Relentless Health Value - Encore! EP225: Why, Right Now, It Is No Longer Optional to Suck at Patient Centricity, With Joe Selby, MD, MPH, Former Executive Director of PCORI

Encore! EP225: Why, Right Now, It Is No Longer Optional to Suck at Patient Centricity, With Joe Selby, MD, MPH, Former Executive Director of PCORI

09/03/20 • 31 min

There is a land grab going on right now, the likes of which the health care industry hasn’t seen before—at least in our generation. Spoiler alert: There’s a whole episode of Relentless Health Value coming up on the impact of the Teladoc-Livongo hookup. And that is totally relevant to the point I’m about to make.

But let me just start with a little bit of background: American patients—let’s get real here—have no more money to spend on health care every year. Really. I mean, you look to employers. The government? Who knows? But let’s just say for the purposes of this discussion that what’s going on right now is a zero-sum game—that the dollars in the system every year are the dollars in the system, and if you want to increase your revenue as any given health care stakeholder, you’ve got to take those dollars from somebody else.

Alright ... now consider this: Previously, if a health system, say, were going to make a list of their competitors, they’d probably list the health system down the street, maybe the one in the next town over if there seems to be a lot of commuting. Oh, my, how we no longer live in that simple world!

Enter the pandemic and patients not only accepting but kind of digging virtual care and its convenience and its accessibility. Now consider what happened to brick-and-mortar stores who didn’t add online retailers to their list of competitive threats. Virtual entities doing chronic care management, diabetes, musculoskeletal, other population health endeavors ... these are now or will soon enough be head-to-head competitors to in-person care settings.

My local health system, they may also decide to stand up to telehealth—and many of them did. But if the playing field is now in the Cloud, how’s the patient experience on their systems? Everybody accepted that, in the beginning, they were kind of buggy and calls dropped and all you could see was the doctor’s ear in a weirdly dark room or something. But six months later or a year later? Not exactly sure when patients’ patience will run out, especially when there are companies out there who built amazing virtual experiences from the ground up and who, by the way, are often hired by health plans, who, by the way, make it financially, let’s just say, attractive for patients to use those services that the plan is providing instead of the big expensive consolidated health plan that raised their rates 30-fold over the past couple of years like one of them anecdotally did.

So, you start to see why, if I were a health system or a provider executive, I’d kind of shuffle the patient centricity, design thinking, patient experience—that whole bunch—to the first tab of my spreadsheet. Patients have, at this moment, unprecedented choice; and so do their employers, nothing for nothing. As Dr. Matt Anderson told me the other day, if a health system thinks that it’s going to make the difference by doing more specialty services and expensive procedures, that might be a risky bet.

So, anyway, I thought it might be a good idea to replay my conversation with Dr. Joe Selby from early last year. Dr. Selby is the [now-retired] executive director of PCORI, otherwise known as the Patient-Centered Outcomes Research Institute. PCORI is an independent nonprofit organization in Washington, DC. Since December 2012, PCORI has funded hundreds of studies that compare health care options to learn which work best given patient circumstances and preference. So, it’s definitely good background information. Anyone driving for the best patient experience might want to have it at their fingertips.

You can learn more at PCORI.org.

You can learn more at PCORI.org.

Previous Episode

EP290: COVID-19—Shining a Light on the Crafty Gambits Used by Some (Not All) Hospital Billing Departments, With Doug Aldeen

Here’s a couple of sentences ripped from the headlines recently: It is free to be tested for COVID-19 in the US, but the cost of treatment can be shocking. Even if you’re insured, the deductible and co-pay can add up to several thousand dollars. And if you’re uninsured, the financial toll is even uglier. That’s what Boston resident Danni Askini learned when she got a $34,927 bill after receiving treatment in a local emergency room for COVID. That’s from Time magazine.

Episode 260 of the show was about the Shkreli Awards and the worst profiteering in health care. The judges of the Shkreli Awards bucketed the winners into a few categories. One of the categories of “winners” was called Schizophrenic Compartmentalization, and this schizophrenic behavior seemed super applicable to hospitals this past year. This schizophrenic compartmentalization happens when the person who wrote the mission statement and probably doctors and nurses are on a totally different planet than the billing department. So, I wanted to take a look at a couple of mission statements just as a reference point, including the mission statements of the hospitals that won Shkreli Awards in the Schizophrenic Compartmentalization category.

Luckily, there is a Web page where hospital mission statements are all collected in one place, so I did not need to travel far to confirm that they are all very, very similar—something along the lines of treat patients with compassion, be a productive member of the community, ease suffering, and give the highest value to all concerned. That’s very noble and what I would expect a hospital, honestly, to be striving toward.

Here’s the thing, though. This is what the whole hospital is supposed to be doing. I didn’t find one mission statement that said everybody except the finance team is subject to this mission statement. Those guys over there? They have their own.

In this health care podcast, I speak with Doug Aldeen. Doug is an attorney. He is generally hired by self-insured employers. He has dealt with hospital finance teams for two decades, so he is the perfect person to dig into the delta between the hospital’s mission statement and the finance team’s mission statement. This is what we talk about in this podcast. Doug also offers up some solutions at the micro and the macro level.

One vocabulary word before we get started: RBP is otherwise known as reference-based pricing. This means when a health plan, usually a self-insured employer’s health plan, says that they’re going to pay for health care services based on usually the Medicare rate. So, they’ll pay, like, 1.5 times or 2 times what Medicare pays, for example.

Do I want to be a little bit sensitive right about now to some of the hospitals that are struggling under the weight of COVID and the shutdowns that have been transpiring across the country? Yeah, I do. At the same time, there is absolutely no excuse to take advantage of those that you claim to serve. There’s a big delta between charging a fair price and wrenching dollar bills out of the sweaty hands of hard-working Americans just because you can.

You can learn more by emailing Doug at [email protected] or following him on LinkedIn.

Doug Aldeen is an Austin, Texas–based health care and Employee Retirement Income Security Act (ERISA) attorney who recently served as ERISA counsel on behalf of the Berkeley Research Group in New York City to the $7.7 billion May 2016 acquisition of Multiplan and its medical bill repricing product Data iSight by the private equity firm Hellman and Friedman. Since 1997, he has represented reference-based pricing organizations, a bundled payment software platform, PPO networks, medium to small self-funded plans, third-party administrators, and provider-sponsored health maintenance organizations in various capacities, including Herdrich v. Pegram, which was argued before the US Supreme Court in 2001. Moreover, he serves as a resource to national news organizations regarding issues on health care and as a consultant with the Governmental Relations Committee at the Self-Insurance Institute of America in Washington, DC, and as an adviser to RIP Medical Debt, which has abolished over $1.2 billion in medical debt. Doug received his JD from the University of Illinois.

03:59 Exploitive hospital billing practices. 04:20 The impact these exploitive billing practices have on patients. 04:45 Why would a hospital exploit the patient with their billing practices? 09:31 “You co...

Next Episode

EP291: What Are Medicare Advantage Plans Up to Right About Now? With Betsy Seals, Cofounder of the Rebellis Group

Medicare Advantage (MA) enrollment has nearly doubled over the past decade. It grew 37% from 2016 to 2020. Right now, MA comprises nearly 40% of the Medicare population—and that number is only expected to grow.

So, in case you’ve been out of the loop, at the beginning of 2020, CMS (Centers for Medicare & Medicaid Services) rolled out a third category of these “chronic supplemental benefits.” And these chronic supplemental benefits allow plans to offer basically services to attenuate social determinants of health to offer stuff like nonemergency transportation, meals, home modifications ... that whole list.

This is all, really, part of a broader bipartisan effort to move Medicare from an acute care to a chronic care program. Then ... corona.

So, the question I’m kind of wondering about at this juncture is, Were/Are MA beneficiaries able to maintain their health status better than, say, other plan designs, especially given some of these chronic supplemental benefits, which you’d think would be super helpful in the middle of a pandemic?

This should make sense, and it should really be true. At its core, MA is, as John Gorman put it when he was on the show last year, the biggest value-based payment experiment in the universe. And patient outcomes have definitely improved for MA patients over traditional FFS (fee for service), especially in the south and in other areas rife with cardiovascular and metabolic disease. So, that sounds great.

Now let’s talk about the cash money denominator in the value equation. Humana reported $1.8 billion in profit for the second quarter. That was nearly double its haul in Q2 2019. So far, 2020 has seen a profit that is a 94.5% increase year over year. Humana’s earnings are not an outlier. MA plans across the board did very well, thank you very much, in the middle of a pandemic.

Given that MA hasn’t actually reduced PMPM (per member per month) costs last time I looked at it, you’d think and hope that the confluence of higher rates and less restrictions on extra benefits should definitely lead to greater scrutiny on the plans by CMS. We’ll see what happens.

Anyway, it occurred to me that it might be interesting to get a bead on what MA plans themselves have been contemplating and thinking about relative to the supplemental benefits et cetera. In this health care podcast, I speak with Betsy Seals, cofounder of the Rebellis Group. Betsy spent many years working with and for Medicare Advantage plans. I thought Betsy would be the perfect person to talk to to get a bead on what’s happening on the MA front right now.

You can learn more at rebellisgroup.com.

Betsy Seals is a cofounder and chief operating officer at Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage organizations and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 18 years of experience.

Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the Medicare landscape. Betsy’s expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that addresses social determinants of health, and health plan operations.

Betsy got her start in managed care on the health plan side, where she held roles in compliance and operations. Betsy also spent many years as a managed care compliance and operations consultant with Gorman Health Group, where she exited as chief consulting officer in the fall of 2018.

03:45 What is a Medicare Advantage plan? 04:02 The core imperatives for leaders of Medicare Advantage plans. 04:31 “How is risk adjustment functioning?” 04:34 Making disenrollment rates and member complaints top of mind for MA leaders. 05:40 “We all want to know why members are leaving. Well, they’re telling you!” 05:50 Star rating measures. 07:33 “Will Medicare beneficiaries really have confidence ... going into the doctor’s office ... next year?” 09:11 “Now, it’s not just ‘Is your doctor in the network?’ It’s ‘Does your plan also offer telehealth?’” 12:13 “When you really look at Medicare beneficiaries aging into the program or ... younger ... beneficiaries, their shopping trends and their consumer expectations are very much the same as yours and mine.” 13:58 CMS’s adjustment in April that allows MA plans to make changes to their benefits midyear to provide to beneficiaries’ changing needs during the pandemic. 16:01 Supplemental benefits as a decision-making factor in enrollees’ Medicare Advantage plan selection. 16:28 “The decisions made during this time with how to increase benefits or how to address the issues going on with your membership will have a really great impact on [...