LUMINA Podcasts

Forty-five years after a Chicago hospital pioneered an integrated network strategy, the healthcare landscape has undergone a significant shift towards prioritizing preventative care. In this episode of Value-Based Care Insights, Jeffry Peters, an expert on medical group strategy, along with Michael Antoniades, President of the University of Chicago Medicine, explore the groundbreaking challenges and strategies that revolutionized healthcare delivery, and how they are still being tackled today. Gain insights on the evolving focus towards preventative care, the measures used to evaluate healthcare delivery, and the pivotal role of primary care in bolstering the entire healthcare ecosystem.

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Within the healthcare industry, effective organizational culture requires building trust, nurturing collaboration, and positioning leaders to drive strategic and impactful change. In this episode of Value-Based Care Insights, we sit down with Dr. Eric Velazquez, Professor of Medicine at Yale, alongside Doug McKinley, a clinical psychologist and leadership coach. Together, they explore the challenges and opportunities of strengthening the workplace culture in order to improve organizational effectiveness, financial performance, and overall patient care. Gain insights on the importance of vision alignment, a healthy culture, team collaboration, and the delicate balance between “steering the ship” and delegating responsibility.

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Behavioral health is pivotal for overall patient well-being, yet healthcare providers are just beginning to recognize the significance of lifestyle factors and social determinants in delivering this sort of whole-person patient-centric care. In this episode of Value-Based Care Insights, host Dan Marino sits down with Dr. Matthew Burg, a clinical health psychologist at Yale, to explore how social determinants and behavioral medicine are addressing the clinical needs of patients. Gain insights into the challenges and opportunities involved in integrating behavioral health into patient care, in prioritizing quality outcomes over services, and in recognizing the importance of preventative measures to establish a more comprehensive patient-centric care delivery system.  

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Improving patient outcomes requires a close look at the latest innovations in healthcare. In this episode of Value-Based Care Insights, we sit down with Dr. Jason Spangler, CEO of the Innovation and Value Initiative, a non-profit organization focused on advancing the science of determining the merit of various clinical innovations. Dr. Spangler sheds light on health technology assessments (HTAs), their history, and how they help leaders decide which new technologies or devices provide interventional benefits to patients that includes clinical outcomes and cost analysis. Listen to gain insights into how HTAs consider clinical outcomes, the incorporation of health equity, and how social determinants provide a broader understanding of the benefits that shape healthcare decisions. 

• A health technology assessment (HTA) is a comprehensive analysis that evaluates the cost-effectiveness and clinical and societal impact of new healthcare technologies and innovations.  
• HTAs have to take into consideration many different kinds of value, from traditional quantitative clinical outcomes to more nuanced preventative measures and patients’ personal values.
• Technology plays a significant role in shaping the efficiency and cost dynamics of population health, with various assessments offering healthcare leaders deeper insights into where the benefits lie.  

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With the recent push for healthcare reform, state governments started to issue crucial legislation to redesign the Medicaid program. In this episode of Value-Based Care Insights, we explore the new terms and conditions of New York’s 1115 demonstration waivers. With Vanessa Guzman, CEO of SmartRise Health, we share insights into the $6 billion initiative focusing on health equity, workforce investments, and the general support of Medicaid programs. Discover how the New York program sets a precedent for other states, addresses DEI initiatives, and strategically allocates funds to improve the care delivery infrastructure and overall patient outcomes.  

• The waivers allocate $6 billion for health equity reform emphasizing workforce investments to create a “Healthcare Equity Regional Organization” to enhance resources and accountability, particularly in underserved areas.  
• This legislation strategically allocates funds to tackle social determinants of health, emphasizing a holistic approach for immediate impact and long-term sustainability.  
• As one of the first states to enact such legislation, New York has demonstrated a commitment to social reimbursement to address diverse healthcare needs and reshape policies nationwide. 

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One of the critical bellwethers of a healthcare organization's success in strategic planning is how well the health system leaders work with their boards. In this episode of Value-Based Care Insights, we sit down with Ivan Mitchell and Ann Scott Blouin to identify 2024 healthcare trends, their impact on provider organizations, and how executive leaders can engage with their board of directors. Gain insights on the top trends that are the greatest hurdles for healthcare providers and the importance of collaborative leadership.

• Achieving short-term goals while maintaining a focus on long-term objectives requires healthcare provider organizations to actively engage and collaborate with health system leaders and boards.
• Challenges in Medicare Advantage, such as misalignment and administrative issues, may pose a threat to provider organizations.
• Improving financial performance requires hospitals to align incentives, engage physicians in decision-making, and leverage tools such as telehealth to address labor shortages and ensure equitable access to care.

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Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. In today's episode, we're going to spend some time talking about some of the challenges that we see as we enter into 2024, I had an opportunity to write an article kind of highlighting. Some of what I see is, is these key trends as moving in 2024. I've done this for the last, probably 7, 8 years. And I often do it by reflecting on what we've seen in in 2023 or the years prior. And then how health systems, how healthcare leaders either reacting to it or what they may face as we enter into this New year. But as I was writing this this year's article, and reflecting on some of the work and the conversations that I've had with healthcare leaders, one of the things that really, that that dawned on me that was an important element was really around effective governance. In 2023 we had an opportunity to do quite a few strategic planning sessions or engagements, and had done a number of board retreats and it and kind of a critical element, as I reflect back on successes of organizations as they've navigated through the challenges of 2023 is how well health system leaders had worked with their boards and effective governance being really a critical component in allowing these organizations to realize some of the opportunities, but also manage through some of the challenges. My article focuses on 8 key trends that we see facing healthcare providers, but it also identifies some insights that healthcare leaders, as well as healthcare boards should consider as they work together to plan some of these exec some of these initiatives.  

Well, I'm really excited today to have as my guest a prominent CEO Ivan Mitchell. He is Chief Executive Officer of Great Plains Health in North Platte, Nebraska, and I'm also joined today by Ann Blouin, a prominent board member, former healthcare executive nursing leader, and a longtime mentor of me. Very excited to have both you, Ann, Ivan, with us today on the program. Welcome. 

Ann Blouin:

Thank you. 

Ivan Mitchell: 

Good to be here.

Daniel J. Marino:

So I think maybe we can. We can start with you as you reflect back on 2023.Talk a little bit about what you see are some of the things that have been really important to you and to your team. And have you worked with your board to kind of navigate through some of the challengeswithin your market. You know, you're in the rural health space. There'sbeen obviously some challenges that you've had, but some opportunities that you've been able to achieve. Talk a little bit about that working relationship with your board.

Ivan Mitchell:

Well, we'revery lucky. Here is an independent nonprofit organization that's locally owned and operated.We just haveWe got great board engagements.as you've said, we've had some real challenging times in healthcare recently. And soI think that from the management perspective, We've tried to do our best to help our board understand kind of what's going on. You know, sharing that in in 2022over 50% of hospitals lost money and just kind of some of the challenges that we have with theworkforce. Medicare advantage some of the pay or mix changes and transitions. And so I think it's important for leadership teams to keep their boardup to date on what's going on in the industry. There were monthly flash reports that shared how hospital financials were doing and just making sure that that's out in front of your board, so that they canif you make a recommendation toward them that they have a good understanding of what'sout there, and what the situations are that we're dealing with right now per second. 

Daniel J. Marino:

Yeah, no, I absolutely agree. I keep in the board engage and using them as a as a resource is key, and you've been on both sides of the fence, you you've been a a healthcare leader for a number of years. And now you're on, you know, at least 5 provider boards.What do you see askind of the success, Ormaybe the role of the board member in supporting the healthcare leaders. As we're navigating through these challenges.

Ann Blouin:

I think that's a great question, Dan, and I think Ivan sort of laid out the importance of board engagement. One of the biggest challenges I'm seeing in boards is being able to balance the focus on the short-term challenges, which are many, as you've pointed out in your article.And the longer term strategic planning, where does the organization want to go? It's tough to do strategic planning, Covid sort of put us all kind of gave us all a little slap across the face, and said, Holy cow! You know things are very different now.But the Board's role from a governance perspective is to help support management that do management but support management in their activities in the short-term challenges. Understand themWell, 140pose appropriate questions, but never take the board's eye off the long-term strategic planning. 

Daniel J. Marino:

Right,Sothey're really incorporating them as a is almost a unified front right in the strategic planningprocess. So I want to, I want to focus our discussion today on what I see are 3 really key trends that we're going to have to work through in in 2024. I think the first one is really around Medicare advantage, we saw in in 2023 the biggest increase in Medicare advantage covered lives the biggest growth across the country, I think, you know, heading into 2024. about close to, you know, 55, maybe close to 60% of Medicare eligible patients are eligible. Beneficiaries are involved in some Medicare advantage plan.The second topic that I'd like to talk a little bit about is going to be around medical group financial performance and the impact on hospitals and health systems. And third is the transition and the growingfocus on in in home care if you will.

But before we get to that, let's touch on Medicare advantage. Ivan, you know, within the rural community no secret. There's been a lot of challenges with Medicare advantage. Lot of articles A lot of research has been done. That kind of speaks to, you know, some of the quality opportunities that have come out of Medicare advantage contracts, but a lot of the a lot of the challenges that that's occurring. And for the most part those challenges have really been as a result of misalignment with the plans and creating a bit of a financial challenge for many of the hospitals. Where do you see Medicare advantage going in particularly rural healthcare as we move into 2024? 

Ivan Mitchell:

Great question. I think you've seen a lot of therenowned healthcare system start to make a change, and you see, Mayo Clinic withdraw from Medicare advantage contracts using scripts healthcare. So you know, all medicare advantage.And I think that's going to be a trend that you're going to see rural healthcare was kind of slow to adopt medicare advantage and good for them theyshould have beenyou know. Here we did end up adding tocontracts. And we we're in network with 2 Medicare advantage plans, and we will be looking at options to exit the markets by the end of this year, if we possibly can. So that's I think we're getting out of it.

Daniel J. Marino:

Yeah. And there's a lot that are no, no doubt about that. Has the challenge been, from your perspective,has it been the reimbursement? I mean most of it is that medicare rates, anyways. Or has it been the administrative challenge? Has it been the lack of pre certifications? Do you feel like it's been more of an administrative burden on your physicians and your providers.Where can you, you know, maybe draw the biggest challenge from some of these medicare advantage contracts.

Ivan Mitchell:

Yeah, I think you'reaccurate. We administrate improvement. We have the Medicare advantage. Contracts will say we will pay you medicare rates. The data at our facility is the link with stay for Medicare advantage. Patient is 2 days longer than a traditional Medicare patient.So if you go from an average length to stay from 4 days to 6 days. Medicare pays what's called a Drg. A diagnosis related group.I just increased my cost by 50%, and I decreased my capacity and access.Along with that, you know, you lose money on Medicare patients, anyway, 80 to 85% of the costs. So what you've done is you've taken a kind of a safety net program, and you've added all of the bad behaviors of the insurance company into a program that doesn't meet your costs. And so it is. It has been a drain on us and, as you said, the incentives are aligned and we've seenvery poor behavior from the insurance industry, and I don't. I don't see that changing.  

Daniel J. Marino:

Yeah, no, I agree with you. I think we'regonna continue to see more and morehealth systems back out ofofmedicare advantage contracts. And it'sit'sgonna be interesting to watch, too, because Cms sees Medicare advantage as a big initiative. They want to get out of the thethe position or out of the thethe place of managing a lot of the Medicare beneficiaries. And from a board perspective, though I think it it, I don't know what are what are your thoughts. It seems to me. It kind of puts the board atthe difficult position because they have relationships with the community. You want to take care of these Medicare patients. But yetyou've got this fiduciary responsibility to the hospital. 

Ann Blouin:

Yeah, I think there are 3 areas from a governance or a board perspective that the board needs to be thoughtful around. One is from a patient serving the community. There are a large number of people that when they sign up for Medicare advantage they either just pay attention to the TV ads, or they look at the price, and they look at everything being included. You know, it sounds so good from a cost perspective and out-of-pocket cost. And so people don't realize when they sign up for medicare advantage exactly what they're getting and what they would not be getting compared to traditional medicare fee for service. And it's a complex thing that that, frankly, is not very well understood and explained to the to the average person in the community. So that's one area is the disappointment and confusion that people have.  

The second area is from a legislative standpoint. State and local government officials, I think, can be called upon to Ivan's point to try to leverage, to understand fairness and equity in payment structures. Because the problem is that if you're losing money on every single Medicare advantage you can see why Mayo and others, want to, you know, get out of it. So leveraging relationships with local legislators, I think, is one strategy the Board can adapt.  

And then, thirdly. I think that a careful understanding of what will happen with people who are in Medicare advantage plans from the Board's perspective. What happens to those community members? Do they are they able to get back into a Medicare plan. How do they do that? It's not. It's not something that's easy to do. So there's some mechanical pieces that I think obviously the health system gets stuck with frankly, the denials of claims are very significant, and to Ivan's point consumes a lot of administrative time.  

Daniel J. Marino:

A lot of administrative time, and, like, you know, as you both mentioned, you don't make a high margin Medicare patients, anyways, in some cases it's even a loss. So when you have the merge administrative burdens that it even makes it a little bit more challenging.  

If you're just tuning in, I am Daniel Marino, you're listening to value based care insights. I am here today talking with Ivan Mitchell, CEO of Great Plains Health, and Ann Blouin, board member of many health of many boards provided boards. We are talking about the importance of effective governance, and navigating some of the headwinds or the challenges that we see in in 2024. It kind of building on Medicare advantage, and the challenges with or the implications to the financial performance of hospitals and health systems.  

Another trend that we're going to see in 2024 is the continued obviously employment of physicians by hospitals, maybe even by private equity and the competition with private equity. But hospitals, they're going to continue to look at the financial performance of their employee medical group. Many hospitals in 2022, 2023, focused on tightening their belt right reducing some of their cost structure, trying to right size the ship, so to speak. There certainly was a focus in 2023 about improving that financial performance. And we feel it's going to continue as we move into this new year, Ivan, when you think about where your group is, and maybe other rural healthcare providers as your employing physicians that are part of your community. Where do you think the biggest opportunity is, is it in maybe the compensation structure? Is it in renegotiating? Some of your professional payer contracts? Is it maybe creating access and efficiencies for your physicians and any anything that you can draw on.

Ivan Mitchell:

Yeah, this is challenging topic. I think that we talked about how Medicare advantage had misaligned incentives. And so I think the key with your physicians is, you need to make sure that your incentives are aligned. I think, ensuring that I know that the position has kind of a panel. a seat at the table, but you know, if the hospital does well, they do well and have some performance based incentives hooked into that. And I've noticed every time we've done that here with our physicians, you know, we'll typically bring them on a guarantee for so many years. And after that practice is built up. When we do a production quality incentive. Every time we move someone into a position to where our incentives are aligned, that that behavior follows. And so I think that's always the best opportunity, I think, of the medical group side. You know, we have a real labor issue, and you know we II don't know the country that you look at how many people try to get into medical school. They can't get into medical school, and the amount of under supply that we have with physicians. I shared that I worked at healthcare.  

Rob Allen was the regional VP of the time. He's currently the CEO of the Company, and I was listening to a to a podcast he was on. And he said that they're in Idaho, Utah, Nevada, and Colorado, Montana. You said, if in around healthcare hires, every single medical graduate from those 4 States or 5 States. it will not replace the supply of those positions that will be retiring. And you know, in around healthcare. They're in Colorado. You have UC health, you have banner. You have all these other organizations that are there. So I think the financial performance of simple, simple economics supply and demand. We're going to see some additional foreign trained doctors that we need to recruit hopefully. That will increase. But it is very frustrating. You have your best paying jobs in your country. We are feeling and scenario that we have in place, and I think the financial performance is going to continue to deteriorate. 

Daniel J. Marino:

Yeah, great point. And I'vespoke many times about the lack of supply. Absolutely. It's contributed to access challenges that we'vehad, you know. I'm sure, in your organization as well. But I'd love your point on aligning incentives, and I'm a firm believer of that right. Have physicians at the table partner with the physicians, create a structure that aligns the incentives. Ann, when you, when you think about it from a from a board perspective. Talk a little bit about that alignment. How could the board support? That Is it around, maybe supporting, creating that stronger alignment with the medical staff. Is it making sure that that physician leadersare integrated in in some form or fashion within the board structure. Any thoughts come to mind?

Ann Blouin:

Yeah, 3 areas one is, I totally agree with Ivan and you, Dan, on the alignment. And I think transparency in that alignment so that they understand exactly how they're being paid, what they're being compensated for, what the productivity standards are. I think that's critical, so that there isn't a feeling of secret secrecy, there is a feeling of trust. 

Secondly, is, I do believe, physicians should be on boards. I think that having a physician, one or 2 physician representatives on a board depending upon the size of the board. who are well respected in the community. I think that is a critical aspect of that alignment and trust and developing respect. 

And then the third area is, the board can help by asking questions around. How can we reduce the hassle for physicians, administrative hassle the managed care documentation hassle that physicians experience. Obviously lots of health systems have begun to use more effectively advanced practice providers, physician assistants and nurse practitioners to expand. The physicians reach and effectiveness and have those advanced practice providers see lower acuity patients, so the physician can concentrate his or her efforts on higher acuity activities. That makes a lot of sense. I think use of telehealth is a is a question the Board should be raising in areas, as Ivan points out, like psychiatry. Where there are, there is a critical nationwide shortage of psychiatrists, and has been for a long time. So I think, not only looking at the supply side, but looking at the demand side. What can we do? As people are aging as the baby boomers are getting older and older and need more physician services. What can we do to assist with that demand? In addition to continuing the recruitment and retention activities on the supply side.  

Daniel J. Marino:

Yeah, I agree with you. I think you know, as we pointed out. The supply of physicians of providers in general. I think we're a long way from increasing that supply in order to meet the demand. So the only way that we're really going to be able to do that is is, we have to incorporate innovation. We have to incorporate technologies. Frankly, we have to change the care model right? That is, allowing us to think a little bit more innovative on how we can deliver the right level of care to patients.  

Which kind of brings us to my third topic. Then in in 2023, of course, artificial intelligence, the increase in technology it has, it's created, you know, different types of care models expanded the care models, incorporated technology into the care models. We saw reasonable growth of home based care. That would allow us to kind of manage through some of these challenges. I I believe, as we look into 2024, and certainly related to the aging baby boomers and some of the requirements that they want in their own care and the delivery of that. I think we're going to see things like, you know, sniffs it at the home hospital at the home different types of models that will incorporate different care delivery systems if you will, different technologies and so forth. Ivan is as as a hospital health system leader. Where are you in in in that level of thinking? Is that part of your strategic planning process? Is it? Is it something that you're kind of, you know, taking a wait and see based on the needs of your community. What are your thoughts there? 

Ivan Mitchell:

Yeah, I think you'regoing to see.And moving healthcare to home base care. And II think you've already seen that just from the inpatient to outpatient transition, you know, surgeries where people used to stay a week and go home same day, and really taking care of by their families. So I think you've already seen kind of a transition going that direction.We at Great plains health we had until this year we have home health and hospice. As well as home medical equipment under our umbrella. We still have home medical equipment. We ended up partnering with a company, another nonprofit called better health.They run nursing homes, and we actually transfer our home health and most hospice services over to them.Over the last 10 years we had lost about $300,000 a year in front of the Hospice. You know, it's a small team, 16 peopleyou have one biller. When that biller turns over it'sit's a totally different billing model. And it's very unique. 

Daniel J. Marino:

So home health Hospice care. I mean, that'sit's very specialized, if you will. So yeah, that makes sense. But I but I also feel like it has to be integrated.Right has to be almosta transparent component of your care model.Soyou're not necessarily seeing the challenges with readmissions, andyou know, over utilization of the emergency room, there's a smooth transition from a queue to the post, acute and to the home environment.

Ivan Mitchell:

Yeah, I agree. You know, we were pretty selective with our partner.I've seen places sell toventure capital. The united healthcare. Some of these other areas, and it kind of seems like their model wastaking a loss on home to get them on Medicare advantage plans or or things.So anything you'regoing to see it. We have seen a lot of health systems do the hospital at home model.You know. And I think you'regoing toprobably see some success there. Most of the hospital at home programs have not been extremely successful. They've been very low census. Andyou know, Haven't really done well at this point. But for us it'son our strategic plan. I think, that for organization our size. Our goal is to once we see best practices that are out there to partner and implement those as quick as we can.So that's kind of wherewe've gone. We think we found a a good partner for help, home, health, and hospital services. Well, and we'll keep our eyes open for the for the next transition best practices that are out there. 

Daniel J. Marino:

So, Ann, as you know, as as a nurse and as a former nursing leader. You know any any quick thoughts on home based care. You see, this is a good thing?

Ann Blouin:

Yeah, yes, I do. And I just was at. I'm on the I Chi Board Institute for Healthcare Improvement Board and went to an innovative session on hospital at home that was conducted by Kaiser Permanente, and Mayo, and it was fascinating. I don't think there's going to be a large super large volume of patients that will qualify for hospital at home. They are selective clinically, certain types of patients are better served, but they may be served in a sniff versus at home and during Covid, one of the boards I sit on, which is a skilled nursing facility Company and assisted living, actually took highly acute hospital patients to decant the emergency departments and the and the critical care units, and became much more acutely focused in the skilled nursing area, upskill and train. So I think there is something here. Cms is pushing us toward this as an industry, because they want to reduce costs. They have a you know they have an interesting perspective there, and their measurements are beginning to look at continuum based measures as opposed. You know, population-based as opposed to all acute care core measures. 

The last thing I'll say about that is that the board needs to understand may need an investment because hospital at home doesn't come without expenses associated with those support services. Whether that's supply chain, human resources. When you're in the hospital, you can reach around and grab another physician or nurse and get some things done very different. If you're in a home environment.  

Daniel J. Marino:

Sure, absolutely. Well, Ivan, Ann, this has been a great discussion, you know never long enough. II we certainly can talkfor quite some time around a number of these issues.And butI think one of the key things is, as you both brought out. The importance of having the healthcare leaders working with their boards and the board supporting the healthcare organizations is just is just critical.It'sgoing to be an interesting 2024. I'm looking forward to see how things move forward and where our industry goes. I want to wish you both a very happy and prosperous 2024. Thanks again for coming on the program. 

Ann Blouin:

Thank you.

Daniel J. Marino:

And for our listeners. I want to wish you all a healthy and prosperous 2024. And until our next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

With post-acute care, providers face various challenges, ranging from reimbursement struggles to meeting the evolving demands of an aging population. Hal Katz, a partner with Husch Blackwell, lends his expertise to shed light on how post-acute providers can navigate these challenges and advance into value-based care (VBC). Gain insights on transforming post-acute care models, establishing integrated networks and how providers can flourish in the VBC ecosystem.

• As providers transition into value-based care, a primary obstacle is to organize post-acute care providers into collaborative networks that prioritize cooperation and integration.
• Post-acute providers, as they move towards value-based care, must navigate diverse obstacles such as funding, payer reimbursement, employment considerations, and effective patient care management.
• Under private equity, a successful integrated network requires payer contract alignment and firm partnerships with health plans and acute care providers.

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Daniel J. Marino: 

Welcome to Value-Based care insights. I'm your host, Daniel Marino. In today's episode I want to spend some time talking about value-based care, as it relates to the post-acute environment, post-acute providers, definitely have been challenged over the last number of years. And I think most of the challenge really comes in in the level of reimbursement. Most acute providers are have contracts with either Medicare or Medicaid. Few of the commercials but they're really challenged. All of them, I think, are under some level of financial pressures. And yet they're such a critical part of the value based care, ecosystem. Especially as we start to see. A number of retiring baby boomers who are who have some level of post-acute needs. And out of that. We're seeing some real changes to the care models. So, for instance, many of the baby boomers really want this at home care. So we're starting to see some of these resources shift to more of a sniff at the At home model, if you will, or a hospital at home or home health, you know, really picking up steam, but all of which has a significant value proposition to it and supports value based care. But the question really comes down to how you structure these arrangements in such a way that it allows the post-acute providers to maybe share in some internal resources to leverage that level of expertise, and just to create more of an integrated model and delivery of care. 

Well, I'm really excited today to have a guest with us. He's been on the program before. A great guy. I've worked with him very closely on a few different client engagements. Hell, cats. Hal is a partner with Husch Blackwell. He leads the healthcare practice, and works with number of organizations around the country very knowledgeable in in this as well as other aspects of Provider Integration Network. So Hal, welcome to the program. 

Hal Katz:

Dan, always great to be with. You, always love the chance to be on your show.and of course, to work with you out in the industry. Thank you. Thank you. Thank you. 

Daniel J. Marino: 

Well, thanks, Hal, for that. I appreciate it. So in in, in working with some of the post, acute providers, you know, and especially as they're giving consideration to moving into value-based care. What are some of the challenges that you're seeing?

Hal Katz:

You set it up nicely, Dan. the points that you laid out are definitely some of the same things that I'm seeing in terms of challenges, be it funding and reimbursement, staffing challenges, complexity of the industry, how that's changingas well as the conditions that patients are experiencing. And then, lastly. patients are becoming very picky. What? Where they want their service, how they want their service. Sothe it'sa very competitivemarket lots of pressures within the space from payers, health systems and the consumer individual consumer. 

Daniel J. Marino:

Yeah. And it's such a critical component of really the care model. Right? So especially when you seepatients who have some level of an acute care visit right? And they're getting discharged. Many of them are being discharged to some level of a post. Acute facility, whether it's skilled nursing, or a senior level facility, or even a rehab facility, so that integration becomes so critical, and I see such a divergence, if you willon the different care models. Right? So there, there's that lack of true, integrated clinical care thatthat's occurring between the post-acute environmentand the hospitals. Are, are you seeing as these networks are starting to be formed? Or maybe this is the reason why these networks are being starting to be formed, to create a little bit more integration, a little more synergy between the post and queue providers and the queue care providers.

Hal Katz:

Dan, I am, for all the reasons we've just laid out.These providers are having to identify the other types ofcare support needed to get the patient what the patient needsto ensure that there are these smooth transitions of care from a more acute facility to the post-acute setting. They can't do it on their own. Historically, that'swhat's happened. They've just tried to go out and hire people to provide those services in house and they've looked across the healthcare space, and they've seen this network model. They've seen how ancillary providers it be therapistsand other social services have been pulled in through independent contractor types of arrangements, to help manage the needs of the patient and to meet the quality standards that are that are expected for the patient outcomes. And that model has been successful. So now we see the post-acute space experimenting with networks clinically integrated networks.I would say. We'reon the earlier stages of that model. But we are quickly seeing markets across the country have more and more activity using that CIN approach.

Daniel J. Marino:

So when and I am a I'm a huge proponent. As I've talked about in this program time and time again huge proponent of integrated provider networks and clinically integrated models. II just think, in my experience I've seen so much value coming out of that when you have the providers come together to really begin to efficiently manage patients. It reduces the cost of care, produces some incredible, incredible outcomes.  

When we look at forming these clinically integrated networks in the post-acute space where are they starting. Is it home health providers coming together to form a home health cin? Is it the skilled nursing facilities coming together to form a cin. Or maybe it's a number of the post-acute providers coming together to find a to almost produce a very longitudinal based cin. Where are you seeing the starting point? 

Hal Katz:

Dan,It's really market specific, I mean you,you know that so well on health care. You see, in one market you've seen one market. It depends on the sophistication of the players in that market, the degree in which they? They have a managed care market, be it Medicare managed care, Medicare advantage specifically. The acopenetration, be it Medicare or otherwise. And what types of value-based arrangements the hospitals are entering into in that market.So it really depends. We can see situations where the hospital, the health system is actually the convener for a cin to aestablished, fairly sophisticated post-acute care provider leading the way to bring in other post-acute care providers to create the network and identify what other supporting providers should be included as participating providers in the network. 

Daniel J. Marino:

Yeah. Well, you, I mean, you clearly have to have one anchor organization right? That that has the vision and is driving a lot of it. And as you mentioned, I mean, I think you know hospitals are in a unique position to possibly do that. Are you seeing private equity getting involved as the catalyst to creating these networks?Or is it really more of the post to queue providers? Or, you know, maybe the hospitals kind of leading the way?

Hal Katz:

I do have at least one example of private equity helping facilitate a lead agency created network. So the agency, I mean in in this particular situation, there's a lot of alignment with the players. Particularly the a health plan who'svery interested. A national health plan that sees the value of a clinically integrated network focused on thissector and then the post-acute care provider having a private equity investor that wants to fund the creating the creation of the network. And in this situationthere's only a fewpost acute care providers that will also be an owner of the cin. But there is that opportunity to invest. There's really 2 opportunities. They caninvest and participate as a provider, or just participate as a provider.

Daniel J. Marino:

And that's an interesting, interesting model. Because, you know, as you know, it's expensive to create this right? I mean, you've got to build the infrastructure and the infrastructure supports a network and supports the performance. Many post-acuteproviders theydon't have the funds who invested. They don't have the reserve. Soyou know, in my mind, having some level of private equity does come with some opportunities. But I think it also comes with some challenges, and that's where I guess the legal component comes into place as you're starting to structure it.

Hal Katz:

For sure.for sure, negotiating those transaction documents. Governance reserve powers becomes the main focus. When structuring that relationship with the investorrelated for this particular scenario on the capitalconsideration, it helps. When you have a an eager health plan. You know. Often they willbe willing to put up some capital. They will also be willing to pay a per member per month reimbursement rate, so that there is some real revenue that starts to flow immediately into the cin, based on the number of attributed lives in a particular market, so that that helpskind of spread both the risk and the negotiating leverage with the private equity investor. It's not all on them.The cin is also bringing a payer to the table for day, one which you know frankly, is not all always, or even often, the case. Usually you have to build it and hope that they will come in the cin world. But in this particular case, and I think there are other opportunities across the country. You have health plans that are so,They see such value in this sector that they're willing to help facilitate the development of the cin on day one. 

Daniel J. Marino:

If you're just tuning in, I'm Daniel Moreno. You're listening to value-based care insights. I'm here with Hal Katz partner with huschBlackwell. And we are talking about post-acute strategies to advance into value-based care. And I'mgoing to build on that Hal because I think it's an interesting point that you just brought up. One of the big challenges the cin have is to create some type of a tangiblecontractual arrangement with a payer, right? So you can start to get some level of dollars and some revenue flowing into the to the cin. I think you'rethe structure of aligning with the payersbecomereally important. But I think it's also a challenge, right? Soas it's sort of the chicken and the egg. Right? Do you build the entity first and create the infrastructure before you have the contract? Or do you create some level of contract that allows you to invest in the infrastructure. Where are you seeing that really come into play?

Hal Katz:

Again, It's market by market. If there is a market where there is a good relationship or an existing relationship with an acute care provider, you know, call it a larger, acute care provider and a health system or not a health system, but a health plan. Starting those conversations. Is there an interest? If we built this, would you, be interested in a relationship? What would that look like? So you have some sense of whether they'regoing to contract with you if you build it.

Daniel J. Marino:

Yeah, yeah, absolutely. Absolutely. And then II can't help but think, you know. So II feel like that's a great approach, becauseit aligns the interests of the health planand then aligns the interests of the post-acute providers, assuming that it's structured right. But I can't help but think that the hospitals would be a little nervous in that regard? Right? Because all of a sudden they're managing that. Sohow does how do you manage that hospital relationship? Do you create? Then, a separate, almost third contractual relationship with the hospital based on alignment, with maybe theirrisk-based contracts or some of their performance based contracts? Or do you almost create a single contracting mechanism across all of the lives? 

Hal Katz:

Great question, Dan, in the in the few situations that I've been involved in the acute care network has leaned on the health plans, contracts withthe Hospitals. At least in these markets. There, there has been confidence in the care that has been provided and the willingness to coordinate without a more formal or structured arrangement. The cin is impacted based on the performance of the hospital. If hospital costsare higher than what they should have been. they can be impacted. So you know, there, there is some risk there. But so far I have not been  I have not seen those arrangements include a direct contractual relationship between the network and the hospital system.  

Daniel J. Marino:

And there's so much opportunity there for the hospital side, because one of the things that we often see isfrom the hospital perspective. Their readmission rates, visits to the er, you know. Some of that comes as a result of a lack ofclinical efficiencies that occur within the post-acute arena.So by having them collaborate, there is a direct opportunity there. But I guess it really comes down to how you how you create that alignment and who the partners are. 

Hal Katz:

And Dan, if I could just add, I mean there is, you know, almost an equal financial slash, economic opportunity for acute care providers to align witha health system. If that health system hasit's own aco, its ownvalue-based care model that's large enough to support this kind of effort. It can have the same kind of financial benefits as what we're talking about with a payer.

Daniel J. Marino:

Yeah, II agree with you. I agree with you. The post acute environment is heavily regulated, are thereyou know you. And of course, when you build a cin. There are also some regulatory impacts, right related to Ftc requirements and legal aspect around clinical integration and so forth. Do those change? Or are there other things that need to be specifically focused on in the post-acute environment? Given all the regulatory regulations and the regulatory requirements? Or is it pretty much aligned with the general thinking of clinical integration?

Hal Katz:

Great question, Dan. It'spretty much in line with the traditional issues that we face when creating a clinically integrated network. For any other provider type physicians and across the board, and II do want to emphasizethat point, especially when it comes to the antitrust considerations and remind people that getting together solely for the purpose of getting better reimbursement rates is seen by the Federal Trade commission as anti-competitive. SoI'm even in the early exploratory stage of this kind ofbusiness relationship arrangement we strongly advise the parties to avoidusing that kind of description. For this effort, providers can definitely or competitors can definitely get together to explore how to create a business that is going to improve care, improve access, improve competition, respond to market demands, market pressures.But we don't want to in incorrectly frame it as a way ofincreasing reimbursement rates from payers. 

Daniel J. Marino:

Great point. Great point, Hal. Because I think a lot of folks don't take that into consideration, and at the end of the day. The reason why organizations need to do this is they really do need to emphasize, to increase the emphasis on their value. Based performance. Right? So that's managing cost of care, managing quality, managing efficiencies, managingutilization and so forth. I couldn't agree more so in in, in thinking through that, you know, I think, that the key documents, the key legal aspects, is really thinking through. You know. What's the bylaws of the organization, how you'regoing to structure it. And then I would assume, you know, the participation agreements become really critical, right? Defining sort of the rules of the road? 

Hal Katz:

Exactly, exactly, you know, from the participating provider agreement, as you know, to policies and procedures that are put in place to ensure quality measures are obtained, achieved, and how corrective action is implemented. 

Daniel J. Marino:

Yeah. So when so, I recently had a conversation with ahome health organization, they were interested in in sort of forming their home health. CIN. Their challenge was really getting the groups together right. Cause they saw that there were different levels of quality andperformance. And plus, you know, it was predominantly in the home health world. 90% of the reimbursement comes from Medicare. Now some of that is changing as ma is occurring, but commercials haven't historically played a large role.What are you seeing? As as some of the other big challenges with moving this forward, as you're as you're starting to have initial discussions with either home health or skilled nursing or other post-acute providers as they start to think about pulling this together?

Hal Katz:

There has to be a need, of course, in a need, an opportunity. So again, back to the market specifics. The providers have to feel the pressure that that we've described as being the motivation for coming together to create a more competitive product. If we don't have that then it's then it's tough to motivate to create this kind of arrangement. But I would say most providers are at least aware of this trend that's happening, even if it's not in their backyard. They know that this is happening across the country. In in traditional Medicare, medicare advantage moving to commercial.

Daniel J. Marino:

Yeah, moving to risk based contracts. I mean all of those, all of those areas. And I, and I think I mean you're spot on. You have to define the need, and they have to define the value proposition. Right? I mean, sort of as we kind of say, define. Why do you wanna do this as it takes work and takes resources.

Hal Katz:

To your, to your point, Dan, just toto emphasize that it takes a lot of work socan't just be an exercise. If if people don't really believe in in the value, the benefits that will come fromthis hard work. 

Daniel J. Marino:

Yeah, no, that's that'sabsolutely true. Well, if any of our listeners today, any of our providers in particular areinterested in in moving forward with this, and you know what's the one piece of advice maybe you could share with some of our listeners. Where would they start?

Hal Katz:

Great question, Dan. Well, besides hiring someone like you or me, they've got to do their research. So you know one. They have to understand their own organization. How are they doing? What's happening in their market?There, there are great publications out there that have been created by trade associations and advisors like the both of us, that that talk about these issues in more detail, that is the homework, and then, in all seriousness, fi! Finding the right advisorto at least guide them on the options and helping them determine if this makes sense for them. And if sohow to get there.

Daniel J. Marino:

Yeah, no, III agree with you. And I think doing the research and really getting the groups together to almost create the vision. I know a lot of times when I when folks come to me and they say, Well, we want to start as clinically integrated network. I often say, Okay, have you done any type of visioning, you know discussions with some of your partners to sort of find why you want to do it. I mean, that's the first thing. And if you don't have that commitment, there's no sense spending the money on anything or going any further. 

Well, this is great. I really II appreciate the time. Great discussion. I know it's a it's an area that is of real importance to many of our listeners. I, if any of our listeners or folks you know, who may be listening in now or down the road. They want to get a hold of you, Can you share your email address, or maybe direct them to your to your website or anything in that regard.  

Hal Katz:

Absolutely. easily found on LinkedIn how cats with Husch, Blackwell.Of course. Huschblackwell.com is our website. You can also find me there. My email address is Hal.Katz@Huschblackwell.com. My phone numbers (512) 703-5715. And I'd love totalk with anybody who's interested in learning more about this type of business arrangement. 

Daniel J. Marino:

Well, Hal, it's great. And I would definitely encourage our listeners to reach out. You know Hal has. He's got a great approach with working with providers and any type of these value-based contracting, and certainly setting up the entities. Hal, thanks again for joining today. I love having you on the program. Just you bring a wealth of knowledge andgreat conversation. Really appreciate it.

Hal Katz:

Dan, always great to be with you thanks for including me today.

Daniel J. Marino:

And I want to thank everyone today. You, our listeners 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.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

As 2023 draws to a close, we’d like to revisit episodes that explored relevant issues we’ve seen throughout the past year. Host Daniel J. Marino revisits these profound discussions and how they impact the future trajectory of health systems, hospitals and the provider community. Featuring esteemed guests in their respective fields, Dan and his guests look back on important elements impacting strategic growth of hospitals, financial performance of medical groups and successes in risk-based contracting.

• Nillie Djassemi, CFO of Houston Physician Hospital, provides insights on how leaders can navigate hospital financial pressures by emphasizing operational efficiency, physician partnerships, employee engagement and strategic management of supply cost and payer contracts.
• Healthcare consultant and industry thought-leader Jeff Peters discusses the evolving landscape of medical groups, valuing the importance of organizational culture, physician empowerment and expanding access in response to improving medical group performance.
• Managed care expert Cliff Frank reflects on the recent shift to risk-based contracts, emphasizing the challenge of managing contracted population risk, the growing demand for health equity, and key takeaways to succeed within Medicare Advantage.

LISTEN TO THE EPISODE:

Transcript:

Daniel J. Marino: 

Welcome to value based care insights I'm your host Daniel Moreno. Every year at this time we take a look back at the most popular episodes as identified by you our listeners, or maybe those episodes that addressed the relevant issues that we saw in this past year.Well we have three episodes that we want to highlight this year and we're gonna play snippets of those episodes during today's program.

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In 2023 hospitals continued to be under financial pressures and some of those pressures resulted with reimbursements some were some challenges with supply costs and wage inflation as well as just some of the strategic positioning. Well one of the programs that we had I really enjoyed the conversation it was with the CFO of Houston physician hospital Nellie Djassemi. Nellie discussed not only those challenges with reimbursement and supply cost, but also discussed what their organization is doing with improving the culture and really engaging their employees which really made a difference in 2022 and in 2023. let's give it a listen. 

So newly given those above challenges that I mentioned and some of the things that are identified in the and all National Hospital last report what are you seeing as some of the major issues affecting Houston physicians hospital financial performance? 

Nillie Djassemi:

I think the two major drivers for this hospital is the reimbursement pressures from the payers.We are in the last like 18 to 24 months we've had to go into renegotiations with the with the few payers and it's we got beat up and we got we got knockout actually on one of them you just got knocked out. And the other one is supplycosts which is not I meanwe're seeing that everywhere every hospital dealing with that and so we're doing some things that are help helping us offset those increases in supply cost that we can talk about later.  

Daniel J. Marino: 

Well in in as you know you know revenue is one side of the equation but your expenses and how you structure those are the other and if your expenses are going up you know you can't just automatically increase your revenues your revenues are fixed and tied into the to the payers.

Nillie Djassemi:

That's correct.yes and so we we'vedefinitely started increasing the revenue and and not through rate but through volume and the volume growth is is helping us help offset the rate impact 

Daniel J. Marino:

Have you focused more on surgeries or is there an ambulatory component either through the ASC or maybe through some of your therapies that are figuring into your volume expansion?

Nillie Djassemi:

Yeahsowe'vedefinitely brought in different types of surgeons.Sowe'veopened up a that opened up but we'vedefinitely expanded our robotics services through the GYN and general surgeries.And so we bought a davinci last year and oh great yeah so just because you know I mean that that'sdefinitely it's for GYN and general surgeons that'sdefinitely something they want and we haven't really focused on that those service lines before so we invested in one.Again that was in play probably three years ago when we made that decision and it just took a long time to get that here because of all the supply chain issues.So we actually weren't able to launch it till mid last year and it was supposed to be launched much sooner than that.So those were things that we had already we knew that we had to prior to the reimbursement pressures coming down the pipeline. 

Daniel J. Marino:

Right so you needed to do something in terms of volume yeah you know I guess the supply chain challenges that you had a couple years ago essentially worked in your favor right because now you're able to get that and add additional surgeries based on some of the robotics to to support it.Which you know I think that'sthat's certainly key. How about some of the turnover and and the staffing challenges?Are you seeing a lot of turnover is it stabilizing are you are you know particularly in the nursing arena are are you able to recruit or or are you still see the same challenge in your organization? 

Nillie Djassemi:

It's the it's I can't say it's a huge issue our turnover rates are are much lower than what I see around the market but it's still a problem.Right because every time someone leaves the cost of bringing them back it's still much more plus the training cost and everything right. I wanna say our people areare our nurses and our non clinical staff are happier here.Our turnover rate is is lower but yeah we still have the challenges of course we do because the nurses and especially on you know on our on the inpatient and the surgery world the history our nurses are right yes they definitely they all talk they know the market.So yes we've had a deal with increases and looking at the market rate we're doing market analysis every six months now we used to never have to do that right so HR has processes that where they actually have to look at market rates market now every six months that's just didn't I mean Dan you know that's crazy yeah but you have to because we don't want to be caught off guard if you know if our CST's are coming to us and like hey someone down the streets paying me X dollar more an hour we don't want to be caught off guard. We wanna be able to have that knowledge in our back pocket to be able to give them nowthat'sactually not true or yes that's this is what we can do.And it it's very difficult it's very very difficult.But we that's the process that we put in place to help for us to be knowledgeable

Daniel J. Marino:

Well you have to be right I mean getting that insight that's the only way to be competitive.And to be yeah totally transparent to our our listeners I've had the the wonderful opportunity to work with Houston physician hospitals for a number of years and nearly a year your leadership team has built a great culture out there. I felt time and time again and I spoke about this with many folks across the country you have to be competitive on rates, but in order to really manage a lot of the turnover challenges, the financial challenges related to our workforce, you have to create a strong culture. You have to create the culture that makes people wanna work there.And as you've said and I agree with you I think people are happy working in in your organization and we see that a lot of times with smaller community hospitals are we specialty hospitals.

Nillie Djassemi:

Right.yeah we definitely I think I've told you this damn before I came to HPH.youknow II came from a more corporate healthcare background and so that employee engagement here is something I've never experienced anywhere else.And I'm not just saying that because I've worked here.But we put in a lot of effort to have that high employee engagement and it'sit's it takes resources and it takes a lot of time.But it does pay off because our turnover rates were so much lower. We still have todeal with itthe pressure, the externally pressures of inflation with saleryrates.I really think that is a huge piece of the puzzle, that we put so much in employee engagement. When I first started here our CEO, I would be like wait,we're spending how much T-shirts? you know.We give out you know we're known for our T-shirts here.

Daniel J. Marino:

It's a little things, they make a difference.

Nillie Djassemi:

It really is. we every month we every in my department we spent one there's one thing we focus on every month and in the department ,and for example last month we focused on integrity.And each person had a banner and it was what does give me what your integrity motto is for you for you as a as a person. And so everyone and again and that it wasn't all across the hospital but for all my departments they did their individual ones but across the hospital what we did was every department made their own banner and then we were able to hang it up and in our cafeteria area and everyone could see what everyone's motto was in terms of integrity that's one of our mission statements that we believe in. And soit's just we really do focus on that and this month we have something else that doing but yeah.

Daniel J. Marino:

And the culture piece is, I mean it'shuge.

Nillie Djassemi:

Yeah.

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Daniel J. Marino:

In 2023 medical groups were also impacted quite a bit and as we reflect back on what it transpired with a lot of our medical groups many continued to look to their hospital partners for employment others decided to align with these four profit organizations like optimum continued to employ many of the independent medical groups and providers in 2023 as well as many groups decided to align with private equity. Well in this episode I was joined by Jeff Peters. Jeff is a national expert on the physician provider space, Medical Group strategy, and we discussed three areas that really impacted medical groups this past year. Access being one of them, physician well-being, and different areas that are affecting strategic growth. Let's listen in. 

So just when you reflect back on where some of these independent medical groups are these different hospitals and through your career close to 40 some years you've been doing this you've worked with over 500 organizations across the country. How have you seen these challenges evolve over the years?  

Jeff Peters:

Yeahso I really thought about the fact that when I first created and employed physician group at Ingles hospital, which is now part of the University of Chicago health system.And the financials are coming out to the board you know the board is just overwhelmingly perplexed as to how we could possibly run physician practices that are losing $30,000 per physician, per primary care.And now when you see the losses over $100,000I'm sort of thinking what were they worried about?that was great. I mean really?you're beating me up over this?you have data on ownpractices and you know it's very clear what the problem is.There's more demand for physicians and advanced providers than there are supply.So you have to pay more to attract and retain physicians. And you also have to pay more for their support staff.

Daniel J. Marino:

Yeah, for their support staff.yeahyeah I believe I I think the you know when when I as well as with you I I talked to many leaders all the time across the country access is the number one issue that they struggle with.Wage inflation, if it's not number one it's a close #2 and retaining the staff is really key.And as well as then physician well-being.So solet's talk a little bit about access though you know if you've got limited number of providersyou've got more demand than you do with supply, what are you seeing on some of these strategies how are organizations how how are they dealing with some of this?

Jeff Peters:

Well I think the first thing is that you've got to assemble teams to manage a group of patients.It's not only physicians,it's advanced practice providers,and in in more quaternary tertiary practices nurses.And you need to allow the advanced practice provider to see the patients that they're qualified to see, and you need to reserve the physician's time for the more complex patients.So the idea that we're always going to see a physician, it's just not going to happen. I mean recently I had a annual skin exam, I called my dermatologist, I was scheduled with an advanced practice provider. I thought she did a fabulous job.yeah she was thorough and personable and identified things.So we've gotta be creative in terms of our workforce and we've gotta save physicians time. When I go to my ENT with a sinus infection,there's a medical assistant who'sassisting him with the scope and just getting everything ready.And he has a scribe.He's dictating as he's seeing me what's going on and he's able to really make efficient use of his time so we've gotta be creative with their time.

Daniel J. Marino:

And really innovative right? these what you just described on these innovative care models around team based care, around helping the physicians succeed, and innovation in the care models, I fully agree with you,that's how we'regonna help to kind of work through some of these access challenges. I think without doing that the traditional model is not sustainable.

Jeff Peters:

No.And physicians like the team model a lot of the work that the team is doing is work that physicians don't like to do.The charting and the things like this, I mean you hear physicians complaining about the fact at the end of the day they're spending one or two hours on the EMR. getting caught up with their documentation to save them an hour or two a day.Phenomenal. And the other thing is just handling the telephone and the patient calls that come in, and the emails that go to the physician. We'vegot to be creative and identifying what work can we take away from the physicians that gives our patients the care that they need and deserve, yet doesn't burden our high costproviders.

Daniel J. Marino:

I absolutely agree. Ithink is worth thinking about the future strategy of medical groups whether you're independent or employed.These innovations that you spoke about this way of ofof kind of making the physicians more efficient spot on. Iabsolutely see that as a necessity of performance.But let's talk a little bit about growth though.You know obviously everybody's concerned about growth, and especially if your expenses are increasing, you can't necessarily cut services you cut can't cut staff. I think we'reprobably as lean as we've ever been you have to focus on increasing the patient volume.You have to focus on increasing revenue.In your opinion where what where are some of those key growth initiatives that help to kind of drivethe financial performance? 

Jeff Peters:

Yeah and I think there's been models in the market for a very long time multispecialty groups are very profitable.And they tend to attract and retain providers.And single specialty groups like urology where you're able to get all the urologists in a market to come together so that they not only share practice overhead, but then it supports pathology, it supports imaging and treatment for it makes sense. So what the growth has to focus on is getting a large enough group of providers that drives ancillary revenue.You're not going to make your money on the profitability of a physician practice.Where you'regoing to make your money particularly for academic medical centers or hospital practices in establishing integrated ambulatory campuses.Where there's urgent aid to take care of the patients that don't have a primary care or don't want to wait at primary care, surrounded by specialists, so the urgent aid for the patient that doesn't have a physician can refer that patient to the primary care so there's an ongoing relationship.As that primary care picks up a heart murmur there's a cardiologist in the building that they can refer them to and there's a spectrum of diagnostics and treatment what we're seeing is in the University of Chicago has been masterful of this creating these integrated campuses with urgent aid, primary care, secondary care.

Daniel J. Marino:

Right so it's all sort of integrated and it's right there for the patient and for the physicians so you can actually have create more of a a longitudinal care model getting the results that you need.

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Daniel J. Marino:

In 2023 our industry saw a continued influence in Medicare Advantage. Medicare Advantage continued to grow and as all of us know if you're continuing to look at a lot of the news and the direction Medicare Advantage, into 2024 is going to be one of those topics that we're going to see continued growth, as well as Medicare Advantage though risk based arrangements also impacted our physicians our medical groups our hospitals our health systems and so forth. In June of last year I was joined by my colleague, Cliff Frank, and we had a great discussion on the rapidly changing Medicare Advantage products as well as some of the risk based arrangements. Cliff always provides great insights along with a little bit of entertaining conversation. Let's listen into this episode.  

So Cliff how this makes sense of this. What are you seeing in terms of some of these changes there's been a lot going on just in in the last month and a half or so. 

Cliff Frank:

Well CMS has been taking a lot of heat from Congress and from industry observers, that they kind of gave away the store for the last 10 years.SoI'mbasically uncapped risk adjustment.Now they signaled with some of the ACO products, a willingness to change that and that they capped the risk score gain the get in in MSSPACO is at 3% over multiple years whereasit's uncapped in Medicare Advantage, until 2024.With the new with the new ratesthey're signaling that that game is going to end.In several ways.First they're making it harder to actually get risk adjustment. a lot of that they went from I CD9 to ice I should be 10 or 10-1, I forget which but anyway,they're they killed a lot of diagnosis that adjust they were like 2000 diagnosed there's a lot particularly in diabetes those are gone.They don't they don'tget you more risk.Then the second thing they did was they said oh we'regonna really start auditing a lot more closely, and it's not and the risk boards have to come in through claims not through some magical home visit that that the plan has orchestrated.So they're really kind of making all that much more difficult. At the same time CMS is signal of a rapidly growing interest in insuring and enticing health plans to tackle health equity.Aad so as if you kind of think of it as a as a kind of a teeter totter as the HealthEquity side goes up the risk score side goes down in terms of dollars so the dollars are still be there but they'll be there for different reasonsin two years.

Daniel J. Marino:

Right so there's really you know two key things that going to see. I think it's thinking about how we're positioning ourselves for risk, within risk, managing risk ,identifying risk within the contracts ,you know that that's a big one.And then the health equity piece and where that comes into play.Let's start with the risk piece because I have a few questions here that I'mkind of working through in my mind. So I you know I'mkind of thinking that there's two pieces to this right? You know we spent a lot of time as providers talking about the fact that we need to capture HCC's. And that HCC's are supporting the RAF scores.And the RAF scores give us a better idea on the sickness, if you will, of our population of which then dollars are tied to that.You know and andand a lot of providers we spent a lot of time educating theirtheirtheir physicians and monitoring it and and almost going back and recalculating that.Was that in particular was it wrong? I mean did we overstated? 

Cliff Frank:

Oh not at all, that's all good stuff for lots of different reasons.The first is that providers like to compare themselves against each other. So if my remember per month spend is 20% higher than you, of course the first thing I'm you know I'mI'mgoing to whine about it well my patients are sick population sicker.Right so so the RAF scores actually level that debate which then moves us to the next level. which is what are you doing that I'm not doing what are you not doing that I'm doing let's have a conversation about clinical path use utilization pattern.So you can't have that without some sort of severity adjustment risk adjustment population standardization.So regardless of what else happens inside CMS in the deal between the payer and the provider it's really useful information. Then further to have some indicator as to what's changing in your in in particular patient, the risk for just jumped 30%.Well there's an indicator for some case management intervention some care support, so further love and attention from the doctor, it could be you know referral to a specialist, could be any number of things. But it's an early indicator it can be an early indicator of a problem that's coming hard and fast at the member and atat the at the provider network. right so all those things still have plenty of value regardless of what else happens. And then the third is remember risk scores can go down.So she isn't saying oh will insulate you from the down as much as we catch you on the up. So you know if if you if you fall asleep on risk scores and suddenly you drop two or three points guess what you're and you've got a percent of premium deal up your revenue just went down. 

Daniel J. Marino:

Yeah, you just went down. So the performance model still has to be there right it still has to be there. You still have to manage that population around cost of care around utilization yeah and then you have to accurately identify the risk. I think the key to it though is that if the risk is going up if the postal care is going up, and and even you know based on overutilization as you mentioned some interventions around Karen here management has to come into play, and you have to show that you're taking some responsibility to manage that. I think as we start to think about it the model has to be clean, but we also have toprepare or some type of audit or some type of realization that this may be questioned right.So we've we'vegotta get back to the data, the model, and the clinical performance to be able to show that hey what we're doing is is actually the right thing to be done.

Cliff Frank:

I think all that is true.There are plenty of places for CMS to come looking.And and I mean it starts with RPM, CCM, telehealth, I mean lots of new areas that are have been exposed already to some pretty significant fraud.Sothey're looking, and then you have their relationship with the plans which now cut through to the provider.Because it's the provider providing the claims information so they'regoing towant to see the documentation that supports that. So if you're just submittingdiagnosis with no documentation good luck.

Daniel J. Marino:

I'm going to thank all of our listeners for tuning in without your support your interest your feedback our program our episodes would never be as successful as it is.For anyone wanting to share their opinions or their comments or even suggestions for additional topics please feel free to reach out,I'd love to hear from you.My e-mail is d.marino@luminahp.com. As we close 2023we're looking into 2024 with some wonderful topics and some real fascinating guests.We're looking forward to bringing that to you in the new year.Until then, I want to wish all of you a very happy holiday season and a very healthy and prosperous 2024 and as always until the next insight I am Daniel Marino bringing you 30 minutes of value to your day, take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

Amidst uncertainties surrounding financial returns and the pace of value-based care, providers and executives harbor reservations regarding the privatization of risk. This episode unravels the intricacies of transitioning from fee-for-service to value-based care, shedding light on the challenges and opportunities that accompany this transformation. In this episode of Value-Based Care Insights, Dan sits down with Dr. Will Faber to explore the effects of value-based care on physicians, dissect payer pressures, and uncover why value-based care presents a golden chance for providers to enhance the quality of patient care.

• Physicians navigating the transition to value-based care face hurdles such as increased workload, concerns with well-being and equitable compensation.
• The changing dynamics of payer systems pose both challenges and opportunities for physicians as they adapt to change. This includes a shift towards concentrating on high-risk populations and embracing contemporary primary care practices.
• The emergence of nontraditional providers compels physicians to take charge, embrace risk, and pool resources to enhance both financial outcomes and patient care.

LISTEN TO THE EPISODE:

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I am your host, Daniel Marino. As we've talked about value-based care numerous times on the show, there's continues to be a lot of discussion around the pace of transformation from fee for service into value based care. There was an interesting article that came out, Oh, I want to say, maybe it was in the summer from HFMA, and many of the the CFOs that were interviewed actually were pushing back on value based care. And We're concerned about that pace and the investments that were required, and not really seeing the returns. Yet when you look across the industry, there's still tremendous amount of momentum that is occurring and moving us to value based care, shifting us to accepting more risk, based contracts, and beginning to identify or help or holding, having provider organization held accountable to the care that they're delivering to their patients.  

It's fascinating right now the environment that we're in. And as we think about moving into 2024, I can't help but think that this, this transformation challenge, and really the pace of which is something that we're gonna continue to discuss and work through as we move into 2024. And as we focus on that, there's tremendous impact on the physicians, physicians and providers in general are the ones that are really stuck in the middle of this fee for service value based care conundrum, if you will. 

Well, I am really excited today to have a guest joining me somebody that I have personally and professionally worked with over the last 15 years. Dr. Will Faber will welcome to the program. 

Dr. Will Faber:

Thanks so much, Dan. Great to be here with you.

Daniel J. Marino: 

Well, I'mreal excited to have you join a program today and talk about this discussion. This is obviously a topic that is near and dear to your heart. You've worked with numerous organizations across the country in your career, helping them to shift into, to value based care. What are you seeing as some of these challenges related to to the pace? right the pace of moving from fee for service into fee for value.

Dr. Will Faber

Well, we're constantly having to adapt, and we're having to adapt as providers. and I will be sharing today my point of view.My point of view is that as value-based care is growing, and I'm going to make a case where it may be growing more than we think it is, or we often recognize that it is. I'm in it for the physicians, and I'm in it for the patients. I'm in it for the providers of the health care. I myself am a primary care doctor, practiced for many years in lots of settings, and I care about population health. I love getting better quality results and outcomes for patients at a lower cost by cutting out waste and unnecessary utilization. And as the shift occurs, it seems like the insurance companies are making as much, if not more, money than they ever did. And executives of large organizations are still making astronomical fees, but primary care, primary care, doctor income relative to inflation and relative to the incomesof other specialists, have not gone up very much. And yet value based care brings with it a lot of things that primary care doctors need to do. And they need to document. Sothere's a lot more work without a lot more money.

Daniel J. Marino:

Yeah, I absolutely agree, especially on the compensation piece. So let's talk a little bit further about that.When you're working with the physicians and your physician colleagues, whether it be primary care or specialists, there's in my mind, there's 3 things thatI think they're struggling with one is the well-being physician, well-being, or the burnout factor.I think the second is the challenges they have with understanding how their care model has to change. And then, third, as you talked about is compensation.Are you seeing those as the main 3 challenges that are really affecting your provider colleagues. 

Dr. Will Faber:

Yeah, I think that's a really nice summary of whatchallenges us, as we know, during the pandemichundreds of thousands of nurses walked off the job, and a lot of doctors have sought early retirement.It's just too much. They're burning out in droves. This is a huge conversation. We've got some thoughts I'd like to share about how to preserve the provider or providers so that they don't have to burn out.The elements of their compensation is changing, and that calls for a change in their care model of the microsystem that they work in, the operational workflows. So be happy to touch on all 3 of those. 

Daniel J. Marino:

Do you think, as these care models as physicians are being forced to change their care models? Are they getting the right level of support or help fromtheir health systems if they're employed, or maybe from the community or from other partners. If they're independent?

Dr. Will Faber:

it depends on the health system.You mentioned independent doctors, and they really struggle. Because if you're an employee physician, you'repart of a of a network that's got resources. I worry about the independent doctors. And of courseI've been associated with you and starting a lot of clinically integrated networks that allow independent doctors to participate in these, and we have to find better ways to support the doctors and support them in a different kind of care model. I can talk about those specific supports If you want here any place along the conversation. 

Daniel J. Marino:

Yeah, no, I agree. I thinkthat's part of what I'mseeing as a challenge more so for the Independence, right? Soyou know, we were on a we were on a conversation recently where we had one of the physician colleagues, that of a CIN that you know both of us had had worked at for a number of years, and he is an independent physician in a in a rural community.And he is really struggling with making that level of investment in order to support what frankly needs to occur. To be successful in these in these contracts right to really drive a lot of value. And those investments are aroundanalytics. They're around care management. It's around care model redesign. It's around all of that. So you know. Again, I mean, What are you seeing? What do you think? How? How is this alignment between either the health systems the CIN, how can it better support physicians in an independent environment?

Dr. Will Faber:

Well, I give you a literal anecdote from 2 months ago. I'm serving right now as an interim executive in a clinically integrated network, and I went out to speak to one of the independent doctors. Matter of fact, I met with all the independent doctors I could get to at least the primary care ones. And he said, Will.I have had to hire 2 part time people just to help me do all the paperwork or computer captured metric, and HCC Coding work just to get that check at the end of the year that shows that I did well in these shared savings contracts that we get through the CIN. And of course I told him, it's my goal that we at the network levelprovide as much of that as possible so you don't have to hire staff in your small business, which just hurts your margin. 

Daniel J. Marino:

And I'll tell you. Well, that's not an unusual commentfrom many independent physician or practices, you know. They feel like they have to add staff.They have to add the infrastructure. And maybe it's because these CINs, these health systems, either don't have the financial means to invest or they don't have the right structure to invest.

Dr. Will Faber:

well, and let's be clear about it. Doctors want to practice medicine. They wanna interact with the patient. They wanna make clinical decisions, and so much of what payers require is proof that you did something. That is a clerical task. It's something doctors should do as little as possible of. And one of my principles is, make it easy for the doctor or the provider to do the right thing. I've talked to doctors who view value based care, unfortunately, and as more check boxes in their day, more in basket tasks. And we need to offload those tasks toother people working at the top of their license. It's not top of license work for a doctor, and certainly in some cases not even for an RN. You can have clerical people do some of this stuff that the provider that the payers are requiring.They they've been burned by people who are fraudulent before saying they were doing things they weren't doingand not ticking the boxes. But that's all infrastructure that needs to support providers so they can actually take care of patients. 

Daniel J. Marino:

Yeah, no, you're absolutely right.Let's shift the conversation a little bit on the pressures or what's occurring in the payer environments. You know, there'sbeen obviously a huge shiftto Medicare advantage.There's CMS has made it very clear that by 2030 they wanna get out of the management of ofMedicare beneficiaries, and either have all these beneficiaries pushed into Medicare advantage or the ACOs.Yet it's created real strains on the physicians to understand how they need to succeed, not to, not to mention all the challenges around the administrative tasks which have really considered seem to continue to increase, which has really been a challenge to delivering care. What are you seeing right now? And with working with your colleagues? What are they saying about the increases in Medicare advantage, and so forth? 

Dr. Will Faber:

Well, many of the doctors that I work with hate Medicare advantage, and they want to not take it. But of course they can't not take it because their competitor might take it. And then they're just gonna lose market share. They'regonna lose patients and it's making them angry all around the country.But let's not make any mistake about it. Medicare. Advantage is growing very rapidly in the last 2 to 3 years. Just in 2023. I think most of our listeners will know Medicare advantageEnrollment now has exceeded straight Medicare in the United States, and the trajectories to continue to grow by leaps and bounds over the next few years. I wanna contextualize this with a statement, that politicians are low to raise taxes and they're low to cut benefits, they wanna get reelected. So the government has not done a very good job keeping Medicare solvent. And of courseit's predicted to become insolvent during this decade. CMS. Has said, the only way we're going to make it is to shift risk off of the government onto individual providers. I call it privatizing riskand to preserve Medicare. They're going to have to do something we're not enjoying taking on the risk. Doctors are very loath to take downside risks and institutions need to step in and help protect the doctors so they can do what they need to do with all the kinds of supportswe're talking about here to continue to float the boat. 

Daniel J. Marino:

If you'rejust turning in, I'm Daniel Marino. You're listening to value based care insights.I'm here today talking to Dr. Will Faber. Will's providing a fantastic perspective on where the physicians are today and the benefits related to value-based care.SoWill just building on what you had mentioned, with the shifting of risk a. As we begin to to think about how the payers are putting a little bit more pressure on the providers as we think about how they're adding additional requirements onto the providers.Where do you feel like there's athere's an opportunity for them to succeed? Is it really being focused on,say that I don't, wanna, you know, just carve out. But you know, is it are, do they need to be more focused on the high risk population? Can they really support all the patients that they need to support under these risk based contracts? Or should there be separate care models or new care models, team-based models, if you will, that help them to succeed? What are you seeing in terms of that, that evolution of the delivery of care under these models?

Dr. Will Faber:

doctors just have to embrace the change that they can't just have the individual pleasant interactions with patients and do it all themselves. Like many of us baby boomer doctors did, we enjoyed sitting down with the patient for a 30 min visit, and sometimes talking about how the grandkids are doing, and so on. Modern primary care is a team sport, for sure. I've often created an analogy with the orthodontist who's got 5 chairs running, and he goes from chair to chair telling his technicians what to do to straighten the teeth of the patients. primary care. Doctors have just got to be the quarterback of the team, and there's so many things that care managers ought to be doing. Clerical people ought to be doing. Coordinators ought to be doing. And I also make a very big point. We've got to tame the electronic health record instead of serving it. It should be serving us. We need to automate all kinds of processes like with Cpt. 2. Coding to capture things that the payers are gonna require to prove that we did something. And of course we're trying to get patients to do things they don't wanna do like get a colonoscopy. We need to let other people go chasing after the patient, chasing after the metric chasing after the data so that we can have meaningful motivational interfaces with our patients.  

Daniel J. Marino:

Yeah, II agree, and you know that infrastructure support in my mind is absolutely critical. As we've talked about you and I. And then, obviously on the program numerous times.We can't ask physicians to do more work. We actually have to reduce the amount of work that they're doing and give them the tools to perform smarter and not harder. And that's really where the infrastructure support comes in.

Dr. Will Faber:

That's a great pivot into talking about physician compensation plans which you and I have helped many an organization to design. I think there's some shortsightedness in rewarding doctors just for our views generated.That makes it sound like they are the only generator of net value. It's really a team of game here. And so just cranking more patients throughwithout a thought of what the mix of those patients are whether or not it's meaningful work for a doctor to be doing, whether or not somebody else should be taking that off your shoulders, and a way to compensate the overall team for performance is probably a preferable direction to go as we evolve our compensation models.

Daniel J. Marino:

Talk a little bit about that, you know, when you've when you're working with organizations and particularly primary care, with new compensation models.What are you seeing? How are you seeing these models evolve? I think you know. for some of the most of the organizations. They're still on a revenue Rv. Based model right of compensation. I think they've started to incorporate some other elements. But it's predominant. RVUs.What are you seeing in terms of the right level of incentive alignment? If you will, betweenfairly rewarding the physiciansrelated their compensation and alignment with any of the risk based contracts? 

Dr. Will Faber:

Well, most organizations of certainly those who employ doctors are dialing in more and more quality dollars, and not just a straight RVU model. Most of them sequester or withhold a certain amount of money that you earn back through your quality performance. But the quality performance is definitely a team game, and I think the degree to which youreward through the compensation plan quality or efficiency related work is related to the penetration of value based contracts in your portfolio. If you've only got 5 to 10% of your income coming through value based care, Well, then, you'd have a relatively low part sequester in the Comp plan for the doctors. But if you're 50 or 60%. Well, then, you should have a much larger amount.

But going back to my basic premise here. All the doctors are doing with that sequestered 20%, let's say, of their income is earning back money to just become whole. What they would have gotten for service. In the first place. 

Daniel J. Marino:

right? They're not making any more yet. They're in in some cases actually working harder, creating a lot more investment just to make the same amount of money they made before.

Dr. Will Faber:

right, and of course it brings up a chronic complaint I've had, and that's the way the value of a primary care doctor is accounted for in a lot of systems. Never talk about the contribution factor to the organization, which is why you have primary care doctors to create access points to feed the whole network.That just isn't accounted for, and it frankly, is a bone of contention with me, and it always has been. But I think it should be because the net benefit of the physicians, particularly primary care to the entire enterpriseis much greater than what seems to get passed on. If you just look at what they generate in terms of the poultry sums that we get for our E and M work. 

Daniel J. Marino:

Yeah, yeah, Iabsolutely agree. So I want to get your thoughts on one other area here, Will. We have seena lot of these what I call the non traditional provider organizations. And in some cases these big for-profit entities coming in and buying these primary care groups. And I'm and I'm referring to sort of the Oak Street health. Who was bought by CVS. Obviously Walgreens and Bootspaid a tremendous amount of money for some medical group and city. Md. How are you seeing this affecting the physicians?

Dr. Will Faber:

Well, I was really hopeful.I've known some of the people that started these amazing organizations like VillageMD, ChenMed, Oak Street and they were disruptors in the model of Clayton Christensen's disruptive innovation model and I thought great. Now physicians are taking control again, and they are leaning into risk, which is a big point I want to make on this broadcast. Doctors have traditionally run away from risk.Well, that actually gives power to the payers. Payers take the risk, and if you're not willing as a provider to take the risk, you're going to get left with some unsavory things. So these doctors went out and said, Okay, we'll take the risk.We'll take on Medicare patients. Specifically, we'll take the high acuity ones. We think we can manage them better and really create a value proposition, and I was so proud of them. It's been discouraging for me to see that asthey've created this better kind of care where less of the money goes to the big payer.One by one I see them being bought out by other organizations. And let's not kid ourselves. Venture capital is really leaning into physician aggregation. And soI don't blame a doctor or group of doctors who created a wonderful a disruptor for them, saying, Okay, well, I guess I get to be a billionaire now. But I would like to see doctors continue to band together, Take on risk, cut out the middleman frankly disintermediate mediation of the insurance company, and stayed true to that, so you could pass the savings on to the patients and the doctors.Andphysician aggregation is the way to go we've seen with United and Optum exactly collecting more and more doctors. They saw this end game 10 years ago.  

Daniel J. Marino:

Yeah. Oh, no, that's true. that's true. Well, it's gonna be fascinating to see where where this goes. You know as more of these entities start to you know, either buy out these practices or just offer tremendous amount of investment dollars to these physician practices can be really interesting to see where it goes. 

Last question that I have. And it's a little off topic. But it's related. You know, we're we. We've spent time talking about the value to the physicians and what the challenges are. What about the patient? Give me your thoughts for the next couple, you know. Maybe the next 30 s or so. Do you feel like patients are benefiting from our transformation into value based care? 

Dr. Will Faber:

In some cases they do, and others not very much. One of the thing that strikes me is in the world of preventive care which I care so much about. We're often trying to get patients to do that which they don't want to do. They don’t wanna have a healthy lifestyle. They don't wanna get their vaccinations. They don't want to take the medications that we control their blood pressure and their lipids, and so on. And so it's a slog for us. If the patients would go along with that, they would definitely benefit in their health. But it's really quite a task, which is why you need an army of care, coordinators and care managers and navigators to help these patients do what is gonna be beneficial to them.   

Of course, one of the biggest things that helps in value based care is great access. Great access is wonderful, for patients. Wouldn’t it be wonderful if all patients could get in with the doctor's office when they really felt they needed it, or could get a hold of somebody on their care team after hours. 365.  

Daniel J. Marino:

yeah, I can't tell you how many people I talked to who have challenged, getting in to see their physicians. And it's not just a couple of weeks out is 3, 4, 5 months out. Well, we'll this is great discussion. I I'm so excited to have you on the show today, and to talk about these topics. You brought up some wonderful points. If any of our colleagues are that are listening today, anybody wannaget in touch with you, you know. Can you share your yourLinkedIn address or your email address? Or how could folks reach out and get in touch with you?

Dr. Will Faber:

Absolutely. I live in service, and I want to help as many providers out there as possible, do the right thing to help patients thrive and do well, and to actually make mebe rewarded better for the work that they do. I will provide all my contact information. I welcome anybody who's listeningto reach out. I'll get back to you as fast as I possibly can. If I can be helpful. 

Daniel J. Marino:

Great, we'll include those in the liner notes and again encourage anybody who's interested just to follow up with Will for future conversations well again. Will, I want to thank you for your time today, and also want to thank our listeners. Really appreciate you tuning in until our next insight. I am Daniel Moreno, bringing you 30 min of value to your day. 

Take care. 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners