them during their hospital stay, what's going to happen to them at time of discharge, and what their overall cost trajectory is going to look like. 

 

Daniel Marino:  

Right? Yeah, I would agree with you. And I think it's that. You know, as you talk about that, I think it's just that that lack of coordination. Right? I mean, when you think about a patient that's coming in for surgery. You know you've got the PCP. That may be involved in the case. You have obviously the consult of the surgeon, but then you have the anesthesiologist, and then you have the nursing staff. Right? So you know what I could just see as a challenge is that inability, or that that lack of continuity coming together to really proactively manage that patient before they even step foot in in the OR. 

 

Amit Jain: 

No, that's exactly right, and I think places that do it well recognize the importance of creating that synergy and having that upstream optimization and expectation management, and then how that drives care management both in the hospital and post discharge. At the end of the day it takes a village to take care of a patient, because it's not just about the surgery or the procedure. It's about all the other stuff. It's about getting the expectations right for the family and making sure that they have care partners to help in that process. It's making sure patient is optimized, you know, months in some cases in advance. It's making sure that all the right stuff is set up so that their length of stay can be optimized and so on. 

 

Daniel Marino:  

Well, absolutely. And I feel like organizations who've done a good job in this arena, who have the right level of outcomes put in place programs or a methodology that really allow them to be proactive with the care of the patient. In other words, they start to anticipate some conditions before you know the episode occurs, and it provides them a better opportunity to then manage the recovery. So with that being said, as we dive into kind of the different elements that really drive the performance of value-based perioperative services. Talk a little bit about what you see are kind of these best practices around the preoperative services that occur. 

 

Amit Jain:  

Yeah, I think it's I really can't emphasize enough the importance of preoperative optimization and expectation setting. And I think this has to happen both at the level of the surgeon or the proceduralist, but, even more importantly, has to happen at the level of the anesthesia team and the people who are going to be helping take care of the patients in the or and post operatively. So I'll give you a very concrete example. At Hopkins we have what's known as the PEC Center, which is the preoperative evaluation center for patients who are essentially optimized and evaluated for both their risk factors around surgery, but also kind of thinking about ways to get these patients ready. So, looking at someone's diabetes, hemoglobin, A1C. Looking at their overall profile of frailty. Thinking about what we need to do in terms of managing their long term medications in the perioperative phase. All these little things, which I think historically, are kind of relegated as afterthoughts are just so important in driving those outcomes and making sure that patients can recover quickly from this and actually have optimal outcomes from surgery or procedure. So I think that's just one area. And there's many others. 

 

Daniel Marino:  

Yeah, but I love that. I love that as an example, so I can't help but think that through that preoperative clinic that that you were describing. I mean, not only does it does it help with sort of proactively identifying issues and managing the episode, but I would certainly think it has to help with aligning communication. Right? So you have the anesthesiologists and the OR staff, as well as then the surgeon collaborating on what that communication needs to look like to get the best possible outcomes. 

 

Amit Jain:  

That's exactly right, and I think more so than that. It also sets the expectation with the patient that what they're going to be dealing with is one team that's working together to create the best possible recovery pathways for them. Another area of this that I particularly feel to be very helpful is having every patient come in for a preoperative visit. So, in other words, as a surgeon doing an expectation, setting talk with the patients, and for many of our programs like joint replacement, which are fairly standardized. We even have classes where the patient and the care partner have to come and take the class ahead of time, and that way they can understand what to expect after surgery. How do you help as a care partner at home when the patient gets discharged. And those are the kind of conversations that are so crucial to avoiding readmissions, avoiding bounce backs and other problems that patients anticipate. 

 

Daniel Marino:  

If you're just joining us. I'm Daniel Marino, and you're listening to value-based care insights. I'm having a fascinating discussion with Dr. Amit Jain, who serves as the director of value-based care for Johns Hopkins health system. We're discussing improving perioperative services to enhance value-based performance. Dr. Jain, I love that because I'll tell you in a lot of the research that we've done and a lot of the programs that we've put in place around helping organizations with their transitions of care. The biggest challenge that we find is being able to not just work with the patients once they become discharged or in recovery. But how to work with the caregiver. Right? Because, you know, oftentimes the patient is they're confused, or you know, they may not necessarily understand what the postoperative instructions are. So they're relying on the caregivers. And if we don't have a program that really is focused on aligning with the caregiver around the patient's condition. That's where the readmissions take place. Is that what you end up seeing a lot of times? 

 

Amit Jain:  

Yeah, that's exactly right. And I think a lot of fee for service focuses on volume. Right? Volume drives the equation. 

 

Daniel Marino:  

It is, yup! 

 

Amit Jain:  

But in value-based care, what really drives the equation is being able to manage the total cost of episode well, and to do that well, you have to make things like readmissions, never events. And we really focus on that with a laser target. And in Maryland we have a total cost of care model for each of our hospitals where it's crucial, otherwise it will totally kill us if we don't manage that well. 

 

Daniel Marino:  

Yeah. 

 

Amit Jain:  

So those are the things that really have to be done well, and having the care partner be an integral part of that team so that they can help manage the expectations they can provide the care to patients. They can anticipate problems and speak up, and, you know, provide the care that the patient needs is so important 

 

Daniel Marino:  

Oh, absolutely. I mean that transition to care program. I mean, it's only one part. It's not the end, all be all. It's only one part, but it is a critical part on making sure that you're really managing that readmission. I want to take a step back a little bit, though, and let's talk about the actual surgical service. Right? What happens in the OR. We do a lot of work on helping organizations improve a lot of their surgical efficiencies in the OR perioperative efficiencies in the OR and a lot of times what we end up seeing is there's challenges with the typical things, right block time. Utilization on time starts and so forth. But an area that we often see is tremendous variation on the surgical service that's being performed by that specialty in your opinion, how important is clinical variation in influencing the total cost of care? 

 

Amit Jain:  

I think variation among clinicians is a major driver that is sometimes hard to control, but truly does drive the outcomes of any value-based care model. We have 12 spine surgeons. Each of us have our own unique practices, and are ready to practice medicine and take care of patients the way we want to, but the things we unify on are the same principles. You want to provide high quality care. You want to keep the net cost down. And I think that has to be part of the ethos of the organization if you want to succeed in this space. So you really, while variability in clinical practice is encouraged for innovation, and for many reasons. You don't want to be wasteful, you know. After each surgery we get a cost sheet down to the line item of every single thing. We utilized, every screw we put in, every item, every consumable. That way I can audit my behavior on the go. And that's just so helpful to alter behavior and really think about hey, do I really need that thing, hey? Is that really helping my patient. Hey? Is that really actually creating efficiencies? Or is that just? Is that just wasteful spending? 

 

Daniel Marino:  

Well, I love that because I'll tell you. And I'm a huge, you know, even when I was used to managing my practices, I'm a huge proponent of sharing that level of information, if for no other reason, to create awareness right?  

 

Amit Jain:  

Yeah. And you have to have systems in place that let you do that because imagine you can't. You know you want to do that. And you don't even have the straw software infrastructure or the technical know-how. Then that's a challenge. And you gotta you gotta invest in those things. 

 

Daniel Marino:  

Yeah, absolutely. Yeah. I agree. I think clinical variation, you know. Certainly that ability to focus on that with those outcomes is definitely a game changer. Let's shift a little bit to some of the some of the rehabilitation services. I had the opportunity a couple of weeks ago to go to the HIMSS meeting lot of technology that is out there. Some of it is around remote, patient monitoring. Some is around, including AI to kind of interact with patients. As we think about the recovery. Obviously, if a patient is able to recover in their home, the outcomes would be better. It reduces the amount of cost versus being in a rehab facility or post-acute facility. What have you seen, as far as best practices that really help to drive some of that care in the home programs? 

  

Amit Jain:  

Yeah, I just think that topic is so important, Dan. And there are 3 areas I feel are just really crucial for this. Number one that preoperative optimization and rehab, so we call it, prehab in many ways. So, in other words, before the patient even steps into the hospital, making sure that they work with a physical therapist. They know what to do after surgery in terms of preoperative education. Going back to that joints class example, I think those kind of educational tools are super important to prepare the patients for what happens after surgery. The second area that I think is really important is eras protocols, and I'm not sure if you know what that is. That's the enhanced recovery after surgery protocols. We have universally gone to that for all our service lines, and that makes such a big difference in terms of reducing variability, improving optimal outcomes and getting patients essentially through the surgical process. And ideally being discharged home or home with the home, care, etc, as opposed to ending up in a facility. And even conversion of one facility, discharge to home discharge, that really changes the value equation in the total cost. 

 

Daniel Marino:  

Oh, tremendously. Yeah. Tremendously. 

 

 

Amit Jain:  

And then the 3rd area that I think, is really a tremendous resource for us is having a really strong care, management and care navigation group. So, having partners who can do things like remote, patient monitoring. And at Hopkins we do that through our care at home group we also have a really great kind of hospital-based programs with these things called transition guides, which are specialized nurses that kind of help patients and check in on them or do post discharge phone calls and a telephonic pre-structured way. But all of these little interventions, you know, add up together where you can, instead of sending somebody to a sniff or to a facility. You can essentially change their post, discharged game plan and get them home safely and have them stay at home. 

 

 

Daniel Marino:  

Yeah, I mean what you're describing that that's a significant game changer, I mean, when we were looking, we've done quite a bit of work on thinking through whole episode of care, and the variance between patients going to a long-term care facility or rehab versus going to home. I mean that could add anywhere between, you know, 7, 8% on the low side up to 15% related to the overall cost. Not to mention, then, the performance outcomes that associated with it. Right? So you know, you definitely can see that. But what I often see, and I'd love to hear your thoughts on this. What I often see is many hospitals, they don't really think about that transition of care as a continuum right? They think about the discharge management, and they create the discharge instructions for the patient. And that's really where their work stops. And I think we you know, the goal would really be to change that mindset, to change that thinking. So it's really a continuum of care approach around what that transition needs to look like. But going all the way back to the pre-surgical testing. Right? So you can actually define what that care model needs to look like as you transition to the home. 

 

Amit Jain:  

That's exactly right. You have to think about the upstream selection on who you are signing up for surgery. You have to think about the upstream optimization. How are you going to get them best prepared for surgery? The expectation setting, then, the perioperative enhanced recovery. And then, most importantly, you really have to manage their post recovery expectations and planning accordingly, so that you get patients to a safe space, and you can manage the total cost of the total episode. I just think that's invaluary care. You have to think differently. You can't just do what works well in a in a high volume fee for service, setting. 

 

Daniel Marino:  

Yeah, no, you're absolutely right. So when you're when you're thinking about this, and maybe with even within Hopkins, what does the governance structure look like you talked a little bit about the reporting, and, you know, sharing that level of information. But what's the level of accountability and the governance structure? Is, you know, clearly, I mean, I'm a huge proponent that a lot of these programs have to be physician led. How do you structure this so you can actually give the right level of information, but really impact the amount of change that needs to occur? 

 

Amit Jain:  

Yeah, I think it really hit the nail on the head. If you look at all the value-based care data and look at the Aco successes. The biggest successes have been in models that were surgeon led or physician led. So there really has to be a physician champion really driving it. And I think I'm a big believer in a joint governance structure where there are clinicians and administrators working together for each service line, really thinking through these problems, and I think it has to also include a nursing partners. It has to include very operative services partners like anesthesia, like supply chain as well as contracting, and others. Because I think, unless all of us kind of come together into 1 alignment, it's really hard to succeed. A good example of this is, we have really thriving programs in orthopedics and spine surgery, in GI surgery, in urological surgeries, etc. And for each of these things we essentially have clinical champions for each service line, and then we have nursing champions who really know that space well, and we have administrative teams who really work with that well, and each of them have these process of improvement and kind of driving efficiency and figuring out where the pain points are and addressing them. Because if you don't, it's hard to make you know valid improvements. 

 

Daniel Marino:  

Well, it does, and it really is a change of mindset. Right? I mean, you're bringing all of these different groups together under the same goal of what's that most optimal performance outcome for the patient? And to really begin to manage the cost.  

 

Amit Jain:

And one of the areas that I think one of the groups that often gets left out is nurses and our nurses are. They really have a lot of, you know, a lot of insight into what actually drives improvement. And some of the best ideas we have in our process improvement actually comes from the nursing team. So you really have to kind of cultivate that you have to have a culture where you create a leadership structure between nurses and have people kind of striving for that high level of leadership and opportunity. 

 

Daniel Marino:  

Oh, that's such a great point, you know. Nurses really do drive that because, hey? They're seeing it day in and day out, you know, and they know exactly where some of those improvements need to come from. Well, Dr. Jain, this has been great. I really appreciate it, and I think we just scratched the surface on some of these, you know, as I've said before, and I think you know, your point came across very clear. The impact on perioperative services. The impact that it can make on value-based care performance and the total cost of care is just absolutely amazing. If any of our listeners are finding are interested in finding out a little bit more, or maybe, you know, want to reach out to you directly. Can you share your contact information? 

 

Amit Jain:  

Yeah, happy to. And certainly. Please feel free to pass on my email address through Lumina, or they can reach out to me via Linkedin, happy to engage. 

 

Daniel Marino:  

Great, great. Well, thank you for this, and you know I'd love to have you back to dive into this a little bit more, because I'll tell you. There's many organizations, you know. They're struggling with this they need to have solutions. And I think, as we start to kind of think through what this needs to look like. There's just a lot of opportunities to be able to, to be more creative and and to drive those outcomes. So thank you again, I really appreciate your time. 

 

Amit Jain:

Thanks. Dan. 

 

Daniel Marino:  

And for our listeners. If you're interested in finding out more information about this topic in perioperative services and the impact on to value-based care as well as some of our other topics. Please feel free to reach out to me directly. dmarino@luminahp.com, or you can visit our website at luminahp.com. In closing. I want to thank all of you for tuning in. Really appreciate it, and until our next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care 

Artificial intelligence (AI) is making headlines everywhere—but how much of it is real, and how much is just hype? In this episode, host Daniel Marino is joined by Rick Howard, Chief Information and Data Officer at Brand Engagement Network, to unpack the growing role of AI in healthcare. Together, they separate fact from fiction, explore the opportunities and challenges AI presents, and discuss how healthcare organizations can responsibly integrate AI to improve operations and patient care. Whether you're excited, confused, or cautious about AI, this conversation offers clarity and insight for navigating the rapidly evolving digital landscape. 

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. You can't listen to the news, or watch anything on TV, or read anything these days without hearing about artificial intelligence and the impact of AI in all of our lives. And we're starting to see that right with using Chat GPT, and incorporating AI into our phones, and so forth. In healthcare, in a lot of the work that we all do in the healthcare community. There's a lot of conversation, a lot of excitement around where artificial intelligence is going. But there's a lot of myths that are out there. There's a lot of what I would call vaporware that is out there from technology firms, and it's really difficult to kind of guide through what is what is real and how will artificial intelligence affect what we're doing in our daily work. How will affect our patients? Versus those things that are just let's say vaporware, or things that are on the horizon, or things that we just need to get excited about. Not to mention a lot of the challenges, or some of the things that are confusing with artificial intelligence.  

Well, I'm really excited today to have a colleague of mine, a good friend who I have known for many, many years. He is the chief information and data officer of an organization called Brand Engagement Network. Ben, for short. He's been there for about a year and a half. leads the whole artificial intelligence, growth and a lot of the data build and so forth for the organization. Prior to that, he was the chief data officer for about 4 years or so for ascension health. Rick Howard. Rick, welcome to the program. 

 

Rick Howard:

Well, thank you, Dan. Glad to be here, and thank you for inviting me. 

 

Daniel Marino:

So, Rick, let's dive into this. Give me your thoughts on where you see AI now, and how do you see it impacting healthcare? And in particular, how do you see it impacting our providers? 

 

Rick Howard:

Well, thank you, Dan. I actually see AI in healthcare offering numerous applications that can significantly enhance both the efficiency of how doctors operate, and quite frankly, the outcomes and the satisfaction against patient care or improving patient care. Let me go into a couple of those, and maybe we can go into some more details later. First, AI serves as a valuable tool to alleviate the current staffing shortages in healthcare. We all know that clinical professionals are difficult to find out there. There's this extreme shortage of nurses. There's a shortage of doctors quite frankly, and Covid kind of helped that along. 

 

Daniel Marino:

Sure. 

 

Rick Howard:

Even though we had a pretty significant shortage before Covid, Covid actually accelerated some of that those challenges. But by automating some of the repetitive tasks and providing personalized patient engagement through digital AI. It enables the healthcare professionals to focus more on more on those complex challenges that they have with those patients. 

 

Daniel Marino:

Well and to your point. It probably allows I would assume a lot of our healthcare resources right, our human resources become much more efficient, be able to do more with less. Do you see AI, in some cases taking the place of some of our providers? 

 

Rick Howard:

I don't really see AI taking the place of providers. I see AI as being a significant tool to complement our providers. Healthcare is going to be personal, no matter which way you go. 

 

Daniel Marino:

Right. 

 

Rick Howard:

The you know, the transaction of a clinical professional and a patient coming together to address needs is always going to be there. I don't really see AI going through the FDA process to be diagnostic. I do see AI as being complementary. 

 

Daniel Marino:

Yeah, kind of as a as a tool to our physicians. As to our providers. I, I would agree with that. What when you when you look at a lot of the vendors that are out there, many, probably every single digital analytics vendor or technology vendor, they have some level of artificial intelligence that they are incorporating into their products. Where do you see some of the biggest advancements of AI occurring in healthcare? Maybe, as it exists now. 

 

Rick Howard:

Well, yeah, I do see a number of advancements there. And you're right. A lot of organizations like to use the new buzzword, which is AI, or I guess the buzz algorithm. In this case. That doesn't necessarily mean that they have learning algorithms which AI is based on the fact that the algorithms are always learning as you apply data to those algorithms, and they get much more specific against the data sets that you present to them. 

 

Rick Howard:

So but I do see a lot of advancements. One of the areas, for example, is revenue cycle. 

 

Daniel Marino:

Yeah. 

 

Rick Howard:

If built correctly on the revenue cycle side, and that, I say, if but for on purpose. Those algorithms can possess the capability to learn and to adapt. And what I mean by that is, when you train those algorithms on best practices and a comprehensive data set, it has the ability to go retrieve the right data to support billing. What that then translates to is potentially minimizing or eliminating denied claims. But if claims do get denied expediting the claims adjudication process. 

 

Daniel Marino:

Yeah, I agree with you. I think the impact of AI on revenue cycle could be quite large. There's so many, all of us right. And I'm a old revenue cycle guy. So run a billing shop. Denial management has been like the bane of my existence. Right? And if you have some type of technology or technology that can come in that helps you think about the challenges with the claim before it goes out, or as the claim is the denied claim is coming in help you to manage it quicker. Boy. You know time is money, right? That's where I think we're going to see a lot of value. 

 

Rick Howard:

Yeah, I agree. And again, even as claims come back denied. If there's a sufficient reason for the denial, the algorithm can learn that reason. And if it learns it, then it can, then it can basically build its model to where it doesn't repeat the challenge on the next claim. So that's the beauty of AI, it's got that machine capability to do those activities and to take on those challenges that most humans won't have at a much more efficient rate than a human. 

 

Daniel Marino:

Right kind of as a, you know, a regular learning process. How about value-based care? You know, there's a lot of, the whole premise around value-based care is to look at quality, to create efficiencies, right? To bring down the total cost of care, to create some proactive care modeling with how we take care of patients. From your perspective, how do you see AI really impacting, or maybe advancing value-based care. 

 

Rick Howard:

I actually think value-based care is one of the immediate opportunities for AI for a number of reasons. But let me go into some of those. I think it's AI can support care management by providing a empathetic data driven, but yet human-like interaction with patients that enables a bidirectional exchange of information. A conversation, if you will, with that digital agent. And we can train our AI agents on very specific data sets like specific chronic condition data sets. Where it only responds to that chronic condition. Or if we want to do multiple cohorts of conditions, we can do that as well. The point being is, we can train a digital agent to have a conversation with a patient and have a very level set exchange of that information with the patient that's empathetic. I think the other component to this is did through that empathy that a digital agent can provide. It disarms the patient. Let me give you an example here. A digital agent is not going to be judgmental. 

 

Daniel Marino:

Right. 

 

Rick Howard:

It's always going to be empathetic. It's going. It's going to create a comfortable environment for that patient. And here's the real benefit to having a comfortable environment. Many patients are reluctant to be fully disclosed with respect to the things that they do that are conversation points for a care manager and that patient in managing those diseases. They don't want to say they've been having a high saturated fat, a high salt diet, because they're afraid of the result. If we can disarm the patient to have a more free exchange of information through the conversation, we get an important valuable data set from that conversation to help train that algorithm to understand how we manage that patient better on a go forward basis. 

 

Daniel Marino:

Right. So what it sounds like to me is you can use the agent then, to look at what some of the past healthcare characteristics are of that patient, maybe incorporate it with what the care pathway should be, or the clinical protocol should be. But then have that outreach, and that conversation with the patient in such a way, where you're making the patient feel relaxed. Maybe you're asking more proactive type questions. You're using this really as a complementary tool or service, if you will, to kind of drive the right level of outcome. 

 

Rick Howard:

Absolutely. And from my days as cheap data option. You know, this data is the lifeblood of any industry. If I've got more complete accurate information coming from the patient, so that I can add that to the very distinct and clinical information that I already have, you can imagine how important that data set combined is in trying to manage that patient which is the very premise behind value-based care. 

 

Daniel Marino:

Well, and I'll tell you, care managers in a lot of the work that we've done. We develop a lot of programs for care managers and help care. Managers and organizations become more efficient, right? To do more with less. One of the biggest challenges that care managers have is aggregating the right clinical data, or all the clinical data from all the sources that are out there. And aggregating that data is the biggest let's say, the amount of time. And they need to do it right before they even have that conversation with the patient. If artificial intelligence can help to aggregate that and place it into some type of a format that allows for an efficient conversation. I think that's where you're not only going to drive a lot of clinical outcomes with a patient. But you're going to have tremendous amount of efficiencies with the care managers. 

 

Rick Howard:

Well. And, Dan, you bring up an important topic right there. Clinical data, at least, the last study I have seen clinical data is doubling every 45 to 60 days. 

 

Daniel Marino:

Wow! Isn't that amazing? 

 

Rick Howard:

That is a lot of information to stay on top of as a human, whereas a machine can ingest that data, adjust its algorithms, adjust its models in seconds or minutes. And the and then be precise with the new data set. In addition to the historical data set that it was trained on so that it knows the sequence of the information to provide. So again, I think you're making an important point here is that there is just too much data out there, and it is doubling too frequently to stay in front of it all. 

 

Daniel Marino:

If you're just tuning in, I am Daniel Marino, and you're listening to value-based care insights. I am here with Rick Howard. Rick is the Chief Information Data Officer of brand engagement network, Ben. Having a fascinating discussion on AI in healthcare. Before we continue our discussion, I do want to offer out to any of our listeners. At Lumina we have what we call our AI readiness assessment. A lot of organizations aren't really sure where they are, where they stand, and being able to incorporate AI into their organization, and in particular into the culture of their organization. We have a simple 6 question assessment. If anybody is interested to help you think about where your organization is, and some of the things that might be important as you integrate that within your organization. Anyone interested, please feel free to reach out at dmarino@luminahp.com. Rick, kind of getting back to our discussion here. One of the comments or the challenges I hear, maybe criticisms, I hear a lot of times is with the use of AI. It's how we manage the bias of AI, right? And as you, you know, your comment, I think, was really interesting as to the level of information that continues to double in size right every 30 to 45 days. How do we know that AI and the information coming out of AI is correct? How do we manage the bias? 

 

Rick Howard:

Well, it's all in how you're training your AI. And quite frankly, if you're training the AI with A, you know with, without considering any of the bias appropriate associated information. Then you're training the AI on the specific data itself. Now, that brings up a different bias point. If we have data that has bias built in, for example, 30 year old clinic trials. As we both know, we have bias built in. There's not much AI organization can do because those clinical trials, if successful, are FDA approved and you have to follow the FDA guidelines associated with that with that particular set of information. You cannot stray from that. You can support updates to some of that that gets approved and gets sent out. But short of the bias built into the physical data. It's all in how you train the model. And if you're training the model, for example, specific to a chronic condition, you're training it on that chronic condition, regardless of any of the bias elements associated with the individual population, that that might be serving. 

 

Daniel Marino:

Well, and I think you have to go back to what are those? What are those leading sources? Right? What are those recognized industry. You know. I don't know main sources that have been recognized by the community as being the preferred or the best. Let's say outcomes or data source, or  what have you. Within, Ben, though maybe we can talk about it in terms of how you're solving for this. Within, Ben, as you're building some of your capabilities around artificial intelligence. How are you managing through the bias? 

 

Rick Howard:

The one thing Ben is doing that a lot others are not doing is, for example, we have our own LLM. Everybody's heard about ChatGPT, or Copilot, which are really popular applications, but they depend on the open Internet to retrieve information. We have our own proprietary LLM. It is built off of a, you know, a llama 2 model or other open source type LLM Models. But the point I'm making here is the data that everything is trained on comes from our customer. I'll give you an example, Dan. We recently did a drug adherence model for a very popular type, 2 diabetes drug that everybody's talking about today. The only data set that is used in that model is the FDA approved data that was released against that particular drug. And we went to the National Institute of Health to pull down type 2 diabetes, data. A trusted source that everybody turns to that model can only speak to the information that it has been trained on which are those 2 particular sources. It cannot stray outside. If you ask the model a question outside of it, it will tell you it doesn't have that information. It's here to provide information on type 2 diabetes, or that drug and redirect you back in that area. So that's 1 of the reasons Ben has taken the approach it has, is we're trying to eliminate hallucinations or incorrect information, if you will. As well as what could be industry inappropriate results you can get from going to the open Internet. 

 

Daniel Marino:

Wow, that's interesting. So really, the way that you're building this, it is just it's really almost restricted right? To that nationally recognized data sources. Just to ensure that the data that is sort of at the foundation or at the source of creating your intelligence is really based off that nationally recognized information. 

 

Rick Howard:

That's correct. We call it ring fence. So we're basically fencing the data that the model is built on so that it doesn't stray outside of the data set. And, Dan, you know, I come from the provider world. 

 

Daniel Marino:

Oh, yeah, sure. 

 

Rick Howard:

My passion is supporting a patient or supporting a clinician that is supporting a patient. So I am very passionate about making sure that we are diligent in following this model of only using customer provided or trusted information to build our model so that we can eliminate all of the challenges that are associated with the open Internet. Tthat helps patient care, that helps physicians, that ensures that we have an honest conversation that is accurate with that patient. 

 

Daniel Marino:

Do you think that the information that we're creating in AI, and let's say, the capabilities that AI can provide in healthcare. Do you think it could almost be too good? And and let me give you an example of this. I was at a I was at a presentation not too long ago, where a digital analytics AI vendor was talking about the ability of the solution to create advanced diagnoses. And this particular vendor was touting the accuracy of the diagnosis, and basically said he thought his solution did a better job of diagnosing a particular patient or a condition more accurately and quicker than the physicians. And of course the physicians in the room are all scratching their heads and saying, there's no way that this could happen. But it led me to think. I mean, do you feel like, maybe physicians or providers could maybe over rely on the technology? And if so, that that does create some challenges. 

 

Rick Howard:

Yeah, I would agree. In fact, there was a study. It's been about a year, maybe a year and a half ago that UC San Diego did, where it compared the responses of the LLM with the responses of the providers, and quite frankly, the LLM won when we look at that data. 

 

Daniel Marino:

Yeah, that's fascinating, isn't it? 

 

Rick Howard:

It is. And what that tells me is that the providers are handicapped by the fact that the algorithm is being armed with the most recent information around the healthcare data that's out there that we just talked about is doubling so frequently, where the provider, unless they're spending an awful lot of time reviewing all of that material which I think would be nearly impossible, given their schedules. They don't have the benefit of being armed with that most recent data. So accuracy is a part is to my perspective, is a part of the data that you have and the understanding of that data, and how you are interpreting that data to make the right diagnosis. 

 

Daniel Marino:

Well, and I and I feel like,  it is so many AI has just so many opportunities and so many advanced capabilities that can support physicians and providers in the care that they're giving to patients. I personally don't feel like it'll ever take the place of it, and I think if physicians, as they, as AI advances, as it becomes more incorporated into the care, model and clinical decision making and so forth. I think the real value of AI is physicians using these capabilities as an advanced tool, right? One of many right one of many tools in their toolbox that they can use to get a more accurate diagnosis, maybe to create a more advanced treatment plan, to provide that level of advanced outcomes to patients, because at the end of the day. That's really what we're working towards. 

 

Rick Howard:

Yeah, I would agree. In fact, we did a little test, if you want to call it that, with a leading university here in the US. And the head of the department gave us a textbook on high-risk pregnancies, and said, I want to test what you guys can do with this. So we ingested the textbook, we ingested about 8 or 10 clinically peer reviewed papers that brought that textbook to current, and we did all this in 4 hours, by the way. So we ingested the entire textbook. We released the model to him through the conversation that he was having with our digital agent. His response was, this textbook could pass the current tests. 

 

Daniel Marino:

Wow! 

 

Rick Howard:

It's only because the model had recent information. The raw model was able to ingest it quickly and interpret it quickly, to be able to have that conversation with that with that physician, to satisfy that him that we were able to ingest and help a provider with more recent information than what they could probably get unless they want to do a lot of reading. So. 

 

Daniel Marino:

Wow! That's that is that's fascinating. So, Rick, when we look at AI right now in healthcare. You know, it's advancing quick, right? And I think there's 2 pieces of it. It's the AI advancement supporting the administrative side as well as AI supporting the clinical side. But there's a lot of what I would call vaporware that is out there right? Everybody's kind of touting that they have the next best thing in artificial intelligence. Any advice for our listeners or our provider community? How can they manage through what is considered vaporware? Maybe in development versus what's actually there, right? And how they can use the actual components of AI right now as a way of maybe dipping their toe in the water, so to speak, related to artificial intelligence. Any thoughts? 

 

Rick Howard:

Yeah, I think there are a number of ways here, and this is some of the things we would have done at Ascension, you test. You test the solution. You create pilots. You put it in a situation where you're going to evaluate its performance against the pilot. And then you do a slow but measured rollout of the technology, assuming it passes your criteria during the pilot for that rollout. I think that's the only way healthcare providers or insurance organizations, or even pharmacies and pharmaceutical companies can get comfortable with the new technology engaging their patients is to pilot this. 

 

Daniel Marino:

Yeah, you have to pilot it. Test it right? 

 

Rick Howard:

Exactly test it. Make sure it's doing it. Test it, you know. Test it rigorously. But then I think what we have to do is, we have to be willing in healthcare to understand that we're not going to eliminate 100% of risk. You can't do it today without digital AI, or without any of these capabilities. So I think, then, adoption has to be open minded, and ready to move forward with those tools so that you can better serve your patient population that you're that you're reaching with these technology sets. 

 

Daniel Marino:

Well, Rick, this has been a fascinating discussion. I'll tell you. This is something that I just, every time I read a little bit more about the impact of AI in healthcare and talk to folks such as yourself. I learn a lot. I just get really jazzed about what these opportunities are. Really want to thank you for coming on the program. If any of our listeners are interested in maybe connecting with you or learning a little bit more about this. Any information that you can share on how they can contact you? 

 

Rick Howard:

Oh, absolutely. It's just Rick Howard at on LinkedIn, or you can reach me on my company email address, which is rick@beninc.ai. 

 

Daniel Marino:

Great. Well, thanks Buddy, I really appreciate it. And oh, by the way, I didn't, I failed to recognize. I wanted to mention this as well. Congratulations on you being on the cover story or on the cover of CIO Review. That that's huge and just, you know, a great congrats to you. 

 

Rick Howard:

Well, thank you, Dan, and thank you for having me on today. This has been a pleasure of mine to have this discussion. 

 

Daniel Marino:

Well, I appreciate it, and would love to have you back again, and to our listeners. Thank you for tuning in. Really appreciate it, and until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

In this special episode of Value-Based Care Insights, host Daniel Marino is joined by Fred Goldstein, President of Accountable Health and podcast host of PopHealth Week, to unpack key takeaways from HIMSS25. They share their experience at this year’s conference, focusing on artificial intelligence (AI), digital technology, and future trends. Already, AI is transforming care delivery and decision-making, while digital technology is revolutionizing patient engagement and operational efficiency.  Join us for an insightful conversation on the evolving healthcare technology landscape and the trends shaping the future of care delivery, driving a more connected and efficient healthcare ecosystem. 

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 spend a little bit more time talking about the HIMSS conference that occurred a couple weeks back. If you recall on the last episode, I had two great interviews with Dr. Allen Young and Steve Overman when we talked about their specific technology that they had displayed at the HIMSS conference. Well I'm really pleased today to have a fellow podcast host with me. He is president of Accountable Care Health and host of his own show pop health week Fred Goldstein. Fred welcome!

 

Fred Goldstein:

Pleasure to be here Dan looking forward to today's discussion, Thanks.

 

Daniel Marino:

Fred it was interesting a couple of days at the HIMSS conference what was your impression?

 

Fred Goldstein:

I thought it was it was maybe a little more subdued than usual but still a very big crowd etcetera. I thought the focus areas were interesting obviously with AI and digital health, and digital tech. Workforce that I didn't spend a lot of time on and obviously cyber security is a big issue but really where do we get to these things actually impacting the patient that's sort of where I was looking at the digital tech and AI and we're using it to improve outcomes and really move into value-based care. And I'm not sure what were your thoughts on that from a value-based their perspective?

 

Daniel Marino:

Well I agree with you I think the artificial intelligence vendors and all the technology as well as the digital technology was quite impressive. I didn't see as much around specifics to value-based care. I was hoping there was going to be a little bit more solutions maybe around care management maybe around some of the performance analytics. And it was interesting because this isn't a major focus of HIMSS. And I did have an opportunity to actually talk to Hal Wolf and I asked him that question specifically. How was HIMSS going to be positioned to support value-based care in the future? Let's take a few minutes and listen to his response.

 

Hal Wolf:

Yeah I mean we we've always been a fan of value-based care. And I think that what value-based care in the state and goal is an efficient healthcare ecosystem that tries very hard to treat individual patients with the best outcomes for the least amount. Right? And that's really what sits behind it. Now that's an old expression it actually came out of intermountain. Intermountain, you know this right? Yeah and so that I always when I heard that mantra from intermountain 20 years ago I personally adopted it and I thought it was a fantastic statement. And I think that's what really is behind value-based care we've seen pieces of it and that's what Medicare Advantage is. So that's an expression of it. Globally we're hearing the same thing. So it's not just the US thing. It's a cultural issue. We're going to see how that comes together. But I don't think what we're trying to do is recognize and say this is the best way to squeeze the highest level of efficiency access quality through the use of these digital areas. There are other things that will contribute to that that's not in our space but when it gets in digital health transformation that's where we sit.

 

Daniel Marino:

An interesting response. Fred I'm really hopeful that HIMSS does focus a little bit more attention on value-based care performance. But let's dive into some of the specifics particularly around artificial intelligence were there a couple of things that really caught your eye as you were talking to any of the vendors?

 

Fred Goldstein:

Yeah, I think the key things we're seeing, and this has been talked about at a number of last couple of years, really is this use of AI to solve various issues that are not directly patient care issues but are workflow issues. And things like that, employees going out and gathering this data or these data and then bringing them in and adjusting them. And I think we're seeing some great progress in those areas. So it was really interesting to see that the clinical side obviously is touchy. And it'll take a while for some of those types of technologies to be accepted by physicians and other clinicians as augmented intelligence versus artificial intelligence. I think that's the key as we begin talking about those areas. And you, how did you see the whole AI spectrum there?

 

Daniel Marino:

I saw a lot more advancement on the business and the administrative side of artificial intelligence. I think to your point we're just starting to figure out how the, what the clinical impact is going to be of artificial intelligence. But the administrative side or the business side related to managing say the revenue cycle or pre authorizations, those type of things, I thought there was quite a bit of advancement. One thing that caught my eye though was the role of agents. Agents within artificial intelligence and how they would interact with patients.

 

Fred Goldstein:

Yeah I think the issue of using agents is really fascinating and I think this also gets back to a few years ago. I'd interviewed an individual who was the CEO of Cleveland Clinic at the time who made the comment I think we may lose 30% of our workforce at the hospital. Because it really is taking some of those workloads by using these agents off of people and allowing them to maybe at the very end take a look at it and validate it. But really whether it's interacting with a with a patient where I've seen these call centers show 14 to 20% more efficiency by using AI. To things like you talked about using it for prior authorization or documents scanning etcetera.

 

Daniel Marino:

Yeah I agree with you. There was 1 vendor that I had an opportunity to do a demo with and they started to incorporate agents within their care management services. And they bear they just started to scratch the surface on what potentially this can do. And I thought some of this was a little bit more of kind of a visionary technology because they were talking about how the agents could work with remote patient monitoring, interact with the physicians, and almost be that virtual care manager. I thought it was really interesting about how they would grab the data and incorporate into an agent and really use that as sort of a first line care manager on being able to drive some of those results.

 

Fred Goldstein:

Yeah absolutely and I think it's as we had discussed earlier you know I did a show for consensus with with mohana nagda who is at Athena health. And we talked about the use of AI for faxing ingesting that data putting it into the EHR and then actually using AI to then push it back out to the appropriate physician for referrals etcetera. and I really think you're going to see these workflow issues solved with some of these AI tools.

 

Daniel Marino:

Yeah I agree with you. And Athena had a pretty big booth there they were doing quite a bit of demonstrations on a lot of their technology. The other one that I had an opportunity to talk about another EHR vendor is eClinicalWorks. And eClinicalWorks has spent quite a bit of time working through a lot of their agents, even incorporating some bots that would allow them to provide some interaction there. Fred, I had an opportunity to interview the vice president of sales for eClinicalWorks his name is Sameer Bhat. I asked Sameer, goes by Sam, what are some of the new and interesting things that he's seeing related to technology that he's incorporating into his into eClinicalWorks that would really drive performance not only for the providers but also for the patients. An interesting conversation let's listen to this for a few minutes.

I am here with Sam Bhat, he is vice president of sales and marketing for eClinicalWorks, someone I've known for quite some time. Sam great to see you.

 

Sam Bhat:

Great to see Dan. It's always a pleasure talking to you.

 

Daniel Marino:

Thank you, thank you. All the conference has been fantastic. And I'll tell you there's such a great momentum push for artificial intelligence, and knowing the experience and my previous experience with eClinicalWorks, you are always at the top of the technology game. So what are some of the things that you're doing with artificial intelligence integrating into your solution?

 

Sam Bhat:

A lot of things. We see artificial intelligence as an integral part of the entire electronic health record and the revenue cycle management. We offer artificial intelligence in two flavors. 1 is called as AI assistant. AI assistant that can help in the front office in the mid office in the back office. But then there is this new concept called AI agents coming into play that can do autonomously multiple things for you both in the front and back office. It may not apply for clinical workflows yet.

 

Daniel Marino:

But for the business workflows, I think it's gotta be incredible. Everybody's looking at trying to get more efficient everybody's looking at trying to do more with less and bring down costs I would think the agent has just got to have some incredible outcomes to it

 

Sam Bhat:

I mean we just introduced this whole agentic revenue cycle management. Where essentially you are 90% of the tasks that you do today through agentic workflow. I mean I'll give you some examples think about sending appeals to payers when you have the insurance denials. it's a nightmare sometimes. An AI agent can actually pick up what the denial reason based on that it will assimilate all the information for you create a packet submit that for you and to an extent where the agent will start communicating with the insurance on the other side, because insurance companies on the other side are implementing agents of their side. The only way to fight that battle is you got to take advantage of the agent.

 

Daniel Marino:

Well I'll tell you for independent practices and I know that's a sweet spot of eClinicalWorks that is so important, right? It's all around efficiencies and it's all about maximizing your revenue potential.

 

Sam Bhat:

Exactly. I'll give you another example. Where you still receive faxes coming into these small practices, and they don't have time to look at those documents, and an AI agent can look at the information that has come in and create a quick summary for you. And think about an EOB coming into your office. As a printed form I mean that's still happens still 10% of the payments are still coming it printed EOBs. But they take 90% of your staff time to post the payment.

 

Daniel Marino:

Can you imagine the productivity that's once this really becomes part of our standard operating approach the productivity is going to be off the charts.

 

Sam Bhat:

Releasing these agents as part of our update this month and we'll be able to see the benefit of but this calendar year, not future.

 

Daniel Marino:

Well that is really exciting and I as I mentioned I mean eClinicalWorks has always been on the cutting edge of technology it's always been something that I've been extremely impressed with your organization and with your leaders so I wish you a lot of luck here. How's the conference going for you?

 

Sam Bhat:

The conference is going really great, and you're seeing a lot of momentum. And a lot of organizations looking for a change. Change not just for change just because they want to change but they want better efficiency and increase their productivity, cut down the physician burnout.

 

Daniel Marino:

And cutting edge technology. and that's what you guys have. Well thanks again Sam I really appreciate your time.

 

Sam Bhat:

Thank you, thank you.

 

Daniel Marino:

Interesting comments by Sam. Loves some of his thoughts on where artificial intelligence is going to go. And in particular some of the activities around the agent. Digital technology, Fred, was also a big focus of HIMSS and of course this was one of the four areas of pillars, if you will, that HIMSS was really focused on. Was there something related to digital technology that really caught your eye?

 

Fred Goldstein:

Yeah I think we're seeing this incredible growth in the potential. Now how much of it's actually being used in the market is less of this remote patient monitoring? And I think back to when I started my disease management care management company, you know typically someone see a doctor once twice maybe a Medicare person might seem 8 times a year and that's 1 little measuring point in this giant data set of what the individual's life is like. And by adding a care manager or somebody who called or talked to him you suddenly increased that data set. Now with remote patient monitoring we can really begin to understand the Natural History of disease of an individual's personalized condition and how it's impacting them. And I think remote patient monitoring has some incredible potential especially when linked up with AI because the data sets will be just gigantic.

 

Daniel Marino:

Yeah I agree with you there was another vendor that I was had a chance to talk to and they were focused on remote patient monitoring and really using that to help create some efficiencies in transitions of care. Going from patients who were in the hospital upon the discharge and care in the home. And it was fascinating for the for me to see how they were integrating remote patient monitoring based on the individual disease condition so those that had say cardiovascular issues or even diabetes or what have you what have you. But the interesting thing about that was how it integrated all of the data into a prioritization of information that was able to give to the care managers. I thought that was really fascinating. That that could potentially be a real game changer as to how we manage care um post you know post discharge or really care in the home.

 

Fred Goldstein:

Yeah and it's as you mentioned that area of transition is a huge drop point where you see real issues show up because the transition doesn't go smoothly. So if you have a system that can be monitoring that and then say in effect, hey here's a here's a warning we've got this going on that we need to address now, that's going to be a huge improvement in outcomes cost etcetera.

 

Daniel Marino:

Yeah and you know the part that I thought was interesting on this was it allows through this district advancement digital technology it allows us to get in front of some of these disease conditions, and to better understand some of these disease conditions. So you know another area that I found that was really interesting was how some of these technology vendors are helping to address issues of cancer and different cancers. So we can begin to not only use AI to identify diagnosis, but we're also then using digital technology to create more advanced therapies and working with the patients. I thought that was really fascinating. Was there anything out there that really caught your eye related to that?

 

Fred Goldstein:

I think the cancer area is really interesting obviously there have been incredible advancements with digital tech applied to image analysis. And when you can get down the pixel level you know you can really begin to understand what's going on. And identify things that may not show up to our normal eyes when we look at it. And so I think that that's going to be an area where we'll see some rapid integration of new technologies. Obviously the radiologists will still need to be involved, but it could take a huge workload off of those individuals so they can become more efficient as well.

 

Daniel Marino:

Well absolutely and you know it helps to as we're starting to think about the technology, I'm working through this with patients, not only is it going to help the cost but I could really see us thinking about having more personalized care and therapies that are really going to drive better outcomes for the patients. And frankly make the patients more comfortable as they're going through their treatments.

 

Fred Goldstein:

Yeah I think you ran on target with that. Whether it's the personalization of the messaging, because obviously I may react to some funny comment when I'm trying to lose weight and stand on the scale and it says what happened to you Fred? Where somebody else may need a different persona that's more gentle or something that helps them get motivated. So I think you can use it in that area obviously in the diagnosis area in looking at new treatment approaches developing. So there's incredible potential how and when we get there I think it's the big question. But we're beginning to see some progress.

 

Daniel Marino:

Absolutely, yeah I agree. So when I was talking to one of the vendors. I asked the question to him about you know how is this being received by physicians? And many of them, this one particular gentleman came back and said you know that's one of the biggest challenges because physicians have their approach and training page treating patients. They have their methodology that they incorporate into their care models. And to have them integrate that technology into the way that they practice is a bit of a is a bit of a challenge. It's almost relearning how to practice medicine. I thought that was really fascinating. Did that come across at all as you were starting to have your conversations as to the integration of that technology and the and the care plans?

 

Fred Goldstein:

Yeah I think there's definitely hesitancy and some of it is based upon reality. When we build these AI models and don't have a broad enough data set as we've seen in the past, we come up with issues where the model isn't correct. And so there needs to be the hesitancy there needs to be standard set, the physicians need to be comfortable with it, the patients need to be comfortable with it. and I think then including them as an augmented intelligence versus just artificial intelligence I think is going to be the key to solving that problem.

 

Daniel Marino:

So I had the opportunity to sit down with the gentleman Dr. Allen Young. He is a physician client executive with point B solutions. And I asked him just that. I asked him what that integration was going to be or how was going with physicians and how they were using that and incorporating it into their into their practice into the way that they deliver care. It was an interesting response. Let's listen to that for a few minutes.

 

Allen Young:

Yeah thanks for having me Dan and appreciate the time. One thing I've noticed is the growing trend and talk around AI agents. And the way agents are defined is that artificial intelligence powered workers that go and complete tasks on their own autonomously and then kind of bring the results or insights back. And what's exciting is to think about just the agents called the work they're doing but the oversight of agent representative or agent coordination. So you have multiple agents doing multiple things and then you have that step in between where someone will actually someone or AI will actually coordinate all of these different activities and hopefully bring the appropriate insights, recommendations, next steps, or even new content to clinicians right? As a physician it could be great if a number of agent I can go and go into a patient's record and come up with a number of different recommendations that kind of don't necessarily interrelate with each other but then have someone then oversee all of that and provide a meaningful recommendation or plan with context and also provide some of the shortcomings and things where they saw there wasn't enough information. Or areas where the clinician definitely needs to lean in more.

 

Daniel Marino:

Well and I think the agents, to your point, are definitely going to be that mechanism that's going to allows us to really not just operationalize but really realizing the benefits of AI pretty quick and pretty quick with patients now. Well thank you for your time I appreciate it, enjoy the rest of the conference.

 

Allen Young:

Thank you.

 

Daniel Marino:

Great response by Dr. Young, really appreciate that. Fred, this was a great conversation. I wanted to get your thoughts you've been going to HIMSS for a number of years. For many of our listeners who've not gone to HIMSS I'd highly recommend it, it's a it's a wonderful experience. As you reflect on this conference and past conferences, Fred, where do you feel like the greatest impact is for providers or for participants to either attend a conference like HIMSS or just participate in HIMSS?

 

Fred Goldsrtein:

Well I think HIMSS obviously is overwhelming and we talked about this before we recorded this show, and you had an incredible idea that I had never really thought about how physicians should approach this and you've been using it apparently for a couple years. So I'd love to hear that again.

 

Daniel Marino:

Yeah so given the fact that you know there's 1000 plus vendors there 28,000 participants it's hard to navigate through the different vendor communities that are there. Oftentimes what we've done on behalf of clients, is if clients wanted to see something specific say they were looking at analytics or they were looking at you know specific types of technology. We would then reach out on behalf of the clients and pre schedule a lot of these meetings. It was a great way to have a very focused approach with the conferences. And we found that that was really a great way to approach it because it is quite large. And to your point it is a little overwhelming if you're just going to show up there on day one.

 

Fred Goldstein:

Absolutely it's you've gotta sort of quickly map out the booths which rows you wanna hit and then kind of that's what I did. I just worked from the low numbers to the high numbers said ohh that ones in this row I gotta go left, I gotta go right, and I had some really fascinating conversations. I got a chance to interview some folks so it was really a great conference overall

 

Daniel Marino:

Yeah I agree I agree. Where do you think HIMSS is gonna go in the future?

 

Fred Goldstein:

Well it looks like they keep getting sort of more tech oriented. And you know as if and this worries me always the tech is the solution. Well tech is part of the solution. At the end of the day we still need people. People do respond better to people typically. So I think when it gets down to value-based care, as you focus on, that still gonna need a combination. And I don't know that we necessarily just solve it with tech. And sometimes I wonder if HIMSS goes a little bit too far in that direction.

 

Daniel Marino:

Yeah I agree with you. You know I I've said a long time the technology is important but it really comes down to the people process and how you use that technology. I think that's really key. It will be interesting to see where things go they clearly make big impact in the whole technology world and certainly the integration with healthcare. Well Fred I wanna I wanna thank you for coming on. I love having a fellow podcast host and again another you know big shout out to your show Pop Health Week, it's a great program, I've listened to it many many times.

 

Fred Goldstein:

Well fantastic it's been my pleasure thanks for having me on.

 

Daniel Marino:

And to you our listeners I want to thank you for tuning in. Until our next insight I am Daniel Marino bringing you 30 minutes of value to your day.

In this special episode of Value-Based Care Insights, host Daniel Marino brings you exclusive interviews recorded live at HIMSS25, where healthcare innovation took center stage. The first interview features Stephen Overman, CEO & Founder of Standpoint Solutions, who shares their groundbreaking technology aimed at improving communication within perioperative services. Next, Dr. Alan Young, Client Executive at Point B Solutions, dives into the transformative role of artificial intelligence (AI) in patient care. The future of AI-driven healthcare is explored, including the rise of intelligent agents and their potential to influence clinical decision-making. Tune in for an insightful discussion on the future of healthcare, technology, and how innovation is reshaping patient care.

LISTEN TO THE EPISODE:

 

 

 

Dan Marino:

Welcome to Value-Based Care Insights, I'm your host Daniel Marino. In today's episode I'm going to spend some time reflecting on the hymns meeting that I went to a couple of weeks back. The theme of this last meeting was really I think twofold. One, talked a lot about digital health technology. But of course artificial intelligence was really a big theme. As part of my work there at HIMSS I had an opportunity to do 2 live interviews. I'm going to broadcast those for you today. The first interview was with Stephen overman. He's CEO and founder of standpoint solutions. Stephen has a really interesting software technology that overlays in perioperative services and really what it sells for is the communication gap that often exists as many providers start to come together to provide the surgery for patients. His technology is sort of like a social media application for perioperative services just a really a great solution. The second interview is with Dr. Alan Young. Dr. Young is client executive for point B solutions or technologies. He has a tremendous amount of experience in artificial intelligence and he and I just have a wonderful conversation where we talk about how artificial intelligence and the advancement of that is going to really change the way physicians are going to take care of patients. And in particular in that conversation he reflected on the use of agents and how agents are going to drive a lot of those outcomes. So why don't we dive into this and listen to Stephen Overman and Dr. Alan Young. Stephen welcome excited to talk with you today.

 

Stephen Overman:

Thank you Dan, it's very exciting to be here at a very large conference with you.

 

Dan Marino:

So I know Standpoint works with a lot of hospitals and focuses a lot on perioperative care, and in particular what I'm what I'm interested in is a lot of the work that you've done in supporting and improving perioperative services and in particular surgical services. And for any of our listeners out there surgical revenue from surgical services accounts for 65 to 70% of overall revenue, right? For a hospital and health system. So one of the areas that I know you're particularly interested in or your solution focuses on is a lot of the value-based outcomes associated with perioperative care. Can you speak to that a little bit?

 

Stephen Overman:

I sure can. It has a lot to do, first of all the term perioperative care was invented in 1966.

 

Daniel Marino:

Yeah, most people don't even understand what that means

 

Stephen Overman:

They don't. All the teams that surround a patient as they go through a surgery and OR room as you can imagine it requires a lot of people a lot of teaming. And they are existing at different times of the day and different teams perpendicular type of surgery and so it's that teaming which excites us to focus our technologies on to improve the team, which creates a better patient experience a better clinical team and a better economic outcome.

 

Daniel Marino:

Well I think what a lot of people unless you're really involved in the OR or you know involved in surgical services you don't really understand the complexity of that. And two things that are particularly important aside from being able to generate the revenues that come from surgical services, it's efficiency and it's managing the cost of care. Right? And both of those are tied very closely. So if there are inefficiencies that occur that that occurs within the surgical setting it increases costs right? Yes clinical variation is one of those things that drives costs. How is your solution helped to identify maybe streamline clinical variation that occurs in sort of in the surgery room?

 

Stephen Overman:

That's a good question because the cost result a lot of times in a change of patient condition as they're in the pre the intro the surgery phase and then specifically in in the post-surgery, the PACU. This is where a lot of problems can arise in both clinically and cost sensitive. So most leaders of the perioperative care episode typically the surgeon and more importantly the anesthesiologist today and some of the nurses, they need clinical and cost feedback right now to the condition of the patient compared to a community of patients of the past. So they can make a comparison of what's driving towards a target that's looking more negative such as length of stay or possibly returning to the hospital in 28 days. Or the cost factor so they can adjust the care pathway adjust the orders toward the patient.

 

Daniel Marino:

Well and I'll tell you so efficiency in the OR is very important right? So how we manage surgical block time, how we manage flip rooms making sure we start and stop on time. But understanding that variation and the efficiency around it to your point is so key. There's so many components that are as a result of inefficiencies that occur in the OR. One in particular is readmission rates you know as you mentioned the length of stay and when you think about it from a value-based care standpoint hospitals are held responsible right? and if patients aren't if you don't understand that post operative rehab service correctly if you don't manage it correctly and you have the right transitions of care what ends up happening is a patient show up in the emergency room and then they're readmitted.

 

Stephen Overman:

Exactly you're starting all over again

 

Daniel Marino:

Yeah, absolutely. So let's talk a little bit about one of the areas in your solution the communication, right? It's complicated from that standpoint because you've got the surgeon you've got the anesthesiologists you may have the OR nursing you know leader and the OR nurses. How does your solution help to streamline improve communication?

 

Stephen Overman:

Well it comes back to that teaming concept. They are a team and we provide them with a interface both mobile and desktop that allows them to interface around that patient. Patients always at the center of the care for that episode. But it looks very much like a social network.

 

Daniel Marino:

Yes.

 

Stephen Overman:

Because it's been found to be we're all used to social networks. It's a great way to formally and informally communicate to share data share thoughts share more importantly feedback a nurse give feedback to a physician that comes out of the PACU. So we chose a very simple very uncomplex social network interface for our platform we call ethos. Which is a a perioperative risk stratification and performance platform. It very easy to use it's centered and secure around the patient, but more importantly 1/3 component or major feature of our of our platform is to measure the teaming effectivity.

 

Daniel Marino:

Ohh wow so you're actually measuring how well the different groups are performing in the teams?

 

Stephen Overman:

Exactly. It comes back out of that social Network World again.

 

Daniel Marino:

Ohh my gosh see that's unusual because I'll tell you a lot of people talk about communication to talk about establishing the team but it's very difficult to be able to measure that. I would think that the contributing challenges in terms of the lack of communication, you probably know the statistics off the top of your head, I would think it would be quite great. So I was working with one organization and what we determined was they didn't not have a very strong pre surgical evaluation structure. So in this scenario patients were evaluated by the primary care physician before they went into surgery. There was also some evaluation that was done by the surgeon of course. But what we found was that that information actually never got into the anesthesiologist. It didn't get shared. And when we were starting to really look at what some of the challenges were and the byproduct of that was they had a large cancellation rate. So when we were looking at the kind of the root cause of those cancellation, which what we found was there were instances with the patient some conditions with the patients that were never communicated to the anesthesiologist. And not only was it disruptive to the scheduling of the surgical schedule but it was extremely disruptive patient right? I mean if you're getting yourself prompted for surgery and then all of a sudden it's cancelled you know that's the last thing you want to experience. So how is your system then connecting those dots? How do you inform particularly the anesthesiologists, who in many organizations you know they're sort of that champion of the surgery activities.

 

Stephen Overman:

Yeah we believe they're one of the leaders. We go back to our first feature in ethos and we calculate that risk stratification.

 

Daniel Marino:

So are you risk scoring patients to a certain extent?

 

Stephen Overman:

We're not scoring we're actually running some very accurate machine learning that gives you what factors clinically and cost and experience related such as the patient or the clinical team that is driving a particular targeted outcome. For instance a total hip replacement length of stay, probability returning the hospital in 30 sixty 90 days, and team effectivity. Those are kinds of risk stratification analysis that we allow the leaders, such surgeon or anesthesiologist, to simply click a button around that patient and have that very accurate incredible deep information. We call it clinical insight. But they also are exposed to cost so they can make cost decisions through that council care pathway. 77% of physicians prefer to see cost data when they see predicted clinical data so they can make a better decision through that flow.

 

Daniel Marino:

And that is so important. A lot of organizations as they're shifting into value-based care are looking at these episode based models right? And they're pricing out these models and they're assuming a level of risk for a lot of these procedures that are occurring. So I would think just having this cost information and just being able to share this information with the with the surgeons with the anesthesiologists to create that awareness.

 

Stephen Overman:

Doctors do want to see it, they are just not given exposure to it.

 

Daniel Marino:

Yeah absolutely. How have you seen organizations take that improved communication, that data, how have they built it into maybe some of their process improvements? Has it been more of a governance issue? Have there been process improvement initiatives? What have you seen?

 

Stephen Overman:

Well, care pathway an episode of care for a patient goes into order sets into the EHR system EMR system. They see inefficiencies with respect to the choices of cost care products that they can better maintain if they're if they're given that kind of relevant data. They can understand if a team is being better communicated too there's less questions. And so you're saving a lot of time of going off channel to texting emails in notes whatever it might be to communicate with each other. And not everybody's on the same time scale and that's where mistakes start happening. So when a in a single social network like environment that's highly secure, they can see all of that data and simply yeah give comment right to how to better optimize the care pathway. Which typically saves costs saves time.

 

Daniel Marino:

Well I'll tell you there's here at HIMSS there's a lot of technology and a lot of folks are focusing on providing information at the point of care and so forth. I think what excites me about what you're describing because it's really it's moving towards proactive care right? You're giving information to the surgical team that's allowing them to be proactive to anticipate some challenge and to communicate about it. And I think when you when you focus when hospitals and health systems focus on moving towards value based care those elements are critically important.

 

Stephen Overman:

Yes it's that's one of the reasons why we've chosen an ROI based revenue model for when we license our application and hospital.

 

Daniel Marino:

So even your financial model is value-based?

 

Stephen Overman:

Yes, if we're doing good, you’re doing good. If we are adding features you find a value because we're learning from our clients. You get that.

 

Daniel Marino:

Well they're aligning incentives right?

 

Stephen Overman:
Exactly.

 

Daniel Marino:

Well Stephen this has been fantastic I really appreciate you joining me. And for anybody that's interested in finding out a little bit more around standpoint please visit https://www.standpointdsoftware.com. If folks are interested in getting a hold of you, can you share your information?

 

Stephen Overman:

I sure can. On our website there is a 1-800 number and this actually gets directed to me and I will be happy to explain and even show you an explainer video and point you to a link that you can watch and see a video of what our application platform does.

 

Daniel Marino:

Wow that's fantastic well I would assume that there's a lot of hospital and health executives out there that would be very interested in your program. You know there's not a great communication tool there's not a great system that really provides a lot of support for perioperative services. Well Stephen I want to thank you for joining me today this has been fantastic I wish you a lot of success that standpoint and please enjoy the rest of the conference.

 

Stephen Overman:

I will thank you so much Dan it's been a pleasure.

 

Daniel Marino:

Welcome back to our live recording of HIMSS25 in Las Vegas, NV. I am your host Daniel Marino, on Value-Based Care Insights. My next guest is Dr Alan Young. Dr. Young is a client solution executive for Point B Solutions. Dr. Young thanks for joining me today.

 

Alan Young:

No problem Daniel, thanks for having me.

 

Daniel Marino:

So I know, Dr. Young, you know one of the areas that you're really focused on is digital health technology. And here at the conference there's been so much information sharing around artificial intelligence. What I find interesting is how digital technology and artificial intelligence will start to come together. And in particular how we're going to start to see that impact for patients. Now I know we're still early in our in our sort of journey into artificial intelligence, well what are you seeing now as some of the biggest impacts that the collaboration of digital technology and artificial intelligence what do you see that having on patients?

 

Alan Young:

Yeah great question. I think since the advent of the electronic health record we've been faced with this challenge of having too much data that keeps growing exponentially every day. Patient data, clinical data, research data, and I see digital health solutions artificial intelligence as potentially closing the gap between what we need at the bedside what patients need at their homes and what we want behavior change and modification to take place in order to kind of achieve better outcomes.

 

Daniel Marino:

Do you think, just kind of building on that for a second, do you think that layering on artificial intelligence is going to help to better organize the data so providers have sort of a stronger picture or a clear direction on the care that's going to be provided to patients?

 

Alan Young:

Yeah I don't want to think about layering it on. I think it needs to be appropriately implemented in the right situation in the right contacts with the right stakeholders involved.

 

Daniel Marino:

We really have to move towards more proactive care as we start to anticipate what's occurring with patients maybe on their different risk conditions and so forth. How do you see AI being able to support that?

 

Alan Young:

I think as clinicians we always wanted to do what's best for our patient and we hope that with patients there'll be two things that happen. They come in to see a doctor and the optimal condition that they had, and that's usually not the case, and when they leave they actually follow our instructions. Or know what to do. And I think that's doesn't happen very often right? So I think artificial intelligence especially some of the applications we have through machine learning and generative AI can now help us to be proactive to look at patient data and the vast sources and multiple sources that we have in order to give a clinician or the healthcare team some insight into what this patient needs as they arrive for their visit or start a telemedicine consultation or even get on the phone. That gives us insights that previously physician would have to go into a record and read on their own they just don't have the time. They have so many administrative and clinical and other possibilities but we need to do that we need to take advantage of the power within the data.

 

Daniel Marino:

Well and I think to be able to aggregate all those data sources I see that as a huge value of artificial intelligence. I mean if you think about it you've got the clinical data you may have some financial data you have the social determinant data and a lot of people would argue and I would be one of these that the social determinant aspect of that that a person is involved in does really influence their clinical outcomes right? Their care or and even their conditions. So as we start to think about that and we pull that together I think that's really where the driver comes in. Is there some immediate solutions that you think may help? For instance remote patient monitoring and how we're interacting with patients taking all those things into consideration or maybe it's just the telehealth visit.

 

Alan Young:

Yeah I think there's one exciting advancement I've seen recently is really focused in the area of patient engagement and education, using digital health driven by AI. So if you think about remote patient monitoring you have you're getting data about a patient they know what their blood pressure is they know what their cholesterol is they know what their you know diabetes continuous glucose monitoring readings are, but they don't know how to react to it in real time.

 

Daniel Marino:

And they really don't truly understand it. So they're saying these are as indicators but I don't understand what it really means.

 

Alan Young:

We have a kind of asset that you can deploy that will be there as a companion and help guide them. And I've seen one company called acolyte health they use digital avatars of celebrities or athletes that then accompany the patient home and help walk them through their care journey. This is what you need to do, this is how you should, this is why it's important to do you're screening, why you should eat exercise and change your diet. It helps empower them to think about who else is motivating them. And so taking that ability to create a digital persona using data that we have and then relying on the patients RPM data or their EHR data to then drive the right messaging through that educational tool, hopefully we'll improve better patient compliance adherence to physician recommendations and even knowing what to do when something is not going well.

 

Daniel Marino:

Right, I mean what you're describing to me just sounds so powerful. When you're when you think about artificial intelligence and you think about then digital health technology we're moving very fast right? What do you see as some of our biggest challenges?

 

Alan Young:

I think the movement and the interest and also the investments focus attention paid on artificial intelligence has caused a lot of organizations to adopt point solutions or boltons to existing systems or even you know legacy IT solutions because they don't they don't know how to use it and there's a demand on them to get it in. One example would be Ambien AI and there's plenty of those vendors around.

 

Daniel Marino:

Yes, a lot of vendors around.

 

Alan Young:

A lot of thought has to go into are you picking the right vendor, does integrate into your system? And so that has been a big challenge to think about what's going to happen down the road when you IT organization looks at their number of solutions or applications sees hundreds of AI tools. So I think where the opportunity is, and I had the chance to meet a few companies during HIMSS, was really to be a platform based company and an AI first company. And build everything from the ground up and then go to market with those solutions. And one of them was focused predominantly on value-based care which I found to be really refreshing, given the timing of our conversation. So much of the platform that's using all the AI tools and capabilities to enforce all of the value-based care activities such as scheduling and you know gap closure analysis and patient engagement.

 

Daniel Marino:

Really you integrate that into whatever that end game would be whether it's going to be for service or value-based care I think would be key. Do you feel that given the speed and and the pace that we're moving at, do you feel that many CIO's of hospitals health systems should they put together a strategy plan as to how we need to integrate this technology? How we need to integrate our data into some type of an artificial intelligence road map if you will?

 

Alan Young:

Right. I think you hit on a very sensitive point because this we're in a decade now halfway through we're in 2025 years of unprecedented change in healthcare and a lot of unknowns and new entrance of technology and processes. And I think there needs to be a thoughtful perspective to say hey my organization is going through this change. I should rely or reach out to someone that has experience doing this or can bring a different perspective. And I think that's the biggest thing. I don't think there's any experts out there that can say ohh you know we've survived the AI boom and we know what to do. No one knows we want to be thought partners to help CIO, CTO, chief medical officers think through do they need a new strategy? What is their data approach to data? Are they investing all into value-based care? Are they moving into a more home based hospital at home model?

 

Daniel Marino:

Well if anything just to share the insights right? And to understand what's occurring and you know to your point earlier and I love that. If you can learn from other people's successes and learn from the challenges that people had wrapped it into your strategy, I mean that makes all the sense in the world. I've said time and time again and we practice this a lot of in the work that we do form follows function you have to understand where you're going. One other item I want to talk a little bit about are some of the real opportunities that are out there, but then some of the challenges around these standalone applications. You know as we look around HIMSS here and we see all of the vendors there's a lot of folks who are building these standalone applications, which may not necessarily integrate with EHR's is that a problem is that a challenge? Or do we feel like that's going to fix itself?

 

Alan Young:

I think the biggest challenge here is that yes there's a myriad of new technology and a large number of entrants into the solution space. For multiple reasons. A) Healthcare is a big industry. It generates 20 plus percent of this country's GDP and it's very personal. B) I think the technology has advanced so quickly and has the cost has dropped dramatically that new companies can be spun up quickly.

 

Daniel Marino:

Ohh and there's private equity dollars that are being funneled right?

 

Alan Young:

And you don't need a team of 10 to 20 engineers overseas anymore. You can spin it up with the Gen. AI applications and you have one or two people manage shop that took months to build it can be done in weeks or days. So that's created a large number of entrances. And then you have the resistance of the industry professionals and I think I recall my experience trying to convince doctors that the HER was going to be the next greatest thing ever, and we see how that went. And the same thing is happening now doctors are not as forthright with admitting they're going to accept and adopt technology that they don't understand or they don't not have sufficient training or education on. No one can tell me they understand all the coding languages the data science, very few of my friends and mentors were physicians can do that but the majority aren't. They're busy seeing patients they go home to their families they just want to do the day-to-day work.

 

Daniel Marino:

Well and I think the underlying message there is there's exciting opportunities as we see these new applications emerge these new organizations emerge but there's also a lot of challenges. So a couple of things for any of our listeners that are out there who are interested in learning a little bit more your organization or maybe about you or just some thoughts that are coming down the pike regarding artificial intelligence, can you share some of your information maybe you know how they can get a hold of you?

 

Alan Young:

Yeah, I work for point B our website is pointb.com. I think the biggest thing that you know take away for the audience is we really thrive building an ecosystem of partners and collaborators. I think talking to physicians executives technology companies from the big ones to the small ones to the middle market ones we can't do it alone. We're not going to be able to solve all these problems and challenges we need partners that understand the tech in a deep you know very focused way. But then we also need people that are more broad based and thinking holistically about the long term impact of accessing care and population health.

 

Daniel Marino:

Well and the fact that you know you've started to kind of build this capability and this knowledge base is as we talked about absolutely invaluable. I think as we as we move forward. Well Dr. Young this has been fantastic conversation. I really appreciate it and I know this isn't going to be the last time we talked about artificial intelligence and digital health technology. I fully expect a lot of movement happening very quick in terms of the integration with AI and digital technology so thank you for spending some time today.

 

Alan Young:

Thank you Daniel.

 

Daniel Marino:

And enjoy the rest of the conference. And to our listeners I'm Daniel Marino I want to thank you for tuning into this episode of Value-Based Care Insights live at HIMSS25 in Las Vegas. And until our next insight I'm bringing you 30 minutes of value to your day. Thanks, and take care.

National healthcare organizations like the Healthcare Financial Management Association (HFMA), American Hospital Association (AHA), and Medical Group Management Association (MGMA) offer valuable industry-wide insights and legislative guidance. However, state associations provide a more tailored, in-depth understanding of the specific challenges healthcare providers face in their local markets.  In this episode of Value-Based Care Insights, host Daniel Marino sits down with fellow Illinois MGMA board members, Meghan Heiy and Jenny Kovich, and explores the growing importance of state healthcare associations in effectively navigating today’s rapidly evolving healthcare landscape. 

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino: 

Welcome to Value-based Care Insights. I am your host, Daniel Marino. National healthcare Associations play a significant role on kind of shaping everything from the legislative impact to providing some insights and data to a lot of its members and so forth. A lot of these associations like Healthcare Financial Management Association, HFMA. Or the American Hospital Association, AHA, or Medical Group Management Association, MGMA, have been around for years and through their national conferences, as well as the information that they share really provide a significant amount of resourcing to a lot of its members. But what I've found over really the last, maybe, you know, 10 years or so in my career is that the state associations also play a significant role, and I found even more of a relevant role as they support healthcare leaders. More so from a from a local perspective. And I've been involved in the Illinois MGMA for some time and recently I was asked to participate on the board of Illinois, MGMA. And been really excited to participate on the board. And although it's only been a few months, it's exciting to see the direction, and I just feel honored that I'm able to kind of share a lot of that information with a lot of my colleagues around the state. So, as I was thinking about this, I thought it would be fascinating to have a conversation around the role of the state associations in support of the local healthcare providers, practice leaders, practice managers, and so forth.  

Well, to help me with this conversation today, I've invited 2 of my board members, Meghan Heiy, she's the director of Finance and accounting at cardiothoracic and vascular Surgical association, or associates. Meghan is the current Board President of Illinois, MGMA. And Jenny Kovich is the regional director of managed care for Solaris health, and she serves as the past president of the Board of Directors for Illinois MGMA. Ladies, welcome to the program. 

 

Jennifer Kovich:

Hi Dan, thanks for having us! 

 

Daniel Marino:

So Meghan maybe we can start with you. in your opinion. What do you see as the big difference between a State association like Illinois, MGMA and the National Association, the larger Medical Group Management Association. 

 

Meghan Heiy:

Definitely. So they both offer some really, really good benefits to their members. National I’ll say is obviously much larger national focus. You can interact with members throughout the country people who are experiencing some similar, some different problems than you are. On top of that they do have some additional resources. They obviously have more staff so they can provide some more reporting metrics. They offer professional certifications. That's kind of the goal of national is those larger things. Locally. I think members really benefit from having an Illinois or a local focused association. So, for example, in Illinois, you can network directly with Illinois members who are experiencing the same or similar issues that you are. With Illinois MGMA, we have a certain specific newsletters that are targeted directly towards issues that really affect Illinois members. I think that is truly the benefit of Illinois is that you can interact with people who are experiencing Illinois specific issues and kind of navigate those things together. 

 

Daniel Marino:

Yeah, I can remember a number of years back. There were some changes in some of the payer communities. It goes back 7, 8 years or so. And I was, I was doing a lot of research around what the changes were with one of the large carriers. I just had such a trouble finding it. And then, through some of the message board, through some of the networking with my colleagues that were part of Illinois, MGMA, at the time. I was able to find, you know, the answer to what that question was. I thought that level of resource was outstanding, and without being part of the Illinois MGMA, that would have been difficult for me to really find that answer, because, you know, it's you don't. It's not easily accessible through the National through the National group. Jen. From your perspective, I know you've been participating in Illinois, MGMA, for quite some time. What have you experienced as some of the benefits of membership? 

 

Jennifer Kovich:

Well, like, Meghan said. You know national has a lot more resources than we have on the local level, but their focus has to be more national. And there's so much going on within the nation than within the States that they can't concentrate on those details that would be happening in a State like Illinois. So it's really beneficial that we can have the team on the ground here to look at that information. And 2 of the things that we really see that with is with our legislative newsletter. So we can look at local Illinois specific laws. And also our payer Newsletter, like you mentioned Dan, having that local information for policies that might only be affecting Illinois. Those are probably our 2 biggest drivers for what we see, the benefits for the local folks. 

 

Daniel Marino:

Yeah. And I can see that, too, especially a lot of the legislative changes. You know, I know in Illinois, and really with a lot of the states you know, you have a national carrier perspective and a lot of the requirements and policies, and so forth. But you know, local Medicaid that occurs. I mean, they're constantly changing the rules there, and I can remember, even years back, when Illinois started a lot of their Medicaid ACOs, it was difficult to find information. So just having that ability to aggregate that information and to provide it to a lot of folks within the local setting. I mean that in and of itself is a huge benefit. You don't get that from all arenas. 

 

Jennifer Kovich:

No, for sure. I also think a lot of the opportunity to build community locally, which you don't get as much on a national level. If they're offering their conferences, you go a couple of times a year you might see the same folks, but then here, on the local level, we'll have webinars or manager meetings and our local conferences. So you get to meet the same people over and over again. Kind of catch up with them. See how maybe issues that you were troubleshooting together went for them, and kind of keep in touch on a local level which I think is really valuable. 

 

Daniel Marino:

Yeah, I would agree. I agree, Meghan, when you think about the State associations and the National Associations, is it an either or for members, or do many members participate in both the State and the National Association, you know, such as Illinois, MGMA. And the National MGMA. 

 

Meghan Heiy:

Absolutely. There's such a benefit to being a member of both. Specifically with Illinois MGMA and national MGMA price wise. There is a discount for joining both, but just benefit wise national, as I mentioned, offers those certifications, you know, you can pull data from national MGMA's website and kind of compare it to different practices around the country around your area. And those are resources that you know, local chapters just can't offer. So nationally, that's a huge benefit, and as Jenny mentioned, the national conferences, which are much larger than local conferences, provide a different sort of education than what a local chapter would be able to offer. Locally, you know, as we've talked about, the focus and the ability to be able to interact with people who are experiencing the same issue as you guys were talking about the payer issues. I know I've personally reached out to people in my area and been like, Hey, have you experienced this denial on this code with this payer? What did you do? And using that is just it's so I can't even describe how helpful it is when you're dealing with these insurance companies to be able to say, Hey, you did this for this other practice, I know you can help me with this problem and resolve it this way. I can't even like I've done that more times than I can count. 

 

Daniel Marino:

Yeah, I agree with you. I think that ability to network with your peers and get that answer really does, that provides a tremendous amount of value. How about the overall networking opportunity, I would think, for an up and coming practice leader, or somebody that, let's say, is a few years out of school, and is interested in developing their career, maybe networking with their peers. I would think the State associations have to provide a tremendous amount of value, probably more so than even the National Associations. 

 

Meghan Heiy:

Oh, absolutely you know, as you're talking about our networking opportunities, there's such a huge opportunity for students as well because we do have student members to interact with companies and leaders in healthcare in Illinois, where they are looking for you know, job opportunities or networking opportunities. This it's so much better to be local for that purpose, because you're obviously living in Illinois if you are a local member. And having those local contacts is huge for professional growth as well as just, you know If you're looking for a new job, if you're looking for volunteer opportunities, all that other stuff you can't get at a national level. You'll get national contacts, of course. 

 

Jennifer Kovich:

I would say, not only from a practice administrator or practice leader perspective, but also from a vendor perspective, because we do have affiliate vendors as well that it gives you the opportunity to find someone. It might be a national company, but your rep on a local level that can also assist you with any needs you have, and they're great resources. Just in general. Our affiliate committee is a really strong committee, and they are all very aware of what each other do. So if you're having a conversation with one of them, and that's not a service that they offer, they'll know somebody that they could say, Hey, you can reach out to so and so, and they'll be able to help you with your issue. So that's really valuable, too, to have that access on a local level. 

 

Daniel Marino:

If you're just tuning you're listening to Value-Based Care Insights. I'm here today talking with Meghan Heiy and Jenny Kovich, and we're discussing the role of local associations, such as the Illinois MGMA and the impact on local healthcare leaders. Jen, let's dive into that a little bit. When you when you think about, let's say the funding of the associations right? And obviously, there's membership fees. But you know, it's in my mind the successful meetings. The successful ways of really structuring the Association is through a collaborative arrangement that is, really entails the alignment of the members of the association leaders, but the affiliates or the vendors play a critical part right? And you mentioned that you know the affiliate committee is one that's really successful. How in the past have you engaged vendors or the affiliates in such a way that they feel value out of the association? 

 

Jennifer Kovich:

No, Dan, you're right. So for sure we would not be able to put on the quality programming we can without sponsorship. That kind of funding is not going to come just from member dues, and that alone. So we've had to develop really strong relationships with these affiliates. And part of that is you know what we can help offer them in having access to these members at these events and putting on really strong events to have a lot of folks come out to have conversations with. And then also we did change our sponsorship, offering a few years back to more of an a la carte. A lot of associations will have kind of, you know, gold bronze level of sponsorship, and then you get certain package throughout the year. We've allowed our affiliates to kind of pick and choose different options that might work better for them and what they're trying to offer, so they can have access to members in a way that's appropriate for their needs. So that's been really valuable, I think, to our affiliates as well. 

 

Daniel Marino:

Yeah, I would agree with you. And I'll tell you from a member perspective, not only does it help put on robust programs, but it provides members with so much access to new solutions, right? New applications, new technologies, if you will, or things that they might be able to take back to their organization and say, Hey, you know we have a solution. I can remember years back I went to one of the meetings and it was amazing, all the new technology that was out there around revenue cycle things that were really focused on supporting and really improving the overall performance of practices, and you know those revenue cycle vendors, and one in particular was just phenomenal. It was just exciting to see. So when talk a little bit about the maybe the meetings or the interactions you have with the members. I know, you know, I want to bring up in a few minutes. I do want to talk about maybe the annual meeting you have coming up. But what are the other ways that the networking opportunities or the education events that you have in place for a lot of your members? 

 

Meghan Heiy:

Okay, I was, I was, gonna say, so in addition to the conferences, we also offer webinars. You know, monthly that our members can join and chat to each other about on top of that we do offer in person networking events. You know where you can connect in smaller groups and truly discuss those issues that you're experiencing at a practice level. On top of that our vendors do sponsor a lot of those events. And so the vendors have that opportunity there to interact directly with our members in a more casual environment. I think that's a huge benefit to vendors and members. You know that the more casual interactions is really where those connections come into play. And I think that's a definite benefit for everybody involved. 

 

Daniel Marino:

Yeah, I would agree, I would agree. So, Jen, when you when you focus some of the programs and you're developing the programs are the vendors driving the programs. Do you get input from a lot of the members? How are you structuring some of the topics? 

 

Jennifer Kovich:

We have sent out surveys in the past to see what's going to engage our membership, and that would also go out to those affiliate members, they'd be able to respond to that survey as well. A lot of it we get just from questions or comments that we've received, and we know what topics are of interest of the time. Our annual conference is more operations and leadership focused. And then our fall conference is more financial focused. So we kind of see what we've seen throughout the year, whether it's an affiliate member or a regular active member, and what kind of offering they're looking for, and that's kind of how we tailor our conferences and our webinars as well. 

 

Daniel Marino:

Okay, great. And when is the annual meeting? 

 

Jennifer Kovich:

Our annual conference is going to be may 1st at Chicago, Winery. 

 

Daniel Marino:

Oh, wow! That's a nice event. That's a nice event. Yeah. So do you. So one of the the challenges, I would think that you have to have as a State association is, where do you have the meetings? Right? Do you have them in, you know, in in the Chicago area or in the larger metropolitan area? Or do you have them in the middle of the State, or you have them in the southern part of the state. Do you find it difficult to really determine where to have it? So you end up kind of supporting, or have a strong, you know geographic presence, if you will. How have you worked through that in the past. 

 

Jennifer Kovich:

That is something that's very difficult with a State like Illinois We have tried to have some events farther down south, not very successful with attendance. So we've kind of stayed around the Chicagoland area. For the most part we tend to have more success with getting folks to come out in that area. It is something that's always on our mind and trying to make sure that we are offering in-person events that the whole State can access. So it's something we consider, and we kind of have to weigh things out, depending on where things are going throughout the year, and also just cost of venue and things like that. So we look at all of that. 

 

Daniel Marino:

Well, and I think it's got to be a pretty nice, pretty nice draw you have people coming to Chicago, and you know, although might be a little bit of travel, you know. It's kind of nice to spend the day up there. Meghan, talk a little bit about the annual meeting. What are some of the topics that you're planning for within the meeting? And you know, maybe, is there a networking event as well. 

 

Meghan Heiy:

Absolutely. So, as Jenny mentioned, It's on May 1st at Chicago Winery, and this is a little bit of a pivot in terms of venue for us in the past. We've done you know, banquet halls and different hotels and things. This is much more unique venue. And in that light, we are, you know, offering a little bit of a different content lineup than we've done in the past. So this year we're going to be more leadership operational focused. But adding to that, our sessions are going to be much more interactive than they've been in the past. So we have a few sessions that are going to have breakouts and different activities associated, and then we have a couple panels as well. So it's a little bit different and much more engaging and interactive than we've done in the past. Our keynote is Carrie Burchell, and she's giving a great presentation on, you know, challenges that leaders face in healthcare. And we're really, really excited about that. You know, I think that's going to be a great event this year. 

 

Daniel Marino:

And then how about for affiliates or vendors that are interested in participating? Is there still room for them to participate? Or is it is it kind of filled at this point? And if so, maybe the fall conference might be a good alternative. 

 

Meghan Heiy:

Yeah, so we're definitely filling up in terms of booths that we've sold. But there are always, you know, sponsorship opportunities available. As Jenny mentioned. Those a la carte options are available for our conferences as well. If a booth, if the booths do fill up, we are open for the fall conference as well. Vendors and affiliates have a lot of different opportunities to interact and engage in these conferences. And then one key thing I did want to mention was the networking event where vendors and our members this year we'll be doing a wine tasting together, and, like I mentioned before. It's those casual sort of interactions where you kind of really see the issues that the vendors can see, the issues that the members are facing. And the members can see the ways, the vendors can, you know, help with those issues in in a casual conversation. I think you know, as I mentioned. There's just so many different opportunities for our vendors to benefit from engaging with Illinois MGMA, this year. 

 

Daniel Marino:

Well, I'll tell you. I am a huge proponent, and always have been of networking building, your network, interacting with your network. I could remember years back, when I was in grad school, I had to do an administrative Residency at a hospital, and my mentor at the time one of the pieces of advice he gave me was, build your network, utilize your network, reach out to your network, interact with your network. And it's the state associations in my mind provide just such a great opportunity to do that. How about volunteering? You know I know not all the members have to be, you know part of the board or part of the association. But are there are there volunteer opportunities? If, say, a new member wants to get involved or has an interest in in, let's say, the legislative side, or the payer side, or one of the others. Jen, what are some of the volunteer opportunities? 

 

Jennifer Kovich:

No, Dan, that's perfect. Because when you were talking about networking, I was thinking about the volunteer opportunities, because that's something that I've been involved with the organization for about a decade now, and I still talk to folks that I worked with, you know, when I 1st started the 1st President that I was under, and we still maintain contact. And they're still a great resource. So volunteering, you get to work closely with other leaders and build those relationships, and we have lots of opportunities whether you want to serve on the board. There are positions on the board. You start as a director, and then you can move up to the Executive Committee. And we also have a number of committees, so you can serve as a committee member and then work your way up to committee chair as well. We have a legislative committee, an ACNP certification committee, membership committee,  events and education committee and our payer committee, our primary committees. So any interest in that I think it's a great opportunity for the members to volunteer get to know the community, do some community service and also build those relationships. 

 

Daniel Marino:

Well, absolutely, and in my experience, even by volunteering, you get so much more out of volunteering and networking than you put in right. 

 

Jennifer Kovich:

Absolutely. 

 

Daniel Marino:

The time commitment isn't great, but the value that you get out of it is just incredible. So, ladies, this has been fantastic, and, as I mentioned, I've just been over the years a huge proponent of Illinois, MGMA. If any of our listeners, whether you're in the State of Illinois or outside the State of Illinois. If they're interested in learning a little bit more, say, about Illinois, MGMA, or maybe seeing the agenda on the annual conference. That's coming up in May, Meghan, what's the website? Or where can we direct them to? 

 

Meghan Heiy:

Yeah, so you can go to https://www.ilmgma.com/ We also have a Linkedin page where all these resources are available as well to see information about the annual conference there is a tab on our page where you can see the agenda. You know all the event details, hotel information, anything you're looking for. You can find it at
https://www.ilmgma.com/

 

Daniel Marino:

And all the committee information is on there as well? 

 

Meghan Heiy:

Yep, it's right there on the home page. 1st thing you'll see. 

 

Daniel Marino:

Oh, wonderful! Well, I would strongly encourage a lot of our listeners to look at the Illinois MGMA page. A lot of great information there. If any of our listeners are interested in contacting each of you as we talked about networking is really key. Would you, can you share your Linkedin site? I'm assuming both of you are on Linkedin. 

 

Meghan Heiy:

Yep. So I'm available at Meghan Heiy on Linkedin. You know you can contact me there if you need anything. 

 

Daniel Marino:

Great, and Jen. 

 

Jennifer Kovich:

Yep, you can contact me on Linkedin, or you can email me directly at jkovich@solarishp.com. 

 

Daniel Marino:

Great. Well, thanks, guys, this has been wonderful. And I'm planning to attend the annual meeting. I'm really looking forward to it. So any of our listeners, particularly in Illinois, that are planning to attend. Please stop in and say hello, love to again, you know. Build our networking opportunity. But want to thank both you, Meghan and Jenny, for coming on the program. Really appreciate it. 

 

Jennifer Kovich:

Great thanks, Dan. 

 

Meghan Heiy:

Thank you for having us. 

 

Daniel Marino:

And I want to thank everyone for listening. Until our next insight, I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

The healthcare industry is grappling with a growing shortage of providers in every specialty, with primary care being hit the hardest. In this episode, host Daniel Marino is joined by primary care physician, Dr. Leila Obeid, to discuss how physician shortages and rising patient demands are forcing many primary care physicians to seek better work-life balance through alternative practice models. One solution? Concierge medicine. Tune in as we discuss how this model helps physicians regain control, improve patient care, and create a sustainable future in healthcare. 

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:  

Welcome to value-based care insights. I am your host, Daniel Marino. It is no secret for all of us that are in healthcare, no secret that we continue to have a shortage of healthcare providers across all specialties within the industry. And when you look at the specialties and the shortage associated with them, I don't think any specialty has been affected more than primary care. And possibly since the since the epidemic I think it's increased more where you, where you have a lot of primary care physicians who have just retired early transitioned out of the industry have decided to move into telehealth. But what it's done is it's created such pressures on the primary care physicians who stayed practicing. And not only is it an access issue for patients, but it has placed tremendous pressures on the primary care physician to the point where they're not able to spend the time that they really want to spend with patients. There's clearly a work-life balance issue there with primary care physicians. And it's just frustrated primary care physicians to the point where we're seeing them continue to move out of primary care and move into other types of models, other types of way of practicing, or in some cases just leaving the healthcare industry altogether. 

Well, I'm really excited today to talk with a physician who has really taken it upon herself to change the way that she is practicing medicine and for primary care. Physicians, there has been this trend of moving to a concierge model of practice. Well, I'm very pleased today to invite Dr. Leila Obeid. She's an internal medicine physician been practicing for 20 years. Over the last 8 years or so, she's been an employed physician with a large health system in Philadelphia. And over the last year she made the decision to transition her practice to a concierge model of care. Leila, I'm really excited to talk with you about this today. Welcome to the program. 

 

Leila Obeid: 

Thank you. Thank you for the introduction. I'm excited to have that conversation with you today. 

 

Daniel Marino:  

So when you were thinking about your practice, and obviously you were faced with a lot of the same challenges I'm sure that many other internal medicine physicians have been faced with, work-life balance issues just a shortage of time. What were some of those factors, or what were the other factors that influenced your decision to move into a concierge medicine practice? 

 

Leila Obeid:  

I think you know, one of the major decision is, you know, I went into primary care because I do like knowing about my patients forming that long-term relationship with patients, and over time, in my last 20 years of practice I've noticed that we've had just shorter amount of time with patients less clinical help in the clinics. And even though I tried my best to create that space and time for the patient, and to take my time with them. I found that I just did not have enough time with them when they needed to come in for a same day, sick or next day sick visit I sometimes my schedule was so full that I was not able to see them. I had to send them to urgent care, which I did not like doing, because I knew my patients best. 

 

Daniel Marino:  

Sure, and it creates, It has to be very frustrating for you. To know that you really want to take care of these patients right, and especially I have a lot of respect for internal medicine as a specialty. I managed early in my career a large internal medicine practice as well, too, and so I appreciate the complexity that goes along with taking care of patients from an internal medicine perspective, so I can't help but think that it was very frustrating, or has been frustrating for you to not be able to give that time. 

 

Leila Obeid:  

Yes, it has been very frustrating, you know. We try our best to give patients the time that they need, and we do. And when we're able to create that unfortunately, on the back end is where you have to take that work home, you have a family on weekend. So it's created a imbalance. I think a life work imbalance, and it's not allowed us to create the time, you know, to take care of patients the way we would like to, and the way patients would like to be taken care of as well, too. So it'll be frustrating for both patients and physicians. 

 

Daniel Marino:  

Absolutely, absolutely so the concierge model. There is this trend of many primary care physicians moving into the concierge model. And there's different structures there, right? So you have a hybrid model. You have a full concierge model. Talk a little bit about your model. What are some of the things that that are contributing to you know how you structured it. I'm assuming you're moving into a hybrid model. Is that correct? 

 

Leila Obeid:  

So what we have decided, so the hybrid model is a practice that basically accepts patients with insurance only without a membership fee, but also has the different group of patients that has the membership fee. And we when we thought about that, we did not want to create a tiered system for patients where the member, the patients that are paying membership get more time than the patients that are just paying insurance. So we decided to do full concierge. We are still opting into Medicare and getting credentialed with the major insurances in order to stay in network. It makes it, I think it's more comforting for patients to know that we are still in their network when we order labs or imaging, or we do subspecialty referrals. We are a known entity we are within the network for patients insurances. And then the other model is the direct, patient care where patients just pay that membership fee without using any insurance. So for us, I think it was very reassuring when patient asked us, are you still accepting my insurance? to say yes, we are staying credentialed with the major insurances and we are still opting into Medicare as well, too. 

 

Daniel Marino: 

So from an economic standpoint, though. So you're still going to get reimbursed from the insurance. Are you charging patients extra above and beyond that, or is it just accepting whatever the insurance gets you? But maybe just limiting your patient panel, so to speak. So you have more time with the patients. 

 

Leila Obeid:  

Right. So for us we are accepting what the insurance gives us. But patients will to be part of that practice in order for us to create the time for patients and the flexibility and scheduling. We've of course, we have that membership fee. So for the membership fee allows us to have a smaller practice, smaller panels, which gives patients basically a more time access, you know, more accessibility to the clinic flexibility and more direct, you know, patient care experience where they can call and get their needs managed, you know, in a in a time, in a timely manner, where they're not waiting for the next day to hear from the physician or the physician's assistance. 

 

Daniel Marino:  

Well from a patient's perspective, they really have to appreciate this right? Because for many of us it's very difficult to get in with the primary care physician, the wait time is really long. And if you have an immediate need, oftentimes you have no choice to go to the urgent care or to the emergency room. So I could see that this could really be a benefit to patients. What are some of the other benefits that you see that that are attractive to patients around the concierge model? 

 

Leila Obeid: 

One is when you do the transition, at least for established patients. You know you are an unknown entity. But the advantages to patients really is the ability to have that personalized care where, where the physician has the time to learn the patient to learn, you know, to understand their perspective about their medical care, and have the time to have the patient centered, you know conversation. Patients have the time to tell you what their needs are, and then you have that conversation where you, where patients can have an informed where they can make informed medical decision as opposed to, you know, having that 15 min visit where we are making the decisions. If patients not agreeable, we don't have that time and space to have that nuanced conversation or that, or create that nuanced patient treatment plan right? Because there's so many different ways to evaluate, not necessarily evaluate, but actually treat patients, and so, taking into account their philosophy about their care, of course, while still providing evidence-based medicine. So that model of care will allow us the time and space to do that. And, of course, for busy patients, flexibility, the ability for us to just lift up the phone and give them a quick phone call between patients. We will have the ability to do that. 

 

Daniel Marino:  

Right. Well, you're offering more time. Right? I mean, you're carving out. You're providing more time to the patient when they're there for your visit. But I think getting around the visit, if patients have questions that more that that personalized care, I think, is a huge benefit to patients. So when you when you went into this and you were starting to kind of transition over, do patients understand what concierge medicine was? Did you have to go through a lot of, you know. Talk a little bit about what were some of the conversations that you had. 

 

Leila Obeid:  

Sure. So I guess the good part for us is that there have, there are other concierge practices around us. So some patients knew what a concierge practice is. 

 

Daniel Marino:

So they were familiar with it. 

 

Leila Obeid:  

They were familiar with it, and others that were not familiar with it. So we had to. Well, we had to explain. Why am I moving to that type of care? And I've had a lot of patients who said, but you treat me in a concierge like manner, and that's you know, and that's my, you know. That's what I want to continue to be able to do. 

 

Daniel Marino:  

Well, that's a real credit and compliment to you. 

 

Leila Obeid:  

Yes, thank you. So you know, I think patients have been when we explain the model to them, the fact that they will have that access, you know the access to us. If there's anything urgent we can deal with in real time, you know, if they need us to talk to their sub specialist right? If there's a nuanced conversation that we have the ability to do, that, we can have that conversation. So patients, I think, have been very excited for us, and the support from our patients has been humbling .I think they do understand it. And they do understand the challenges because they've also experienced. You know, the hurdles to being able to reach their physician when they when they phone the office. You know their phone calls are not answered immediately, and there's many prompts so, and there's such a big. 

 

Daniel Marino:  

Yeah, they're frustrated as much as physicians are frustrated. 

 

Leila Obeid:  

Yes, yes. 

 

Daniel Marino:  

If you if you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm having a fascinating discussion with Dr. Leila Obeid on her journey and transition from primary care into a concierge model of practice. So let's talk real quick about maybe some of the some of the economics, right? So some of the things that share that that scare physicians as they've considered moving into this is well, you know. Am I going to make less money? I know I'm going to give up a little bit for having maybe a better work-life balance. How do I? How do I create that balance within their life? That's 1 of the questions that I often get asked when you went into this. What were some of the economic drivers that you were thinking about as you were, you know, structuring your model of practice and really launching you from your traditional primary care into this new concierge model? 

 

Leila Obeid: 

 So I mean, we definitely have to think you know how you know how many of our patients will be willing to follow us for this type of care. You know, we as we thought about this, you know, it's kind of been, I would say, over a year in the making of thinking about, you know, is this going to be the right model for us? It was so important to have that work-life balance. But from an economic perspective you know, is this something that I could do on my own right? I'm in a situation where I'm lucky enough that I have the support of my husband, and even though I may not be initially making the same amount as I am currently making, but I am able to make that sacrifice kind of for and knowing that and believing that you can build the practice and patients come to you because you've also built a reputation in the, you know, in the area. And then and then thinking that yes, that I may have to, I may have to create, or at least sacrifice some in the short term, but for the greater gain. Honestly for me it was not so much the economics. but more of that life balance, that quality of care, and even just enjoying that, yu know that care while I'm practicing. You know. Yes, and you know I won't be unrealistic to say, you know, currently with the model we're in, you know you. You work so hard, but you only get a certain percentage of your value as opposed to when you own that practice and you work hard, but you also feel, you know, that it is a I guess, more of a fair system. 

 

Daniel Marino:  

Well, and you're making a difference right? And what I hear you saying, and what other physicians who've gone through the same journey as you, they've said. Well, one of the big drivers was, you get back to practicing medicine like how you originally thought about going to medical school when you graduated right? You were excited about taking care of patients. You were excited about making a difference somewhere along the way, in primary care, and really in medicine in general. The business side got in the way right, and the love of practicing medicine really in some cases got either pushed to the back burner, or is just no longer there. I think I can. I can tell just by talking with you. You've recaptured that love. 

 

Leila Obeid:  

Yes, definitely. And I have now the you know, I am excited. I'm excited about creating this new practice. It's you can think about it as recreating traditional medicine. The type of medicine people used to have, you know your primary care, doctor. You're out in the community. They know you. They know your family. So. And that's the type of practice you know, that I envisioned, and I'm pretty sure a lot of primary care doctors envisioned otherwise, you know, they may have, you know that's the type of practice they envisioned when they thought about primary care. And with time you know that, you know you, you essentially, you feel that. No, that's not how we should be practicing. And yes, we. We're going to take a step forward, and we're going to try to recreate that love and passion for primary care, and create an environment of for patients, honestly for patients be taken care of the way they should be taken. 

 

Daniel Marino: 

Should be taken care of. Yeah, absolutely. So. In looking at your when you look at your panel when you 1st started, I guess 2 questions, you know, and what percentage of your patients were you able to retain or transition into your into your new concierge model? And I guess, second to that I would think that many patients who started with you in the concierge model probably brought in their family. Right? Probably said, Hey, this is great. Let's expand from just me to, you know, having my family members in there. Did that happen? 

 

Leila Obeid:  

Yeah. So that's the, I guess the nice element of surprise is that I found that I you know some of my patients are bringing in their husbands, or. 

 

Daniel Marino:  

Certainly. 

 

Leila Obeid:  

My panel had been closed for a while. So you know I have patients that are now excited. They're like, are you able to take on my friend now. So yes, patients are bringing in their family members, or you know they're bringing in their friends as well, too. So that. And you know, and patients do talk. It's interesting enough. Patients do talk about that doctors and who they're and they and they, and in some ways brag about their doctors as well. So yes, patients in the community are talking, and you know I've even had some patients who may not be able to follow me that, but they recommended me so highly to their good friends. So they're coming in and to join me. So that's been a nice, nice surprise. Yes. 

 

Daniel Marino:  

Well, I would think you would have no problem building up your practice, you know, again, concierge model is not for all patients. I think there are certain economic, maybe a fluency drivers there that I can't think influence that. But for some patients. And I think that growing that some is growing for these patients. The concierge model practice makes a lot of sense, and I think just hearing you and how you practice just seems to me that your practices has got to be exploding right now. Do you have, do you have a do you have partners that are with you? 

 

Leila Obeid:  

Yes, I have 3 other amazing physicians, Dr. Oler, Dr. Henrisi, and Dr. Jones, and we basically met 2 of us. So I met Dr. Oler, Dr. Jones through the institution that I'm working at right now, and Dr. Henrisi is as a good friend of Dr. Oler and a colleague of Dr. Oler. So we basically were all in the same boat and same feeling. We practice very similarly. You know, we really enjoy love taking care of our patients. So we decided, you know, what? Why not try to do this on our own and like, I said, the support from the community and from the patients has been great. 

 

Daniel Marino:  

Yeah, that's that is, that's very exciting. So for any of our physicians listeners that are out there, if any of those if any of them are considering, I'm sure there's quite a few, considering moving into this concierge model any pieces of advice you'd share? 

 

Leila Obeid:  

Yes, I think, doing your homework right? Take your time. Take your time to see if you can call other concierge doctors see, or if you have friends that may know a concierge doctor, have them connect you with them. Look at your in the environment you're working with. Look at the other concierge practices. You know the thriving ones. What have they done that that is working? I think it's important to take into account your environment, the area you live in. 

 

Daniel Marino:  

Because it's not the environment in the community is not for everybody in a concierge model. 

 

Leila Obeid:  

It's true, it's true, and but there are also some direct, patient care models that are in different communities in different states that I've learned about where that model is also working, working for them. Right? I guess. Still. And then, of course, you want to you want to make sure that that's also is your Is your family supportive? Are you able to maybe not make as much initially, but knowing that in the future as you grow slowly, that you, you will be in a better place. So we are in some ways lucky that I also have 3 amazing doctors who are going to be my partner. So I'm not doing this on my own. If I'm going on vacation, they can cover for me, and we trust each other, and I think our patients will be will be happy with my partner. We're going to be happy with my partners, and then, of course, you know, having that conversation with your with your partner? Is this something, you know? Are they support of this? Are they able to maybe take some of that load, you know, and maybe talking to your family as well to have you know I've heard in some situations where extended family members have been, have been also supportive. And you know, in financial ways, sometimes. So explore thought, we've been having that conversation for the last year. And so we've accumulated a lot of data. You know, we've talked to our concierge doctors in in the area. And that's kind of helped us create a more, a clear vision of what we wanted to do, and you know where the future can take us. 

 

Daniel Marino:  

Well that those shared those conversations that shared learning is absolutely key. Because, you know again. I think, just from the conversation we're having here. There's your level of expertise. Your ability to share your insights is invaluable. And I agree, I think, just having physicians just network and then having the support structure internally as well as externally right. Building your external support, whether it's through a business support or support from your family, or what have you, I think, is really critical. This has been fantastic. I'll tell you. I give you a lot of credit. I wish you a tremendous amount of success. I know you're going to be successful in this. You're just approaching this the right way. If any of our listeners, particularly our physician listeners, are interested in hearing a little bit more, or maybe connecting with you. Can you share your website? 

 

Leila Obeid:  

Sure. Sure, our web, our website is called Brynmore personalized primary care. So if they type it in, it's https://brynmawrppc.com And I can also share an email with you. It's info@brynmawrppc.com. 

 

Daniel Marino:  

Wow! That's great. Well, again, Leila, thank you so much for coming on the program, sharing your thoughts. Would love to have you back sometime down the road just to hear how things are going, because I have a feeling this is going to be a very big success for you and for your partners. 

 

Leila Obeid: 

Well, thank you for allowing me the time to speak on behalf of myself, but also, I think, on behalf of a lot of primary care doctors, I look forward to connecting again in the future. 

 

Daniel Marino:  

That's great. Well, thank you. Thank you as well, and thank you to everyone listening and tuning in. For any of you that want to hear more information about the concierge model or any of the topics that we discuss on Value-Based Care Insights. Please reach out to luminahp.com, or can reach out to me directly at dmarino@luminahp.com. Until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

In 2025, the continued growth of Medicare Advantage underscores the increasing importance of specialists in value-based care, as healthcare models shift toward more integrated, patient-centered approaches. In this episode of Value-Based Care Insights, host Dan Marino sits down with Lynn Carroll, COO and Head of Strategy at HSblox, to explore how specialists can successfully engage in value-based care models. Tune in to explore current value-based programs that incorporate specialty providers, key challenges encountered, and the critical infrastructure required for success in this evolving healthcare landscape.

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino: 

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As we move from 2024 into 2025, there's going to be a continued shift in Medicare advantage obviously and looking at the ACO performance that was released for looking at 2023 it's clear that as we move into this next year, specialists role within value-based care arrangements is going to be extremely important. Obviously, specialists control a lot of the or influence a lot of the cost of care targets. Their ability to integrate with primary care is absolutely critical on creating an efficient care plan if you will. And just the ability to be able to drive overall performance of patients and populations, that integration of the specialists and the primary care physician is absolutely critical. So in in today's episode, I'm really excited to talk a little bit about the role of the specialists in value-based care arrangements. Many specialty groups have reached out to us and have said, Hey, how can we get more involved in value-based care? How can we better integrate with ACOs with CINs, with primary cares, for that matter. The time is right. They want to do it.  

Well, I'm really excited today to have a guest who's been on the program before Lynn Carroll is COO head of strategy at HSBlox. I think he's been the COO for about the last 6 years. Great guy expert in the area of value-based care and value-based contracts. Lynn, welcome to the program. 

 

Lynn Carroll:  

Hey, Dan, it's great to be back on the show. Looking forward to our discussion today. 

 

Daniel Marino:  

So I know you're doing a lot of work with different providers across the country. And you know, as I reflect on some of the recent conversations I've had over, let's say, the last 2 or 3 months, the time is right for specialists to get more involved in value-based care. But there's a lot of challenges there, right? There's economic challenges. There's integration challenges. When you look at the specialists and the specialty community you have medical specialists, surgical specialists, hospital-based specialists. From your perspective why has it been so difficult for specialists to really gain traction in the in the value-based care world? 

 

Lynn Carroll:  

Well, I think, some of the things that come to mind are understanding the different incentives and levers that exist between primary and specialty care. And you know, in a lot of cases it may be the fact that specialists have traditionally been reimbursed, based upon procedural volume or things of that nature. And I think it's becoming pretty clear in these program designs that while primary care models in VBC may be fairly mature and certainly are pretty familiar within the marketplace. The reality is that a significant amount of the spending is driven in the specialty realm and so trying to get specialists into the value-based arena requires thoughtful approaches like you mentioned for care coordination for data sharing, taking advantage of more digital exchange of information. Some of the things that also come to mind are just looking at what expenditures are driven in trying to get to an accurate diagnosis. For example. 

 

Daniel Marino:  

Right.

 

Lynn Carroll:  

There can be a decent amount of spending that occurs before you can even get to a correct diagnosis. And so all those things beg a more collaborative approach across the disciplines, and certainly a multidisciplinary approach where there's poly chronic disease involved, for example. And I think folks have known, probably for a number of years. But it's becoming a little bit more important now to understand that if you don't bring specialists in, it's going to be really hard to continue to put total cost of care types of programs in and be successful with them. 

 

 

Daniel Marino: 

I absolutely agree.  But don't you think you need to look at the different value based arrangements almost separately or uniquely, if you will. So, for instance, you know, if you think about the total cost of care target for an ACO  population, right? Cancer, for instance, is a big driver of the cost of care. But when you look at dermatology services, for instance, it's not really a big dollar amount, right? So how do you create an alignment of specialists and specialty within the value-based care arenas when I guess the output is very different, depending upon the types of diagnosis or the types of clinical service? 

 

Lynn Carroll:  

Yeah. So I think it's, you know, program design obviously, is one of the things that it comes to mind. And even CMS, right is, you know, proposing more value-based insurance design types of mechanisms. So you look at the chronic diseases where you know an argument from the specialty side is, you know, what is the primary driver of this individual's care? And am I responsible for all of the specialty care? Or is it really specific to my specialty? Because if you have polychronic individuals, you risk a fragmented care environment and trying to bring primary care, specialty care and multiple specialists into the equation means the program design has to be efficient, not only in terms of how risk or incentives are aligned amongst the constituents, but also how information is going to be shared. So that gets into referral patterns. It also gets into looking at what would be the organizational designs like clinically integrated networks or specialty networks so that you can look for efficient referral patterns and efficient use of services. And in some of the more hospital aligned or health system aligned scenarios reduce leakage. 

 

Daniel Marino:  

Right? Right? So when we're looking at some of those drivers of value-based care and the ability of the specialist to influence it, I mean, cost is just one area, right? So reducing the cost care is critical. But what I'm hearing you say is, you have to look at some other factors. So you have to look at how your, what your internal referral structure is and the value that's coming out of in using the network and creating efficiencies around referrals. I agree with you. Leakage is huge. Right? I mean, if you, if you, if you refer a patient to a physician or a specialist that's outside of your network, you know, your ability to be able to manage the cost and influence. The quality goes down dramatically. Right? So you really do have to have to focus on that so when you're when you're thinking about that, is it important, then, for providers to think about, maybe how they create the VBC contracting structure, I mean, should they really think about it and take more of a proactive approach like, Hey, let's come up with some episode based pricing models for orthopedics, for instance. And then maybe a separate program for cancer? Or should they be approaching this from more of an enterprise based perspective, where, hey we're coming up with an enterprise based cost model, and maybe it will lead to some overall value for all of our participating providers. 

 

Lynn Carroll:  

Yeah, I I think we're definitely seeing you know, sometimes. And this is probably something you've seen as well. What's old is new again, and you know there was a heavy push in BPCI and episodes of care, and I think episodes of care sort of coming back around right. If you look at the need to align not only primary and specialty care but also align the inpatient components of things as well as post-acute care, which can also drive significant cost if example, patients are discharged either too early or inappropriately, you can drive a significant amount of the cost, post-acute and results in a readmission and things along those lines. So I think you know, as we kind of look at the landscape of what's happening, episodes certainly make a lot of sense with regard to targeting areas where you know, spend as well as outcomes can be, where spend can be reduced and outcomes can be improved. A lot of that then gets back to how are you going to effectively manage care, coordination deal with network optimization to ensure appropriate services are available but that they are efficiently tapped into, and you're creating an environment where not only the patient has a better outcome, but the care team also has a better experience as well. 

 

Daniel Marino:

Well, and I'll tell you, Lynn. I like what your suggestion there, I'm a big proponent of these episode-based pricing models for specialty care services. I think they accomplish a number of things. One, it allows for a very strong focus on the different care models within the specialty areas, and it allows you to track the outcomes plus you're able to price it in such a way that you can clearly align the incentives for the hospital for the specialty groups and for other types of ancillaries. Plus, I think, as you, as organizations, start to move forward with these episode-based pricing models, the payers are becoming more receptive to it, right? Because they're understanding what drives the cost. They know that the specialists that the specialty care, you know, could be 50, 60, 70% of overall costs for their attributed lives. I mean, they see it right? So it does provide a mechanism to really allow all the incentives, all the alignment of the Care plan, not to mention higher outcomes, to patient. All that to be considered as you're really beginning to design a Viable VBC structure. 

 

Lynn Carroll:  

Right. And I think that you know some of this goes to some fundamentals of you know population health analytics, which is to kind of think about, where are the, you know, the high spend areas or disproportionately high spending areas and then trying to understand, you know what condition or conditions are the primary drivers at the, at the patient level? And what is the primary need that a given patient has? Right? So you know, some of these conditions may not be adequately addressed by a primary care steerage model and really beg more of a collaborative approach to not only cost containment, but also ensuring a better outcome as a result. So we started the program, I think, talking a little bit about insurance design and thinking about how these value-based insurance programs are put into place. I think payers look at things from a perspective of saying, if you know, the next frontier and value based programs is engaging specialists. Episodes make a lot of sense. And so do clinically integrated, you know, types of models. And I think that the more global approach of a total cost of care gets boiled down to a more targeted approach under an episode type of a model. 

 

Daniel Marino:  

Yeah, absolutely. I couldn't agree with you more. If you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today talking with Lynn Carroll. COO has strategy at HSblocks, and we're talking about the need to integrate specialists more in value-based care and value-based contracts. 

Lynn. Let's kind of build on a point that that you brought up, and it's really around the support in the infrastructure, right? Because clearly, if specialists are going to expand into value-based care, be successful within value-based care arrangements. From my perspective, I think they need to do a couple of things. They need to be integrated within the CIN and the ACO in such a way that they've become a very active participant. But in order to make that work. You need to have the right level of infrastructure. You need to have the data and analytics and provide the information tools back to the specialists so they can succeed. But they also need to have the levels of support. And you touched on this a little bit. You need to have the right level of care management in place in order to provide the support and drive the outcomes. What are you seeing in terms of the challenges right now that that providers have in place, or maybe that have not been in place in order to support some of their specialists? 

 

Lynn Carroll:  

Yeah. So I think, some of the things that we've seen happening is evolution, you know, to more engagement techniques, not only at the patient level, but from a care, coordination, standpoint in managing things like referrals targeted to high value specialists. Looking at the different you know transitions and care, and having effective engagement in place, not only from, like, I mentioned the patient side, but also being able to share information appropriately and on a timely basis, so that there's, you know, collaborative decision making. So you think about the decision making in polychronic scenarios of not only involving primary care and special care, but the patient themselves. And that sort of gets you into thinking about what are some of the digital tools that can assist in that area, and things that come to mind for me would be remote, patient, monitoring capabilities. And you know, wearables, for example, that can help to inform a change in patient status and allow for more timely intervention, and mentioned another thing you know, sort of at the at the at the outset, which was time to diagnosis, right? Because part of the intervention scenario is to understand number one, what is the what is the diagnosis here of a given condition and get an intervention, plan or a care plan in place. And some of these models, you know, certainly create an environment where these types of programs that are episodic in nature can succeed. 

 

Daniel Marino:

Yeah. And they could succeed, timely right? And you know, you brought up remote, patient monitoring, I think in, you know, is this, this is becoming even more prevalent right now, and certainly in certain specialties, like, you know, cardiology, for instance, I think it's absolutely critical as these organizations move forward with it, or these specialists move forward with it. But you know so as you were as you were describing, that, I guess a thought came to mind, and I recently had a conversation with a actually it was a cardiovascular group, and one of one of the things they brought to me to my attention. Maybe it was orthopedics I forget. Was that in a lot of the ASCs in the surgical areas there's a lot of inefficiencies that are occurring. And the question that he asked me, and I thought was a great question, are there things that they can do to create efficiencies in a lot of their clinical services. So whether it's in the OR in the ASC, or maybe it's even in their own clinic operations as they're seeing patients, are there things that they do can do to increase efficiencies that allow them to better position themselves in value-based care, while at the same time being able to expand their fee for service opportunities as well, too. And I thought it was an interesting question, and I've gone back, and I've actually worked on it quite a bit, and I believe that there are. But I want to I want to kind of get your thoughts on that. 

 

Lynn Carroll:

Well, I think you know the 1st thing is understanding the population that you're primarily serving and then understanding things like, you know your sourcing. 

 

Daniel Marino:

Sure. 

 

Lynn Carroll:

And your underlying cost. Structures that are, you know, maybe need to be changed a little bit or be reinvented underneath a more value-based or fixed type of a reimbursement model. 

 

Daniel Marino:

Even streamlined right? 

 

Lynn Carroll:

Right. 

 

Daniel Marino: 

So I would think if you're looking at specialists, one big area of efficiency has to be around improving clinical variation right? 

 

Lynn Carroll:

Sure. 

 

Daniel Marino:

So if you improve clinical variation and you remove some of those inefficiencies, I think right off the bat. It's going to position you a heck of a lot stronger for value-based care. But it's certainly going to improve your ability to grow your fee for service business. 

 

Lynn Carroll:  

Well, and I think the other thing. And this probably gets back to, you know, talking about episodes again. One of the things that's always been positive about episode definitions is getting to a common set of them, Right? So that there is standardization and that there's not unnecessary components being, you know, unnecessary components of spend occurring because of variation in the definition of an episode, for example. That has been a common driver of why episodes have been posited as one of the things that can be a good driver for not only outcomes, but certainly cost containment. 

 

Daniel Marino:  

Yeah, yeah. Well, it creates some standardization around that. So you know, when you think about putting forth, you know, you don't want to call it, it's not cookbook medicine, but let's say you come up with a common care, model or common pathway, that all of the specialty providers subscribe to that are within that particular group. Well, then, it feeds into your outreach to the patients, the way you're navigating the care with the patients. And to a certain extent, even how you're using some services like remote, patient monitoring, how you're pricing it, and all of that figures into your ability, then to support your fee for service model, but positioned you across positions you well with great outcomes in the, in the value based care setting. 

 

Lynn Carroll:  

Well. And I think it's a good point, too. Because while we're focusing on value-based programs, and we're focusing on cost containment and outcome improvement. The reality is that many of these principles, if not significantly, all of these principles apply across fee for service just as well as across value-based care, because the commonality between the 2 reimbursement models is one thing we want good outcomes for the patient. 

 

Daniel Marino:  

We do, we do, and I'll tell you so. This kind of builds on to where I was going with this. So, as I was having this discussion with this, you know, I think it was an orthopedic surgeon, I said. You know. Look, these are things that you should do, because not only is it going to help your position you well for value-based care, but it's going to help you support Fee for service, but if you do this well, and you're able to see a return on what you're investing in on a fee for service side that becomes your investment for future value, based care, initiatives and infrastructure that you undoubtedly are going to have to make. So if you're if you're really prescribed on the approach, it financially could really work out well for the specialists assuming they're aligned. You know the whole group is aligned on that thought process. 

 

Lynn Carroll:  

Well, I think that's a great point, Dan, because you know, one of the arguments, or some of the dialogue is probably a better term around, you know, straddling with one foot sort of in and one foot out of value-based programs would be addressed by that methodology right? Which is to think about it in terms of a standardized approach to how you're going to handle the case, whether it's a fee for service or a value-based patient. 

 

Daniel Marino:  

Yeah, no, I agree. Well, well, then, this is this is great. I think you know. I think we just barely touched the service on this I really feel like the integration of the specialists into value.-based care has to occur. I think it's going to come down to a couple of things. Where you start. How quickly do you move. And then how do you make it economically viable over time, making that shift from value based care, you know, or from fee for service to value based care. Lynn, you know we're coming up to our time here. If any of our listeners want to get in touch with you. You know you're a wealth of knowledge. You've got great services and capabilities within your company. Mind sharing any of your contact information with our listeners. 

 

Lynn Carroll:  

Sure it's really simple. Go to hsblocks.com. We've got ability for you to put your name in on a form you can also call give us a call as well. It's on the website. And usually you'll see us fairly often posting a lot on Linkedin. And so that's a really great way to get a hold of me directly, or any members of our team, because we do share a lot of information about the value-based space on our Linkedin page. 

 

Daniel Marino:

Yeah, you guys do a nice job. I always kind of watch that. And you know, you do a nice job of sharing material. So you know, I'm really I appreciate reviewing. It is as well. So, thanks again, Lynn, I really appreciate you coming on the program, always a great discussion. 

 

Lynn Carroll:  

You bet. Great, great, great to be here today, Dan. Good to see you. 

 

Daniel Marino:

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

The Physician Fee Schedule (PFS) Final Rule for Calendar Year (CY) 2025 introduces several key updates to Medicare payment policies, aiming to enhance care delivery and reduce administrative burdens. In this episode, Daniel Marino is joined by Managing Partner, Lucy Zielinski, and Sarah Hartley, to explore the implications of the PFS Final Rule on physicians and other billing professionals. Together, they discuss the key changes and opportunities for physician services furnished in various settings including physician offices, hospitals, ambulatory surgery centers (ASCs), and others.  Tune in to stay informed and gain valuable perspectives on navigating these critical regulatory updates. 

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. As we now move into 2025, I'm sure many of you realize that we have a new fee schedule from Medicare. Our friends at Medicare released the new final rule last November, November first to be exact. And there are some pretty significant changes that we really need to consider as we're now moving into to 2025. And some of those changes as I kind of dove into it a little bit we're really focused on some new codes, some strategies to make more equitable reimbursement for the different physicians, medical groups, and so forth, around quality, around innovation, around managing what's occurring with some of our Medicare beneficiaries. And when I looked at it, there were 4 key areas that really resonated with me. And again, our background, and my background in particular, is really supporting a lot of the medical groups and the physician practices as well as the hospitals that have many employed physicians. So those 4 areas are really start with really the payment impact. So there is a pretty significant impact to providers, to how we're going to code with the new fee schedule. Second is, there's numerous new and expanded services, new codes, new ways to begin to get reimbursed for the services that are being provided. The 3rd area is around surgery and no secret, there's a big incentive to shift from acute to ambulatory, there's a new series of codes that are being proposed and included and build and allow for some reimbursement that really provider organizations need to be aware of. And then, lastly there's a major impact on rural health clinics and federally qualified healthcare centers. And as we think about the coding, these organizations, in particular, have a real opportunity to improve some of their coding, improve their billing, improve some of their collections.

Well, I'm excited today to have 2 of my colleagues. They've been on the show before, extremely knowledgeable in this area. Lucy Zielinski. She's a certified coder managing partner with Lumina health partners, and Sarah Hartley, former executive of a large health system in the Chicago area, and is a true expert in coding and clinical documentation improvement ladies welcome to the program.

 

Lucy Zielinski:

Thanks Dan.

 

Daniel Marino:

So, Lucy, let's start with you. Maybe you just give a quick, you know, couple a minute or 2 summary. What are some of the big changes that you're seeing with this new rule as we move into 2025?

 

Lucy Zielinski:

Well, 1 clearly rule that changes every year is kind of that conversion factor, the impact on payments. Right? This is a general thing, as we all know, there's this thing called budget neutrality, and they've been kind of poking away at the conversion factor. So this year 2025, we are going to be seeing a decrease of 94 cents of the conversion factor compared to 2024, and this amounts to almost 3% of total dollars or revenue. So that's a big chunk.

 

Daniel Marino:

It is a big chunk, and I'll tell you. It's amazing that when I saw this, this is one of the things that really surprised me, and I know there was a this was pretty controversial, so I know folks like MGMA and HFMA, and so forth, pushed back on it. But as inflation has increased and costs have increased, you would think that the payment and the revenue would increase, but it actually has gone down almost 3%.

 

Lucy Zielinski:

Well, and it's gone down fee for service, as you know. But what we're seeing is an increase on the value-based care side. You mentioned that earlier, Dan. And there's also some changes with the HCCs, hierarchical condition categories. We are moving versions this year, and, as you know, HCCs impact many of the quality programs, including MIPS, MSSP, the ACOs and Medicare advantage plans. So providers really need to be aware of that impact as well.

 

Daniel Marino:

Yeah, it's interesting and good observation. I'll tell you, there's definitely an incentive that's out there, moving from fee for service to value-based care, and around some of these programs. So, Sarah, let me kind of dive into this with you when you look at the new rule and the new codes, what are the newer expanding services that you see that are included in this new rule that maybe our provider colleagues need to pay attention to?

 

Sarah Hartley:

Yeah. So some new coding and payment for caregiver training for providing direct caregiver services and supports some expansion. On our G 2211 codes, Medicare will pay when this code is added to the annual wellness visit or the vaccine administration, any Medicare part B preventative services they'll pay for this additional code, when you append the modifier.

 

Daniel Marino:

So let's dive into that a little bit, because I think this is an important point. So when providers are billing the annual wellness visit. You're saying now that, based on the risk or the complexity of the patient, they could also now, Bill, the G Code G 2211 code with that?

 

Sarah Hartley:

That's correct. So if they are treating a patient that has a complex condition, and they are continuing a relationship with that patient for this serious, complex condition over an extended period of time. They can bill for this code.

 

Daniel Marino:

Hmm, yeah, that's interesting. And what's the reimbursement? Or is there an RVU impact to it?

 

Sarah Hartley:

There is an RVU impact, Lucy.

 

Lucy Zielinski:

Yeah. So the reimbursement again depends on the state you're in and the local. However, it's around $16, and the RVU value is point 5. So physicians who whose compensation is based on RVUs, they're doing the work. They might as well capture this bill for it, and have that credit.

 

Daniel Marino:

Well, and I'll tell you again, another incentive to shift to value-based care right? Because annual wellness visits are a critical point or part of being able to identify all of the historical conditions of the patients as well as capturing HCCs. What about telehealth services? Telehealth has been, I think, for the most part, providers really like it. I think most patients really like it. There's a discussion as to whether telehealth is going to continue. It looks like heading into 2025. That's still going to remain an important part.

 

Sarah Hartley:

It is remaining an important part. And we've seen several services actually being added to telehealth for 2025, including caregiver training and some interactive telecommunication systems which now can include 2 way, real time audio only technology for the beneficiaries in their home.

 

Daniel Marino:

What about for behavioral health? I read an article that you know again, I think it was a study that came out. That said I think the article spoke to the fact that behavioral health performance and the output of behavioral health telehealth services was recognized and well received by patients even more so than some of the medical services. How does behavioral health telehealth fit into this.

 

Sarah Hartley:

They are allowing for 20 min increments around safety planning and they are also have some new codes for digital mental health treatment devices as well. So they are also recognizing the importance of telehealth in the behavioral health services.

 

Daniel Marino:

Yeah, I think that's a good one. I really do. You know, access and behavioral health is such a challenge, and many behavioral health providers have started to integrate telehealth services and just try to expand their provider resources and offering telehealth services, I think, is an excellent way of being able to provide those services. So I was really this was one of the things I was happy to see. Talk a little bit about some of the caregiver training. You mentioned it earlier. What's included in there? And then how do you know who's considered the caregiver? How do we bill for those?

 

Lucy Zielinski:

So Dan caregiver, caregiver training is being paid now. So these are new services, as you know, are being recognized for caregivers who are taking care of patients or their loved ones, and some of the topics that CMS is going to be reimbursing for our training for techniques. To prevent some of these conditions, like ulcers, wound care, infection, control as well as behavior, management and telehealth services will be paid as well. So any training via telehealth. They'll pay for those services now.

 

Daniel Marino:

They're going to actually combine and pay for both of those then, so they'll be as well as telehealth.

 

Lucy Zielinski:

Right training, via telehealth.

 

Daniel Marino:

Training via telehealth, which really makes sense. Well, if you're just tuning in, I'm Daniel Marino. You're listening to Value-based Care Insights. We're having a great discussion on the new 2025 CMS Medicare rules fee schedule rule that came out, and that we're all kind of working through as we enter into this New Year, and I'm here with Lucy Zielinski and Sarah Hartley. So one area that I or 2 areas I want to dive into a little bit further. One of them is dear and dear to my heart. It's really around care management, I've said for the longest time, and I think people have heard me say this, that care management is really the engine behind value-based care. Right? It's what drives a lot of the performance. But oftentimes it is really under reimbursed, and it's, I think, undervalued per se. How are what's changed, or what's enhanced with some of the new care management services? As we look at the new role?

 

Sarah Hartley:

This is really exciting, Dan. I agree. There's a new set of codes that we're seeing for advanced primary care management services that will support several existing care management and technology based services into a bundle of services that's then going to reflect those core elements when delivering that care.

 

Daniel Marino:

So is it. But what can you elaborate a little bit further? What needs to be documented, or does it look like, you know our providers doing this anyways, right now, or nurses doing this, anyways? Or how is this kind of linked into what the services that they're currently doing versus what some of the new services maybe they need to think about going forward.

 

Sarah Hartley:

So any physicians, nurse practitioners who are who use an advanced primary care model of care can bill for these services when they are the continued focal point for all of the health services. They have to be responsible for all primary care services for that beneficiary. So that means that their documentation has to support that documentation has to support the continuity of care. This really helps ensure that our patients have access to that high quality care in primary care services.

 

Daniel Marino:

Hmm, yeah.

 

Lucy Zielinski:

Yeah these codes are really replacing those chronic care management codes that physicians. Before, and they used to have to track time right? So you had to watch the clock, measure the time, notate the time, so there is no time threshold now, it's based on how many chronic conditions. So there's 3 levels now, and based on how many chronic conditions, there's a corresponding code.

 

Daniel Marino:

Yeah, that's interesting. And I'll tell you hopefully, a lot of the care managers are happy about this, because I'll tell you trying to keep a patient on the on the phone or talk with them. To hit that 20 min, mark to me, seemed like it was a little unfair. I think if you're managing the patient and the patient has 2 or even 3 chronic conditions, and you're doing your check-ins, you're evaluating the meds, you're only spending 10 or 15 min, not the full 20. You should be able to bill the higher code because you're still managing the conditions around the risk level.

 

Lucy Zielinski:

Yeah, Dan, so there's 3 levels of these codes now. And the 1st Level is for people with one chronic condition and the reimbursement there is 16, about $16 a month per member. And the Second Level G0557 is for persons with 2 or more chronic conditions. And the last one is G0558 is for qualified Medicare beneficiaries with 2 or more conditions, and that reimbursement is around a $112 per member per month. So that's quite a bit of money.

 

Daniel Marino:

It is, it is. And you know the big takeaway for me is this, you know, they're removing the time based factor on this, and you know, in working with many organizations on building their care management platform, so many care managers were so focused on hitting the time criteria where for me it didn't really make much sense, you know, if you've got a patient with 2 or 3 conditions, and you're checking in with that patient, and maybe just adjusting their meds or following up, and you only spend 15 min on the call with that patient. You should be able to bill at a higher rate, because you're still managing the condition around that patient's risk level. So I think this is a really good thing.

 

Lucy Zielinski:

Right and it's important to again grab those HCCs, so correct documentation and diagnosis codes. And Sarah, you could even speak to that right? We're changing versions.

 

Sarah Hartley:

Yeah, we this year, we're 67% in V28. 60% of that reimbursement is coming from version 28, the other 33% will be from version 24. So in 2026 100% version 28 documentation matters, this truly is a great step to recognize how complex the care is that's being provided.

 

Daniel Marino:

Yeah. So going now into V28, maybe you can just elaborate on that a little bit more. So folks really do have to pay attention to their documentation. The clinical documentation improvement initiatives that many organizations are undertaking is really what's going to support it. I'm assuming Sarah, as well as then, you know, supporting the HCC capture, and so forth.

 

Sarah Hartley:

That's correct. Our physicians have never been trained on how to document to get chronic conditions paid for now we have. We are changing the way that we're reimbursed. That's not. You know. We are providing great care. We need to be make sure that our doctors are documenting that, and we have clinicians and coders that you know are experienced and can really help our providers get to that next level to get to these extra G codes for those chronic conditions.

 

Daniel Marino:

Well, and I'm going to give a little bit of a plug here to the Lumina team for any of our listeners who are interested in understanding more around. V28, clinical documentation, improvement, care management. We have a fabulous team that has done a real nice job with working with organizations both around education, putting in new workflows and just helping organizations take advantage of that. I'm really proud of the work this group has done. So anybody interested in learning more please feel free to reach out. I want to switch to another area. And it's really probably more hospital focused, or it's really focused on some of the surgeons. And it's around global surgery. And I know there's a there's this continued shift inside of service from the acute arena to more of the ambulatory area. Lucy, maybe we could start with you. What's changed this year in some of the new surgical codes, or some of the big changes that are going to impact surgeries or that level of reimbursement.

 

Lucy Zielinski:

Yeah, Dan, I think it has a lot to do with some of the changes that we are seeing have to do with denials, because in the past we've had a global period, maybe of 90 days, but often care was transferred from one physician to the next. So maybe there was physician A did a couple of the visits post-OP. But then the physician, the patient, went to another physician, who also provided care during the post-OP period. So this new changes to the rule, address some of that.

 

Daniel Marino:

Hmm! That's interesting. Sarah, any additional thoughts.

 

Sarah Hartley:

Yeah, really, the goal here is to appropriately reflect the time and the resources involved in the follow up care that's being performed by the providers who work involved in furnishing the surgery. So giving credit where credit is due, basically.

 

Daniel Marino:

Well, and it seems to me, as I looked at it, there was a big post operative component that was tied to this. And again, I focus a lot on not only what's occurring in the fee for service arena, but also in the value-based care arena. This to me by adding on these additional codes and the G codes, and so forth. Allow for this transition to more to stronger post-operative care.

 

Sarah Hartley:

Correct, I would agree. It's really provide allowing the providers to provide that support appropriately and then be reimbursed appropriately for it as well.

 

Daniel Marino:

The last area that, as I was looking through, the rule seemed to me there was a focus on enhancing some of the financial opportunities for rural health clinics and federally qualified FQHCs. Federally qualified healthcare centers, health centers. What are some of the things, Sarah, that that you seen as you've looked at it, that are positive impacts or some of our RSCs FQHCs need to pay attention to?

 

Sarah Hartley:

Yeah. So what I see happening here is the alignment with other healthcare organizations in the way that rural health clinics and federally qualified healthcare centers are being reimbursed, starting with care, coordination services. And really aligning with other entities who are furnishing similar services. This year. Entities have to report individual CPT and HCPCs codes for those care coordination services, telehealth. They are aligning telehealth and allowing them to continue to bill for that technology for non-behavioral health visits here in the Rural Health community, but by reporting the HCSPCs and the G Codes on the claim that they, for the services that they furnish. So the big thing here is that they're aligning with other entities in the way that they are reimbursed.

 

Daniel Marino:

Yeah, well, I mean, that makes sense. And you know there's always some challenges in terms of you know how you bill it, and the reimbursement you get with the cost reporting, and all that other, all that other good stuff. But I think when you look at what has been, what they've included as additional codes and opportunities to really coordinate that care with other providers. I mean to me, this is a pretty big. This is a significant impact.

 

Sarah Hartley:

I would agree I would agree there. We I also see that they are allowing these rural health care centers and the FQHCs to bill and be paid for part B preventative vaccines and their administration. So that's a huge thing, too.

 

Daniel Marino:

Oh, really? Oh, yeah, that I didn't catch. Yeah, that's a good one. So also, you know, they could start to bill for some of the vaccinations and some of the reimbursement for activities, you know, for any vaccinations and so forth, that are being done by the FQHCs?

 

Sarah Hartley:

That's correct, and the payment will rates will align with other settings.

 

Daniel Marino:

Oh, that's great! Well, I ladies, I appreciate I appreciate your quick and dirty input and interpretation of the rule. There's a lot that's included in that. If any of our listeners are interested in finding out more, is there a place where maybe they can go for a summary, or any thoughts that we can direct them to.

 

Lucy Zielinski:

Well, so CMS puts out a fact sheet, which is nice. It's a high-level fact sheet. I usually read through the whole federal register rule, because there's some nice graphs, charts, more explanation, especially for coders and revenue cycle departments out there. I would recommend that they go directly to the to the Federal Register.

 

Daniel Marino:

Yeah. And I'm sure that's a real exciting read.

 

Lucy Zielinski:

It's a weekend long read. You were wondering what I was doing last weekend, Dan.

 

Daniel Marino:

No wonder, no wonder you look so well rested.

 

Lucy Zielinski:

Yeah. And then I would lastly, I would say, your local and national associations and specialty physician associations. They put together a nice summary specific to your specialty, so I would I would look there as well.

 

Daniel Marino:

Yeah, that's great. Well, and also, too, I'd love to direct everybody to the Lumina website. And if you do want any information we provide a lot of great information, great education, as well as some tools to help organizations, help providers think about how they need to train and change a lot of their coding activities to maximize a lot of these new rules that are coming down the pipe. Sarah, I want to turn to you. Thanks for all your help on this any parting words of wisdom.

 

Sarah Hartley:

No, we're just seeing it's becoming more and more important to document those chronic conditions in their interactions. So keep doing the good work.

 

Daniel Marino:

Yeah, and there's going to be a lot more to come, that is, for sure. Well, ladies, thank you really appreciate your time today. This was a great discussion. Love, to have you back to talk about some further changes, particularly around the V28. I think that's probably a big topic for us to cover sometime down the road.

 

Sarah Hartley:

Great look forward to it.

 

Daniel Marino:

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

Healthcare providers will continue to move toward value-based care, fostering a more equitable healthcare system that enhances accessibility, quality, affordability, and innovation. In this episode of Value-Based Care Insights, I sit down with Lumina’s Managing Partner, Lucy Zielinski, to explore the healthcare trends of 2025, the effects of new regulatory changes, and the pressures these developments place on providers. Tune in to learn about the top five trends that health systems should include in their strategic planning.  

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. Well, happy New Year everyone as we are now into 2025, and preparing for this New year. It's gonna be interesting when you look at the potential changes that we're going to be faced within 2025. Obviously, with the new administration coming in there's going to be a lot of activity with CMS. I think we're continuing to see a lot of growth in artificial intelligence. And it's really going to impact hospitals, physician groups, and in particular, their operations. In one respect, I'm really excited about the potential and the changes that we see or are going to see. But in in next respect, you know, it's sort of the fear of the unknown right. What is the what is the next few months going to look like? Well, every year at this time we always spend a little bit of time talking about the potential trends that we anticipate seeing as a consulting firm moving into the next year. And we're very fortunate because we work with organizations all over the country and leading up to these conversations, I often reach out and have discussions with healthcare leaders all across the country to kind of get their thoughts on one, what’s keeping them up at night? What do they focus on in the New Year? And then what are the big trends or initiatives that we see emerging as we move into the next year. So to help me discuss this today, I'm really excited to have my close colleague partner in crime at Lumina, Lucy Zielinski. Lucy, welcome.

 

Lucy Zielinski:

Thank you, Dan. Happy to be here and happy 2025.

 

Daniel Marino:

Yes, thank you. Thank you. So let's talk a little bit about this. And you know, obviously, an area that you're very close to is medical group performance physician performance. You know, in your consulting practice you do quite a bit of work on helping medical groups improve, and in particular, around coding HCCs and so forth. So as we, we think about what we're going to be faced with in 2025, what are the couple of things that you believe that are really going to impact some of these either medical groups or the provider community as we start to think about some of these new, these new challenges.

 

Lucy Zielinski:

Yeah, Dan, so it's interesting. But we have definitely seen a focus on the expansion of ambulatory services and providing patients access in in communities and with value-based care, we continue to see these delivery models continue to evolve. It's interesting. The recent statistic is about 60% of health care payments are tied to value and quality. According to the American Hospital Association. And value based care has seen some great results, right? Decrease in hospital admissions, increased rates of preventative care, lower medical costs. As a matter of fact, even Medicare, advantage reported savings compared to traditional medicare.

 

Daniel Marino:

Yeah, and even the Aco. So you know, the 2023 performance ACO showed a significant improvement in in the amount of savings it continues to make to make some great strides in in that regard. So when you think about, then, how medical groups need to position themselves you're really talking about changing the care model right? Or continuing to evolve the care model. What would be a couple of things that you feel like medical groups should focus on?

 

Lucy Zielinski:

Yeah, I think one key area is definitely around care management. And that's evidenced by the 2025 Medicare fee schedule updates. If you take a look at those updates, we're seeing expansion of billing, reimbursement and coding around such things like care management services as well as caregiver training, which is really interesting.

 

Daniel Marino:

It's really interesting. And I'll tell you. I've said for the longest time that care management is the engine behind value-based care. If you're going to do a good job, you have to be able to have a good care management program. And I share your excitement. I'm really looking forward to these new codes in 2025, in support of the caregivers, in support of transitions of care. Things that haven't been appropriately coded, and physician groups haven't necessarily been reimbursed, for that's going to change in 2025.

 

Lucy Zielinski:

Yeah. And I mean, there, you're right. It's the advanced primary care management services around transitions. In addition to a focus on behavioral health and mental health. We even saw just recently published innovation project around behavioral health model, a new model. So definitely a focus on some of these areas that traditional medical groups have not focused on.

 

Daniel Marino:

Let's talk for a few minutes about Medicare Advantage. I believe that as we head into 2025 Medicare Advantage is going to continue to be a focus in the next few weeks we are going to see the new Enrollment numbers. Last year there was about 54% of Medicare beneficiaries were enrolled in Medicare Advantage. I would not be surprised at all, Lucy, if this approach is 60%. But it's interesting, because you're seeing again some of these smaller hospitals, some of the rural hospitals, they terminated their contract Medicare Advantage, yet the Government is, is still pushing it. When you, when we think about Medicare Advantage, What are the things that you believe are gonna continue to be a focus on?

 

Lucy Zielinski:

Yeah, I think you're right. Growth is definitely going to be there. But many providers are scratching their heads and wondering should they continue in these plans just because they're very burdened from an administrative standpoint. So I think the focus is really going to be about managing some of these claim denials. Which is really interesting, because in the last couple of years Medicare Advantage the denials have been quite higher than traditional Medicare, and many of them have focused around the prior off denials which really would have been avoided in traditional Medicare.

 

Daniel Marino:

Yeah, well, and so in 2025, there's been a lot of discussion around some legislative changes for Medicare advantage to handle these pro pre authorizations. And I'll tell you certainly over the last month, month and a half, the spotlight has been on these insurance companies and the carriers, and in particular, around Medicare advantage. I really believe that if we are going to succeed in shifting Medicare beneficiaries to Medicare Advantage if we're going to hit the goal that Medicare wants by 2030 of having Medicare beneficiaries, and either an ACO or Medicare Advantage, or some type of value-based performance structure. How we handle denials, how we handle pre certifications, how we handle just taking care of patients on a timely basis. All of that has to change. Without those changes. You're going to continue to see a lot of these providers just not accepting Medicare advantage.

 

Lucy Zielinski:

Yep, I think you're right.

 

Daniel Marino:

So let's talk a little bit about some of the financial pressures. In 2024, I think the hospital margins in general improved from prior years, but not really much right? You're talking, maybe a percent and a half. I think the last statistics that I've seen the average hospital margin was somewhere around, maybe 2 and a half to 4%, and for smaller independent hospitals they were lucky if they were able to operate at a break even. Most of them made money or covered their operations from a lot of their performance and their capital, their capital investments. But as we move into 2025, what do you see are some of the big drivers that organization providers should focus on to maybe either respond to some of these financial pressures, or to react to changes within their organization, to put themselves in a better financial position. Any thoughts?

 

Lucy Zielinski:

Yeah, I think definitely the pharmaceutical costs those are rising. And, as you know, Dan, the baby movers are aging we're seeing seniors. There was a recent statistic in 2023 majority of seniors are 75, and older, and then we see younger sicker population. Obesity rates are high, which is a trigger, right? A risk factor cancer strokes, heart failure and so forth. So definitely, there's this focus on a pharmaceutical costs.

 

Daniel Marino:

Yeah, I agree. You know, pharmaceutical costs. It's, I've spent a lot of time looking at different cost structures, particularly around Medicare advantage. And even some of the commercial contracts, as you know, we do a lot of managed care contracting on behalf of the provider groups with the plans, and oftentimes we'll dive into the total cost of care, and when you really separate that and you put them into 2 buckets, you look at the medical service costs. And you look at the pharmaceutical costs. The medical service costs the rise has actually slowed. Right? So we're seeing that rise in the medical service costs, probably being somewhere around 4 to 5%, a little higher than what the CPI or the inflation rate is, but not too far off. But when you look at the pharmaceutical costs, you know, it's somewhere around 8 to 10%. And some of these drugs have even gone up a couple 100%. I really feel like if we're going to get our arms around managing total cost of care, we have to figure out we have to come up with some solutions on how to better manage the pharmaceutical costs. And it's interesting. I don't know if it's with the drug companies, or if it's with the PBMs. You know. There's a lot of pressure on the PBMs right now, right? And is kind of the middleman. As we've heard soon to be, our elected President Donald Trump make mention. So, you know again, it's going to be interesting to see where that where that goes, any thoughts?

 

Lucy Zielinski:

Yeah, I agree. And even the form formularies, right? Certain medications are covered. Certain are, certain medications are not. So, I sense that there's definitely going to be a pressure on these PBMs to manage these costs better.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today with my colleague, Lucy Zielinski, and we are talking about the potential trends in 2025, and how it potentially will impact hospitals and medical groups. Lucy, you know some of the pharmaceutical costs as we begin to think about it, and how it's integrated with the PBMs. You know, we're seeing different types of contracting opportunities there. And as you mentioned the older population, you know, that's where a lot of the cost structures are in place. Any thoughts come to mind as to maybe what medical groups or physician groups can do as they think about you know, getting their arms around this? I mean, should they try to carve it out, should they? And you know, maybe try to manage it differently with the commercials. Any thoughts?

 

Lucy Zielinski:

So, Dan, I think some of the things that medical groups can do is to carve out those costs or out of their contracts out of their contracts with the commercial payers. Also, another option could be to do a direct contract with these PBM pharmacies.

 

Daniel Marino:

Yeah, I agree with you. I think you know the rise in these costs make it very vulnerable for the medical groups, and you know what I've often said to them is, look, you should only contract around those things that you can be responsible for. So if you can't be, if you can't have direct responsibility for influencing the cost of the pharmaceuticals, then you should really carve those out in some of your contracting. So we are seeing that, or, as you mentioned, and I think it's a great point contract differently. Right? So go through a PBM that's willing to work with you to begin to manage some of those costs. One of the areas that I'm watching closely is what Doctor Mehmet Oz is going to do as he starts to lead CMS. He's been fairly vocal about his stance with Medicare Advantage. He's a proponent of Medicare Advantage. He does understand that things need to change. I think, potentially, he's going to be the one who might push through this new legislation. And you know it was interesting. I was interviewed by another host not too long ago, and one of the questions that was asked of me is, who do you think is going to be a bigger influencer? Is it going to be Robert Kennedy, or is it going to be Mehmet Oz? And I really feel like for providers and for the physicians? I think it's going to be Dr. Oz. To tell you the truth, it's going to be really interesting, and to a certain extent, I think fun to watch what he does, because he's a very successful surgeon. He's been involved in value-based care for many, many years, and he gets it. So I'm looking forward to seeing where what he's going to be able to do and where this is going to go.

 

Lucy Zielinski:

Yeah. And Dan, I'll just say the obvious. He's a physician, right? He's a clinician. So he understands how the healthcare system has worked or hasn't worked, and I think he has some great insight on how to definitely improve things.

 

Daniel Marino:

Yeah, yeah, I agree. So I'm looking forward to that as a trend and just to begin to see. I know, you know, within Lumina we constantly watch where the market's going, and try to get out in front of it, so we'll I'll be publishing some blogs and some my thoughts going into 2025 as we start to interpret what direction we believe he's going to take, and that impact on medical groups and providers. The last topic that I want to spend a little bit of time on is the impact of artificial intelligence. Within our technology platforms and within the provider groups. You know, it's when you look at artificial intelligence, I sort of put it into 2 buckets, right? So I see AI impacting clinical outcomes and clinical performance. And then AI impacting administrative technology and operations. I believe and this is my opinion, I don't know if folks share the same. I think we're going to see a lot more quick, let's say, quicker advancement in the administrative side of AI supporting maybe revenue cycle management. Some of these digital health tools, care management performance and so forth. I think we're going to see quicker, quicker impact and rollouts related to that than we are in the clinical piece of it right? I think there's a lot of research being done as to how we can use AI to maybe do some advanced diagnosis coding. But I think there's a lot of detail that we need to work out there. What are your thoughts? I know you're probably a little closer to the administrative side than the clinical side, but any thoughts come to mind?

 

Lucy Zielinski:

Yes, I think on the administrative side, right? When we look at processes, AI could really support some of that. So when we're thinking about that entire revenue cycle from really the time that the patient schedules the appointment check, you know the office checking eligibility and then managing some of the denials and identifying some of the risk factors. Right? Those HCCs are so important now to manage patients. And I think that's where we're going to see more AI support in the EMRs. We're seeing it right now already.

 

Daniel Marino:

Well, I'll tell you the HCC capture that to me, seems like a no brainer, very natural for artificial intelligence. If you can create an algorithm that's able to look at past medical histories of visits. Consulting, you know consult notes if you will, lab pathology notes and you're able to proactively identify HCCs that providers could incorporate on their visits. I mean to me, that's going to create so much more efficiency and just support the visit. The value, I think is just unbelievable.

 

Lucy Zielinski:

Yeah, and Dan, it's not only the visit, right? So it definitely can be integrated with all sorts of population health management protocols, right? Or even around care management with the patients. So there are some digital tools out there that provide, based on those that risk assessment or those HCCs or the condition of the patient. There's on demand education, you can hold patients accountable to certain things. I mean, there's an app for that right? We hear that all the time, and I think we're going to see that more and more. Even insurers! We see insurers providing incentives to consumers for wellness, prevention behavioral health. There's credits, and we're starting to see the younger population, I think. Take advantage of a lot of that.

 

Daniel Marino:

Yeah, I think it's really going to evolve healthcare quite a bit and make our care and the delivery of that care much more efficient. What about for rejections and denials? Thoughts on how AI could potentially impact it? And do you see it happening within this year? Or are we still a year or so out?

 

Lucy Zielinski:

Yeah, that's a that's definitely a good question. You know, being in the revenue cycle denials, especially some of the complicated ones, take a lot of research and appeal and time research. And I think that's where AI can definitely support some of these denials is come quicker to a solution and update the claim, correct the claim, and then resubmit so it is accurate and then reimbursed.

 

Daniel Marino:

Yeah, I agree with you. I think it does have an impact. And you know the interesting part about AI related to rejection and denial management is, there's a direct return on investment that can be tracked. So if you go into this and you have an idea that, or you know that your denial rate is, let's say, even 5 or 7%. If you're able to incorporate new technology, you should be able to see a quick return in your revenue by the decrease of those denials. And you know, I agree, if we can do more with less and create these algorithms that allow us to either properly code the 1st time around or manage these denials once they do become denied, then I think it'll make it easier for all of us.

 

Lucy Zielinski:

Yeah, Dan, I would love to see that FTE count in that billing office, and with revenue cycle decrease, and the FTE count, with the care management, taking care of patients and managing patients, care helping them navigate the system, especially those with chronic conditions, increase. So kind of a shift of resources over to the clinical side, from the administrative side.

 

Daniel Marino:

Yeah, yeah, I agree. Well, Lucy, one thing I do want to make mention. And I think on behalf of our audience, it might be interesting just to spend a couple of minutes. The last couple of conversations that I've had with some of the leaders. One of them actually turned the table on me and said, What's Lumina doing to position itself to for some of these trends in 2025? And I thought it was a great question most time. I'm the one asking the questions. Right? So it was It was a great question really got me thinking that, well, maybe I should spend a couple of minutes talking about how we are evolving Lumina health partners, into 2025 to continue to support hospitals, medical groups, and you know, and the provider community. So we're going to be focusing on 3 things right? And I think you know, those 3 things are one enterprise strategy and included in that is value-based strategy. So how can organizations position themselves for continued success in 2025 and beyond, with some of their value, based contracts and their structures. The second area is medical group performance. And I know this is an area that's you know, you're very close to everything from revenue cycle to capturing HCCs and coding. We're doing a lot of education around HCC's code capture as well as clinical documentation improvement. That's a big area. And then, of course, payer contracting, we do a lot of payer contracting support. And then the 3rd area which we're really excited about is the expansion of supporting single specialty service lines as we move into value-based care and particularly position organizations for risk we have to do a better job of integrating specialists around the cost models, but it also has a fee for service component to it as well, so one of the areas that we are focused on is operational improvement of the operating rooms, integrating anesthesia, because not only does it help with value based performance, there is a direct ROI associated with it, so I would suggest to any of our of our listeners. If you're interested in finding a little bit more everything from just blogs and articles, or just information you could share with your teams, or if you just want to have a conversation, please feel free to reach out to either me or Lucy. My email, as you know, is dmarino@luminahp.com, or please visit luminahp.com/insights for more information. Lucy. Any final comments or thoughts?

 

Lucy Zielinski:

I think we're going to see Dan like we talked about today definitely, a shift in the healthcare industry. It's going to be a big year, I think, in 2025, with a more focus on quality and just really taking better care of our patients. And I'm really excited to see that come to fruition.

 

Daniel Marino:

Yeah, I share your excitement. I'm looking forward to seeing how we can put some of these things in place. Respond to some of the changes in healthcare and really see some of our providers and our provider community get back to really, you know, enjoying the care and providing good care to our patients. I'm looking forward to that as well.

Well, I want to thank all of our listeners for tuning in a very, very happy and prosperous 2025 as you enter into this new Year until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.