LUMINA Podcasts

In 2025, the continued growth of Medicare Advantage underscores the increasing importance of specialists in value-based care, as healthcare models shift toward more integrated, patient-centered approaches. In this episode of Value-Based Care Insights, host Dan Marino sits down with Lynn Carroll, COO and Head of Strategy at HSblox, to explore how specialists can successfully engage in value-based care models. Tune in to explore current value-based programs that incorporate specialty providers, key challenges encountered, and the critical infrastructure required for success in this evolving healthcare landscape.

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino: 

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As we move from 2024 into 2025, there's going to be a continued shift in Medicare advantage obviously and looking at the ACO performance that was released for looking at 2023 it's clear that as we move into this next year, specialists role within value-based care arrangements is going to be extremely important. Obviously, specialists control a lot of the or influence a lot of the cost of care targets. Their ability to integrate with primary care is absolutely critical on creating an efficient care plan if you will. And just the ability to be able to drive overall performance of patients and populations, that integration of the specialists and the primary care physician is absolutely critical. So in in today's episode, I'm really excited to talk a little bit about the role of the specialists in value-based care arrangements. Many specialty groups have reached out to us and have said, Hey, how can we get more involved in value-based care? How can we better integrate with ACOs with CINs, with primary cares, for that matter. The time is right. They want to do it.  

Well, I'm really excited today to have a guest who's been on the program before Lynn Carroll is COO head of strategy at HSBlox. I think he's been the COO for about the last 6 years. Great guy expert in the area of value-based care and value-based contracts. Lynn, welcome to the program. 

 

Lynn Carroll:  

Hey, Dan, it's great to be back on the show. Looking forward to our discussion today. 

 

Daniel Marino:  

So I know you're doing a lot of work with different providers across the country. And you know, as I reflect on some of the recent conversations I've had over, let's say, the last 2 or 3 months, the time is right for specialists to get more involved in value-based care. But there's a lot of challenges there, right? There's economic challenges. There's integration challenges. When you look at the specialists and the specialty community you have medical specialists, surgical specialists, hospital-based specialists. From your perspective why has it been so difficult for specialists to really gain traction in the in the value-based care world? 

 

Lynn Carroll:  

Well, I think, some of the things that come to mind are understanding the different incentives and levers that exist between primary and specialty care. And you know, in a lot of cases it may be the fact that specialists have traditionally been reimbursed, based upon procedural volume or things of that nature. And I think it's becoming pretty clear in these program designs that while primary care models in VBC may be fairly mature and certainly are pretty familiar within the marketplace. The reality is that a significant amount of the spending is driven in the specialty realm and so trying to get specialists into the value-based arena requires thoughtful approaches like you mentioned for care coordination for data sharing, taking advantage of more digital exchange of information. Some of the things that also come to mind are just looking at what expenditures are driven in trying to get to an accurate diagnosis. For example. 

 

Daniel Marino:  

Right.

 

Lynn Carroll:  

There can be a decent amount of spending that occurs before you can even get to a correct diagnosis. And so all those things beg a more collaborative approach across the disciplines, and certainly a multidisciplinary approach where there's poly chronic disease involved, for example. And I think folks have known, probably for a number of years. But it's becoming a little bit more important now to understand that if you don't bring specialists in, it's going to be really hard to continue to put total cost of care types of programs in and be successful with them. 

 

 

Daniel Marino: 

I absolutely agree.  But don't you think you need to look at the different value based arrangements almost separately or uniquely, if you will. So, for instance, you know, if you think about the total cost of care target for an ACO  population, right? Cancer, for instance, is a big driver of the cost of care. But when you look at dermatology services, for instance, it's not really a big dollar amount, right? So how do you create an alignment of specialists and specialty within the value-based care arenas when I guess the output is very different, depending upon the types of diagnosis or the types of clinical service? 

 

Lynn Carroll:  

Yeah. So I think it's, you know, program design obviously, is one of the things that it comes to mind. And even CMS, right is, you know, proposing more value-based insurance design types of mechanisms. So you look at the chronic diseases where you know an argument from the specialty side is, you know, what is the primary driver of this individual's care? And am I responsible for all of the specialty care? Or is it really specific to my specialty? Because if you have polychronic individuals, you risk a fragmented care environment and trying to bring primary care, specialty care and multiple specialists into the equation means the program design has to be efficient, not only in terms of how risk or incentives are aligned amongst the constituents, but also how information is going to be shared. So that gets into referral patterns. It also gets into looking at what would be the organizational designs like clinically integrated networks or specialty networks so that you can look for efficient referral patterns and efficient use of services. And in some of the more hospital aligned or health system aligned scenarios reduce leakage. 

 

Daniel Marino:  

Right? Right? So when we're looking at some of those drivers of value-based care and the ability of the specialist to influence it, I mean, cost is just one area, right? So reducing the cost care is critical. But what I'm hearing you say is, you have to look at some other factors. So you have to look at how your, what your internal referral structure is and the value that's coming out of in using the network and creating efficiencies around referrals. I agree with you. Leakage is huge. Right? I mean, if you, if you, if you refer a patient to a physician or a specialist that's outside of your network, you know, your ability to be able to manage the cost and influence. The quality goes down dramatically. Right? So you really do have to have to focus on that so when you're when you're thinking about that, is it important, then, for providers to think about, maybe how they create the VBC contracting structure, I mean, should they really think about it and take more of a proactive approach like, Hey, let's come up with some episode based pricing models for orthopedics, for instance. And then maybe a separate program for cancer? Or should they be approaching this from more of an enterprise based perspective, where, hey we're coming up with an enterprise based cost model, and maybe it will lead to some overall value for all of our participating providers. 

 

Lynn Carroll:  

Yeah, I I think we're definitely seeing you know, sometimes. And this is probably something you've seen as well. What's old is new again, and you know there was a heavy push in BPCI and episodes of care, and I think episodes of care sort of coming back around right. If you look at the need to align not only primary and specialty care but also align the inpatient components of things as well as post-acute care, which can also drive significant cost if example, patients are discharged either too early or inappropriately, you can drive a significant amount of the cost, post-acute and results in a readmission and things along those lines. So I think you know, as we kind of look at the landscape of what's happening, episodes certainly make a lot of sense with regard to targeting areas where you know, spend as well as outcomes can be, where spend can be reduced and outcomes can be improved. A lot of that then gets back to how are you going to effectively manage care, coordination deal with network optimization to ensure appropriate services are available but that they are efficiently tapped into, and you're creating an environment where not only the patient has a better outcome, but the care team also has a better experience as well. 

 

Daniel Marino:

Well, and I'll tell you, Lynn. I like what your suggestion there, I'm a big proponent of these episode-based pricing models for specialty care services. I think they accomplish a number of things. One, it allows for a very strong focus on the different care models within the specialty areas, and it allows you to track the outcomes plus you're able to price it in such a way that you can clearly align the incentives for the hospital for the specialty groups and for other types of ancillaries. Plus, I think, as you, as organizations, start to move forward with these episode-based pricing models, the payers are becoming more receptive to it, right? Because they're understanding what drives the cost. They know that the specialists that the specialty care, you know, could be 50, 60, 70% of overall costs for their attributed lives. I mean, they see it right? So it does provide a mechanism to really allow all the incentives, all the alignment of the Care plan, not to mention higher outcomes, to patient. All that to be considered as you're really beginning to design a Viable VBC structure. 

 

Lynn Carroll:  

Right. And I think that you know some of this goes to some fundamentals of you know population health analytics, which is to kind of think about, where are the, you know, the high spend areas or disproportionately high spending areas and then trying to understand, you know what condition or conditions are the primary drivers at the, at the patient level? And what is the primary need that a given patient has? Right? So you know, some of these conditions may not be adequately addressed by a primary care steerage model and really beg more of a collaborative approach to not only cost containment, but also ensuring a better outcome as a result. So we started the program, I think, talking a little bit about insurance design and thinking about how these value-based insurance programs are put into place. I think payers look at things from a perspective of saying, if you know, the next frontier and value based programs is engaging specialists. Episodes make a lot of sense. And so do clinically integrated, you know, types of models. And I think that the more global approach of a total cost of care gets boiled down to a more targeted approach under an episode type of a model. 

 

Daniel Marino:  

Yeah, absolutely. I couldn't agree with you more. If you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today talking with Lynn Carroll. COO has strategy at HSblocks, and we're talking about the need to integrate specialists more in value-based care and value-based contracts. 

Lynn. Let's kind of build on a point that that you brought up, and it's really around the support in the infrastructure, right? Because clearly, if specialists are going to expand into value-based care, be successful within value-based care arrangements. From my perspective, I think they need to do a couple of things. They need to be integrated within the CIN and the ACO in such a way that they've become a very active participant. But in order to make that work. You need to have the right level of infrastructure. You need to have the data and analytics and provide the information tools back to the specialists so they can succeed. But they also need to have the levels of support. And you touched on this a little bit. You need to have the right level of care management in place in order to provide the support and drive the outcomes. What are you seeing in terms of the challenges right now that that providers have in place, or maybe that have not been in place in order to support some of their specialists? 

 

Lynn Carroll:  

Yeah. So I think, some of the things that we've seen happening is evolution, you know, to more engagement techniques, not only at the patient level, but from a care, coordination, standpoint in managing things like referrals targeted to high value specialists. Looking at the different you know transitions and care, and having effective engagement in place, not only from, like, I mentioned the patient side, but also being able to share information appropriately and on a timely basis, so that there's, you know, collaborative decision making. So you think about the decision making in polychronic scenarios of not only involving primary care and special care, but the patient themselves. And that sort of gets you into thinking about what are some of the digital tools that can assist in that area, and things that come to mind for me would be remote, patient, monitoring capabilities. And you know, wearables, for example, that can help to inform a change in patient status and allow for more timely intervention, and mentioned another thing you know, sort of at the at the at the outset, which was time to diagnosis, right? Because part of the intervention scenario is to understand number one, what is the what is the diagnosis here of a given condition and get an intervention, plan or a care plan in place. And some of these models, you know, certainly create an environment where these types of programs that are episodic in nature can succeed. 

 

Daniel Marino:

Yeah. And they could succeed, timely right? And you know, you brought up remote, patient monitoring, I think in, you know, is this, this is becoming even more prevalent right now, and certainly in certain specialties, like, you know, cardiology, for instance, I think it's absolutely critical as these organizations move forward with it, or these specialists move forward with it. But you know so as you were as you were describing, that, I guess a thought came to mind, and I recently had a conversation with a actually it was a cardiovascular group, and one of one of the things they brought to me to my attention. Maybe it was orthopedics I forget. Was that in a lot of the ASCs in the surgical areas there's a lot of inefficiencies that are occurring. And the question that he asked me, and I thought was a great question, are there things that they can do to create efficiencies in a lot of their clinical services. So whether it's in the OR in the ASC, or maybe it's even in their own clinic operations as they're seeing patients, are there things that they do can do to increase efficiencies that allow them to better position themselves in value-based care, while at the same time being able to expand their fee for service opportunities as well, too. And I thought it was an interesting question, and I've gone back, and I've actually worked on it quite a bit, and I believe that there are. But I want to I want to kind of get your thoughts on that. 

 

Lynn Carroll:

Well, I think you know the 1st thing is understanding the population that you're primarily serving and then understanding things like, you know your sourcing. 

 

Daniel Marino:

Sure. 

 

Lynn Carroll:

And your underlying cost. Structures that are, you know, maybe need to be changed a little bit or be reinvented underneath a more value-based or fixed type of a reimbursement model. 

 

Daniel Marino:

Even streamlined right? 

 

Lynn Carroll:

Right. 

 

Daniel Marino: 

So I would think if you're looking at specialists, one big area of efficiency has to be around improving clinical variation right? 

 

Lynn Carroll:

Sure. 

 

Daniel Marino:

So if you improve clinical variation and you remove some of those inefficiencies, I think right off the bat. It's going to position you a heck of a lot stronger for value-based care. But it's certainly going to improve your ability to grow your fee for service business. 

 

Lynn Carroll:  

Well, and I think the other thing. And this probably gets back to, you know, talking about episodes again. One of the things that's always been positive about episode definitions is getting to a common set of them, Right? So that there is standardization and that there's not unnecessary components being, you know, unnecessary components of spend occurring because of variation in the definition of an episode, for example. That has been a common driver of why episodes have been posited as one of the things that can be a good driver for not only outcomes, but certainly cost containment. 

 

Daniel Marino:  

Yeah, yeah. Well, it creates some standardization around that. So you know, when you think about putting forth, you know, you don't want to call it, it's not cookbook medicine, but let's say you come up with a common care, model or common pathway, that all of the specialty providers subscribe to that are within that particular group. Well, then, it feeds into your outreach to the patients, the way you're navigating the care with the patients. And to a certain extent, even how you're using some services like remote, patient monitoring, how you're pricing it, and all of that figures into your ability, then to support your fee for service model, but positioned you across positions you well with great outcomes in the, in the value based care setting. 

 

Lynn Carroll:  

Well. And I think it's a good point, too. Because while we're focusing on value-based programs, and we're focusing on cost containment and outcome improvement. The reality is that many of these principles, if not significantly, all of these principles apply across fee for service just as well as across value-based care, because the commonality between the 2 reimbursement models is one thing we want good outcomes for the patient. 

 

Daniel Marino:  

We do, we do, and I'll tell you so. This kind of builds on to where I was going with this. So, as I was having this discussion with this, you know, I think it was an orthopedic surgeon, I said. You know. Look, these are things that you should do, because not only is it going to help your position you well for value-based care, but it's going to help you support Fee for service, but if you do this well, and you're able to see a return on what you're investing in on a fee for service side that becomes your investment for future value, based care, initiatives and infrastructure that you undoubtedly are going to have to make. So if you're if you're really prescribed on the approach, it financially could really work out well for the specialists assuming they're aligned. You know the whole group is aligned on that thought process. 

 

Lynn Carroll:  

Well, I think that's a great point, Dan, because you know, one of the arguments, or some of the dialogue is probably a better term around, you know, straddling with one foot sort of in and one foot out of value-based programs would be addressed by that methodology right? Which is to think about it in terms of a standardized approach to how you're going to handle the case, whether it's a fee for service or a value-based patient. 

 

Daniel Marino:  

Yeah, no, I agree. Well, well, then, this is this is great. I think you know. I think we just barely touched the service on this I really feel like the integration of the specialists into value.-based care has to occur. I think it's going to come down to a couple of things. Where you start. How quickly do you move. And then how do you make it economically viable over time, making that shift from value based care, you know, or from fee for service to value based care. Lynn, you know we're coming up to our time here. If any of our listeners want to get in touch with you. You know you're a wealth of knowledge. You've got great services and capabilities within your company. Mind sharing any of your contact information with our listeners. 

 

Lynn Carroll:  

Sure it's really simple. Go to hsblocks.com. We've got ability for you to put your name in on a form you can also call give us a call as well. It's on the website. And usually you'll see us fairly often posting a lot on Linkedin. And so that's a really great way to get a hold of me directly, or any members of our team, because we do share a lot of information about the value-based space on our Linkedin page. 

 

Daniel Marino:

Yeah, you guys do a nice job. I always kind of watch that. And you know, you do a nice job of sharing material. So you know, I'm really I appreciate reviewing. It is as well. So, thanks again, Lynn, I really appreciate you coming on the program, always a great discussion. 

 

Lynn Carroll:  

You bet. Great, great, great to be here today, Dan. Good to see 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. 

The Physician Fee Schedule (PFS) Final Rule for Calendar Year (CY) 2025 introduces several key updates to Medicare payment policies, aiming to enhance care delivery and reduce administrative burdens. In this episode, Daniel Marino is joined by Managing Partner, Lucy Zielinski, and Sarah Hartley, to explore the implications of the PFS Final Rule on physicians and other billing professionals. Together, they discuss the key changes and opportunities for physician services furnished in various settings including physician offices, hospitals, ambulatory surgery centers (ASCs), and others.  Tune in to stay informed and gain valuable perspectives on navigating these critical regulatory updates. 

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. As we now move into 2025, I'm sure many of you realize that we have a new fee schedule from Medicare. Our friends at Medicare released the new final rule last November, November first to be exact. And there are some pretty significant changes that we really need to consider as we're now moving into to 2025. And some of those changes as I kind of dove into it a little bit we're really focused on some new codes, some strategies to make more equitable reimbursement for the different physicians, medical groups, and so forth, around quality, around innovation, around managing what's occurring with some of our Medicare beneficiaries. And when I looked at it, there were 4 key areas that really resonated with me. And again, our background, and my background in particular, is really supporting a lot of the medical groups and the physician practices as well as the hospitals that have many employed physicians. So those 4 areas are really start with really the payment impact. So there is a pretty significant impact to providers, to how we're going to code with the new fee schedule. Second is, there's numerous new and expanded services, new codes, new ways to begin to get reimbursed for the services that are being provided. The 3rd area is around surgery and no secret, there's a big incentive to shift from acute to ambulatory, there's a new series of codes that are being proposed and included and build and allow for some reimbursement that really provider organizations need to be aware of. And then, lastly there's a major impact on rural health clinics and federally qualified healthcare centers. And as we think about the coding, these organizations, in particular, have a real opportunity to improve some of their coding, improve their billing, improve some of their collections.

Well, I'm excited today to have 2 of my colleagues. They've been on the show before, extremely knowledgeable in this area. Lucy Zielinski. She's a certified coder managing partner with Lumina health partners, and Sarah Hartley, former executive of a large health system in the Chicago area, and is a true expert in coding and clinical documentation improvement ladies welcome to the program.

 

Lucy Zielinski:

Thanks Dan.

 

Daniel Marino:

So, Lucy, let's start with you. Maybe you just give a quick, you know, couple a minute or 2 summary. What are some of the big changes that you're seeing with this new rule as we move into 2025?

 

Lucy Zielinski:

Well, 1 clearly rule that changes every year is kind of that conversion factor, the impact on payments. Right? This is a general thing, as we all know, there's this thing called budget neutrality, and they've been kind of poking away at the conversion factor. So this year 2025, we are going to be seeing a decrease of 94 cents of the conversion factor compared to 2024, and this amounts to almost 3% of total dollars or revenue. So that's a big chunk.

 

Daniel Marino:

It is a big chunk, and I'll tell you. It's amazing that when I saw this, this is one of the things that really surprised me, and I know there was a this was pretty controversial, so I know folks like MGMA and HFMA, and so forth, pushed back on it. But as inflation has increased and costs have increased, you would think that the payment and the revenue would increase, but it actually has gone down almost 3%.

 

Lucy Zielinski:

Well, and it's gone down fee for service, as you know. But what we're seeing is an increase on the value-based care side. You mentioned that earlier, Dan. And there's also some changes with the HCCs, hierarchical condition categories. We are moving versions this year, and, as you know, HCCs impact many of the quality programs, including MIPS, MSSP, the ACOs and Medicare advantage plans. So providers really need to be aware of that impact as well.

 

Daniel Marino:

Yeah, it's interesting and good observation. I'll tell you, there's definitely an incentive that's out there, moving from fee for service to value-based care, and around some of these programs. So, Sarah, let me kind of dive into this with you when you look at the new rule and the new codes, what are the newer expanding services that you see that are included in this new rule that maybe our provider colleagues need to pay attention to?

 

Sarah Hartley:

Yeah. So some new coding and payment for caregiver training for providing direct caregiver services and supports some expansion. On our G 2211 codes, Medicare will pay when this code is added to the annual wellness visit or the vaccine administration, any Medicare part B preventative services they'll pay for this additional code, when you append the modifier.

 

Daniel Marino:

So let's dive into that a little bit, because I think this is an important point. So when providers are billing the annual wellness visit. You're saying now that, based on the risk or the complexity of the patient, they could also now, Bill, the G Code G 2211 code with that?

 

Sarah Hartley:

That's correct. So if they are treating a patient that has a complex condition, and they are continuing a relationship with that patient for this serious, complex condition over an extended period of time. They can bill for this code.

 

Daniel Marino:

Hmm, yeah, that's interesting. And what's the reimbursement? Or is there an RVU impact to it?

 

Sarah Hartley:

There is an RVU impact, Lucy.

 

Lucy Zielinski:

Yeah. So the reimbursement again depends on the state you're in and the local. However, it's around $16, and the RVU value is point 5. So physicians who whose compensation is based on RVUs, they're doing the work. They might as well capture this bill for it, and have that credit.

 

Daniel Marino:

Well, and I'll tell you again, another incentive to shift to value-based care right? Because annual wellness visits are a critical point or part of being able to identify all of the historical conditions of the patients as well as capturing HCCs. What about telehealth services? Telehealth has been, I think, for the most part, providers really like it. I think most patients really like it. There's a discussion as to whether telehealth is going to continue. It looks like heading into 2025. That's still going to remain an important part.

 

Sarah Hartley:

It is remaining an important part. And we've seen several services actually being added to telehealth for 2025, including caregiver training and some interactive telecommunication systems which now can include 2 way, real time audio only technology for the beneficiaries in their home.

 

Daniel Marino:

What about for behavioral health? I read an article that you know again, I think it was a study that came out. That said I think the article spoke to the fact that behavioral health performance and the output of behavioral health telehealth services was recognized and well received by patients even more so than some of the medical services. How does behavioral health telehealth fit into this.

 

Sarah Hartley:

They are allowing for 20 min increments around safety planning and they are also have some new codes for digital mental health treatment devices as well. So they are also recognizing the importance of telehealth in the behavioral health services.

 

Daniel Marino:

Yeah, I think that's a good one. I really do. You know, access and behavioral health is such a challenge, and many behavioral health providers have started to integrate telehealth services and just try to expand their provider resources and offering telehealth services, I think, is an excellent way of being able to provide those services. So I was really this was one of the things I was happy to see. Talk a little bit about some of the caregiver training. You mentioned it earlier. What's included in there? And then how do you know who's considered the caregiver? How do we bill for those?

 

Lucy Zielinski:

So Dan caregiver, caregiver training is being paid now. So these are new services, as you know, are being recognized for caregivers who are taking care of patients or their loved ones, and some of the topics that CMS is going to be reimbursing for our training for techniques. To prevent some of these conditions, like ulcers, wound care, infection, control as well as behavior, management and telehealth services will be paid as well. So any training via telehealth. They'll pay for those services now.

 

Daniel Marino:

They're going to actually combine and pay for both of those then, so they'll be as well as telehealth.

 

Lucy Zielinski:

Right training, via telehealth.

 

Daniel Marino:

Training via telehealth, which really makes sense. Well, if you're just tuning in, I'm Daniel Marino. You're listening to Value-based Care Insights. We're having a great discussion on the new 2025 CMS Medicare rules fee schedule rule that came out, and that we're all kind of working through as we enter into this New Year, and I'm here with Lucy Zielinski and Sarah Hartley. So one area that I or 2 areas I want to dive into a little bit further. One of them is dear and dear to my heart. It's really around care management, I've said for the longest time, and I think people have heard me say this, that care management is really the engine behind value-based care. Right? It's what drives a lot of the performance. But oftentimes it is really under reimbursed, and it's, I think, undervalued per se. How are what's changed, or what's enhanced with some of the new care management services? As we look at the new role?

 

Sarah Hartley:

This is really exciting, Dan. I agree. There's a new set of codes that we're seeing for advanced primary care management services that will support several existing care management and technology based services into a bundle of services that's then going to reflect those core elements when delivering that care.

 

Daniel Marino:

So is it. But what can you elaborate a little bit further? What needs to be documented, or does it look like, you know our providers doing this anyways, right now, or nurses doing this, anyways? Or how is this kind of linked into what the services that they're currently doing versus what some of the new services maybe they need to think about going forward.

 

Sarah Hartley:

So any physicians, nurse practitioners who are who use an advanced primary care model of care can bill for these services when they are the continued focal point for all of the health services. They have to be responsible for all primary care services for that beneficiary. So that means that their documentation has to support that documentation has to support the continuity of care. This really helps ensure that our patients have access to that high quality care in primary care services.

 

Daniel Marino:

Hmm, yeah.

 

Lucy Zielinski:

Yeah these codes are really replacing those chronic care management codes that physicians. Before, and they used to have to track time right? So you had to watch the clock, measure the time, notate the time, so there is no time threshold now, it's based on how many chronic conditions. So there's 3 levels now, and based on how many chronic conditions, there's a corresponding code.

 

Daniel Marino:

Yeah, that's interesting. And I'll tell you hopefully, a lot of the care managers are happy about this, because I'll tell you trying to keep a patient on the on the phone or talk with them. To hit that 20 min, mark to me, seemed like it was a little unfair. I think if you're managing the patient and the patient has 2 or even 3 chronic conditions, and you're doing your check-ins, you're evaluating the meds, you're only spending 10 or 15 min, not the full 20. You should be able to bill the higher code because you're still managing the conditions around the risk level.

 

Lucy Zielinski:

Yeah, Dan, so there's 3 levels of these codes now. And the 1st Level is for people with one chronic condition and the reimbursement there is 16, about $16 a month per member. And the Second Level G0557 is for persons with 2 or more chronic conditions. And the last one is G0558 is for qualified Medicare beneficiaries with 2 or more conditions, and that reimbursement is around a $112 per member per month. So that's quite a bit of money.

 

Daniel Marino:

It is, it is. And you know the big takeaway for me is this, you know, they're removing the time based factor on this, and you know, in working with many organizations on building their care management platform, so many care managers were so focused on hitting the time criteria where for me it didn't really make much sense, you know, if you've got a patient with 2 or 3 conditions, and you're checking in with that patient, and maybe just adjusting their meds or following up, and you only spend 15 min on the call with that patient. You should be able to bill at a higher rate, because you're still managing the condition around that patient's risk level. So I think this is a really good thing.

 

Lucy Zielinski:

Right and it's important to again grab those HCCs, so correct documentation and diagnosis codes. And Sarah, you could even speak to that right? We're changing versions.

 

Sarah Hartley:

Yeah, we this year, we're 67% in V28. 60% of that reimbursement is coming from version 28, the other 33% will be from version 24. So in 2026 100% version 28 documentation matters, this truly is a great step to recognize how complex the care is that's being provided.

 

Daniel Marino:

Yeah. So going now into V28, maybe you can just elaborate on that a little bit more. So folks really do have to pay attention to their documentation. The clinical documentation improvement initiatives that many organizations are undertaking is really what's going to support it. I'm assuming Sarah, as well as then, you know, supporting the HCC capture, and so forth.

 

Sarah Hartley:

That's correct. Our physicians have never been trained on how to document to get chronic conditions paid for now we have. We are changing the way that we're reimbursed. That's not. You know. We are providing great care. We need to be make sure that our doctors are documenting that, and we have clinicians and coders that you know are experienced and can really help our providers get to that next level to get to these extra G codes for those chronic conditions.

 

Daniel Marino:

Well, and I'm going to give a little bit of a plug here to the Lumina team for any of our listeners who are interested in understanding more around. V28, clinical documentation, improvement, care management. We have a fabulous team that has done a real nice job with working with organizations both around education, putting in new workflows and just helping organizations take advantage of that. I'm really proud of the work this group has done. So anybody interested in learning more please feel free to reach out. I want to switch to another area. And it's really probably more hospital focused, or it's really focused on some of the surgeons. And it's around global surgery. And I know there's a there's this continued shift inside of service from the acute arena to more of the ambulatory area. Lucy, maybe we could start with you. What's changed this year in some of the new surgical codes, or some of the big changes that are going to impact surgeries or that level of reimbursement.

 

Lucy Zielinski:

Yeah, Dan, I think it has a lot to do with some of the changes that we are seeing have to do with denials, because in the past we've had a global period, maybe of 90 days, but often care was transferred from one physician to the next. So maybe there was physician A did a couple of the visits post-OP. But then the physician, the patient, went to another physician, who also provided care during the post-OP period. So this new changes to the rule, address some of that.

 

Daniel Marino:

Hmm! That's interesting. Sarah, any additional thoughts.

 

Sarah Hartley:

Yeah, really, the goal here is to appropriately reflect the time and the resources involved in the follow up care that's being performed by the providers who work involved in furnishing the surgery. So giving credit where credit is due, basically.

 

Daniel Marino:

Well, and it seems to me, as I looked at it, there was a big post operative component that was tied to this. And again, I focus a lot on not only what's occurring in the fee for service arena, but also in the value-based care arena. This to me by adding on these additional codes and the G codes, and so forth. Allow for this transition to more to stronger post-operative care.

 

Sarah Hartley:

Correct, I would agree. It's really provide allowing the providers to provide that support appropriately and then be reimbursed appropriately for it as well.

 

Daniel Marino:

The last area that, as I was looking through, the rule seemed to me there was a focus on enhancing some of the financial opportunities for rural health clinics and federally qualified FQHCs. Federally qualified healthcare centers, health centers. What are some of the things, Sarah, that that you seen as you've looked at it, that are positive impacts or some of our RSCs FQHCs need to pay attention to?

 

Sarah Hartley:

Yeah. So what I see happening here is the alignment with other healthcare organizations in the way that rural health clinics and federally qualified healthcare centers are being reimbursed, starting with care, coordination services. And really aligning with other entities who are furnishing similar services. This year. Entities have to report individual CPT and HCPCs codes for those care coordination services, telehealth. They are aligning telehealth and allowing them to continue to bill for that technology for non-behavioral health visits here in the Rural Health community, but by reporting the HCSPCs and the G Codes on the claim that they, for the services that they furnish. So the big thing here is that they're aligning with other entities in the way that they are reimbursed.

 

Daniel Marino:

Yeah, well, I mean, that makes sense. And you know there's always some challenges in terms of you know how you bill it, and the reimbursement you get with the cost reporting, and all that other, all that other good stuff. But I think when you look at what has been, what they've included as additional codes and opportunities to really coordinate that care with other providers. I mean to me, this is a pretty big. This is a significant impact.

 

Sarah Hartley:

I would agree I would agree there. We I also see that they are allowing these rural health care centers and the FQHCs to bill and be paid for part B preventative vaccines and their administration. So that's a huge thing, too.

 

Daniel Marino:

Oh, really? Oh, yeah, that I didn't catch. Yeah, that's a good one. So also, you know, they could start to bill for some of the vaccinations and some of the reimbursement for activities, you know, for any vaccinations and so forth, that are being done by the FQHCs?

 

Sarah Hartley:

That's correct, and the payment will rates will align with other settings.

 

Daniel Marino:

Oh, that's great! Well, I ladies, I appreciate I appreciate your quick and dirty input and interpretation of the rule. There's a lot that's included in that. If any of our listeners are interested in finding out more, is there a place where maybe they can go for a summary, or any thoughts that we can direct them to.

 

Lucy Zielinski:

Well, so CMS puts out a fact sheet, which is nice. It's a high-level fact sheet. I usually read through the whole federal register rule, because there's some nice graphs, charts, more explanation, especially for coders and revenue cycle departments out there. I would recommend that they go directly to the to the Federal Register.

 

Daniel Marino:

Yeah. And I'm sure that's a real exciting read.

 

Lucy Zielinski:

It's a weekend long read. You were wondering what I was doing last weekend, Dan.

 

Daniel Marino:

No wonder, no wonder you look so well rested.

 

Lucy Zielinski:

Yeah. And then I would lastly, I would say, your local and national associations and specialty physician associations. They put together a nice summary specific to your specialty, so I would I would look there as well.

 

Daniel Marino:

Yeah, that's great. Well, and also, too, I'd love to direct everybody to the Lumina website. And if you do want any information we provide a lot of great information, great education, as well as some tools to help organizations, help providers think about how they need to train and change a lot of their coding activities to maximize a lot of these new rules that are coming down the pipe. Sarah, I want to turn to you. Thanks for all your help on this any parting words of wisdom.

 

Sarah Hartley:

No, we're just seeing it's becoming more and more important to document those chronic conditions in their interactions. So keep doing the good work.

 

Daniel Marino:

Yeah, and there's going to be a lot more to come, that is, for sure. Well, ladies, thank you really appreciate your time today. This was a great discussion. Love, to have you back to talk about some further changes, particularly around the V28. I think that's probably a big topic for us to cover sometime down the road.

 

Sarah Hartley:

Great look forward to it.

 

Daniel Marino:

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

Healthcare providers will continue to move toward value-based care, fostering a more equitable healthcare system that enhances accessibility, quality, affordability, and innovation. In this episode of Value-Based Care Insights, I sit down with Lumina’s Managing Partner, Lucy Zielinski, to explore the healthcare trends of 2025, the effects of new regulatory changes, and the pressures these developments place on providers. Tune in to learn about the top five trends that health systems should include in their strategic planning.  

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I am your host, Daniel Marino. Well, happy New Year everyone as we are now into 2025, and preparing for this New year. It's gonna be interesting when you look at the potential changes that we're going to be faced within 2025. Obviously, with the new administration coming in there's going to be a lot of activity with CMS. I think we're continuing to see a lot of growth in artificial intelligence. And it's really going to impact hospitals, physician groups, and in particular, their operations. In one respect, I'm really excited about the potential and the changes that we see or are going to see. But in in next respect, you know, it's sort of the fear of the unknown right. What is the what is the next few months going to look like? Well, every year at this time we always spend a little bit of time talking about the potential trends that we anticipate seeing as a consulting firm moving into the next year. And we're very fortunate because we work with organizations all over the country and leading up to these conversations, I often reach out and have discussions with healthcare leaders all across the country to kind of get their thoughts on one, what’s keeping them up at night? What do they focus on in the New Year? And then what are the big trends or initiatives that we see emerging as we move into the next year. So to help me discuss this today, I'm really excited to have my close colleague partner in crime at Lumina, Lucy Zielinski. Lucy, welcome.

 

Lucy Zielinski:

Thank you, Dan. Happy to be here and happy 2025.

 

Daniel Marino:

Yes, thank you. Thank you. So let's talk a little bit about this. And you know, obviously, an area that you're very close to is medical group performance physician performance. You know, in your consulting practice you do quite a bit of work on helping medical groups improve, and in particular, around coding HCCs and so forth. So as we, we think about what we're going to be faced with in 2025, what are the couple of things that you believe that are really going to impact some of these either medical groups or the provider community as we start to think about some of these new, these new challenges.

 

Lucy Zielinski:

Yeah, Dan, so it's interesting. But we have definitely seen a focus on the expansion of ambulatory services and providing patients access in in communities and with value-based care, we continue to see these delivery models continue to evolve. It's interesting. The recent statistic is about 60% of health care payments are tied to value and quality. According to the American Hospital Association. And value based care has seen some great results, right? Decrease in hospital admissions, increased rates of preventative care, lower medical costs. As a matter of fact, even Medicare, advantage reported savings compared to traditional medicare.

 

Daniel Marino:

Yeah, and even the Aco. So you know, the 2023 performance ACO showed a significant improvement in in the amount of savings it continues to make to make some great strides in in that regard. So when you think about, then, how medical groups need to position themselves you're really talking about changing the care model right? Or continuing to evolve the care model. What would be a couple of things that you feel like medical groups should focus on?

 

Lucy Zielinski:

Yeah, I think one key area is definitely around care management. And that's evidenced by the 2025 Medicare fee schedule updates. If you take a look at those updates, we're seeing expansion of billing, reimbursement and coding around such things like care management services as well as caregiver training, which is really interesting.

 

Daniel Marino:

It's really interesting. And I'll tell you. I've said for the longest time that care management is the engine behind value-based care. If you're going to do a good job, you have to be able to have a good care management program. And I share your excitement. I'm really looking forward to these new codes in 2025, in support of the caregivers, in support of transitions of care. Things that haven't been appropriately coded, and physician groups haven't necessarily been reimbursed, for that's going to change in 2025.

 

Lucy Zielinski:

Yeah. And I mean, there, you're right. It's the advanced primary care management services around transitions. In addition to a focus on behavioral health and mental health. We even saw just recently published innovation project around behavioral health model, a new model. So definitely a focus on some of these areas that traditional medical groups have not focused on.

 

Daniel Marino:

Let's talk for a few minutes about Medicare Advantage. I believe that as we head into 2025 Medicare Advantage is going to continue to be a focus in the next few weeks we are going to see the new Enrollment numbers. Last year there was about 54% of Medicare beneficiaries were enrolled in Medicare Advantage. I would not be surprised at all, Lucy, if this approach is 60%. But it's interesting, because you're seeing again some of these smaller hospitals, some of the rural hospitals, they terminated their contract Medicare Advantage, yet the Government is, is still pushing it. When you, when we think about Medicare Advantage, What are the things that you believe are gonna continue to be a focus on?

 

Lucy Zielinski:

Yeah, I think you're right. Growth is definitely going to be there. But many providers are scratching their heads and wondering should they continue in these plans just because they're very burdened from an administrative standpoint. So I think the focus is really going to be about managing some of these claim denials. Which is really interesting, because in the last couple of years Medicare Advantage the denials have been quite higher than traditional Medicare, and many of them have focused around the prior off denials which really would have been avoided in traditional Medicare.

 

Daniel Marino:

Yeah, well, and so in 2025, there's been a lot of discussion around some legislative changes for Medicare advantage to handle these pro pre authorizations. And I'll tell you certainly over the last month, month and a half, the spotlight has been on these insurance companies and the carriers, and in particular, around Medicare advantage. I really believe that if we are going to succeed in shifting Medicare beneficiaries to Medicare Advantage if we're going to hit the goal that Medicare wants by 2030 of having Medicare beneficiaries, and either an ACO or Medicare Advantage, or some type of value-based performance structure. How we handle denials, how we handle pre certifications, how we handle just taking care of patients on a timely basis. All of that has to change. Without those changes. You're going to continue to see a lot of these providers just not accepting Medicare advantage.

 

Lucy Zielinski:

Yep, I think you're right.

 

Daniel Marino:

So let's talk a little bit about some of the financial pressures. In 2024, I think the hospital margins in general improved from prior years, but not really much right? You're talking, maybe a percent and a half. I think the last statistics that I've seen the average hospital margin was somewhere around, maybe 2 and a half to 4%, and for smaller independent hospitals they were lucky if they were able to operate at a break even. Most of them made money or covered their operations from a lot of their performance and their capital, their capital investments. But as we move into 2025, what do you see are some of the big drivers that organization providers should focus on to maybe either respond to some of these financial pressures, or to react to changes within their organization, to put themselves in a better financial position. Any thoughts?

 

Lucy Zielinski:

Yeah, I think definitely the pharmaceutical costs those are rising. And, as you know, Dan, the baby movers are aging we're seeing seniors. There was a recent statistic in 2023 majority of seniors are 75, and older, and then we see younger sicker population. Obesity rates are high, which is a trigger, right? A risk factor cancer strokes, heart failure and so forth. So definitely, there's this focus on a pharmaceutical costs.

 

Daniel Marino:

Yeah, I agree. You know, pharmaceutical costs. It's, I've spent a lot of time looking at different cost structures, particularly around Medicare advantage. And even some of the commercial contracts, as you know, we do a lot of managed care contracting on behalf of the provider groups with the plans, and oftentimes we'll dive into the total cost of care, and when you really separate that and you put them into 2 buckets, you look at the medical service costs. And you look at the pharmaceutical costs. The medical service costs the rise has actually slowed. Right? So we're seeing that rise in the medical service costs, probably being somewhere around 4 to 5%, a little higher than what the CPI or the inflation rate is, but not too far off. But when you look at the pharmaceutical costs, you know, it's somewhere around 8 to 10%. And some of these drugs have even gone up a couple 100%. I really feel like if we're going to get our arms around managing total cost of care, we have to figure out we have to come up with some solutions on how to better manage the pharmaceutical costs. And it's interesting. I don't know if it's with the drug companies, or if it's with the PBMs. You know. There's a lot of pressure on the PBMs right now, right? And is kind of the middleman. As we've heard soon to be, our elected President Donald Trump make mention. So, you know again, it's going to be interesting to see where that where that goes, any thoughts?

 

Lucy Zielinski:

Yeah, I agree. And even the form formularies, right? Certain medications are covered. Certain are, certain medications are not. So, I sense that there's definitely going to be a pressure on these PBMs to manage these costs better.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today with my colleague, Lucy Zielinski, and we are talking about the potential trends in 2025, and how it potentially will impact hospitals and medical groups. Lucy, you know some of the pharmaceutical costs as we begin to think about it, and how it's integrated with the PBMs. You know, we're seeing different types of contracting opportunities there. And as you mentioned the older population, you know, that's where a lot of the cost structures are in place. Any thoughts come to mind as to maybe what medical groups or physician groups can do as they think about you know, getting their arms around this? I mean, should they try to carve it out, should they? And you know, maybe try to manage it differently with the commercials. Any thoughts?

 

Lucy Zielinski:

So, Dan, I think some of the things that medical groups can do is to carve out those costs or out of their contracts out of their contracts with the commercial payers. Also, another option could be to do a direct contract with these PBM pharmacies.

 

Daniel Marino:

Yeah, I agree with you. I think you know the rise in these costs make it very vulnerable for the medical groups, and you know what I've often said to them is, look, you should only contract around those things that you can be responsible for. So if you can't be, if you can't have direct responsibility for influencing the cost of the pharmaceuticals, then you should really carve those out in some of your contracting. So we are seeing that, or, as you mentioned, and I think it's a great point contract differently. Right? So go through a PBM that's willing to work with you to begin to manage some of those costs. One of the areas that I'm watching closely is what Doctor Mehmet Oz is going to do as he starts to lead CMS. He's been fairly vocal about his stance with Medicare Advantage. He's a proponent of Medicare Advantage. He does understand that things need to change. I think, potentially, he's going to be the one who might push through this new legislation. And you know it was interesting. I was interviewed by another host not too long ago, and one of the questions that was asked of me is, who do you think is going to be a bigger influencer? Is it going to be Robert Kennedy, or is it going to be Mehmet Oz? And I really feel like for providers and for the physicians? I think it's going to be Dr. Oz. To tell you the truth, it's going to be really interesting, and to a certain extent, I think fun to watch what he does, because he's a very successful surgeon. He's been involved in value-based care for many, many years, and he gets it. So I'm looking forward to seeing where what he's going to be able to do and where this is going to go.

 

Lucy Zielinski:

Yeah. And Dan, I'll just say the obvious. He's a physician, right? He's a clinician. So he understands how the healthcare system has worked or hasn't worked, and I think he has some great insight on how to definitely improve things.

 

Daniel Marino:

Yeah, yeah, I agree. So I'm looking forward to that as a trend and just to begin to see. I know, you know, within Lumina we constantly watch where the market's going, and try to get out in front of it, so we'll I'll be publishing some blogs and some my thoughts going into 2025 as we start to interpret what direction we believe he's going to take, and that impact on medical groups and providers. The last topic that I want to spend a little bit of time on is the impact of artificial intelligence. Within our technology platforms and within the provider groups. You know, it's when you look at artificial intelligence, I sort of put it into 2 buckets, right? So I see AI impacting clinical outcomes and clinical performance. And then AI impacting administrative technology and operations. I believe and this is my opinion, I don't know if folks share the same. I think we're going to see a lot more quick, let's say, quicker advancement in the administrative side of AI supporting maybe revenue cycle management. Some of these digital health tools, care management performance and so forth. I think we're going to see quicker, quicker impact and rollouts related to that than we are in the clinical piece of it right? I think there's a lot of research being done as to how we can use AI to maybe do some advanced diagnosis coding. But I think there's a lot of detail that we need to work out there. What are your thoughts? I know you're probably a little closer to the administrative side than the clinical side, but any thoughts come to mind?

 

Lucy Zielinski:

Yes, I think on the administrative side, right? When we look at processes, AI could really support some of that. So when we're thinking about that entire revenue cycle from really the time that the patient schedules the appointment check, you know the office checking eligibility and then managing some of the denials and identifying some of the risk factors. Right? Those HCCs are so important now to manage patients. And I think that's where we're going to see more AI support in the EMRs. We're seeing it right now already.

 

Daniel Marino:

Well, I'll tell you the HCC capture that to me, seems like a no brainer, very natural for artificial intelligence. If you can create an algorithm that's able to look at past medical histories of visits. Consulting, you know consult notes if you will, lab pathology notes and you're able to proactively identify HCCs that providers could incorporate on their visits. I mean to me, that's going to create so much more efficiency and just support the visit. The value, I think is just unbelievable.

 

Lucy Zielinski:

Yeah, and Dan, it's not only the visit, right? So it definitely can be integrated with all sorts of population health management protocols, right? Or even around care management with the patients. So there are some digital tools out there that provide, based on those that risk assessment or those HCCs or the condition of the patient. There's on demand education, you can hold patients accountable to certain things. I mean, there's an app for that right? We hear that all the time, and I think we're going to see that more and more. Even insurers! We see insurers providing incentives to consumers for wellness, prevention behavioral health. There's credits, and we're starting to see the younger population, I think. Take advantage of a lot of that.

 

Daniel Marino:

Yeah, I think it's really going to evolve healthcare quite a bit and make our care and the delivery of that care much more efficient. What about for rejections and denials? Thoughts on how AI could potentially impact it? And do you see it happening within this year? Or are we still a year or so out?

 

Lucy Zielinski:

Yeah, that's a that's definitely a good question. You know, being in the revenue cycle denials, especially some of the complicated ones, take a lot of research and appeal and time research. And I think that's where AI can definitely support some of these denials is come quicker to a solution and update the claim, correct the claim, and then resubmit so it is accurate and then reimbursed.

 

Daniel Marino:

Yeah, I agree with you. I think it does have an impact. And you know the interesting part about AI related to rejection and denial management is, there's a direct return on investment that can be tracked. So if you go into this and you have an idea that, or you know that your denial rate is, let's say, even 5 or 7%. If you're able to incorporate new technology, you should be able to see a quick return in your revenue by the decrease of those denials. And you know, I agree, if we can do more with less and create these algorithms that allow us to either properly code the 1st time around or manage these denials once they do become denied, then I think it'll make it easier for all of us.

 

Lucy Zielinski:

Yeah, Dan, I would love to see that FTE count in that billing office, and with revenue cycle decrease, and the FTE count, with the care management, taking care of patients and managing patients, care helping them navigate the system, especially those with chronic conditions, increase. So kind of a shift of resources over to the clinical side, from the administrative side.

 

Daniel Marino:

Yeah, yeah, I agree. Well, Lucy, one thing I do want to make mention. And I think on behalf of our audience, it might be interesting just to spend a couple of minutes. The last couple of conversations that I've had with some of the leaders. One of them actually turned the table on me and said, What's Lumina doing to position itself to for some of these trends in 2025? And I thought it was a great question most time. I'm the one asking the questions. Right? So it was It was a great question really got me thinking that, well, maybe I should spend a couple of minutes talking about how we are evolving Lumina health partners, into 2025 to continue to support hospitals, medical groups, and you know, and the provider community. So we're going to be focusing on 3 things right? And I think you know, those 3 things are one enterprise strategy and included in that is value-based strategy. So how can organizations position themselves for continued success in 2025 and beyond, with some of their value, based contracts and their structures. The second area is medical group performance. And I know this is an area that's you know, you're very close to everything from revenue cycle to capturing HCCs and coding. We're doing a lot of education around HCC's code capture as well as clinical documentation improvement. That's a big area. And then, of course, payer contracting, we do a lot of payer contracting support. And then the 3rd area which we're really excited about is the expansion of supporting single specialty service lines as we move into value-based care and particularly position organizations for risk we have to do a better job of integrating specialists around the cost models, but it also has a fee for service component to it as well, so one of the areas that we are focused on is operational improvement of the operating rooms, integrating anesthesia, because not only does it help with value based performance, there is a direct ROI associated with it, so I would suggest to any of our of our listeners. If you're interested in finding a little bit more everything from just blogs and articles, or just information you could share with your teams, or if you just want to have a conversation, please feel free to reach out to either me or Lucy. My email, as you know, is dmarino@luminahp.com, or please visit luminahp.com/insights for more information. Lucy. Any final comments or thoughts?

 

Lucy Zielinski:

I think we're going to see Dan like we talked about today definitely, a shift in the healthcare industry. It's going to be a big year, I think, in 2025, with a more focus on quality and just really taking better care of our patients. And I'm really excited to see that come to fruition.

 

Daniel Marino:

Yeah, I share your excitement. I'm looking forward to seeing how we can put some of these things in place. Respond to some of the changes in healthcare and really see some of our providers and our provider community get back to really, you know, enjoying the care and providing good care to our patients. I'm looking forward to that as well.

Well, I want to thank all of our listeners for tuning in a very, very happy and prosperous 2025 as you enter into this new Year until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

Based on your feedback, our listeners, we've selected the top three episodes for 2024. We dive into the key challenges and opportunities defining healthcare trends this past year through three captivating Value-Based Care Insights episodes. In Episode 102, Sarah Hartley discusses the unique demands of managing Medicare Advantage contracts, offering creative strategies to align providers and patients. Episode 98 features Dr. Riya Pulicharam and Kevin Zhao exploring how integrating clinical data and fostering cultural change within care management transforms patient outcomes. In Episode 106, Tim Hanners and Dr. Dave Lebec tackle the anesthesia provider shortage and delve into tactics to boost financial performance, optimize staffing models, and improve payer reimbursement.

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to Value-Based Care Insights, I am your host Daniel Marino. Well we have a special episode today where we are going to cover what we see as the three most popular episodes of this past year that cover a lot of the major topics I think that we've all been struggling with. We've identified these episodes really coming from you our listeners based on the number of impressions the feedback that we received directly through you know to anyone of us comments and so forth, and just some suggestion in terms in terms of additional topics you'd like to talk about. Our first episode that I'd like to share addresses a topic that I think we've all works so it's kind of been top of mind for the industry and that's really around Medicare advantage. For some organizations Medicare advantage has done really well other organizations it's been a challenge. Our first episode i'd like to share i'm from last spring and has done a great job of working with her Medicare Advantage payers as well as her providers creating a real strong collaboration that has driven a lot of success for her organization. Let's listen to parts of that episode.

Sarah, as I mentioned you know it's no secret many organizations have really struggled with Medicare Advantage. I think from a from a couple of perspectives many of them have seen a lot of the administrative challenges associated with the level of reimbursement from Medicare or Medicare Advantage, there's challenges with getting recertifications there's increased denials there's administrative costs that that have been associated with managing the relationship. What are some of the challenges that that you've experienced with that you've seen as you've worked through a lot of your MA contracts and your MA relationships with your payers?

 

Sarah Hartley:

I would say probably our biggest challenge is taking on that administrative burden and getting the physician buying in that because there is a lot of administrative burden back from MA plans in terms of data the amount of data that we receive. The requirements to meet all of the measures and so the challenge is how do we make it easy enough for our physicians to address it with their patients and meet the needs of our payers as well.

 

Daniel Marino:

Yeah I could see that and you know the reimbursement when you look at the economics the reimbursement is at Medicare rates, right? In some cases they look below Medicare rates or associated with the MAM contracts. But the key to it is as the performance of the plan improves as the star ratings of the plans improve then there's associate then there's incentives that are associated with that right? So if you're if you're looking at a four and a half star rated plan that incentive on top of Medicare reimbursement is higher than a than a 3 ½. But it does not take the place I think of the administrative services right that are required. Are you seeing when you talk to some of your colleagues are you seeing that an increase in a lot of them say denials related to some of these pre certs and other activities that you normally wouldn't get if you were in straight Medicare?

 

Sarah Hartley:

Yes we see a lot of denials and research the increased scrutiny with our DME providers increased scrutiny with the annual wellness visits. There are quite a bit of denials coming through that we just don't know how to manage yeah especially in the new space.

 

Daniel Marino:

Well absolutely I think that's where a lot of folks are looking at the other area that you touched on a little bit it's the performance algorithms. So the other challenge that we have Medicare Advantage is not only are we faced with potentially higher denials and reduced reimbursement but there's also performance outcomes that we have to hit as an organization. How have you been able to overcome that challenge?

 

Sarah Hartley:

I think the key is to have a holistic approach we have to get out of working in silos in healthcare. The goal is to keep our patients out of the hospital and we have to work with our hospital providers and our outpatient providers to look at the patient as a whole and treat them as a whole and so getting that data from our payers can really help us manage that. So getting the subject matter experts at the table that can speak to each piece of that movement for the patient through the system

 

Daniel Marino:

Has getting the data from the payers you know you have your own data right and you're looking at your billing data you're looking at your quality data I'm sure you know you're fairly you're pretty sophisticated so you're looking at a lot of the reports to identify how you can kind of close the gaps and so forth. But the data from the payer is really important. Have you been able to create that alignment around sharing of that data with your payers?

 

Sarah Hartley:

Not yet we are building a platform to do so the challenge is that our internal data just looked at our claims. A patient can go anywhere and so when you look at them as a whole patient they're wraps or their quality measures under that contract they can go anywhere in the patient needs to be managed appropriately. So as we align and we can see the data align we get in under one platform then we can see the pictures the I'm sorry the patients whole story regardless of where they go. So ingesting that data is the path that we're on right now to paint that picture of the whole story

 

Daniel Marino:

Yeah so it's really the claims data right? Because as you said when patients go anywhere and you have your billing data so you know what's occurring within your organization but you don't necessarily know what you know you're in Chicago so you may have a lot of folks that go down to Florida right? The snowbirds are the Arizona correct if you're responsible for them you need to get that claims data and really begin to understand what's occurring is they do get the care elsewhere. How about the vastness of the data? I mean I one of the one of my clients I was talking to we were helping with some modeling of a Medicare Advantage contract. And the amount of data that they have both internally in the organization and then they did get sample data from the payer pulling that together there was enormous. Is the vastness of the data typically an issue?

 

Sarah Hartley:

It's a major issue especially if you think about all of the plans that you contract with. Everybody has a different way of looking at the data they have different terms for their data they have different processes different platforms and then when you get into managing all of the patients or all of the beneficiaries in those plans it can be enormous, and it's overwhelming. So the biggest question the most important question to me is what are we going to do with it is it actionable data.

 

Daniel Marino:

The second topic that we've all been working through is really balancing fee for service versus the advancement of value-based care and we have seen value based care increase in terms of the number of contracts in terms of the number of revenue attributed revenue to that based contracts and so forth. One of the areas that we've heard from all of you and as we've worked with our clients around the country an important topic is around the infrastructure, and in particular air management. Well late last spring early summer I invited Dr. Riya Pulicharam and Kevin Zhao on the program to share their solutions around care management. And what struck me about this episode was how Dr. Riya really highlighted the need to have performance reports of the care managers but making sure that it's integrated well with the clinical pathways that help support positions proactively, as well as then supporting the quality of care delivering to patients. Let's listen to a little bit of that episode.

So this this concept of prospective care management is really gaining a lot of attention especially as we start to work with organizations or as we see organizations taking on more full risk global risk contracts. Well I'm excited today to have two extremely knowledgeable guests talk about this concept of prospective care management. Our first guest is Dr. Riya Pulicharam. She's a national expert in population health, has over 25 years of experience as a physician researcher and a national medical director. She's done a lot of research around outcomes cost of care models incorporating that into the right elements to drive efficient population health. My second guest as well is Kevin Zhao. He's co-founder and CEO of Caret Health. Caret Health is a platform that is really looking at a lot of different data and artificial intelligence to drive new care models and new care management. Dr. Riya, Kevin welcome to the program!

 

Dr. Riya:

Thank you Dan

 

Kevin Zhoa:

Thank you for having us, appreciate it.

 

Daniel Marino:

So Dr. Riya, maybe we could start with you. Given your experience and you know certainly have had a lot over your over your career what do you see as some of the key challenges in the traditional care management structure that that we often see today?

 

Dr. Riya:

Yes so you know I think we should there's lots of challenges in the care management processes and structure today. It hasn't I mean it was still the same when I first started 25 years ago. It hasn't changed much over the years. One of the main challenges that is it's more metrics driven not outcomes driven. When I say metrics it's important metrics is important because that's how they're measured right the care manager so I'm not saying it should not be metrics driven, but it has to be equally and more outcomes driven. It also depends on the organization right? Some organizations are more metrics driven and some organizations are shooting for outcomes driven as well

 

Daniel Marino:

Let me dive into that for a second because you bring up a really interesting point so when we think about diabetes and let's say you have a patient who is a high risk diabetic and we have let's say a metric to measure their A1C level and high risk let's say we consider it you know they have a a 7.5 for instance. So I think what you're saying is oftentimes care management is really building the interventions around that metrics of 7.5 instead of thinking about what are the care management solutions that would that would almost drive the outcomes of reducing the high risk diabetic to maybe a 6.9 if you will?

 

Dr. Riya:

Yes but I was also focusing more on the metrics of how its traditionally care management processes are set up, like high touch. How many calls did you make? So reducing hemoglobin A1C would be an outcome sure right? So if you made your calls as a care manager you've met your target who are the patients that you need to call so they're focusing on that and that's how they staff right?

 

Daniel Marino:

So that's really the outcome what the care managers are doing that needs to be that needs to be tracked.

 

Dr. Riya:

Yeah what is the result right? So of course when I'm the manager leading a team of care managers I do want to set the metrics because I can measure how many calls they had to make. But at the end of the day yeah it is also the outcomes of their call.

 

Daniel Marino:

Well it's the it's the efficiency absolutely. So Kevin let me turn to you for a second. Historically it's been very difficult to measure the let's say the productivity of care managers, and I think especially to track it how Dr. Riya is describing thinking about not only what they're doing, but what's the what are they producing out of the work that that they are creating within the care management platform. What's some of the data that you begin to look at to really to drive that level of outcome?

 

Kevin Zhoa:

Yeah I think there are a lot of existing points solutions today that track I guess the metrics that Dr. Riya was talking about, so how many calls you made how many minutes you spent etcetera. And these platforms tend to do well in more of a fee for service type environment where the goal is to rack up you know I think generally as many transactions as possible and bill insurance. Within their value based care space, which is where I focus on, these types of you know transactional tracking methods work less well and what we have to do then is far out ways to translate some of these you know transactional tracking methods into more of these outcomes you know based you know assessments. One way to do this for example is let's say if you have an entire population of patients, you want to be able to identify you know one for each you know cohort of patients, what's their likelihood of receptiveness to various interventions or outreach. You know if you reach out to the patient for example how likely is that patients actually follow through with what you're asking them the patient to do? The second is for example you know the amount of effort you know that each intervention outreach your task is going to take. So for example if you want a patient to let's say you complete a colonoscopy for example or you'll get a test done you know how much effort it's going to take to reach out the patient set those appointments and follow up with them. And then the last one is the actual outcomes ROI of that you know you know task or that this intervention effort so if a patient does go through with their colonoscopy mammogram or etc you know what's that ROI for you as a value based organization. I think measuring the overall effectiveness productivity is a factor that it's a formula you have to multiply all these together, you know in terms of knowing that your team you know has very limited resources let's say I have 1000 tasks like outstanding gaps you'll only be able to handle let's say 100 per week or 100 per month or whatever the bandwidth is. How do you make sure that the highest ROI you know overall tests are done you know first before trying to get to the rest.

 

Daniel Marino:

And that's a great point because I'll tell you many CFO's they understand what the costs are of investing in care management. What it's difficult to track is the ROI. And I think if you're going to start with that, Dr. Riya, it seems to me as Kevin was talking about it and describing you know those three elements the care pathway the care protocol the clinical pathway care protocols that are put in place are critical right? I mean I think that's the source of truth.

 

Dr. Riya:

Yes so care pathways you know very important as they assist us in clinical decision making right? And they also provide a recommended course of action. As these patients unfortunately especially the most you know expensive patients right? The high risk patients they don't come with just one chronic condition they come with multiple chronic conditions. And when you have multiple chronic conditions you really need to balance. And you also need to you know ordinate this care pathway with social determinant issues. So if they're tied together then it becomes a really good protocol and if that is not automated then it's very difficult by any care manager if their data resides you know in a siloed manner in excel spreadsheets and it's not it's not all tied in appropriately. Then what happens is there is there are these blind spots you're not aware of some things you forget some things and at the end of the day it just becomes more complex. And more confusing and then you don't get to the right data. So care pathways are only as good as how you position them and how you automate them and how accessible it is for you on every patient.

 

Daniel Marino:

A third topic of interest this past year was the advancement of clinical service lines. Everything from cardiovascular services surgical services to even some of the medical specialties. A lot of organizations were considering their strategy to advance their service lines. One area that we continue to see as a challenge is supporting surgical services and the OR activities of hospital and in particular overcoming the anesthesia shortages that we see around the country. Last summer I invited Dr. Dave Lebec and my colleague Tim Hanners to the program we spend some time talking about those challenges of the anesthesia as well as some solutions that providers should consider as they start to enhance their surgical services and create more profitability for their organization. Let's listen to a little bit of that episode.

Some of the real challenges that health care providers are struggling with as they're thinking about maybe either realigning some anesthesia services or just responding to some of the surgical needs that they have within their community

 

Tim Hanners:

Yeah so you hit you know the hospital administrators CEO's and in particular CFO's are really struggling right now they're very frustrated. Because you're right the traditionally the OR has been a real driver for financial performance for everything. And there's some things that are a bit out of their control because the payers of course the financial margins of the OR shrink and our shrinking greatly and then there's some other things factors where a lot of their OR business has gone to ASCs, not and that's of course been orthopedic but a lot of other things are moving to the ASC procedures and surgeries

 

Daniel Marino:

Right so we're seeing that shift inside the service. Dave I can't help but think that this puts probably the anesthesiologists in a real difficult position right I mean to one extent it's always great to be needed and yet you know and I'm sure they can get pretty much roles anywhere but they have to be I would think certainly professionally challenged on really meeting the needs of the provider organization and even there's their surgical counterparts.

 

Dr. Dave Lebec:

Yeah so first off thanks Dan for inviting me for this this great topic today and yes you're correct in in the post pandemic world we've seen a shift in how providers both perform their duties anesthesiologists as well as CRNAs roles expanding roles changing we've also seen a shift in the employment models which we're going to talk about as well. And the primary kind of stressor we see is that anesthesiologists still want to take care of their patients work with their surgical colleagues, yet sometimes they do feel they're caught in the middle of a battle between say a national service provider company as well as the hospital. And they feel that sometimes this creates a barrier and then providing the care they need for the patients that they see each day. And importantly I think we mentioned already by Tim the expansion into this ambulatory surgery centers as well. Prior to the pandemic surgery centers were often taking care of lower acuity patients with a small diverse not so diverse set of surgical procedures but now we're seeing the rapid expansion of surgery centers some with 24 to 40 hours stays doing more complex procedures that require different skill sets. So we're seeing we're seeing these surgery centers expanding with a higher demand or higher sets of skill sets and yet a national shortage of anesthesia providers both CRNA's as well as anesthesiologists. So as you can see there is a production pressure as well as a service pressure that's placed on all the providers.

 

Daniel Marino:

But you made one interesting comment Dave that I want to dive into a little bit. So are you starting to see more of a trend towards employment and if so why is that the case? Is it is it because of those economic pressures? Or do hospitals feel like they could I don't know create a better relationship with their anesthesiologists and align them with the surgical providers? What's the big driver of this?

 

Dr. Dave Lebec:

Great question Dan and what we're seeing is a shift of more towards the employed model by the hospitals. Traditionally this has not been a very appealing model to anesthesiologists or CNA's in the past prior to the pandemic. As hospitals often would only be able to provide certain compensation packages that were very stringent very strict we're not very dynamic reflective of the types of cases each provider was doing as well as the demands placed on those providers. Post pandemic when we saw a lot of the private anesthesia practices become stressed financially as well as operationally being unable to support financially their own practice as well as recruit providers with the national shortage we saw those private groups go under. And that created a market for both the PRN or the per diem providers independent contractors which we're seeing a large spread of that throughout the northeast especially. As well as also having the providers move towards the hospital models in the hospital models have become more transparent have been able to reflect incentive based compensation which is a key for anesthesia employment going forward, and the hospitals being able to adapt their models to attract these providers notwithstanding the new legislation out there for not competes, but also allow the anesthesia providers if they do have a non-compete it's now not geographically widespread is with a national company. But more focused on just a hospital in most cases the hospitals don't even have enough compete or non solicitation clause in their contracts. So it allows the providers to maintain their place of practice or their families have grown up with the hospitals insurgents they have worked with throughout their careers with less stress more transparency and more importantly compensation models are aligned with what they want to do with the work life balance as well as being rewarded for the work they're doing clinically as well as engagement with the hospitals.

 

Daniel Marino:

Well and I'm sure it allows the hospitals to have more influence as to what's occurring with their providers and especially if you have all of these dynamics around shortage and recruitment and so forth. You know the hospitals may not be able to solve the problem but at least they can they can influence it. Tim when you're when you're having conversations with your CFO counterparts or the administrative counterparts what are they seeing as some of their economic opportunities related to employment?

 

Tim Hanners:

You know the well first of all they're also sort of struggling with that right because today's point they haven't done this with anesthesia the staffing models are different and they're really scratching their heads on what is the right way to do this what's the right structure to have for my staffing models and anesthesia, I don't know if how many MD's I need compared to CNA's or even in some states AA's. And so they're really trying to figure out where is my financial opportunity I can't I know I can't sustain what's what we're doing these subsidies continue to increase but I I don't know how to restructure it and what are my options for employment? You know Dave can speak to some various different models they it's not always with anesthesia just employ or not to employ or to contract but there's a lot of you know variables there. They can employ Sierra and a but maybe they aren't my state regulation allowed to employ the MD's.

 

Daniel Marino:

Three great episodes I hope you enjoyed that as much as I did. I want to thank all of you our listeners for tuning in and also a special thanks to all of our guests. If down the road you have any questions for one additional information or have an idea around future topics or just want to connect, please reach out to me and Dmarino@luminahp.com you could also find me on LinkedIn by searching Daniel J Marino. Looking forward to many great episodes in 2025. And again as always looking forward to your comments as well. I want to thank everyone for listening and tuning in until our next insight I am Daniel Marino bringing you 30 minutes to value to your day take care.

Accountable Care Organizations (ACOs) have made great strides in enhancing patient care and reducing costs, saving $3.1 billion in 2023. The recently released report based on ACO performance in 2023 (PY2023) provides valuable insights into where ACOs are excelling. In this episode of Value-Based Care Insights, Dan Marino sits down with Sarah Kachur PharmD, MBA, BCACP, Executive Director of Strategy and Solutions at Johns Hopkins Population Health Analytics, to discuss the key findings of the report and what it reveals about the future of ACOs. Gain insights into the priorities of the most successful ACOs (in PY 2023) and their predictions for changes and challenges in 2025 and beyond.

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino

Welcome to value-based peer insights. I am your host, Daniel Marino. I have a very special topic today, one that I've been tracking for quite some time, and that's a review of the 2023 performance year for the ACOs. Many of us obviously have been involved in the MSSP ACOs for quite some time, and really the ACO reach. And just a couple of weeks ago, maybe a month ago or so, the performance activities were released on the ACOs, and it was quite exciting to see as we dove into it and looked at a lot of the outcomes. There was about 3.1 billion dollars in savings from all the participating ACOs really exciting to see that the ACOs are making stride in really reducing the total cost of care. And I believe this is the largest milestone that CMS has realized since the inception of the program. So, as I was doing a lot of my research. I came across a wonderful post on LinkedIn that summarized a lot of the ACO activities. 

Well, I am really excited today to have as my guest Sarah Kachur, who is with Johns Hopkins health system and supports the health plan. Sarah is a pharmacist by background, has worked in the population health value-based care space for many, many years and is in charge of the analytics works with the ACG risk adjustment tool and just has a wealth of experience with ACOs. So welcome Sarah, to the program. 

 

Sarah Kachur:

Dan, thank you for having me. This is a really exciting year for ACOs, and it was so inspiring to see the progress of all the ACOs in 2023, and many of them have continued that momentum into 2024. 

 

Daniel Marino:

Yes. 

 

Sarah Kachur:

Friendly topic, and thanks for having me. 

 

Daniel Marino:

Thank you. Well, thanks for coming on. This has been. This has been great, and I agree with you. It was kind of nice to see. So, as you were, as you were looking at the outcomes as you were looking at some of the results to see CMS, you know, produce what were some key things that that you identified, or some conclusions that you saw from, you know, from the ACO performance? 

 

Sarah Kachur:

Well, the top line for me was that 73% of the ACO Reach participants achieved savings, and I think we saw a similar rate within the MSSP ACOs. So if we think back into 2022, what we were asking at that time of these ACOs was, were they going to continue with the MSSP Model? Were they going to take on more risk? Were they going to migrate into the new Reach model? How would changes in performance and quality measures and benchmark impact that decision? And a lot of these ACOs have made enormous investments financially, staffing, expertise processes, analytics. And it was a risk for them, particularly for the smaller groups. So it's really heartening to see that the majority of them are achieving shared savings. And I think it's a mandate for continuation of the program and validate some of those investments that they made 2 years ago. 

 

Daniel Marino:

Yeah, I agree with you. I think you know. There we were at a crossroad 2 years ago. I know we had worked with many organizations where they were evaluating where they go. And really did they want to continue? Especially with all the investments that was required? So when you look at, kind of dive into that, that 73% of the earned savings. Talk a little bit about where you see some of the savings coming from. How did it start to bend the cost curve? If you will. Were there a couple of key things that came to mind, chronic diseases, maybe. How we handle the risk, pop you, you know, maybe the rising risk or the high risk population. What were some of the conclusions you saw? 

 

Sarah Kachur:

Well, that's a really good point, Dan. And you know, I'll say it's interesting the data that we get for these Reach ACOs. Tells us a lot about their cost and their benchmark information. And then we get about 10 quality scores. So unlike the MSSP Program, we don't really get detailed drivers of cost at the ACO level. So some of what I'll say is kind of an extrapolation from the MSSP. Program, and some is based on our work with our customers across the country. I think the ACOs have driven by the cost of care and the readmissions measure they have really laser focused on high utilizers. Patients who are frail, those who have multiple complex conditions and are really at high risk for hospitalization. And if hospitalized readmission. We've seen some success as well in reducing length of stay. How can we get patients out of the hospital earlier? And once they're out of the hospital. How can we support them at home? DME, transitions of care medication management. So we're seeing good results in many of the ACOs in terms of their unplanned readmissions, and also in the unplanned admission measures. 

 

Daniel Marino:

Yeah, I would agree with that. And especially, I think, a lot of ACOs have focused on their readmissions that that was so when you when you think back into 2022, and even before some of the you know, the high condition costs, such as you know, sepsis management and COPD, and so forth, contributed a lot to readmissions, and I think there has been a big, a big focus on that. But you know I always kind of turned to what were some of the things that these ACOs did? What were some of the programs that they put in place? I can't help but think that maybe the strong transitions of care programs that they put in place made a difference. 

 

Sarah Kachur:

I think so, too, Dan. And I think we're getting into a landscape where those timely and focused transitions of care programs are table stakes for ACO success. They need to pick up the admit as best they can, either from their local hospital partnerships or in many states we have HIE, admit, discharge, and transfer feeds and they need to even think about the discharge before the discharge happens. As soon as the patient is admitted. There. We yeah, it can be really effective to focus on high risk of readmissions, medication management and social determinants of health. 

 

Daniel Marino:

Yeah, I agree with you and created more of a connected community. So when you look at some of the ACOs, the larger ACOs that have been successful created a connected community of providers that allow for that transition, that handoff and they monitor it right. They put in place the programs, as you said, medication management programs. But they're transitioning that to their connected care of providers. And I think, as you start to look at the high performing ACOs versus the mid, or even the low performing ACOs. I think a big difference is how they create that connected care network. 

 

Sarah Kachur:

You're absolutely right. And that post discharge visit from the patient's own PCP. Very quickly after discharge is a critical component. There are so many gaps in these complex patients. They need a walker. They need DME. They need Meds. Family and caregivers are often struggling, but somebody who's come home from the hospital and needs a lot of help. So I think that outreach is really important within a connected PCP relationship. 

 

Daniel Marino:

Yeah, I agree. Let's try to focus a little bit on the risk adjustment measures. You know, there has been some evolution of how CMS EMI is calculating the risk adjustment ratios and evaluating, and the elements that go into identifying the risk scores the risk attribution of some of the population. In your opinion, in looking at the data and the performance outcome, how has that affected the ACO's ability to perform? And in particular how is it impacted the outcomes within this last performance?  

 

Sarah Kachur:

The end risk adjustment is critical for the ACOs, as we all know, and has been since the inception of the program. The big change that we saw in 2023 and migrating now into 2024. Is that in the future we're seeing more and more roll in of the HCC version 28, migrating off of version 24 and into 28. So that'll be in more effect in 2024, and it'll be a hundred percent in effect as we migrate into 2025. So this will have a significant impact on the ACOs, they need to code correctly. But what we're seeing is that the HCC captures will begin to Max out over the coming years, and the ACOs are going to have to really start doing the hard work of how do we manage utilization? How do we touch patients who are impactable? How do we manage site of care and episodes of care and patients who are on that rising risk spectrum that you mentioned earlier. 

 

Daniel Marino:

Yeah. And that's a, you know, that's a great point. We're we've done a lot of work helping ACOs helping organizations improve their HCC code capture right? And you know, the benchmark we use right now. I think the industry benchmark I last saw was, you know, nationally about, you know, say, 85% or so in terms of the ratio of code captures kind of the best practice benchmark. Some organizations are still below that, but they're rising right? So it is going to get to the point where I think we were going to max out on being able to capture that. And we're going to do a better job of identifying these patients with the risk level based on the coding. But that hard work is going to come into play right? Because now that we've identified the appropriate risk score, if you will of the population, you have to put in place the additional programs to really manage through and manage within that risk activity, and then perform around it. 

 

Sarah Kachur:

You're absolutely right. We have to maintain performance on risk. That'll be a table stakes. And we have to maintain performance on our quality measures and readmissions. Those are also becoming table stakes. And what will we do in 25, and 26 to keep moving forward as things that were new in 2023 are now table stakes in 2025. 

 

Daniel Marino:

If you're just joining us. I'm joined today by Sarah Kachur from Johns Hopkins. She's leads the population analytics team there, and we're having a fascinating discussion on the performance year 2023 of the ACOs that was recently released. Sarah, building on one of the areas that you mentioned briefly. As we think about utilization, and as we think about providing the right level of care to the right type patient, that is timely right? And really moving into more proactive care versus reactive care. How much is the, when you look at these performance outcomes, how much does utilization management? How much did it come into play within these outcomes? 

 

Sarah Kachur:

Dan. It was an enormous driver of these outcomes. When we look specifically at the ACO Reach program, the 2 utilization driven measures, unplanned readmits and unplanned admits are very hospital focused. So it's important to keep patients out of the hospital. ACOs were very focused on that, and as we know, a hospital stay is a significant expenditure both for the patient and for the ACO. So the quality metrics that we have today are very inpatient focused. And I think what we'll see in the coming years is a little bit additional focus on those patients who don't go to the hospital. And, in fact, nationally, as you've mentioned before, are many, many procedures are no longer even requiring an inpatient stay. So we have to start focusing on those outpatient and ASC procedures as inpatient, becomes less and less common. 

 

Daniel Marino:

Yeah, I agree with you, and I'll tell you it is definitely a paradigm shift, right? For many of the hospitals to think about that, because you know, is, I'm talking to CFOs around the country hospitals. They're still very fee for service driven. Vast majority of the reimbursement is still fee for service. Yet if you're going to continue to shift and be successful in value-based care. And in particular, the ACO programs, even Medicare advantage. If you will, you have to. You have to change that paradigm you really do have to think about where should the appropriate pair take place versus maximizing care in just the hospital, because that's the way we've always done it. 

 

Sarah Kachur:

You're absolutely right, Dan, and I'll mention 2 findings from the MSSP Program that I think are related one is that PCP Led ACOs perform better than ACOs that are led by hospitals and health systems. And we can understand from your comments, hospitals, and health systems. There's a a little bit of challenge in that. We want to have our beds filled. We want to have our emergency room well staffed and filled. But many patients, particularly those in the ACO programs that are at risk of an admission or a readmission. If they go to the emergency room, they're sick enough that they'll be admitted. So it's a challenge for health systems and hospitals to think about. How do we keep patients out of the hospital by keeping them out of the emergency room by keeping them well at home? And we might have some empty beds. And how are we going to account for that financially? 

 

Daniel Marino:

Well, and I think that's always the challenge, right as you're starting to invest in and kind of the bricks and mortar, you know, I guess? Answer, asking the question, do we? Do we really need that going forward. You know, when we look at the performance outcomes a lot of it is obviously around trying to bend the cost curve. A lot of it is around managing utilization. A lot of it is around managing the risk cohorts of that population. But an element that is also very important is the quality, right? The quality of care that we're delivering to these patients. How have you seen the quality measurement, the quality outcomes in the 2023 ACOs? how was that changed? Or how is that presented differently within this last performance year versus prior performance years? 

 

Sarah Kachur:

Well, that's a good point, Dan. And these quality outcomes are very important. One thing that we note if we look at the ACO Reach program compared to MSSP is the quality measure reporting group is very broad for MSSP. We migrate, you know, from healthy well patients getting cancer screening all the way into these readmission and admission measures that are relevant to the sickest and most risky of our population. We don't have that depth of measures for the ACO Reach participants. And I think that that makes sense to reduce reporting burden. But unfortunately, we don't get as strong of a lens for these participants into how they perform on things like cancer screening. So analytically, it's very hard to know. However, I can say from our work across the country that these groups are doing a great job. They're very focused on PCP access, high quality specialist high quality specialist access and connecting care across the ecosystem. So on the ground. I think they're doing a great job. And we don't always get to see all of that in the data. 

 

Daniel Marino:

Yeah, I agree with you. I you know. And I'm glad you brought that up, because I've seen the same thing. You know, especially with the higher performing ACOs. You can't just focus on utilization management or costs. You have to focus on quality as a driver of cost management. And I agree with you. I've seen that I think it is tough to report. Sometimes it's tough to see that in all of the data. But I think when we dove into it as well with some of the ACOs across the country. We certainly have seen that. So turning our attention to 2025. What are some of the things that you see potentially could be either lessons learned as we move into 2025, or maybe areas of focus that some of the either the hospital based ACOs or the PCP focus. PC, ACOs, what should they be focusing on as we move into the New Year? 

 

Sarah Kachur:

Sure. So I'll well, there's a lot to focus on, and I know they're very busy. 2 things that I like to focus on when I speak to our leadership or to our ACO partners that, I think are sometimes easily overlooked. So I'll mention those one is the part B drug cost and the other is social determinants and health equity. Part B drugs are hitting the bottom line of every single ACO in the country. It's very hard to get at that data, and some of these products are extraordinarily costly. 

 

Daniel Marino:

Yes. 

 

Sarah Kachur:

The price of these products is also increasing 8, 10, 13% a year. So if we think about cancer infusions, other biologics, rare drugs. It's often possible for these part B drug costs to eat into hospital and outpatient physician savings that would otherwise drive great ACO performance. So I would. 

 

Daniel Marino:

Oh, I couldn't agree with you more. And I'll tell you something. One of the things that I'm thinking about for a future episode is just having conversations on how to manage some of the part B drugs, because the you know, variation in the PBMs variation just in the drug costs and support of where we want to go, I mean in itself, is it? I mean, that's a huge, variable. 

 

Sarah Kachur:

Absolutely, and it's very non-transparent to the prescriber. 

 

Daniel Marino:

Very much. 

 

Sarah Kachur:

And often handled by a specialist who may or may not be aware of the cost, either on the part B or the outpatient pharmacy side. 

 

Daniel Marino:

Yeah, yeah, I agree. So what about the what about social equity or social determinants and health equity? I mean, obviously, that's going to be a big focus correct. 

 

Sarah Kachur:

Absolutely, it's a reporting focus. So in 2024, which we're just finishing ACO Reach, participants were required to report demographic data. And for the 1st time social determinants data on their population. Both of those are captured by surveys. In 2025. For the 1st time we can see a potential negative adjustment to the benchmark for inadequately capturing patient race and patient spoken language. So you know, as a provider office, you're thinking, oh, of course I know my patient's race, but if you're not capturing it in the format that CMS. Wants it and reporting it to CMS. In their format, you could see a negative impact to the benchmark. But more important than that regulatory factor is that in every ACO in the country high need zip codes and geographies are driving suboptimal outcomes. Patients can't afford their meds. They can't get to appointments. They need support. They're getting readmitted. They don't have access to specialists, like you know, higher income or less deprived geographies do. Patients in high ADI areas are driving suboptimal outcomes in every single population that I've looked at. And until we can get at that data and give those patients some extra supports we're not going to be able to bend that curve. 

 

Daniel Marino:

Yeah, I agree with you, and I think you know. So as difficult as it is as it is for some of the ECPs in particular to capture that information. It's critical. It's critical to really driving care to where it's needed. And I also believe, and I've had many conversations with many leaders in community health systems or community health centers. It's going to be important for us to change that care model around what we identify as challenges to health equity. I think that's really the only way that we're going to be able to move forward. Well, Sarah, I want to thank you. This has been a fascinating discussion. This is an area that you know is I'm passionate about and I really want to thank you for inspiring us and sharing some of your wisdom and your outcomes. As you, as you begin to look at the results of the ACO. How could some of our, I'm sure some of our listeners would love to connect with you would love to maybe even contact you. Can you share any of your contact information. 

 

Sarah Kachur:

Sure, Dan, happy to speak to your listeners. I'm on LinkedIn at Sarah Kachur, K-A-C-H-U-R. And also my email is skacher2@jh.edu. 

 

Daniel Marino:

Great. Well, and again, I want to I want to thank you and would love to have you back to kind of dive into, you know maybe a few more of these outcomes related to some of the programs or the interventions, or something in that regard. I think it's so critical to the both current and future performance of the ACOs. 

 

Sarah Kachur:

Well, thanks, Dan. I enjoyed our time today, and we'll have to get together next year and see if these predictions came true. 

 

Daniel Marino:

Absolutely. I agree. Well, thank you again, and thank you to our listeners for tuning in. Until the next insight, I am Daniel Marino providing you 30 min of value to your day. Take care. 

 

Care management is critical, especially for individuals with chronic conditions like dementia, because it ensures coordinated, comprehensive, and individualized care. Currently, more than 6.7 million Americans are living with dementia and Alzheimer’s disease, and this number is projected to continue rising. While the impact of the disease on individuals is widely recognized, the personal and financial burden it places on caregivers is less often highlighted. Today, on Value-Based Care Insights, Dan Marino sits down with Smartrise Health's CEO Vanessa Guzman and JVS Health Co-founder Seth Hyman to discuss the GUIDE Model, a Centers for Medicare & Medicaid Services (CMS) supplement for caregivers of patients with dementia and Alzheimer’s disease. Gain insights into the valuable services within the GUIDE model that can support and benefit individuals living with dementia and their unpaid caregivers.

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:

Welcome to value-based care insights. I'm your host, Daniel Marino. As we talk about different population health topics, or value-based care topics most of the time we talk about those around certain conditions and how we need to manage those conditions. And in particular, we often focus on the rising risk population or the high-risk population. But there is a large segment of the of our population that either may not have necessarily a chronic condition or have a condition which oftentimes needs a lot of care but doesn't necessarily have the reimbursement. And I'm particularly talking about patients who have dementia or Alzheimer's, and it really does take a toll on not only the patients who have dementia or Alzheimer's, but it takes a tremendous toll on the caregivers and the thing that we struggle with as an industry is the support around patients with dementia and with Alzheimer's, and particularly the financial support, there is really not reimbursable by Medicare and even by Medicare advantage. And yet we see the numbers increasing. Right now, there's approximately about 6.7 million Americans who have some form of Alzheimer's or dementia, and that number is only expected to grow as our population ages. Well, CMS. Has recognized this, and over the last year has put forth a new innovation project. I'm really excited to talk about this today. It's called the GUIDE model. It stands for guiding and improved dementia experience. There's been a number of organizations through this innovation concept offered by CMS. That has been awarded as a recipient to manage it.

One of our well, our guest today is from JVS Health. JVS has been awarded as a recipient of the guide model. I'm excited today to invite Vanessa Guzman. Vanessa has been on the program before. She is a industry leader in population health and is CEO of Smartrise Health also joined by our partner, Seth Hyman, who's co-founder of JVS Health. And again, just, Seth has had a lot of experience in working with different ACOs around the country. Vanessa, Seth, welcome to the program.

 

Vanessa Guzman:

Thank you for having us

 

Seth Hyman:

Thanks for having me. Thanks for having us, man. It's good to be here.

 

Daniel Marino:

Well, I have. I have to tell you. I think everybody, either indirectly in your family, or we all know somebody who has some form of dementia. Whether it's like dementia or it's advanced dementia. It takes a significant toll on the families. And I was when we started to 1st talk about this, I really did get excited just because I feel like this is such a need that really we, we need to embrace as a healthcare industry and as healthcare providers. Maybe, Vanessa, we could turn to you. Can you give just a little bit of background on the GUIDE program and sort of the goals.

 

Vanessa Guzman:

Yeah, the model. And thanks again, Dan, for having us, because it's such an important discussion because one of the biggest challenges in dementia care has been the lack of consistent care and consistent support, especially for caregivers. So what this model does is it convenes and integrates 3 key components that from my perspective are key success factors for any dementia program. One is standardized assessment and care planning, and how you deliver those services that are appropriate for dementia patients and their families. It does include also interdisciplinary care that integrates not only services that are delivered at home, but wraparound services for both the caregiver and the patient, and it also includes a training component to support the caregiver. You know those are core factors that I feel will stand up any program for any population, but especially for dementia. From a from a services delivery perspective. It delivers 2 main things. There's care coordination, and, as you all know Dan working with ACOs across the country, one of the biggest challenges that we always bump into is helping patients navigate the complexities of any health system. But when a relative or a loved one or family member friend is diagnosed with dementia, there is confusion across not only taxes the care, but to really understand. What exactly do I need to care for my loved one? Right? So the care coordination is a key component, and then the other component is the actual caregiver services that are provided which include assessment and planning community resources and then access to support line 24/7 within what's appropriate for the for the dementia patient.

 

Daniel Marino:

Well. And you're absolutely right, Vanessa. I think one of the key things that I really appreciate about the program is it provides a direction to the caregivers right? Because many of the caregivers you're right. They don't know where to go, and unless the patient has some type of a health condition, you know, and many of them don't. Many of the patients who have dementia or Alzheimer's may be perfectly healthy right unless they have a condition. Where do they go for support? Right? And there's just there's just nothing out there.

 

Vanessa Guzman:

Nothing out there.

 

Daniel Marino:

So. So, Seth, let me let me turn to you. Talk a little bit about the specifics of the caregiver support. Right? Because I'm assuming the program has quite a bit of resources that are available to it. What are some of those resources that that would be available to the caregivers.

 

Seth Hyman:

Yeah, exactly. You're exactly right. And I think what differentiates this program, and what we're so excited about is the is the care navigators. That's really the engine or the driving force of this program is that every family, every patient, is going to have a 1 on one relationship with the care navigator. So it's not, It's different than some other chronic care management programs where you might have a nurse that you talk to once a month and then every month it's a different nurse. This is really a program tailored to the specific needs of the family and the care and the care recipient. So those care navigators will be able to, as Vanessa kind of touched on, do everything from coordinating transportation, coordinating meals, coordinating care between the specialties. Right? Sometimes these folks will have multiple different providers, and it becomes overwhelming, just keeping all the visits in order. So having that one-on-one relationship is really going to be a very something that's very beneficial for these families. So we're very excited about that. And of course, we're, going to you know, utilize our technology to do it in a way that makes it convenient for these families.

 

Daniel Marino:

So, you know. Let me share a quick story with you. You know I have a good friend of mine and his parents were in their mid to upper seventies, and his father came down with dementia. And his mother, you know. Bless her soul! Did a fantastic job of really taking care of his father, and but it would have created such a strain on his mother, and as much as the family tried to intervene and provide the level of support. It was hard, right, because she was taking care of her husband. 24/7, you know. I know that there's included in the program. I've read that there's respite services. There's other care services that would be provided. Seth, what are some of the things that would be included as part of the guide model?

 

Seth Hyman:

Yeah. So the thing that one of the aspects of this program that we're most excited about and everyone is most excited about is the respite care. So this is the 1st time that CMS is paying for any sort of respite care, and what that means is home care, adult day centers, or even a stay in a facility. So this is the 1st time they've done it, and there's no cost to the patients. So any Medicare beneficiary is eligible. As long as they have traditional Medicare they're eligible for the program. There's no cost, no cost, sharing no copays, no deductibles, nothing like that. So, being able to provide that sort of relief just you know you were mentioning your friend. You know we all have someone. My grandfather. I was taking care of my grandmother with dementia, and it's just, you know, little things like you don't have time to go get a haircut right? You don't have time to do anything. So, being able to provide these free home health services, even for a couple hours a week, is going to be such a game changer for these folks and we are just so excited about that, so we will work again with the family to come up with an offering that works for them, you know. If they want some portion it to be home health, some portion to be stay in a 10 day facility stay in a facility for 10 days where you know, they're going on vacation or something like that. We'll work with them to manage those resources and provide the resources that work best for the family. So the respite care. I can't stress enough. You know how excited we are about that. And I think once people hear about it, you know, their eyes light up because it's like this is something they've been needing.

 

Daniel Marino:

Yeah, absolutely, absolutely. And it just, you know, it just provides that additional support. And, as you mentioned, it, does provide some needed support to the caregivers. But what I like particularly about the program is that there's really 2 key aspects that drive the care plan for our patients with dementia and Alzheimer's. And it's really that care coordination between the providers and it's the caregiver services. I think those are absolutely key, and as many healthcare providers are working through their care management, this, you know, I could see, being a natural progression of how we want to manage care for patients who do have dementia and Alzheimer's. How do patients get enrolled? Right? You know this is a free service, but you know, at the end of the day Medicare is paying for this right? So at some point, you know, we need to be able to connect the dots around what the funds phone economic model look like, how do patients get enrolled into the program?

 

Vanessa Guzman:

Yeah. So there are a few pathways where patients can be enrolled. The 1st one is, and regardless of pathway chosen, is a diagnosis of dementia based on a care assessment that is designed to help identify the severity according to their unapproved clinician that will determine the level of effort or level of services provided to each patient. With that diagnosis. either the patient caregiver or provider can refer the patient to the program to a participant like JVS Health, which, and then we'll kick off a series of next steps and enrollment and engagement, including providing with the caregiver or the patient or the provider, with an overview of how the program works. Of course, Cms. Has dedicated much resources and providing participants like JVS Health with data to also help us identify the opportunities to engage families in care that potentially don't know about the program. You know I think one of the challenges that we will face inevitably is that most families that have a loved one or is caring for someone with dementia is that they don't even know where to start. So we really want to be proactive with working with providers this entire year, going into July, which is when we kick off the program officially, to raise awareness that this actually exists so that they can carry on effective conversations with their providers. So that this is this program is integrated into their primary care, into their specialty care. This should not be like a standalone thing in order for it to be as effective as it can be. It has to work closely with the providers as well. So a number of ways to get referred. But we all need to have a proactive role in making sure. We raise awareness in order for families to know that we even exist.

 

Daniel Marino:

Take advantage of it. Know that this is out there. If you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today talking with Vanessa Guzman and Seth Hyman, and we're discussing the newly launched GUIDE model that's being offered through CMS. Seth, one as Vanessa was talking about the program, I guess one thing that came to mind is, how does that integrate with our with the current CMS ACOs that are out there? I would imagine some of these Medicare patients are part of ACOs or part of Medicare advantage. Is this a separate ACO for dementia patients? Or how does it integrate with the current ACO structure?

 

Seth Hyman:

That's a fantastic question. And I'm glad you asked that because CMS has designed this to be a parallel program with other ACOs or other MSSP programs like ACO REACH, for example. So they actually want patients to participate in both. So just because the patient is in an ACO is participating in an ACO through their provider or a health organization. they could still be enrolled in a GUIDE program. And, in fact, CMS just announced, which was, which is great news that the respite payments will not factor in to the benchmarks for those patients.

 

Daniel Marino:

That's great!

 

Seth Hyman:

They are really encouraging folks to get signed up for the GUIDE model, and for other. We're actually in discussions with other ACOs to kind of work with them, and to get their dementia population to come, join and join up with the GUIDE, because they see the value in this. They see, you know, we could help reduce the total cost of care for these folks by devoting minimal resources. And a lot of time. What happens is a lot of times patients with dementia Alzheimer's end up in the emergency room frequently. Just because they're having an episode and the family doesn't know what to do, so they take them to the emergency room. And as you know that so those are some of the highest drivers of cost. So, for example, if we have this 24 hotline that they could just call and sort of alleviate some of the stress that they're feeling we could help to maybe reduce some of those hospitalizations and ultimately delay, you know, admission to a skilled nursing facility as well. That's the one of the main goals of the program. So it's really designed to work with the MSSP program and other value based care programs. And they really are. They want us to have that integration.

 

Daniel Marino:

I think. Oh, go ahead, Vanessa. I'm sorry.

 

Vanessa Guzman:

No, I just wanted to make a note that it's the way that it's designed It requires participants to infuse or integrate a health equity plan. Which is huge. Right? Because when we're thinking about innovation models like ahead or ACO REACH, that's very much baked in there as well not to mention that in value-based care several States are requiring health, equity, accreditation. So my point is that there's infrastructure that ACOs, or those in the journey of value-based care can leverage and help advance via, you know, participating or enrolling patients helping us enroll patients in this model. My dad has dementia. He was diagnosed 11 years ago. I am Latina all the way. My parents are both Dominican. They only speak Spanish. My mom has been caring for my Dad for 11 years. Putting aside her own priorities, as you mentioned in your story, Dan, and we could see we've seen a decline in her own health. She misses appointments all the time, because there's something going on with him, and that takes priority in her world, and the fact that we can tailor the services based on the caregiver needs from a cultural appropriateness perspective, that that fills my heart because this is not just going to work magically. Via, oh, we have a program. And now we're going to provide you with resources. It has to carry the right naming, shared language, appropriate language, right for non English speakers, for instance, and the trust we have to be able to like the trust of our communities for us to engage their care. One of their loved one or the person they're caring for. Otherwise we won't be successful. So I just wanted to point out the equity piece of this is integral to the success of the program.

 

Daniel Marino:

Absolutely and to your point. It certainly does have to be multifaceted where it really aligns with what the care needs are of the community the care needs are of, you know I would say, of this population, because, you know again, when you think about it, the demographics associated with dementia, you know, I mean, you hear patients who, you know it's tough to say. But there's patients, even in their late fifties, early sixties who have dementia versus those that are are much older in life who have dementia. So I think it does have to be multifaceted, and I think this could be, as I see it a tremendous opportunity for ACOs, who do have a large attributed population within their ACO to be an extension of managing patients. I think it has a real opportunity associated with it.

 

Vanessa Guzman:

Absolutely.

 

Daniel Marino:

So let's talk a little bit about some of the funds flow, because I think this becomes important. This is a free service, right? But primary care, or somewhere, the physician has to be able to either refer or recommend, or if a patient, your caregiver does you know self-refer? How do the economics work, I mean are, are is JVS Health getting support from this? Or do primary care still can build the same way at a high level, you know. Maybe, Seth, you could address this. How does the funds flow work?

 

Seth Hyman:

Yeah, absolutely. So there are CMS is design UG codes specifically for the GUIDE model that only GUIDE participant, that only GUIDE participants are able to bill for so and that's on the respite side, and also for the for the monthly per beneficiary per month payments as well in terms of how primary. This won't affect the primary care providers, though at all. So they continue to see that, you know, we want to stress this. We can't stress this enough. Continue to see the patients the way they normally would doesn't affect any billing or any care that they're providing to their patients. Whether that be primary care, neurology, geriatricians, whomever they continue to just see the patients where they normally would. But they could just.

 

Daniel Marino:

So they continue the patient. They continue to treat the patients for every condition that they have, and they continue to bill, you know, as they normally have fee for service code. Still, you know, still work the same. So you know they're not, they're not limited, based on their reimbursement, based on patients enrolled in the program.

 

Seth Hyman:

Exactly. We wanna do not want anyone to think that we're trying to take over the care of these patients. We are not practicing medicine, we are strictly providing support for those for these families and these patients, and just providing additional resources. And you know, as we know, our other partner, Dr. Hyman. He's been a primary care practicing primary care physician, for, you know almost 40 years now, and a lot of times he feels overwhelmed when he gets, you know, a new patient with a new diagnosis of dementia. It breaks his heart because he does not know what to tell the families. He doesn't have the resources to kind of help them. So I think we have a real opportunity to help and be a great partner to primary care physicians all through, or any primary care provider throughout the country, and help them manage these patients and give them resources that they just wouldn't have access to otherwise.

 

Daniel Marino:

Yeah, well, it. It makes sense, then. So it sounds like it's patience are referred to you all and get enrolled into the program. Then you're providing some of that coordination that caregiver services billing Medicare separately. And then you get reimbursed. So you're an extended, almost an extended provider of the care that's being provided, then, through their normal physician community, if you will. Again, I mean, that sounds great, because there's no conflict of interest there.

 

Vanessa Guzman:

Correct.

 

Seth Hyman:

Yeah, that's a great way to put it.

 

Vanessa Guzman:

And it doesn't weigh on their total cost of care. If there are an ACOs participant, as Seth mentioned earlier which means there shouldn't be any hesitation right in using our services, because it just doesn't go to that to that bottom line for lack of a better term.

 

Daniel Marino:

Well, I'm sure this is new to a lot of folks, and I and I'm sure after our listeners kind of dive into it. They're going to get excited, particularly our provider community. You know. Again, I think, from an emotional standpoint, and certain from a practical standpoint. This makes a lot of sense to our caregivers and to our provider community. How can folks learn more about this? Anywhere that you would direct them, or maybe they can reach out to you all any thoughts.

 

Vanessa Guzman: Yeah, there's several ways we have informational content on our website. www.jvshealth.com just click on the GUIDE model tab on the top banner. You can also email us at info@jvshealth.com. You have the ability to submit a form or send an email with any questions but what we encourage you to do the most is talk to your provider also about it, because they may be able to also answer specific questions on what you could do now. Our program does kick off in July of 2025. So in the meantime we will work with providers across your community to make sure that there is awareness, and that we build partnerships, so that when we get to the July time frame we are ready to enroll you and your family member.

 

Daniel Marino:

Wow! Well, that's great. Well, I wish you all a lot of luck in this program. And you know again, I think this is something that is near and dear to my heart, and I'd love to have you all back, maybe in another 6 or 8 months as you started to kind of go through this a little bit, and just to hear how things are going, I know you're not kicking off until July of 2025. But wish you a lot of luck and a lot of success. I think it's going to be great.

 

Vanessa Guzman:

Thank you. We appreciate you having us.

 

Seth Hyman:

Yeah, thanks, and really appreciate the opportunity to talk about this.

 

Daniel Marino:

My pleasure, my pleasure, and I want to thank all of our listeners for tuning in. If you want to learn more about this topic, and others. Please visit luminahp.com until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

 

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.