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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.  

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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.

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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.

 

With private equity's growing influence in healthcare systems, the significance of aligning healthcare providers has never been greater. In this episode of Value-Based Care Insights, we delve into the complexities of private equity interests and their profound impact on healthcare providers. Join Ericka Adler, a seasoned attorney at Roetzel & Andress, as she explores the current trends in private equity and their implications on physicians and healthcare systems. Gain insights into physician employment models, the regulatory landscape, and effective strategies for healthcare transactions.

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As Medicare Advantage enrollment rises and traditional Medicare enrollment declines, collaboration between payers and providers becomes essential. However, these relationships have historically been fraught with challenges and various administrative complexities. In this episode of Value-Based Care Insights, we explore the critical need for effective payer-provider partnerships with SueEllen Carroll, Managing Director at AArete, and Darren Ghanayem, a seasoned expert in healthcare and IT. SueEllen and Darren join us to share their insights on building trust between payers and providers, along with strategies for improving governance. Gain insights into fostering payer-provider contract collaboration, improving patient care, and reducing the administrative burden often associated with Medicare Advantage contracts.

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Transcript:

As healthcare providers engage in payer contract negotiations, understanding their contractual reimbursement rates compared to the market has never been more crucial. In this episode of Value-Based Care Insights, we sit down with Damon Morse, an expert in payer rate analyses, to discuss the challenges healthcare providers face with payer contract negotiations, and the strategies required to level discussions. Gain insights into how thorough analysis and strategic positioning can ensure fair reimbursement for provider organizations and support organizational growth.

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Transcript:

Medicare Advantage has been the subject of significant attention lately among provider organizations due to its distinctive demands that influence traditional practice operations norms. In this episode of Value-Based Care Insights, we sit down with Sarah Hartley, an expert in health information management, to discuss some of the hurdles with new Medicare Advantage contracts, along with the efforts needed to align providers and patients. Gain insights into the administrative challenges, diverse strategies for effective patient data management, and the essential cultural shift required to promote collaboration between provider organizations and payers.

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Transcript:

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

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Transcript:

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

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