The One Big Beautiful Bill Act: Leveraging Clinically Integrated Networks for Change

Daniel Marino:  

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. Well, I think we've all been aware of the newly signed One Big Beautiful Bill Act, that was signed into law in around July 4th. And many of the healthcare leaders that I talk to around the country are spending a considerable amount of time. Trying to, work through aspects of the law, trying to understand how it's going to not only impact their organization, but impact the community that they serve. And when you dive into kind of the specifics of the bill, there are quite a few Impacts or implications to our industry, frankly, and to the providers, and really, I think when I look at the bill, and I've spent a considerable amount of time reading it, I really have focused on 4 key areas that I think, as a healthcare community, we do have to focus on. One is really the impact to Medicaid. And according to the CBO, the projections are that 10 to 12 million Americans could lose Medicaid coverage over the next number of years. And again, it's a phased-in process, so things can change, but that's a considerable number. Second is the funding that's going to occur, through Medicare, through Medicaid, through the states, and that impact to hospitals, and particularly rural healthcare. I think rural healthcare, in my opinion, could potentially be really challenged over these next number of years from the bill. Third is insurance access, and there's going to be some stricter rules around the ACA. CMMI is continuing to put forth and really focused on value-based contracts, pushing a lot of that risk down to the providers, and used to be where you can opt in on the risk, now they're making a lot of these programs mandatory. Which is increasing the risk. And then the fourth area there is really the fiscal and political fallout. And I think we're gonna see tremendous amount of fiscal pressure, as well as political implications, depending upon your state, as a result of the bill. 

So, I'm really excited today to have one of the top industry leaders, join us today, Ben Sparks. Ben is the president of Bryan HealthConnect. That's part of Bryan Health in Lincoln, Nebraska. Large health system, but Bryan HealthConnect, in particular, is a physician hospital organization, PHO, that has gradually moved into a strong clinically integrated network. They also have an accountable care organization and have been involved in the value-based care space for quite some time. One of the things that's really impressed me about Bryan HealthConnect is their ability to not only connect with their local providers within the Lincoln area. But they really have extended to, across the state of Nebraska, to many of the rural healthcare providers. Ben, very excited to have you on the program today. Welcome. 

Ben Sparks: 

 Thank you, Dan. Really excited to be here. Appreciate the opportunity. 

Daniel Marino:  

So, Ben, let's, let's jump right into this. Give me your initial thoughts on the One Big Beautiful Bill. 

Ben Sparks:  

Oh, that is a great and very loaded question. 

Daniel Marino: 

 It is. 

Ben Sparks:  

Fundamentally, I think, and you touched on this, there are a lot of things we don't know. I think a lot of opportunities, you know, the Medicaid cuts, you know, who and when and how is a big question we have. The rural transformation funding is a huge hot topic now, and, you know, I think a lot of rural facilities view that as a lifeline, or a chance to maybe make some big changes that they've lacked funding for in the past, so there's a lot of excitement around that. And then, you know, I think just generally, and you touched on this, this movement towards risk, which is bigger than the big, beautiful bill, but kind of fits that same frame. A lot of rural providers, I think, are really nervous what that means for their communities. So, you know, as you very well know, rural facilities tend to have, depending where they are, much larger government payer mixes. So, you know, the changes that happen to Medicare and Medicaid really impact them usually earlier and more aggressively. You know, cuts to Medicaid, when you're on a razor-thin margin, you know, the small changes there can have huge impacts on the viability of your facility, so there's a lot of anxiety, but also maybe, you know, a lot of hope that some of these changes might give these facilities and these providers a chance to do things differently in the future as well. 

Daniel Marino:  

Well, when you look at this, you know, I think the one thing that stands out is, government is definitely trying to put more accountability on the states, right? And changing a lot of the funding, as to how they're going to support Medicaid, and it seems like, you know, they're shifting a lot of those,a lot of those dollars and responsibilities. But for rural healthcare, I think it's a particular challenge, because you don't have a lot of large health systems, you have a lot of rural health community providers, you have a lot of critical access providers, and many of the critical access hospitals, for instance, probably, you know, they only provide maybe around 25 or 30% of, really, the care needed within the community, right? Patients and the population have to travel, and in some cases, maybe they won't even travel. They may not even be able to focus on getting the care that they need. As a large health system, how are you responding to that? You don't want to create a healthcare desert, but how do you respond to that challenge and that level of support? 

Ben Sparks:  

Yeah, that's a great question, and this is something I think, you know, isn't necessarily unique to Bryan Health, because I've seen other providers do this as well, but something that Bryan Health really focuses on is providing outreach. And a lot of our specialists that are part of our network provide outreach to dozens, upon dozens of small communities across the state, and even in neighboring states. You know, so we really try to provide access to specialties that would otherwise be unavailable in these communities. You know, that doesn't necessarily mean that you want, you know, an open-heart procedure done at a 10-bed hospital when there's one per year. But, it prevents those patients who would use that hospital as kind of their care nexus within their community from having to travel for checkup appointments or monitoring, because what we've also seen, is in those deserts where specialty care specifically is unavailable, the reality is people just don't get their screenings, they don't go to their phone visits, and you end up with worse outcomes. And what we really try to avoid at Bryan Health broadly is the disparity between, you know, we have communities, up to about 350,000, you know, down to probably 50, you know, unincorporated communities that we serve. And we, we really focus on removing as many of the disparities in health access, as well as other social determinants, but certainly access is a big priority of ours. 

Daniel Marino:  

Well, I tell you, I've been following Bright Health for many, many years, and I've been very impressed with the mission and the values of the organization. And one of the areas that I've always been impressed with is just the focus on outreach and serving the community. And one of the things that I know, and we touched on it kind of in my opening, one of the things that the organization has been focused on is the physician-hospital organization, but really moving into more of a clinically integrated structure of care. How are you leveraging the CIN to support, let's say, the providers that are in some of these rural communities or critical access hospitals and so forth? 

Ben Sparks:  

Yeah, great question. I think the story kind of goes back, 10 years or so at this point to, you know, ACO. Bryan Health, Bryan Health Connect have been involved in value-based care for a long time. 

Daniel Marino: 

 Right. 

Ben Sparks:  

You've had a lot of success on commercial agreements, government payer agreements. And so the next logical step for an ACO is to start to meld that world between value-based and fee-for-service, so it's a bit more full continuum, full spectrum. And so, the reason we're driving towards CIN is to bring those two parts of our organization together in a more formal type of arrangement. Informally, there's a lot of self-support that happens today. But, a big driver has been payers. You know, payers want to work with a self-enclosed network that is at risk. You know, we talk about, and you brought this up about moving to risk. Well, it's hard for providers who are outside of an ACO to take on risk. And so within the CIN, we can do that. But the other big, kind of, behind-the-scenes actors here that are really driving this are employers. So employers are, you know, facing a ton of stress, you know, you've seen commercial trends at very high single digits, low double digits for a while now. And it's a bit like playing whack-a-mole, where you make a little progress here, and we lose a little there. But employers are really looking for systems to partner with to help them manage their population. And so, in order for us to do that effectively, we have to be a CIN. You know, to bring the most tools we have to the table. 

Daniel Marino:  

So, it sounds like to me, Ben, you really have an integrated partnership strategy, right? Where you're trying to focus on bringing together, obviously, the payers, right? And the commercial payers are going to have to step up and really support the providers, particularly in rural health, but I think in all areas, to ensure that economically, we're still able to provide the care we need. But along with the payers, partnering with the employers, as well as the different providers, do you feel it's giving a lot of support to the providers in the community? Do they see this as a lifeline? Is this helping them get over some of the anxiety or the challenges that they're feeling with the One Big Beautiful Bill and the potential reduction in reimbursement? 

Ben Sparks:  

Yeah, you know, I've often said to a couple groups is that I fully understand why individuals are skeptical about value-based care, specifically specialists, because it's hard. A lot of the models, almost all of the models, historically have been focused on primary care. But, if you can find a way to bring specialists in, if you can find a way to engage them in the same activities. I'll use an example. Ambulary care sensitive conditions. It's a little bit of primary care, a little bit of specialty care. If you can bring those groups together. Our ACO, you know, transparently, that's a huge opportunity for us. Because we have a very rural population that, you know, struggles with access. And so, there's such a large opportunity there that by lowering the cost of care, there's plenty of shared savings, there's plenty of value-based incentives to pass around. And I have found that providers who are skeptical, you know, when they enter into the work, as long as they're engaged in the work and doing what they need to do, that first shared savings payment changes their mentality overnight. 

Daniel Marino:  

Oh my goodness, yes. I mean, you want to talk about the change of focus, you know, they see this, because a lot of times they hear all of this, but they don't necessarily believe it. You send them that first check, and it's like, oof. The light bulb has gone on, and then some. 

Ben Sparks: 

Yes, absolutely. 

Daniel Marino:  

If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm talking today with Ben Sparks, and we are reviewing the One Big Beautiful Bill, and the impact on rural healthcare. So Ben, let me dive into this a little bit further, and I'd love to talk a little bit about some of the rural transformation funding. You mentioned in some of your comments that, potentially this is a lifeline. I think when I look at it, I think there's somewhere in the range of about $50 billion that, are included in the fund, but it's a $10 billion release, I believe, that's going to occur over, say, the next, you know, 5 years or so. When you think about it, and you think about rural healthcare across the whole United States, it's not really a lot of money, right? So how does this figure into your strategy? I mean, obviously, you can't be just relying on this to support, all of the services and make up for, kind of, the lost support for the Medicaid population and so forth. How is this fitting into your strategy? Have you given that much thought? 

Ben Sparks:  

Yeah, and, you know, the first thing I'll say is, very thankful, so I would say within Nebraska, the hospital systems, you know, the state government, the hospital association, you know, and several other organizations that support rural providers work very well together, and I think there's a lot of there's a great spirit of partnership, about how to maybe invest these dollars in a way that has the maximum benefit. I mean, the risk here is these getting all parsed out, because you're 100% right that, you know, it seems like a lot of money on the surface, but as soon as this gets divided, you know, 100 different ways, you're talking a bunch of really small payments that, you know, if there's a facility today that's on the verge of closing, these dollars might help them limp along for a few years. But 5 years from now to be in the exact same crisis we're in today. So a lot of what we're talking about is how do  you know, infrastructure funding for, you know, clinical integration, or, social determinants work, or, you know, telehealth. Like, we're looking at some big solutions. You know, we're a big believer if we can make some critical investments in the infrastructure to provide care more easily, and make it more accessible for communities, I think you'll get a bit of a revitalization for some of these critical access hospitals and these rural health clinics, who are today facing small, you know, shrinking populations, aging populations. It's all about care sustainability. Yeah. So, how do you get the most bang for your buck in the sustainability realm? So, 10 years, 15 years from now, the return on investment for these dollars is very clear. 

Daniel Marino: 

Well, it sounds like, to me, you're putting in place kind of a multi-pronged strategy, right? To kind of build what I would sort of call it an organized system of clinically integrated care. But it sounds like, to me, that you're providing the care support that providers need, and that may be actual providers going out to the community, but it also sounds like you're leveraging technology as well, too. To really be able to drive that care. Do you see as an impact or an outcome of the one big beautiful bill and some of the things that are going to occur. Do you feel like there's going to be a lot of consolidation, or continued consolidation, or maybe these smaller providers are going to look for maybe joining the systems? Or do you think that they're still going to try to remain somewhat independent? And at least to be able to, you know, do what they can do to make things work? 

Ben Sparks:  

Yeah, that's a great question. I think, you know, this is specific to Nebraska, because I think every market's a little bit different here. I think it depends on the provider, right? So, I mean, you there are certainly critical access hospitals within Nebraska that are exceptional facilities with excellent finances and really well-established, built systems of care. There are some that are barely getting by. There are a lot that are in between. You know, for some of those it might make more sense, you know, specifically when you look at patient populations or the cost of infrastructure administration to affiliate with, another system or another hospital. You know, back to clinical integration, however, you know, I think that when you do a CIN the right way, and this is important, when you bring providers across the system of care, you brought up a point earlier around 25 to 30% of the care being actually done at the critical access hospitals, and a larger chunk being done, you know, hour, two hours away in a larger system or a specialist office. Bringing those providers together, I mean, if you think from the patient's perspective, what a patient wants, you know, I want to send my parents, is I want them to know that the physician they're seeing in their small town is coordinated and connected with whoever they have to go in the city, whatever specialist or facility they need to go to. And so you know, I think you can create this big tent, highly integrated care experience without having to go through all of the mergers and affiliations and kind of, you know, what has to go where, you know, the loss of identity that can come with some of that. And so, you know, CIN, I think, allows you to do a lot of the things and get a lot of the benefits you would have in consolidation without having to go through the formal step of consolidation. 

Daniel Marino:  

And that is just such a great point, Ben, and I couldn't agree with you more. I think if you're really able to leverage the elements of the CIN, you know, and had you invested in this for years, I agree with you. I think this is the point where you're gonna start to see the return on the investment, both in terms of financial dollars, but really return around clinical support, right? That we've been waiting for for years, because it does not allow an opportunity to create efficiency. It does allow an opportunity to support providers in communities where they may not have all that support. It is going to provide a lot of opportunity to be able to provide technology and analytics and just information insights that these small hospitals won't be able to do. Or to be able to provide on their own. So, I absolutely agree with you. Do you feel like the payers are gonna step up? When you're having these conversations with the payers, are they recognizing this kind of this burning platform to change?  Or do you feel like it's still going to be a big challenge in the negotiations for them to understand, you know, to really think about, or for them to take their own economic focus. Where do you think that partnership discussion with the payers is going to occur? 

Ben Sparks:  

Yeah, that's a great question, and I will even rope in the brokers and producers here as well, because I think, you know, when we talk about sitting across the table, I think all parties need to be engaged and supportive when it comes to employers. I think a lot of the payers, and certainly all of the brokers we're working with, are very engaged. There's a general understanding that the current process isn't working. You can only lean out deductibles so far. You can only, you know, restrict access to the network so far that you have to come up with innovative solutions. And to their credit, I think you have these progressive employers that are really pushing that to the payout. 

Daniel Marino: 

Yeah, they are. 

Ben Sparks:  

And so, you know, we're finding a lot of payers are working with us, I would say, collaboratively, to make this work. We're looking at some innovative value-based care models with some payers in our state right now that wouldn't work without their engagement. So, I'm excited. I think the stress of the current healthcare finance landscape is creating maybe some space for innovation that hasn't been there historically. Yeah. So I think we have, you know, the next one to five years, I'm hoping we're going to see some really rapid innovation in how we manage and control risk, and share the costs and benefits of care with providers and with payers, along with the employers. And they're brokers as well. 

Daniel Marino:  

Yeah, I agree with you, and  and I, and I do think that it is a multi-pronged strategy, right? You do need to have these conversations and partner with the payers, but having this direct conversation with the employers and engaging them, as well as the brokers, right? Because obviously they're they influence a lot of that, and they're kind of the go-between between the payers and the employers. But to engage the employers in these levels of conversation so we're all clear what the costs are, how do we both how do we best serve the employers and or the employees and their families in a coordinated clinical partnership model, I think is really important. I also feel like there's gonna be some new, innovative programs that are gonna come out, or that are gonna continue to evolve with the direct-to-employer model as a result of the one big beautiful bill. I think it has to, right? We have to create that level of innovation in order to ensure that the financials and the support. And patients are able to be served within their communities. Are there specific things that, right now, as you start to engage your employers, are there certain things or questions that they're asking, or certain things that you need to respond to to ensure that you're providing that right level of support to them? 

Ben Sparks: 

Yeah, I mean, I would say generally, so, you know, a little bit of background on me. I actually started my healthcare career on the insurance side. 

Daniel Marino:  

You've seen both sides. 

Ben Sparks:

Yeah, I have, and a ton has changed. I mean, it's crazy to me. You know, if you go back 15, definitely 15 years, certainly, you know, 20 or 25, this push from we're seeing this push from large you know, I would say poorly controlled networks. Access being and, you know, number of providers in your network being the most critical thing, the most critical value proposition, and it's coming back around where, you know, not that we're going back to the old HMO model, but you're seeing, you know, a much larger attraction towards not necessarily narrow, but maybe slimmer, more highly coordinated networks.  And I think what we're finding is those networks are actually leading to better responses from patients. Patients are more satisfied because their care is more coordinated. They feel they have fewer obstacles to access. And so, I think a lot of the fear around our employees, our beneficiaries are going to hate a narrow network is starting to dissolve, because once they experience it. Or maybe a tiered network is a better way of saying it. Once they experience it, they actually prefer those care pathways more than kind of the wild west of, you know, you pick here and you pick here, and they may or may not talk to each other kind of experience that we've had for a while. 

Daniel Marino:  

Well, I agree with you. I think if you do it right, these narrow networks and the services that can be provided within the networks, can be really designed specific to what the needs are of a certain population. They're not for everybody, but I think as you begin to design those, you're really meeting the needs of the patient and the population, and frankly, I think bringing it back to the one big beautiful bill, I think that is a component of the partnership is really what's going to allow organizations, particularly rural health providers really excel, right? Because it's that community outreach. Well, Ben, I want to thank you. This has been a great discussion. I feel like we've just barely scratched the surface on what's going to occur with, with the bill, how it's going to impact healthcare, how it's going to impact rural health providers, but the one thing I am excited about is how Bryan HealthConnect has positioned itself, to really continue to provide that outreach to the rural health providers. You’ve done a great job, and I wish you a lot of luck. 

Ben Sparks:  

Appreciate that. Yeah, we are excited, you know, our 2,400 plus providers in our network are… are excited for this as well. I think while we're gonna have some short-term anxiety, you know, as part of maybe some longer-term challenges, we do have a few years where we have an opportunity to reinvent things in ways that are more sustainable, and hopefully better for patients, providers, employers, brokers, and everyone else. 

Daniel Marino:  

If any of our listeners today are interested in maybe contacting you, or at least connecting with you, networking with you at some point, can you share any of your information? 

Ben Sparks:  

Absolutely. You're certainly welcome to go to the Bryan Health Connect website. If you want my email, my email is just ben.sparks@bryanhealth.org. Feel free to reach out. 

Daniel Marino:  

Wonderful. Well, thanks again, Ben, and  I'll be watching a lot of the great work that Bryan HealthConnect is doing, and wish you a tremendous amount of luck, as you're working through this. So, thanks again. 

Ben Sparks:  

Thank you, Dan, for the opportunity to be here. 

Daniel Marino:  

And I want to thank all of you, all of our listeners, for tuning in. If you're interested in learning a little more about this topic and others, please reach out to me directly at dmarino@luminaHP.com, or feel free to, go to LuminaHP.com. Until our 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