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This year presented significant challenges for clinically integrated networks (CINs) delivering value-based care, with the disruption from Medicare Advantage reaching widespread levels. As we look toward 2025, it is crucial for CINs to reflect and gear up for success  by focusing on risk-based contracting, engaging specialists, and investing in care management. In this episode of Value-Based Care Insights, Dan Marino sits down with Dr. Will Faber, to tackle several challenges, including the lack of structure among commercial payers to effectively handle value-based contracts and obstacles in negotiating such contracts with specialty providers. Gain insights into strategies and data utilization that will position your provider organization for success in 2025.

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. Recently I was working with a number of healthcare leaders who were working in a health system, and have a very successful clinically integrated network. And I had the opportunity to work with them on helping them with their strategy finishing out 2024 and had a real interesting discussion with them around where our clinically integrated network, or where their clinically integrated network, needs to go, and how it needs to expand as we move into 2025. And as I thought about that discussion, I thought, you know, that would be a fantastic topic to discuss on our program today, especially as organizations are starting to prepare for a lot of their strategic initiatives as we head into 2025.  

Well, I am excited to have a longtime colleague of mine, Dr. Will Faber, join me on the program today to talk about this topic. Will and I have gone back, probably. Oh, gosh! At least 15, maybe 20 years have worked together on numerous, with numerous organizations, helping them set up their clinically integrated network helping them to improve their network performance and so forth. Will right now is an interim chief Medical Officer for a large CIN that's in the Northwest. Will very excited to have you as part of the program today.  

 

Will Faber:

Great to be back with you, Dan, and thanks for this opportunity. 

 

Daniel Marino:

So will, as, as I mentioned, ending the year ending 2024. It's been interesting to see how value-based care has continued to evolve in this in this past year. And a couple of things if I think back on the year, have sort of resonated with me, I think one is that the commercial plans continue to offer these value-based care products. There's no structure around any of the products that they offer, meaning that, you know, Aetna versus united versus anthem. All have different types of products. I think the second thing that I've noticed is there's been a high growth, continued high growth of Medicare advantage, with many Medicare beneficiaries joining MA the MA world. Yet there's been a lot of pressure from providers around the performance of those plans, and that many of them have backed out. And then I think the 3rd piece that I've seen is that there's been this continued pressure on CINs to move into risk right? And providers community to engage in a lot of their risk contracts with their payers. What are you seeing how any of those 3 things that I mentioned. How are they resonating with you? 

 

Will Faber:

Absolutely well when you and I were setting up clinically integrated networks 10 years ago. It was a relatively small stream compared to fee for service. But you talked about 2024, that was the year when more Americans were more Medicare beneficiaries were in Medicare advantage plans than in straight Medicare, and that trend is not going away. More and more people are going into Medicare advantage, which is a risk product. 

 

Daniel Marino:

Yeah. 

 

Will Faber:

Then you think about Medicaid being managed in almost every State. And then these commercial plans are popping up like mushrooms. They're definitely getting into the value-based care world now, too. So it's a good thing there are CINs because you need a lot of infrastructure to manage these. One of the big observations that I've got over the last 2 years which really hit us hard in 24 is the inflation of healthcare costs, particularly around pharmaceuticals, and we're going to get into that here today in terms of what we should do strategically and tactically about it. But the bottom line for the for your listenership here today is to realize competition amongst these MA plans and amongst the commercial plans have them in such a state that they often offer a 0 premium plan because they're just trying to get market share. But 0 premium means they're not taking any more top line revenue in. And if expenses are going up, which they are, that is, shrinking the pool of available dollars. 

 

Daniel Marino:

Yes. 

 

Will Faber:

One of the big points I'll make we'll come back to it is that more than ever CINs have got to negotiate very assertively with the payers to make sure the provider gets their fair share, or, as you say. The providers are going to lose interest and drop these plans, and we're seeing that in the news every day. 

 

Daniel Marino:

Well, you're absolutely right. And I think from you know, from the plans perspective, you're right. They're offering 0 premium plans to the consumers. So they're not getting any more revenue. The medical costs continue to go up, so they're putting a lot of pressure on the providers and providers are pushing back. I have a number of client organizations around the the country, particularly the rural community, who are basically saying, Look, our denials for services have gone up tremendously. We have to hire one to 3 new FTEs just to manage the pre-certification. It isn't worth it. And so, as organizations think about how they need to position themselves in this next year, I think, for these MA plans, It comes down to the negotiating right. You have to negotiate out some of these pre certs to make it more efficient. You also have to understand how you create more of a collaborative approach with your payers, so you can really drive to performance, not just drive to the bottom line. 

 

Will Faber:

Absolutely. You know, any good business plan is a collaboration where both parties win and the way the traditional risk models were set up, it was relatively easy, because there was more money in the pool. As the pool shrinks it's getting more fierce. And we have to go back and revisit those contracts whenever they come up for renewal. Take a hard look, get professional help. Preferably somebody who's worked for insurances. 

 

Daniel Marino:

Right. 

 

Will Faber:

You know there are partners, and I keep reminding the payers that they are partners of shared savings implies a win-win. So you've got to put certain things in your benefit plan that cooperates with what the provider wants to do to curb the cost of care. Another 2 things we're going to talk about here today, I'm sure, is technology. And the other one is how you engage with specialists because so much of the spend now is being controlled by specialists. For years and years I've done population health management where we're working with the primary care doctors to limit utilization per unit. But if the unit cost has gone up 20% in the last 2 years, it totally swamps the effect of carving 1, 2, 3, 5% off of utilization, and a lot of the unit cost spend is in chemotherapy, biological, infusions that are done by rheumatologists and others. And the GLP one drugs. They're killing us. 

 

 Daniel Marino:

Yep. 

 

Will Faber:

Have to work with the payers on some reasonable limits, to that and or new ways to work with the providers, to control that cost of care. 

 

Daniel Marino:

Well, you're absolutely right. Well, you know I've I get asked a lot is  organizations are thinking about their payer strategy as they're thinking about shifting from, let's say, from shared savings to taking on risk what's required. Right? What's the path? And I always I kind of bring it down to the simplest terms. And I say, you know, there's 4 things you really need to focus on. You need to focus on your data and your analytics. Right? You need to understand what's going on and why. And that's what the data is going to tell you. You need to make sure you have a strong network that's aligned right? So all your providers, your specialists, your primary care, even your post-acute providers, have to be aligned in a strong network. But the 3rd and the 4th point that you bring up are critical. We have to engage the specialists different in a risk-based environment than we previously had, and you have to have the infrastructure to support it. Right? You have to have the analytics. You have to have care management, you have to be able to provide the right level of support to the network, and in particular to the specialists. But really, I guess to all the physicians that allows us to create efficiency, to drive down that cost of care. 

 

Will Faber:

Well, yeah. And analytics can tell you a lot in the CIN where I currently work, we got a big Milliman study to show us, basically where the money was going with our specialty providers. And there's a particular cancer center that's way out of line with Milliman standards. 36% above the national spend. Well, in the old days we spent so much focus on the primary care doctors, and you know there's only so many hours of the day to get around to those people. But now we absolutely have to be out in the offices of the specialists with credible data. And of course, if it's not credible, you're going to lose any doctor in the conversation. So you got to do your homework to make sure you're going out with an apples to apples, comparison of their cost. But there's no escaping having those crucial conversations with the specialists, just like we've always had with the primary care. Doctors. 

 

Daniel Marino:

Well, and I think the time is right to do that, especially as organizations are thinking about assuming into risk. We have worked for years as an industry in the value-based care world, working with our primary care, physicians to build their expertise, build their support structure around managing the chronic diseases and that high risk population right? And I sort of say, you know, I sort of describe it this way. That's been the chassis of our value-based performance. But now, if we're going to take it to that next level, we have to do a better job of integrating the specialists, right? We need to think about to your point earlier, how the specialists are influencing the cost of care and how we could. We can change that paradigm, you know, keeping them whole to a certain extent, but changing the thought process, moving from straight fee for service to that you know, that's basically encounter base to making it more performance based in the value-based care world. I don't know if you have any thoughts. What are some of the specialty measures that you're seeing that maybe you know that have been, let's say relevant. Or you know, that have really made a difference to help specialists kind of move from that fee for service to fee for value. 

 

Will Faber:

Well, you know, each of the specialties has a professional society, and they often have quality metrics. I've helped map these to CINs for many years, and some of them are particularly good. Particularly on oncology, where a lot of the a lot of where the spend goes. Today, I'm a big fan of NCCN guidelines. 

 

Daniel Marino:

Sure. 

 

Will Faber:

So things like chemotherapy administered in the last 14 days of life is a great one to talk to, to kind of uncover where certain practices are highly aggressive frequency of imaging protocols for follow up, you know you're going to see them every month. You're going to see them every 6 months. Things like that can make a big difference. But I want to point out a couple other things you can do as a strategy with specialists. If specialists are under coding, and they need to be doing HCC coding just as much, if not more, than the primary care doctors. It makes a huge difference even if they're expending more money on some of these drugs or infusions, or the treatment protocols which, they may argue is state of the art, I'm going to say, yeah. But if you've got a bunch, you know, you're telling me your patients are all stage 4, 3 and 4, and they're sicker. I said, well, then, why is your coding index lower. 

 

Daniel Marino:

Right. 

 

Will Faber:

Than the other group over here, because that I mean, that actually brings in more revenue. And I can't skip over how critically important HCC coding is across the entire network. There's some wonderful new products that are coming out technologically to help us capture that. And as everybody knows, on the call, if you're not moving forward. If you're just staying stagnant with HCC coding, and the rest of the world's going forward. You're going backwards, and you're losing revenue to help offset these costs. So HCC coding is important, and you got to support the specialists in that, too. 

 

Daniel Marino:

Yeah, you are absolutely right. Well, if you're just tuning in, I am Daniel Marino, and you're listening to value-based care insights. I am here today with Dr. Will Faber. We're having a great discussion on advancing your clinically integrated network into 2025. So Will, I want to talk a little bit about kind of building on that around the specialty measures and maybe around the specialty integration there. You know, the we've really have relied on our primary care physicians, to sort of be that that quarterback of the care right? And I think it served us well. But as we start to think about integrating specialists and the performance outcomes that are critical in a risk-based contract, and I'll throw a few out at you. And you know these off top of your head right? So you know, focusing on the 30 day readmission rate and making sure you know that is as efficient as possible. Transitions of care, making sure that your transitions are as efficient as possible, making sure that as we're looking at delivering care, not just to the high risk population, but to the rising risk population and that efficiencies that really drive down the cost of care again critical to a risk-based contract. How are you seeing the relationship between primary care and specialists evolving? What are the things that that a CIN has to put in place to ensure that that collaboration is there? 

 

Will Faber:

Well, for one thing, if you're a big enough CIN and a big enough market to enjoy multiple specialists, that's always multiple specialists in the same field is always a great thing, because I go to my primary care, doctors, and say, Do you want some shared savings at the end of the year? Well, then, I want you to know what Milliman says you can send to this specialist that's X above the National Benchmark, or you can send to this one, and we're going to show you that the outcomes are equal. So that's 1 strategy. But lots of CINs are not big enough to have more than one provider in each specialty group. Then you have to go out, as I stated. Well, you want to do this in any case, and work with the specialists. Here's a 3rd thing you can do. In the CIN that I'm in right now. We long ago divided specialists in our incentive compensation distribution from what so-called high impact specialists and low impact specialists. There are some specialists that really don't impact the cost curve very much. But cancer is a great example of something where there's a big impact on total cost of care. So consider segmenting your specialists as well. And then, yeah, big fan of not just asking people to do things, ask people to do things, but also saying, here’s how we're going to support you producing that result for us, and sometimes they need help with their technology to get their workflows better, better HCC capture methodologies, other ways to track their costs and expenses. 

 

Daniel Marino:

Well, I agree with you, I think, getting back to a point you made around the compensation and the incentive design. I really believe that's where it starts. You know, I'm a proponent, and I've said it time and time again on the program. Form follows function, and if you are going to. If you want to achieve a certain behavior, you have to create the right incentive. And for specialists I don't feel like you can put all specialists into one bucket. I feel like you need to create in certain incentives for the medical specialists certain incentives for the surgical specialists, certain incentives for the hospital based specialists. Now, in some cases you need to have those incentives that are network based. But each of the specialty areas influence patients in the cost of care different. And if you can start to align those, I feel that that's how you're really going to achieve those. You know, the goals that you want out of that level of collaboration any thoughts with that? 

 

Will Faber:

Absolutely. So we talked about certain medical specialties where there's a high drug cost. All the payers give us feedback on where the money went, and when it comes to surgery, I think we all know the name of the game is to take anything that can be done safely out of the hospital into an ambulatory surgery center that can often be a win-win for the surgeons, because they're often the co-owners in a joint venture of the ambulatory surgery center. 

 

Daniel Marino:

Right. 

 

Will Faber:

Now the hospital might get a little bit upset with you. But I have a different argument with the CFO of the hospital about the role of the CIN in this whole value-based care world. It's not our fault that patients are choosing value-based care. Don't you want us to manage our value-based care contracts as well as possible, and that involves sometimes taking people out of the hospital. But, again, if you can incentivize surgeons to do more care in an ambulatory surgery center, never decreasing the quality of care, never taking an inappropriate case out of the hospital. Please always hear me on that one. That would be an example of aligning incentives with surgeons. 

 

Daniel Marino:

Yeah, I agree. So you know, again, I think you know just a piece of advice for clinically integrated networks as you're moving into 2025, give some real thought to the specialty incentives and the compensation piece, because that's what's really going to help drive some things forward, especially as you're assuming risk. So Will, one of the one thing I want to also get your opinion on. I often get asked how quickly organizations should move into assuming a risk based contract. Right? They're getting a lot of pressure from the payers. I just, we just got done negotiating one contract with a very large payer for one of our clients, and it was a predominant fee for service contract but over 4 years, but in year 3, and then in 4, the payer wanted to include a risk component or an incentive based component to the contract right? And they were throwing out a few more percentage points there. So you know again, it's real. So I guess when you think about it. What are some of the things that can be done to advance or ensure the right level of fee for service growth, as well as those things that will then position us for fee for value. I have a few things that come to mind, but any thoughts that you have? 

 

Will Faber:

Well, some of this is out of our control. People shifting, due to the cost of the premium from straight Medicare to Medicare Advantage is a shift to Downside risk. I mean, it's a shift to risk. And of course CMS has stated that by 2030 all straight Medicare is going to have Downside. There's no getting away from it. And I remind listeners if doctors think they could just jump out of value-based care because it's not so attractive anymore. No, you don't want to go back to Medicare. Then, taking away some of the reimbursement they give you for being in an advanced payment system, and you certainly don't want to do MIPS reporting again. We're in this for the long run. So we got to learn how to make it work. But the other point I make is competition. Again, this changes market to market. And I've said this for years. Your strategy changes according to market realities. Rural systems are playing a completely different game than big metropolitan areas where there's competition. And you just have to make sure you've got a potential payer out there. But I'm not abashed to say that when you've got 3 different Medicare advantage plans in your neighborhood, all vying for the patients that gives you some leverage as a provider to negotiate, because if a rural player says sorry you've made terms where we can never win, and we pull out what that means for payer one, is that all their patients are going to have to find product in payer 2 or 3 that was willing to work with us. So. 

 

Daniel Marino:

Yeah, I agree with you. 

 

Will Faber:

I'm a I’m a doctor. I used to do this just to manage cost effective care on the ones. But now I've become a hard nose negotiator, because these payers have got to either cooperate with us or we're going to have to find another payer. 

 

Daniel Marino:

Well, and I think I think, moving forward with that that philosophy of collaboration with the payer. I mean, you know, that's the big difference between fee for service and fee for value, right? And we. We have to change the conversation to make sure that we are collaborating, and I think we've got to collaborate on some really key areas. I think one collaborating on our transitions of care. As an example, payers have their case managers who are, you know, they know who the high risk patients are. Those case managers are calling patients. For CINs, transitions of care is also an area so that becomes an opportunity to really build it and to establish some level of collaboration. But I think to your point, too, you have to understand what your differentiator is in the market. I think you also have to understand what are the key drivers, but you need as a CIN, as we enter into 2025, and Medicare advantage isn't going away. How do we create more efficiencies within our own CIN to position ourselves around that level of success? 

 

Will Faber:

Absolutely, and I know our time is running out. But to this point, not everything that I'm talking about is being a hard-nosed negotiator. There are lots of win-win strategies, and that's what you're making reference to. You know, payers that are in risk products. Get it that what you do these days is to control total cost of care and to decrease unnecessary readmissions is decreasing. The MLR. That's good. All I'm saying is, if that produces a pool of money, share it fairly with those of us who are helping control those readmissions. 

 

Daniel Marino:

Absolutely well, well, this is. This is fantastic. I know. You know the lot of lot more discussions going to ensue in terms of how CINs and ACOs need to continue to evolve as we move into 2025. I think we're going to continue to see different types of MA plans. MA is going to continue to grow right. We're entering into open enrollment now. So by the end of December we're going to know the number of total enrollees, and I'm sure we're going to see an increase, but also position ourselves around commercials as well. You know, I think that's going to be key. Well, my friend, thank you for coming on always great to talk with you Will, and wish you a lot of success in the work you're doing, so glad that you still have your hands in all of the buckets and doing quite a bit of work in the in the value-based care front. 

 

Will Faber:

Great to talk to you, Dan, and thanks for having me on the show anytime. 

 

Daniel Marino:

Well, thanks again. I appreciate it, and a special thank you to our listeners until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

 

Success in the operating room is critical to the financial health of many healthcare organizations, with perioperative services contributing up to 75% of primary revenue streams. Effective perioperative care relies on skilled nurses who balance patient care while collaborating with other teams. In this episode of Value-Based Care Insights, Dan Marino sits down with Cindy Mahal, Chief Administrative Officer of Providence Saint Joseph Medical Center, to explore the challenges nurses face in achieving alignment and how to overcome them. We’ll uncover insights into key strategies administrators can implement to empower nurses, giving them a voice and enabling them to not only align but also lead.

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value based care insights. I am your host, Daniel Marino. Over this past year, and probably for the last couple of years. Hospitals and health systems are still focused on improving their financial performance. And they're really doing it in a couple of ways. Right? I mean, you're focusing on trying to create more volume. Of course you're limited by the reimbursement that we get from payers, but we're also focused on reducing cost. And cost reduction through performance improvement or quality improvement has been a pretty significant initiative. Of course, driving financial performance for hospitals and health systems is really based on your Surgical services. Surgical services, perioperative services. Whether it's in the hospital or the Ambulatory Surgery Center accounts for anywhere between 55 to maybe 75% of overall revenue. It's considerable. So the focus on creating efficiencies in your OR through making sure that your on-time starts are occurring on time, turning around your rooms efficiently preparing patients, both pre-OP and post-OP. All of those items go into the efficiency and impact your revenue as well as impact your cost structure. And of course, the alignment between the hospital and the surgeons is really an important factor in making that happen. However, when you look at what it really takes to drive that performance. The nursing support is really the key in our opinion, in my opinion, to driving that success. And having strong alignment with the nurses that bridge the gap between what's required within the hospital and the health system and leadership, and with the surgeons is really what then drives the results. But it's a difficult role for nurses, and many nurses find themselves in a predicament where they have certain requirements of the hospital and leadership but patient care requirements for the surgeons. 

So here to talk about that is a Senior Level nursing executive. Someone I've known for quite some time. Cindy Mahal. She is the chief administrative officer for a large health system in California. Cindy has held numerous leadership roles, including nursing leadership and surgical services and in other areas of health system. She's also COO and in charge of the vision operations and strategy for a large system in California, Cindy, welcome to the program. 

 

Cindy Mahal:

Thanks, Dan. Thanks for having me. 

 

Daniel Marino:

So Cindy, as I mentioned oftentimes what we see, and I and I hear this a lot, either from the surgeons or from leadership, that the alignment of the surgeons with the vision of where the hospital wants to go around perioperative services or surgical services is critical. But really the key in making this work is, nurses and nurses are, they're challenged with this right? And I think for a whole host of reasons which I'd love to dive into. But why do you think that nursing oftentimes, as we think about making those changes? Why is there such a challenge for nurses. Why are they placed in this in this difficult role? 

 

Cindy Mahal:

Yeah. And I think from a nursing perspective, when you talk to the nurses at the at the bedside, believe they're balancing patient safety, which should be our priority with efficiency right? And they also want to find meaning in their work. They don't want to be this factory worker who's being pushed to go faster or focus on metrics. They want to focus on patient care. So it really puts them in a very difficult spot. They do know that, you know, surgery makes money. So you're part of that machine, and you have to accept that but you also want to be able to make sure you are focusing on your patient so. And we know surgery is an extreme sport, right? That is an extreme team sport where everyone has their role, and we all have to work together, and each of us have competing priorities. So I think nurses are put in a in a tough spot to get what we need for the patient, for the physicians and for the organization. 

 

Daniel Marino:

You know, we've been part of a number of perioperative improvement engagements and some of the consulting work that we've done. And governance is always a really an important part of that right. And what we see as part of that is that that's where leadership and the surgeons have to come together to create the common version of process or performance improvement. But then it's really led and directed by the nurses. What do you feel like? The nursing role should be in driving that change? How much influence should they have? Or do they have in working with the surgeons? 

 

Cindy Mahal:

Well, nurses have to be at the table, right? Because we're the ones getting the. I hate to say it getting the work done and seeing the big picture of what everybody needs. So you have to get their buy in. You have to be able to say, what are the barriers from your perspective, because the physician will tell you their barriers, you know. They'll say, Oh, it was a 40 min turnover when reality it was 25. You just weren't in the room for a significant portion. But, you know, talking to the nurses to find out what could we do to help them meet this target in a reasonable, right? I mean, you'll get things from well, we need 5 more of this, or give me a reasonable solution to kind of help you. So really bringing nurses to the table, explaining to him the value of why we're doing this right? We are very common sense people. We understand the whys behind thing, If it's explained to us in a proper manner that you know the or is your cash cow, and we need to keep things going in order to keep this organization going, and so be a part of that. Be a part of the success. And you know we'll highlight you. So I think that's really important. 

 

Daniel Marino:

You know. Sometimes I think surgeons could be a little difficult to work with. Right?  

 

Cindy Mahal:

Sometimes. 

 

Daniel Marino:

Just sometimes. And do you see situations where for those challenging surgeons, the nurses kind of put in the middle of this, right? How do you, how do you deal with that? That difficult surgeon, that surgeon, who, you know, wants to do it their way? They may have a number of reasons for that. So either their practice style or maybe they're extremely, you know, they have just a real busy practice. What wouldn't nurses do? They're like stuck in the middle. 

 

Cindy Mahal:

And I think you know those are the best ones to start projects with. Because if they're a success, then you've got them, and others will say, Hey, if so, and so can do it, and I know he has his, his or her routines. Then it must be something I need to get on board with. So, 1st of all, working with that surgeon to seek to understand.  Why won't you participate with me? Help me understand, because this is going to benefit you as well, and your patients. So really trying to get the buy in and bringing that group together and seeing what the win is for each of them. But I do like, you know, tackling that difficult surgeon and saying, you're gonna do this with me, and we're gonna be successful. And you're gonna see a benefit in the end, and I need your partnership, right? Pleading to them for that, because they do want to, partner they all have. We all have the same goals. We may articulate them differently. But I think you know, seeking their partnership, working with them, explaining to them what the nurses are doing, and why. Because sometimes they may not understand that, or their state requirements, why the nurse must do this, or must ask these questions, or take time with the patient. 

 

Daniel Marino:

Well, and maybe to your point. Maybe the surgeons don't really recognize all that right. I mean, really busy. And they're focused on again, taking care of the patient and performing the procedure, and probably getting in and getting out as quick as they can. Or you know, I mean, there could be other influences there. But I think you know, when I think about performance improvement, and I think about that level of support, you know, there's a there's, there's a couple of really important elements that come into play that drive that success. I think one is the operational support that if nurses are leading this, and they should or be a, you know, significant contributor, having that right level of operational support is so critical. But then, having the cultural change report the support as well, too. What role should administration play in supporting maybe the nurses, or the process in ensuring that that right level of both operational and culture support is occurring? 

 

Cindy Mahal:

Yeah. And you know again, as leaders, we have to lead by example. And I think that is key. And from an administrative perspective, again seeking to understand. Why can't we get to this target? And what can I do to help the nurses get to this target? I think that is something that's really important and not treating people as if they're not wanting to do the right thing right, giving them the benefit of the doubt to say, you know, we all have pride in the work we do, so why wouldn't I want to be, you know, the most efficient and the highest quality OR around. Of course we want. So people do want that, and for administrative to be supportive. And if we do have barriers helping us break it down right? Helping them break down why we have this barrier and letting them know, giving them the kudos when they do have some small wins. I think that's really important rounding in those areas. If we know we're kicking off a on time, start project from an administrative perspective, be around, be visible, show your support. So that way the nurses and the physicians all know that you've got administrative support for this as well. I think that's really important. 

 

Daniel Marino:

Well, and that's such a good point. I think administration has to be visible right? They have to be visible, and at least be able to show that support. Because I you know, as we've talked about. And I've heard this from many nursing leaders. They sort of feel like they're on an island sometimes on their own, and you can't just do it on their own right. This has to be a team based approach. And there's it's difficult. It's difficult whether you're managing the culture, change the operational change, you know. I mean, there could be a whole host of reasons that are influencing it. 

If you're just tuning in. I'm Daniel Marino, and you're listening to value-based care insights. I am here today with Cindy Mahal. She is a chief operating officer of a large health system, a seasoned nurse executive, and we are talking about the nursing support or enhancing the nursing support that is required as organizations go through improvements in surgical services. Cindy, I wanna I wanna get back to kind of the role of the nursing leader if you will. You know when you, when you think about surgical services, and you think about the services that are occurring either in the ASC, Or in the hospital OR, you know you'll have the director of nursing who's in who's in the OR and then, you know, you'll have the or nurses that are included in in there. How should that team work together come together to support any type of perioperative improvement process? 

 

Cindy Mahal:

Well, they have to be a team, and they have to be able to be empowered to take chances, take risk right? And really put themselves out there. And then, as an executive leader like myself, I have to be there to give them opportunities to, to shine, to excel, to build their confidence because it is a tough. A tough, OR is a tough environment to work with. You've got a lot of competing priorities, a lot of big personalities. So as a nursing leader, it's my job to support them and create a psychologically safe environment where they can come to me with different things as well as empower them to make mistakes. Hopefully they don't but feel confident enough where, if they do make a mistake. They're going to be supported. So, we have to grow our own leaders because leadership is tough. People don't really want to take on that 24, 7 responsibilities. You never know what's coming at you. 

 

Daniel Marino:

As you mentioned, you have to. You have to have the more what I would call maybe the junior nurses really engaged in the process right? I mean, if they're if they're part of the improvement process, the perioperative process, if they're being held to the same standard, if they're part of the outcomes that are being measured. Then, you know, again, they feel like they're contributing to it. It's a growth area for some of these junior nurses. But I also feel like some of these folks that are, you know, that are actually in the OR doing the work. I mean, they've got the answers right. They know some of the things that that could either are creating bottlenecks or challenges in in the OR. Engaging them is just so critical. So in your experience when you've done, when you put forth a lot of perioperative improvement initiatives. Talk a little bit about the type of teams that you've created that has focused on engaging the nurses. So in in such a role that you know you're hearing from them, and they're part of the process. 

 

Cindy Mahal:

Yeah. And I think part of that again, we talked about being visible, you know, being rounding, being available, watching what they're doing, watching their struggles, but also giving the nurses opportunities to be able to highlight their knowledge base and building them up. So simple example, if we're working with a supply chain meeting, and they're talking about orthopedics, you know, having that orthopedic team leader on the line and letting her be there to explain the whys behind certain choices, or showing, giving her the ability to shine, to be quite honest amongst her peers. So that way you can build their confidence, and they can take on different things. Having some of the team leaders also take on certain projects. Right? I think that gives them an opportunity to be able to learn different skills, expose them to different leaders in the organization as well, so they can grow and see which leadership styles and tips they like but I think, really giving them opportunities. And when I pick my team, you know, I pick people who 1st of all are hungry to learn right? I will teach you whatever you want to know. And people who want to grow, that's great. There's yeah. You you see it. You know the people who are looking at you, engaging and asking questions, and then sometimes I'll pick a naysayer, just because I want to say, Yeah, if I can turn this one around, then you know, others will follow right? Just to give them that exposure. 

 

Daniel Marino:

Yeah, I like, I like that philosophy, though getting the you know, the staff, the nurses involved that are hungry, right? That want to learn. Because, boy, they can, you know, that's a great way of changing the culture. So when you, when you think about perioperative services, when we've worked with a number of organizations. We looked at a couple, you know, you look at a couple of really key statistics. Right? You look at block utilization. 1st case on time start. That's a big one, right? Because if you don't start on time for that 1st case that you know, you sort of have a trickle down effect throughout the day. That's hard to pick up and then turnaround time of the rooms. So when you create those, let's say, overarching macro statistics that are affecting the overall performance of perioperative services. Do have you in the past parsed out specific KPIs for your nursing team that says, Look, in order to achieve, let's say, the turnaround time that we need of these rooms as a nursing team we need to do this. Have you gotten to that level, or do they? Are they held responsible to those larger Macro key performance indicators? 

 

Cindy Mahal:

A little bit of both. We've tried when we had the key performance measures for turnover, because that was one that I really focused on, because that's a that can be a lot of downtime and a big physician to satisfy her. Really, working with the teams on the support they needed, and having those nurses involved in that. What is it? What is it going to take? What can we do to do that? We did that for a couple of years where that was part of their performance. Review. Right did they meet that. But It had to be. It had to be tangible again, just like, you know, when I have a goal that I know there's no way, I'm going to meet that right? So how much energy do you really give to it? So really making that, you know, having the goal and then potential a little bit of a stretch goal to see what we can do to give the team a little something to rally around. We've also tried other metrics where we and I've gotten this from my other OR AORN leaders when we meet annually to talk about different team concepts where you could incentivize teams and have goals for specific teams, physicians, and nurses. Your, you know, your non licensed practitioners in the in the OR as well. How can we all work together to get this turnover to where we needed to be as well as the on time start, and then creating some sort of financial incentive. It's not huge. It's not like we're throwing millions of dollars. But at least it's something. 

 

Daniel Marino:

Yeah, that kind of behavior, right? Rewards the work that you're putting in, plus it gives you an opportunity to celebrate the successes. Yeah. So I I agree with you. 

 

Cindy Mahal:

Right. You're building a team, and everybody wants to be part of something. And with your part of this team, and you're really kicking it out. You can see it when you walk down that hallway, you know which teams are doing it and which teams are not right? They're together. Okay, I'm going to get the patient. Okay, you go get this. You know, you get that. Okay, anesthesia. Are you ready? Yeah, I'll meet you there. So you see, when it's when it's humming. 

 

Daniel Marino:

Yeah. And you're building that excite. You're building that excitement. And I agree with you. And I think an important point that you brought up, which I think is really critical. You know. Again, I've done numerous performance improvement engagements, and I always believe that if you can't measure it, you can't manage it, and you need to have goals right? So I think for perioperative services. If you have a team goal and you have indicators that are being measured, and then you have, say, surgical goals as well as how you're measuring. But then nursing goals and indicators of how you're measuring. Then, all of a sudden all of those pieces. You know that behavior, that the work, the performance, improvement. You're tying that to some type of an end goal, right so to kind of like that shining star. And then not only does it allow you to ensure that you're moving at the right pace and achieving what you want to achieve. But you're able to celebrate the wins, which, frankly, I think doesn't happen enough in a lot of the work. 

 

Cindy Mahal:

I agree, or we celebrate quickly, and then we move on right? And I think we I don't know. That's because we're just in a such a fast-paced environment and high intensity. So we forget. 

 

Daniel Marino:

We do. Yeah. And I'll tell you. You know it's good to sit back once in a while, and just, you know, celebrate the wins, because, you know, there's it's a hard business that we're in. And, as you said, it's stressful, and especially for the nurses. I give a lot of credit to the nurses who are placed in these difficult roles because it is, it is stressful, no doubt about it. So you know, for any of our listeners, for folks that are tuning in. And you know, as I said in my opening comments. Many organizations, you know, and I would almost go so far as to say, maybe all hospitals and health systems have some opportunity, one way or another, to improve perioperative services. And again nursing is so critical towards achieving that goal and making that happen. Any piece of advice come to mind where organizations should start, or how they should better align their nursing team to accomplish some of those goals? 

 

Cindy Mahal:

Well, I think they have to have them at the table right? I think I've been from the bottom to the top, so I know what it's like to be in that boardroom where someone is setting that goal for you. And you're like, wait, wait, you know. Hold on right now we've got 25 nurses and orientation, and we've got this and that. And you know this is not the time to do that. So really, making sure that you have nursing at the table to understand what's going on there and in the culture to help them. But listening to the voice of the nurses, what can we do? Where's our? Where's our biggest problem? What can we do to get a couple quick wins right. I think you want to at least kick off a project, not taking on the biggest monster in the room, but at least taking on a few little things. That can really help you. Having a retreat. I've done that before when I kicked off big projects, you know. Let's have a retreat. Get all the key stakeholders there, and let's hash it out in an environment that is not in the workplace where we can talk about it, and people feel comfortable. 

 

Daniel Marino:

I love that idea. I love that idea. 

 

Cindy Mahal:

That has helped. 

 

Daniel Marino:

Yeah. It gives you a great opportunity, then, to brainstorm, to feel comfortable, you know, in in a safe place where you know, you can talk about not only where we want to go, but identify the barriers which oftentimes the challenges and barriers. Many folks know it, but they're afraid to verbalize it, and I think if you're in a safe space in a retreat, great place to do it. 

 

Cindy Mahal:

Yeah. Yeah. And then I always throw in a little bit of leadership development as well. You know, we'll talk about crucial conversations, or we'll talk about how to create a culture of psychological safety. So it helps them. So they walk away with a little tool for their toolbox as well. 

 

Daniel Marino:

Yeah, and then the other one that I would add to that. And you mentioned it earlier is making sure we have the administrative support there, because I often do feel like, you know, in talking with many of the nurses nursing leaders, if they're facing a difficult challenge, you know, they have to turn to somebody right? There has to be levels of support there because it is a difficult role, and sometimes they're faced with some, some real tough challenges, whether it's issues of patient safety or understanding. You know how to begin to build the right culture of change. All of those things that administrative support is really key. 

 

Cindy Mahal:

Yeah. And I've been lucky because I've had even our system COO come to our retreats when we've had them, or the Presidents have been there to show support. So I think that's key. 

 

Daniel Marino:

Yeah, that's great. Well, Cindy, this is fantastic. And I appreciate you sharing some, your, your insight. This has been really, really valuable. If any of our listeners are interested in connecting with you. You know I'm assuming you're on Linkedin. 

 

Cindy Mahal:

Yes, I'm on Linkedin. It's MAHAL. Cindy. So please reach out to me. Love to chit, chat, and help wherever I can. 

 

Daniel Marino:

Good, good, well, and a special congratulations to you in your new role. I know it's, you know, kind of a big move for you to relocate. But I know you're gonna do great. And you've got a lot of great expertise and experience under your belt, which I'm sure you're gonna draw from in in your role as you move forward. 

 

Cindy Mahal:

Thanks. Dan. 

 

Daniel Marino:

Thanks, Cindy. I really appreciate it. And to you our listeners. Thank you so much for tuning in until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care! 

 

A coherent and consistent approach to evaluating and optimizing surgical patients not only minimizes avoidable harm and complications but also impacts inefficiencies such as case cancellation, delayed case starts, and turnover rates. Furthermore, avoidable complications are becoming more costly due to post-acute care utilization, readmissions, and never events. Facilities, surgeons, anesthesiologists, patients and families  all have a common goal of improving outcomes from the start of the surgical journey.  On today’s episode of  Value-Based Care Insights, Daniel Marino explores how to identify and capture opportunities to streamline care.  He is joined by Alex Hannenberg, former President of the American Society of Anesthesiologists and Adjunct Clinical Professor of Anesthesiology at Tufts School of Medicine, and Art Boudreaux, Professor of Anesthesiology and Perioperative Medicine at the University of Alabama, Birmingham. Gain insights into the importance of aligning and standardizing perioperative processes, and how to leverage data to reduce inefficiencies and costs, and improve patient outcomes.

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value based care insights. I'm your host, Daniel Marino. As I've mentioned time and time again on the program, I spend quite a bit of time in our consulting practice networking with a lot of hospital leaders around the country. And there continues to be a theme with many hospital leaders, particularly CFOs, where they recognize that there's opportunities to improve their overall efficiencies within their OR within their operating rooms, improve overall surgical services. But many of them struggle with understanding where some of that improvement would really need to come from. And, a lot of times, they're not even sure what the opportunity is. What they do here is that there's challenges from the medical staff related to perioperative services. They may have a maybe the chief of surgery coming into their office or to the CEO's office, and complaining about how inefficient the or is, or maybe we're late on our 1st time start, which is backing up the whole day, and it has such economic impact to the organization. And as I'm talking with folks around the country, oftentimes they're not really sure where to even start in in improving perioperative services. 

Well, I I'm really excited today to have 2 wonderful gentlemen join us on the program. With a tremendous amount of knowledge and expertise in this area. The 1st is Dr. Alex. Hannenberg. Dr. Hannenberg was a 2,010 president of the American Society of Anesthesiologists. He served as the chief quality officer and oversaw the Perioperative Surgical Home Initiative. He's also the adjunct Clinical Professor of Anesthesiology at Tufts University Medical School, or Tufts University School of Medicine. As well, we have Dr. Art Boudreaux. Dr. Boudreaux is Professor of Anesthesiology and Perioperative Medicine at UAB Health Services Foundation. He's also an anesthesiologist and a physician executive, and has servedpreviously served as the system chief of staff at UAB Medicine. Gentlemen, welcome to the program. 

 

Dr Alexander Hannenberg:

Glad to be with you, Dan. 

 

Daniel Marino:

So, Dr. Hannenberg, maybe we could start with you as you work as you work with hospitals and health system leaders and physician executives around the country. As I mentioned many of them. You know they're struggling with their perioperative services. Where do you see some of the biggest challenges occurring within the or within perioperative care? 

 

Dr Alexander Hannenberg:

Yes, I would park most of the issues we confront under the heading, Unwarranted Variation. And that is meant to say that you have multiple surgeons and proceduralists and multiple anesthesiologists. In many instances, everybody doing their own thing. And it is an inescapable truth that in that situation not everybody is doing it the best way, and not from the point of view of patient outcomes or institutional efficiency. So therein lies the opportunity to try to get all of the above-mentioned players aligned, and deciding how we are going to do that. And the we can cross, you know, different private practices, different departments, and so forth. 

 

Daniel Marino:

Yeah. So you know. And that makes a lot of sense to me. You know, I used to manage a number of physician practices years back, and one of the things that you know, I learned early on in my career was, physicians have different practice styles, right? So they have different ways of being able to practice, that's important to them. But it does create some clinical variation, and it does create a lot of inefficiencies, and especially when you think of perioperative care that inefficiency really does drive up costs and really does have a negative impact on patients. So, Dr. Boudreaux, when you're when you're working with organizations. What are some of the metrics that are important as we start to think about identifying these inefficiencies? Obviously some of these metrics are leading into a lot of increased costs. But what are some of the things that you look at? 

 

Dr. Boudreaux :

When we look at metrics of inefficiencies, such as the number of cases that are cancelled on the morning of surgery or delayed, because, an anesthesiologist or a surgeon doesn't believe that the patient has had an appropriate workup before the operation. Length of stay, readmission to the hospital because of surgical complications. Those are kind of metrics that we look at. 

 

Dr Alexander Hannenberg:

And those, and those obviously are the things, because, as you say, Dan, there are huge costs associated with them, that handicap performance and value based purchasing arrangements also because everybody's doing something different. The surgeon doesn't know what the anesthesiologist wants to do and vice versa. And there's a potential for conflict there. And to the extent that everybody knows what's meant to happen. Conflict is reduced, and culture is improved. 

 

Daniel Marino:

So when you, when you bring when you think about some of those metrics, and you think about some of the inefficiencies. Yeah, and not that we want to point fingers. But is it more? Is it more influential to have the surgeons being very aware of some of these metrics? Or is it more influential to have the anesthesiologists be aware of these metrics? Or maybe it's both bringing them both or both groups together, to say, Hey, look! The only way we're going to become efficient is to really begin to begin to collaborate on what a what we would consider a best practice approach. 

 

Dr. Boudreaux:

If everybody believes that they're if everybody believes that they're on the same page and the patient gets a standardized best practice type of care we will eliminate, eliminate a lot of the delays and the problems that happen on the morning of surgery. 

 

Dr Alexander Hannenberg:

And to your point, Dan. Both the anesthesiologists and the surgeons hate those delays and cancel a cancellations, and to the extent that they have a shared financial interest in value based performance. They also hate it for that reason. 

 

Daniel Marino:

Yeah, absolutely. I mean, you know, if you have the anesthesiologist there, and the surgeon comes in late to a case right? Then, you know, that's excess time that they're not able to perform, or to bill around it, and vice versa. Right? So I agree with you. I think it really does come down to creating the efficiencies of the overall process. So when you think about that, and you think about kind of bringing these groups together. What are some of the guiding principles that are important to creating some of these efficiencies? Dr. Handenberg? Any thoughts. 

 

Dr Alexander Hannenberg:

Yeah. Well, I think to the extent possible of sharing the evidence. To inform best practices is an important key to getting people on board, and it is not always possible to pull out a published practice guideline on every question but even locally vetting ideas about how we want to do something is a critical part of getting the adherence to a standardized protocol. And you know, let's not forget that most of these protocols and everything we're really talking about has a lot to do with avoiding preventable harm to patients and improving outcomes. And that's why we all chose the careers we chose. 

 

Daniel Marino:

Right. Well, at the end of the day it's patient outcomes and patient safety, right? And I mean, that's really what's driving it. So when you when you talk about these guidelines, how important is the data, right? How important is the data to really understand where some of our inefficiencies are? Or does it really just come down to understanding process and trying to hear to the guidelines to support the process? Dr. Boudreaux, any thoughts. 

 

Dr. Boudreaux :

Well, I think like in our institution. When we develop a protocol or a process for care, let's say if a patient is having surgery, and they take a diuretic in their serum potassium is within a certain range. We, as a as a faculty, agree that we will do the or proceed with the anesthetic. If the theorem potassium is within a certain range, and all of us have agreed to that, and we looked at literature to support whether that is a good idea, or that improves the care of a patient. So we have we have all gotten together on a numerous things like that, and agreed what we will do going forward. 

 

Daniel Marino:

So you have your clinical outcomes. You have your clinical measures right that are supporting good, patient care, which is absolutely key. How about some of the operational measures are there operational key performance measures that you look at that really drive some of the performance or identify the inefficiencies. 

 

Dr Alexander Hannenberg:

Well, I think the frequency of complications we've already mentioned. Things like same day cancellations, utilization of post acute care, optimize a patient meaning, identify problems and address them before surgery reduces complications, improves recovery. And one of the big financial outcomes of that is reduction in the utilization of post acute care. So those and readmission for sure, avoiding never events. There are lots of metrics to use, most of most of which, really come back to having the patient to the best possible condition they can be in before you take them into that operating room. So it's 2 parts. Let's make sure we identify problems early in the process at the moment surgery is contemplated and then go beyond that to say, Okay, we've identified, you know, poor diabetic control or anemia, or what have what have you? And there's quite a list, and we have a lubricated process for getting that addressed and fixed to the extent possible, so that the surgery can proceed in a timely fashion. 

 

Daniel Marino:

If you're just turning in today, I'm Daniel Marino you're listening to value based care insights. I'm having a great discussion with Dr. Alex Hannenberg, Dr. Arthur Boudreaux, and we're talking about opportunities to enhance perioperative services within the hospital ORs. And Hannenberg, let's just build on that for a second. So when you start to identify some of these clinical outcomes, some of these opportunities and even some of the inefficiency outcomes there. What are some of the solutions or the steps you want to put in place to create the right solution around the efficiencies? Are there models that are out there? We had mentioned best practice. What are some of the things that you look at to kind of drive this level of improvement in perioperative care? 

 

Dr Alexander Hannenberg:

The optimal arrangement is a predictable and agreed upon model for flagging and identifying problems. For knowing what to do about the about them and delivering on that in a reliable fashion. One thing I want to emphasize is, as I said before, you can think about anemia diabetic control respiratory, respiratory capacity and reserve. There's a long, long list, and there's a lot. A great variety of surgical procedures. One thing that I see as a successful approach is not a biting off more than you can chew. To say. We can choose in the total joint population to launch this kind of initiative around diabetic care. 

 

Daniel Marino:

Right? Well, and there's many organizations around the country who have I think, have started to really become quite proficient in implementing a lot of these best practices. I don't think they have to reinvent the wheel right? So there's standardized best practices that are out there that I think organizations can turn to. Dr. Boudreaux, when you're when you're having conversations with folks. You know. We've heard some pithy names around, for instance, like the Surgical home, or you know, other types of ways of being able to characterize some of these best practice approaches. What are some of the things that you've seen as organizations are turning to looking at some of these standardized best practices? 

 

Dr. Boudreaux:

Well, we look at the concept of the perioperative surgical home, or enhanced recovery after surgery is pretty popular around the country nowadays, and both surgeons and anesthesiologists realize that if we implement these standardized best practices for each patient that is, having a particular procedure, their outcomes would be better, and their efficiencies in the operating room will be better. As an example, let's say, a patient comes to have surgery for a total joint replacement, a hip replacement, and we recognize in the preoperative evaluation that they have out of control diabetes. Well, we know from the literature that those patients have a higher incidence of post-operative infection, reoperation or joint failure, and the like. So we can recognize that we can do something about it, gain better control of their diabetes, or, you know, postpone the operation for that to happen. And the surgeons are now all coming on board with that concept. We're all trying to work together to get the best outcome. 

 

Daniel Marino:

So, Dr. Boudreaux, when you, when you're talking through that, how important is the governance structure that you put in place to? I guess both align the surgency anesthesiologists around what that best practice is, but I would assume then to monitor it ongoing so you continue to improve? 

 

Dr. Boudreaux:

Well, governance is really important, and one of the ways that you can do that you can get a group of physicians together. A group of surgeons, a group of anesthesiologists, a small group. And have them get together and agree and look at the literature, agree on what they think a best practice would be for a particular operation, and everybody gets on board with that best practice and starts to implement. And what has happened? What has happened in our institution? At least the patients that go through this standardized process their outcomes are better. 

 

Daniel Marino:

Yeah. 

 

Dr. Boudreaux:

And their cancellations for fewer, and all the other surgical colleagues start noticing that. Hey, those guy, those patients are doing better than mine. 

 

Daniel Marino:

Right, yeah. 

 

Dr. Boudreaux:

And everybody now wants to get on board with that. 

 

Daniel Marino:

So there's really a culture change that that you need to really integrate as well as then the monitoring component right. And all of that really needs to be built into the overall governance structure. I would assume. 

 

Dr Alexander Hannenberg:

Yeah, it's governance structure. And it's what I would call clinical leadership that is influential thought leaders in a surgical domain need to be the champions, and that goes a long way to launching this in the right way and promoting adherence. 

 

 

Dr. Boudreaux:

And the hospitals have to. The hospital administrator has to recognize the benefit of this and to be willing to help fund it. 

 

Daniel Marino:

And help support it. You are absolutely right. And in a lot of my conversations that I'm having many of the hospital leaders, whether it's the CEO, or it's the CFO, you know, even the COO right that's in charge of operations. They're all willing to support it. But a lot of times either the medical staff politics get in the way, or they're not sure where to start. Having them part of that process. I think it needs to be physician, or, you know, certainly, physician led, but administratively supported. I think, as you as you pull that model together, that's what's going to drive a lot of the change. 

 

Dr. Boudreaux:

I hear him. 

 

Dr Alexander Hannenberg:

Have having a hospital administration understand the downstream benefits that come from a legitimate investment in putting this together is absolutely critical. You're a thousand percent right. 

 

Daniel Marino:

Dr. Hanneberg, you know, as you're you know, you were past president of the American Society of Anesthesiologists. You've seen the role of the anesthesiologist sort of evolve over time. What should their role be in this level of governance? In in some cases, what I've heard in talking with some of our anesthesia colleagues around the country. I mean, some of them feel strongly that you know they should be the ones that are really influencing some of these governance structures and perioperative care, or even running the board, if you will. Any thoughts there on where anesthesiologists, the role that they should take in moving this forward? 

 

Dr Alexander Hannenberg:

Well, the bi the bias will be obvious, but what I would say is that the training of an anesthesiologist focuses a great deal on the medical management of surgical patients, number one. And number 2. Anesthesiology is the single common pathway for all surgical or increasingly procedural care patients, that that is that the anesthesiologists take care of the cardiac patients and the orthopedic patients, etc, etc. And so that alone, I think, suggests that there's a logical role for the anesthesiologist at the core of this work. 

 

Daniel Marino:

Yeah. Well, my question was definitely meant to be a little biased there. But I love the answer nonetheless. But how important, then, is aligned incentives between the anesthesiologists and the surgeons. 

 

 Dr. Boudreaux:

Aligned to incentives are always important. I think all of us want to take the best care of patients that we can. We want to do it in the most efficient way possible, and we want to all have great outcomes. And I think if we all agree to that. And we work toward that goal We'll accomplish that outcome. 

 

Dr Alexander Hannenberg:

And so they're those are one type of aligned incentives. But you know, if you are living in a value-based purchase purchasing or capitated ma model. It is, you know, natural extension to build financial performance measures around some of the things we've been talking about. 

 

Daniel Marino:

Yeah. And that's really what my thoughts are. As well, too. I think you need to have some aligned financial incentives there, right? And there's different models that you can structure. But you know, form follows function. So if we have an idea of where we want to go, we're able to measure it. The incentives help us to get there, and they could be multi level of incentives. 

 

Dr Alexander Hannenberg:

So I mean, the only thing I'd say I'd say I'd say is, I don't need to remind you that time is money. A lot of what we're talking about is waste, you know, avoiding wasted time. There is just under the surface a financial incentive, even without a, you know, a capitated environment. 

 

Daniel Marino:

Well, and there is. I mean there's that financial incentives for the surgeons, but also for the hospitals. Right? So if you do this the right way. 

 

Dr. Boudreaux:

Right. 

 

Daniel Marino:

It would be a just, a natural collaboration around that level of incentives. Well, gentlemen, this has been fantastic. Last quick question for both of you, and maybe we could start with you Dr. Boudreaux. As organizations, as hospitals are thinking about taking a look and improving their perioperative care. Perioperative services, in your opinion, where should they start. 

 

Dr. Boudreaux:

They should pick a procedure, for instance, that they do the most of. 

 

Daniel Marino:

Yeah. 

 

Dr. Boudreaux:

Or a procedure, a procedural area where they're having problem the most problems. And they could, they should focus on that area 1st and get physician leaders involved in in this standardization process and try to fix those areas first. And once you succeed in fixing a specific area, it becomes contagious. 

 

Daniel Marino:

That really will drive the change. 

 

Dr. Boudreaux:

Right. 

 

Daniel Marino:

Yeah, so. And from your perspective down, Dr. Hannenberg, how about from the from the physicians? Where do we start on being able to bring the anesthesiologists, the surgeons together to really drive this change? 

 

Dr Alexander Hannenberg:

It is leadership and persuasion. The problems that drives you nutty every day understanding that what we're talking about is the solution to those problems. 

 

Daniel Marino:

Yeah. 

 

Dr Alexander Hannenberg:

And if that doesn't motivate the physicians and everybody who works with them frankly, the administrators, the nurses, and so forth. I don't know what will. But connecting those dots, the delays, the cancellations, the unplanned admissions, etc, and connecting that dot to why is that happening? Because we didn't do anything about the anemia or the diabetes, or whatever, because we didn't recognize it. And we didn't have a organized system to address it. I think that's the key to putting this together. We suffer problems every day, and our patients do as well. 

 

Daniel Marino:

You need to connect those dots right, and bring the folks together to look at where the challenges are, and then be very forthcoming in addressing them. Well, gentlemen, this has been fantastic. I really appreciate your time. And if anybody wants to connect with you. You know your organization that that you work with is ORDX. It's a perioperative consulting firm and should they go to your website, maybe you can give the website, address, or something in that regard. 

 

Dr Alexander Hannenberg:

That's an efficient way. Because art and I work with ordxrx.com is the website. And it is a multi professional surgical nursing, anesthesia collaboration to address problems such as the ones we've talked about today. 

 

Daniel Marino:

Yeah, well, it's a definitely a great organization. And I've enjoyed the number of conversations that you and I have had, and all of us have had, and certainly with your colleagues. I want to thank you for joining us today, and if anybody, any of our listeners specifically want to connect with either Dr. Hannenberg or Dr. Boudreaux. Please reach out to me directly at Dmarino@Luminahp.com, and I'll be happy to direct you. But, gentlemen, thanks again for your time. I really appreciate it. 

 

Dr Alexander Hannenberg:

A pleasure. Thanks for your interest. 

 

Dr. Boudreaux:

Thank you. 

 

Daniel Marino:

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

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

LISTEN TO THE EPISODE:

 

Daniel Marino:

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Daniel Marino: Yeah.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Daniel Marino: Oh!

 

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

 

Daniel Marino: Absolutely.

 

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

 

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

 

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

 

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

 

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

 

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

 

Lisa Stockdale: Exactly.

 

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

 

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

 

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

 

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

 

Daniel Marino: Unrealistic. Absolutely. Yeah.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

LISTEN TO THE EPISODE:

 

Daniel Marino:

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

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

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

Sameer Sheth:

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

 

Daniel Marino:

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

 

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

 

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

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

LISTEN TO THE EPISODE:

 

Daniel Marino:

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

 

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

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

Okay. 

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

Yeah. 

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

Yeah, it's true. 

 

Annette Kenney:

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

 

Daniel Marino:

Yeah, right. 

 

Annette Kenney:

And that's all. So. 

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

Sure. 

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

Really having a scorecard right. 

 

Annette Kenney:

Yes. 

 

Daniel Marino:

You're going to track it! 

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

Annette Kenney:

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

 

Daniel Marino:

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

 

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

LISTEN TO THE EPISODE:

 

Daniel Marino:

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

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

 

Joseph Bosco:

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

 

Jeffry Peters:

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

 

Daniel Marino:

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

 

Joseph Bosco:

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

 

Daniel Marino:

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

 

Joseph Bosco:

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

 

Daniel Marino:

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

 

Jeffry Peters:

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

 

Daniel Marino:

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

 

Joseph Bosco:

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

 

Daniel Marino:

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

 

Jeffry Peters:

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

 

Daniel Marino:

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

 

Joseph Bosco:

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

 

Daniel Marino:

Great Point.

 

Joseph Bosco:

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

 

Daniel Marino:

Yeah, it doesn't work now.

 

Joseph Bosco:

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

 

Daniel Marino:

Yeah, that's a great point. Great.

 

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

 

Daniel Marino:

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

 

Joseph Bosco:

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

 

Daniel Marino:

Yeah.

 

Joseph Bosco:

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

 

Daniel Marino:

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

 

Jeffry Peters:

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

 

Daniel Marino:

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

 

Jeffry Peters:

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

 

Daniel Marino:

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

 

Joseph Bosco:

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

 

Daniel Marino:

Right.

 

Joseph Bosco:

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

 

Daniel Marino:

Right.

 

Joseph Bosco:

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

 

Daniel Marino:

Yeah.

 

Joseph Bosco:

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

 

Daniel Marino:

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

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

 

Joseph Bosco:

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

 

Daniel Marino:

Great. And how about you too.

 

Jeffry Peters:

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

 

Daniel Marino:

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

 

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

LISTEN TO THE EPISODE:

 

Daniel Marino:

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

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

 

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

 

Cliff Frank:

Thanks, Dan. Glad to be here. 

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Right. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Yes. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Right?  

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

They're gonna call the doctor. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

Wrong. Place. Yeah. 

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Oh, yeah, yeah, yeah, absolutely. 

 

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

 

Daniel Marino:

Right. 

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. Well, and I can. 

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Yes. 

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. Cost, shifting. 

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Sure. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

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

 

Daniel Marino:

Good point yes. 

 

Cliff Frank:

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

 

Daniel Marino:

Yeah. 

 

Cliff Frank:

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

 

Daniel Marino:

Yeah, so. 

 

Cliff Frank:

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

 

Daniel Marino:

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

 

Cliff Frank:

It's always good man. 

 

Daniel Marino:

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

 

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

LISTEN TO THE EPISODE:

 

Daniel Marino:

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

 

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

 

Hal Katz:

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

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

LISTEN TO THE EPISODE:

 

Daniel Marino:

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

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