Crosswinds
Crosswinds is a series of casual conversations with national thought leaders hosted by Tom Robertson, executive director of the Vizient Research Institute. New episodes released every month feature the brightest people in health care considering questions that others haven’t thought to ask – always remarkable, never exactly what you’d expect, and having fun along the way. Crosswinds: Two old friends sitting in comfortable chairs… talking.
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Episodes
Tuesday Jul 20, 2021
Tuesday Jul 20, 2021
Tom Robertson, Executive Director of the Vizient Research Institute and Cathy Jacobson, President and CEO of Froedtert Health in Milwaukee return to discuss macroeconomic challenges facing the U.S. health care system rooted in its Byzantine financing system involving counter-productive cross-subsidies between payers and a historic imbalance in payments across clinical services. They consider the merits of systemic changes reducing payment rate disparities, and the potential advantages of a future in which providers were payer agnostic and more empowered to invest in traditionally under-funded areas such as mental health and primary care. Cathy shares Froedtert’s initiatives to identify adverse social determinants of health early and a community-wide partnership that uses a single tool to curate social services resources for medical providers.
Guest speaker:
Catherine A. Jacobson, FHFMA, CPA
President and CEO
Froedtert Health
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[1:00] Health care finance is like a Jenga Game – the reimbursement system is Byzantine and doesn’t make sense
[2:20] Health systems make their entire margins on very few things- they lose money on other things that they must do but are paid for by the former.
[4:13] Health care needs to move away from the current reimbursement system
[9:17] It would be far better if pricing was the same for all payers, government and private, and we competed on access, service and quality rather than price
[12:15] We get what we pay for – if we don’t pay for it, we don’t have it. (Example: behavioral health, family medicine)
[14:42] Price leveling would better enable providers to address social determinants of health
[16:52] Froedtert approach to mitigating social determinants of health: 1. Identify affected patients much earlier and more consistently than we did before, 2. Created a community-wide partnership to curate all available social services resources in the market by using one common software tool
[19:09] Health care organizations are economic anchors in the community
[20:00] Froedtert creating educational grants targeted at effective high schools and especially vulnerable populations
[21:40] If revenue was more fungible, would invest heavily in behavioral health
Links | Resources:
Cathy Jacobson’s Biographical Summary Click here
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Tuesday Jul 13, 2021
Tuesday Jul 13, 2021
Tom Robertson, Executive Director of the Vizient Research Institute sits down with Cathy Jacobson, President and CEO of Froedtert Health In Milwaukee, Wisconsin to discuss everything from agile decision-making during the COVID pandemic to deliberate system rationalization of clinical resources, including program consolidation and efficient utilization of both tertiary and lower acuity facilities. As a long-time chief financial officer, Cathy shares insights around economic incentives and the importance of avoiding inadvertent structural impediments to doing the right things.
Guest speaker:
Catherine A. Jacobson, FHFMA, CPA
President and CEO
Froedtert Health
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[1:13] America has the best health care in the world, but not the best health care system. (Cost, quality, and access for all citizens of the United States)
[1:13] We do best in science, innovation, treatment and education
[04:08] Hospital systems must have local scale to accomplish rationalization of services; provider consolidation across distant markets does not serve that purpose
[10:05] The pandemic led to command centers that made decision-making more agile; Froedtert will keep the “recovery command” infrastructure in place moving forward because decisions are “deliberate but at speed”
[12:43] Unexpected consequence of the pandemic: Froedtert advanced the pace of their long-term cost reduction goals by one year
[14:16] During the pandemic shutdown, Froedtert management intentionally thought about what new structures to keep after the pandemic (i.e. organizational change and enhanced communication)
[17:05] Video visits are down from mid-pandemic peaks; Froedtert targeting areas to re-establish more virtual
[18:24] When patients are seen in video visits, not as many lab tests and x-rays are done
[19:21] When volume comes back, it’s going to come back sicker and worse – we’re going to see double-up rebound on Medicare payer mix.
[23:05] For systems to work, it’s essential not to inadvertently create financial incentives that impede good people doing the right things; at Froedtert, individual hospitals are not evaluated on their own performance, everyone rides on the system’s bottom line.
Links | Resources:
Cathy Jacobson’s Biographical Summary Click here
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Tuesday Jun 15, 2021
Tuesday Jun 15, 2021
Tom Robertson, Executive Director of the Vizient Research Institute and Will Ferniany, CEO of the UAB Health System return to discuss a possible role for genomics in reducing health inequities, the shortage of mental health resources, Will’s thoughts on national investments in public health and education, and their shared view that macroeconomic systemic change is unavoidable in the long term.
Guest speaker:
Will Ferniany, PhD
CEO
University of Alabama at Birmingham Health System
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[0:34] Global budgeting
[03:15] Health inequities
[04:25] Healthy Alabama 2030
[5:11] Alabama Genomics Initiative to improve treatment of minority populations in the state
[05:46] Mental health
[07:28] America health care is in the sickness industry, not in the health industry. Resources come when organizations care for the sick.
[8:00] Suggestions: 1. Invest in public health and education; 2. Pay hospitals based on total cost to get the patient at highest level of life function
[10:00] Defining health care as a public good
[10:54] Leaders of health care organizations has to be willing to disrupt the industry before health care reaches its breaking point
Links | Resources:
Dr. Will Ferniany’s bio Click here
UAB Medicine: About UAB Click here
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Tuesday Jun 15, 2021
Tuesday Jun 15, 2021
Tom Robertson, Executive Director of the Vizient Research Institute sits down with Will Ferniany, CEO of the UAB Health System to discuss virtual patient encounters (before and after COVID) and their impact on ambulatory facility capacity, Will’s thoughts on the unique challenges facing rural health care providers, and the concept of global spending budgets as an alternative to traditional funding.
Guest speaker:
Will Ferniany, PhD
CEO
University of Alabama at Birmingham Health System
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[01:13] Virtual options: eUAB and telemedicine
[03:57] UAB’s Health Loop uses apps
[07:50] Need to figure out what to do with excess ancillary clinical facilities and office space
[10:45] UAB’s payment model has faculty complete agnostic to the payer class of the patient
[12:35] Rural hospitals in Alabama are financially stronger than they ere before the pandemic
[12:50] Systemic changes needed for rural care
[13:56] Rural hospitals should not be paid on a fee-for-service basis like the big urban hospitals
[14:20] Global budgeting
[15:05] Manpower shortages in rural hospitals due to restricted J-1 visas
Links | Resources:
Dr. Will Ferniany’s bio Click here
UAB Medicine: About UAB Click here
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Tuesday May 25, 2021
Tuesday May 25, 2021
Tom Robertson, Executive Director of the Vizient Research Institute, sits down with Yale New Haven Health’s CEO, Marna Borgstrom, for a second time. Tom and Marna shift gears to discuss macroeconomic issues affecting the affordability of health care for middle class households.
Guest speaker:
Marna Borgstrom, MPH
CEO
Yale New Haven Health System
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[00:56] Marna has been in academic health care for 42 years, loves it and believes in it for all it does in health care delivery, however she believes health care providers have gotten very insular in the way they look at and provide care.
[01:50] Historically, there’s been an attitude that if health care built systems that suit them, including how they bring people in, that the people or patients would be grateful that the providers are making time to see them.
[3:00] Health care organizations exist for one reason, our patients – whether it’s in education, whether it’s in research or whether it’s in the delivery of care, we exist to provide better health care and a better health care experience to our patients
[5:36] It’s concerning how health care has a negative financial impact people’s lives – some to the point of bankruptcy.
[6:27] The majority of patients care what health care costs. We’re pricing ourselves out of the market because patients don’t know how to assess the value of care.
[7:18] To the average person, value is what you pay because they aren’t able to discern the right diagnosis. It’s a challenge for health care to get the value equation right, because the only thing people can really evaluate is their experience and how we made them feel.
[7:50] Health care may be heading for an all-payer rate-regulated public utility model where providers compete on service rather than on price.
[9:17] At YNHH 65% of patient care is paid by the state or federal government; on Medicare, which is the largest piece, they lose 11 cents per dollar of cost – not price, but cost.
[9:50] With Medicaid, YNHH loses 53 cents on the dollar of cost and not covering their variable costs in most cases.
[13:30] Physicians largely practice in a payer-agnostic way.
[16:06] YNHH spends a lot of time and investment developing talent across the health system.
[16:30] People are rewarded for what they do. We promote people for their potential, and potential is not based on what you’ve done in the past, it’s a cumulative on how you’ve developed and how you do what you do.
[17:00] Important for leadership: 1. lead with humility (no one leads by themselves); 2. be self-aware – you have to be courageous, take thoughtful risks and learn from your mistakes; 3. drive alignment and collaboration with diversity, equity and inclusion; and 4. strive for improvements and innovation.
Links | Resources:
Marna Borgstrom’s biographical information Click here
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Tuesday May 25, 2021
Tuesday May 25, 2021
Tom Robertson, Executive Director of the Vizient Research Institute sits down with Marna Borgstrom, CEO of Yale New Haven Health, to discuss everything from a purposeful restart following the COVID-19 crisis to creative approaches to dealing with the manifestations of social determinants of health...in the meantime offering insights into what American medicine does particularly well and where we could do better.
Guest speaker:
Marna Borgstrom, MPH
CEO
Yale New Haven Health System
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[01:00] What health care gets right: It’s a great “sick care system”
[01:48] Where we fall short: We are not a health care system, we’re a sick care system
[02:15] Marna likes the book The Paradox of America’s Health Care by Betsy Bradley and Lauren Taylor. Marna says it says if you combine social infrastructure spending and health care spending per capita the United States doesn’t spend more than other developed countries.
[3:00] The authors say since many illnesses are a function of socioeconomic issues; countries that invest in social infrastructure treat fewer catastrophic health care events.
[4:44] Health care organizations have a unique role to be both investor and conveners of other businesses and government.
[5:22] In Connecticut there are no safety city/county hospitals to act as safety net hospitals, so Yale New Haven Health academic medical centers must support Bridgeport and New Haven communities – two of the 50 poorest midsize cities in the United States.
[6:18] Yale New Haven has a joint venture with federally qualified community health centers to create integrated, primary ambulatory care and access to specialty care for medically indigent patients.
[6:38] Yale New Haven has a “Promise” program which guarantees a 4-year college experience for high school students who have a B average, low absenteeism, and family support. Over the past 10-years, that program has dramatically increased the graduation rate. It not only educates but gives students skills.
[7:40] They also cooperate with Habitat for Humanity and other corporate community partners to improve social infrastructure.
[8:55] Beyond financial investments, Yale New Haven brings organizational skills and people who can drive the community’s socioeconomic initiatives
[11:11] Have about 40 rapid-cycle performance improvement initiatives going
[12:37] Electronic Health Record prompts pathways to diagnostics for diagnosis
[13:26] Signature care when anyone you care about can come into the health system, and you don’t feel compelled to make a call for a work-around to give them good care. Instead, the system works well for each patient. Making progress to achieve that.
[16:50] Volume-based procedures are driven by local physician requests and local competition
[18:00] “Academically-based health system” where you can make your physicians part of an integrated network that moves around the physicians to different health system facilities a few days a week to provide specialty care. In aggregate you’re getting more volume, expertise delivered to local markets without having it all come from those markets.
Links | Resources:
Marna Borgstrom’s biographical information Click here
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Tuesday May 04, 2021
Tuesday May 04, 2021
Tom Robertson, Executive Director of the Vizient Research Institute, sits down with Johns Hopkins’ president, Kevin Sowers, for a second time. Tom and Kevin talk about the redesign of primary care, telemedicine and mental health reimbursement.
Guest speaker:
Kevin Sowers, MSN, RN, FAAN
Executive Vice President, Johns Hopkins Medicine
President
Johns Hopkins Health System
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[00:28] Recap of global budgeted revenue (GBR)
[01:35] Global budgeted revenue allows each hospital to decide how they will spend their money to care for people, while achieving expected quality and satisfaction metrics
[02:26] Shift in care to begin building primary care practices that are chronic illness focused; can make huge impacts on utilization patterns
[04:58] Redesigning your primary care practice to effectively team manage for high-risk patients to avoid hospitalization
[06:29] Redesigning primary care: Create contact moments through telemedicine and technology to deliver better care for the chronically ill
[07:35] Be flexible in seeing chronically ill patients when they need to be seen
[08:31] Partner with primary care practices to design new models to innovate and transform the way we see very complex patients and to drive utilization
[09:49] The GBR allows better incentives to take lower acuity services and put them into a lower cost setting
[10:30] Acting as an integrated delivery system, under GBR, moving services to outpatient setting allowed hospitals to keep 50% of total cost for that population and allows you to do the right thing
[11:04] How the GBR payment system in Maryland addresses mental health better than with other payment models
[12:19] Reimbursement of mental health care costs in all-payer model plus transformational grant from HSCRC to begin addressing the gaps in behavioral health system
[13:18] Expanding behavioral health crisis services to include care traffic control system--a high tech, crisis hotline and referral system to allow patients with same day access
[14:07] Single managed service organization to oversee the work of getting patients into the care models they need, in the communities in which they live but not requiring them to visit the hospital
[15:01] Virtual care benefits from pandemic, highlights the advantages of a rate-regulated financing system despite revenue loss on cancelled surgeries and procedures
[16:29] Protection mechanism to keep Maryland hospitals viable during unprecedented times when the rest of country did not have a revenue stream that continually supports them
[17:15] Challenges with Academic Medical Centers and how they fit into this all-payer model, as well as how you pay for innovation. All-payer still has more positives. There will always be mechanical issues of policy.
[19:03] Kevin’s most admirable characteristic of his management style is compassion. Brought nursing experience into the executive suite that has translated into inspirational behavior modeling
[19:48] Two lessons learned
[21:20] Rise above the moment of chaos, listen to the people who are feeling the emotions, but respond to the moment with facts.
Links | Resources:
Kevin Sowers’ biographical information Click here
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Tuesday May 04, 2021
Tuesday May 04, 2021
Tom Robertson, Executive Director of the Vizient Research Institute sits down with John Hopkins’ president, Kevin Sowers to discuss possible future directions for health care finance. They consider the unintended consequences of payment rate disparity between public and private insurance and how Maryland’s unique all-payer rate-setting model empowers providers to make investments in patient well-being that would be more difficult under the traditional payment system. Kevin shares his insights on programmatic investment to deal with the manifestations of social determinants of health and partnering with others to create healthier communities.
Guest speaker:
Kevin Sowers, MSN, RN, FAAN
Executive Vice President, Johns Hopkins Medicine
President
Johns Hopkins Health System
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[01:01] Payment rate disparity between public and private insurance
[01:48] Maryland model payer system vs. other systems
[02:55] Advantages of Maryland model: Helps decrease ED utilization and hospital days
[04:15] Model forces you to consider community strategies to better manage high utilizers – Example of dental care patients
[05:24] Global Budget Revenue (GBR) total cost of care advantage – allows you to think how to integrate into the community to focus on the10% of patients who drive up 90% of your costs
[07:00] With GBR hospital gets paid the same amount whether it has 10 patients or 1,000 patients.
[07:52] GBR only for hospitals; unregulated and professional fees need to still be negotiated
[08:30] Example: Utilization patterns of the ED and hospital care to the homeless. Partnering with others to fund housing services for the homeless resulting in decreases in ED utilization and overall health care costs
[11:00] Use of grants to invest in social determinants of health, resulting in decreased health care utilization
[11:43] Developing systems of care with others in community to assist with socioeconomic factors and social determinants
[12:30] Example: Jobs program created to recruit, train and hire individuals previously excluded from workforce were hired to be community health workers
[13:00] Transforming lives to make a difference – “Living with options”
[13:56] Total cost of care model (GBR) enables you to do the right thing, and that’s rewarding
[14:47] Hospital at Home program to create healthier communities
[16:42] Background on Kevin and how he became a nurse
Links | Resources:
Kevin Sowers’ biographical information Click here
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Tuesday Apr 13, 2021
Tuesday Apr 13, 2021
Tom Robertson, Executive Director of the Vizient Research Institute sits down with Stanford’s president and CEO, David Entwistle for a second time. Tom and David shift from operations to health care finance and contemplate how things may change in the future.
Guest speaker:
David Entwistle
President and CEO
Stanford Health Care
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[01:16] Group practices with a collection of specialists that provide a one stop shop that considers the whole patient
[02:09] Group specialty practices help you to remain competitive, manage care and costs
[03:44] One of the biggest cost drivers is the variation of care
[04:24] The ability to reduce the avoidable variation will help reduce costs
[04:37] Creating transparency of the variation data is monumental. Show physicians how they treated the same patient with the same diagnosis
[05:15] Have to look at large data sets to show a true variation difference that’s controllable to create a better-quality experience and lower costs
[05:32] To make movement in variation, you can’t just go after the costs. You have to show it’s a better outcome and start with quality or it won’t be successful.
[06:47] To make the change, you have to ask how do you create the best outcome? Once you apply the data to the outcome, then the costs come down.
[07:24] Scenario: if all-payers pay the same. How would you think differently – operationally and strategically?
[08:42] All patients are treated equally. It wouldn’t change anything operationally.
[09:30] Strategically: Think how much we spend to be attractive to commercial insurance companies that are funding the private to public payer subsidy, there are nuances that collectively make a difference.
[10:00] Margins produced in academics are different because they are funding research and teaching.
[11:46] Examples of how career paths are evolving today
Links | Resources:
David Entwistle’s biographical description (Click Here)
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Monday Apr 12, 2021
Monday Apr 12, 2021
Tom Robertson, Executive Director of the Vizient Research Institute sits down with David Entwistle, President and CEO of Stanford Health, to discuss lessons learned during the global pandemic. David describes Stanford’s new inpatient facility, with a particular emphasis on the use of emerging technology to improve the patient’s experience while realizing economic efficiencies.
Guest speaker:
David Entwistle
President and CEO
Stanford Health Care
Moderator:
Tom Robertson
Executive Director
Vizient Research Institute
Show Notes:
[02:29] Stanford Health Care recipient of 2020 Gartner Eye on Innovation Award for technological advances
[03:15] The most technologically sophisticated hospital in the world
[03:50] Hospital has flexibility to change with technological advances
[04:17] Possible to have 10,000 devices stream with 4K video
[04:45] EMR can facilitate a real time e-consult with the patient in the hospital bed
[05:17] Robots to pick, fill and verify pharmaceutical doses
[06:00] It’s the people who built the inspirational, flexible facility
[06:43] 5,000 locator beacons will use EMR information and will text patient while they’re in the building about their appointments, location and check in
[08:00] Texting platform for nurses and doctors to communicate
[10:40] Virtual technology
[11:19] During height of the pandemic, 70% were virtual visits. 96% providers provided virtual visits.
[11:45] 90% of all pathology is being done digitally
[12:10] Using virtual visits for reconnaissance
[16:00] What would David Entwistle want to change in health care overall?
[17:06] Technology example: using wearable algorithms to track and monitor patients to determine likelihood they would contract COVID disease
[17:35] Predicted 4 days earlier that an individual would likely contract COVID
[18:10] Why not use the technology to enable the care platform for individual providers?
[19:13] Hope to create a consumer-oriented experience
[23:15] Possibilities of using technology to track patient’s real time health
[25:00] Using medical database to evaluate treatment probabilities for individual patient
[28:50] Using technology of recognition of facial patterns and eye movement to predict patient’s pain level in ICU
Links | Resources:
Gartner Press Release: Winners of the 2020 Gartner Healthcare and Life Sciences Eye on Innovation Award Click here
David Entwistle’s biographical description Click here
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