true pay-for-value. Finally, I think that payment innovation will happen, and there are encouraging signs of a move to narrower networks. For example, in California, there’s Canopy Health Network, and Sutter Health Plus, with Sutter and Stanford Health. So I see some signs for optimism; but today, it’s a mixed bag.”

“It’s now ten-and-a-half years since Obamacare passed,” said MediSync’s Matthews, referring to the Affordable Care Act (ACA). “And looking back, back then, I and a lot of others assumed we’d have a lot more value in our rev- enue packages than we do today. Our organization doesn’t want to be in the fee-for-service business. The fee-for- service business in 2020, especially for primary care, is a bad business model. It’s underpaid, and the incentives are to not do what’s best for patients. We’re ten years in and would like to be further along.”

Matthews went on to say, “So why is this happening? Speaking very broadly, and throwing pharma out for a minute, there are two big inside players in health- care, nationwide. One is the hospital- based integrated health systems; by and large, they are not interested in value. There are some exceptions, such as Sharp Rees-Stealy. And the other group is insur- ers; they’re making a ton of money in fee-for-service, and are quite happy with it. If they were to go to fee-for-value, it would blow their brand, which is to claim that they are the progenitor of all that’s good in healthcare. So the inside players are slow-walking, with excep- tions. The people more interested in cost and quality are the outside players. The government, purchasers, and patients simply cannot afford what’s going on in healthcare. I don’t see health insurers and hospital systems saying en masse that they’re going to change over. And in some places, there is Medicare capitation. We make very good money in Medicaid in our group, which is extremely hard to do. But on the commercial side, we render far more value than we get paid for. And insurers don’t want to turn the money over to us.”

Mount Sinai’s Gandhi said, “I’m optimistic because I only know how to be optimistic—and am planning to be in the industry for another 35 years. So I would say it will be smooth sailing, but with a really long way to go. We’ve been able in our organization to deliver a lot of value that others are reaping the benefit of. What we’re talking about is not incremental change; we need trans- formative change. You ultimately have

to rip out the fee-for-service system and replace it. This system was set up for fee- for-service, churn-and-burn medicine. Everything in the system is designed for fee-for-service, mediocre, care. And so we have to rearchitect this $3 trillion system that employs 35 million people.” In short, Gandhi said, “We want trans-

formation, not incremental change; we want it at scale, not just in pockets; and we want it fast, not slow. But we can only get two of the three. So we can have at- scale change that’s slow, and you get that through the shared-savings programs. And that will take two decades. Health systems like Mount Sinai are embracing value by taking risk, and pressures will inevitably push us to a new model of high-value care, at scale, with real value; it will just take a while to get there.” “So, a yes-or-no question: is the move

from volume to value in the inter- est of health plans?” Crane asked the discussants. “Not today,” Matthews said. When they own more and more delivery systems, which is their goal, then they will” want to shift to value-based pay- ment. Joyner opined, “I think it depends on the price. Health plans are rational economic actors. If a health plan can provide predictable amounts to provid- ers, they’ll select fee-for-service-based or value-based payment, based on what’s in their best interest. Per COVID, we were very relieved to have capitation here at Hill, because we’ve been able to support some of our practices better during this crisis. But I can tell that some health plans looked at this situation and said, ‘Wow, if they had fee-for-service right now, we could have benefited in this crisis.’” “Yes, it’s in health plans’ interest [to move forward into value] on managed Medicaid, and if it hasn’t happened that’s because some providers aren’t there,” Gandhi added. “On the self-funded side, sometimes we talk out of both sides of our mouths. We’re returning value to the employers, which is who wants that return. We just haven’t figured out the value proposition on the self-insured or PPO side.”

“Why do most providers want to move

into prospective payment?” Crane asked Matthews. “Everyone wants choice,” Matthews responded. “I think there are lots of problems, and I don’t dispute some of the complexities of the PPO market. But in general, when you’re kill- ing it financially, as some of the carriers are doing these days, nobody wants to change it all. On the provider side, there are 450 very large provider systems. On average, if you go to the large-system

club, there aren’t a lot of people wanting to go into risk. But, first, they don’t know how. They went out and hired zillions of care and case managers 20 years ago, and that hasn’t changed things. And the second thing is that these hospital systems have gotten bigger and bigger. Now, I believe that primary care, done right, saves an absolute fortunate. But these hospital-based systems are using primary care as the wide end of the fun- nel, to fill up beds.”

Why Mount Sinai removed a major chunk of its capacity “Niyum, why did you guys decide to go into value?” Crane asked Gandhi. “Our oldest institution just celebrated its 200th anniversary; and we want to serve the New York community for another 200 years,” Gandhi responded. “And the only way to be around that long is to provide value. We have to do it. It came about after our chairman of the board emeritus worked with our CEO on this. We knew that it would not provide a quick ROI; we had to can- nibalize parts of the system to make this happen. We have taken out underlying capacity and we’re on a path to take out 1,000 beds from the system.” The reality, Gandhi said, is that “Unless you take out the underlying cost, no matter how hard you run towards risk, you end up losing money. You can try to jack up your rates. And I’m not saying the others are bad people; they’re just being shortsighted, because ultimately, the market share will be awarded to those who deliver higher value. Here in New York City, the second-largest labor union in the market with 200,000 members went live with a tiered network, with a rich benefit and a $100 copay if you go to Mount Sinai, and $1,000 if you go elsewhere. That moved market, because we give them bundled pricing, and our prices are 20 to 30 percent lower, because our cost structure is 20 to 30 percent lower. But we’ve spent 10 years and $100 million to get there. Most systems don’t want to try that if they don’t think it’ll work.” Finally, Crane asked, “What lessons are we learning about technology?” Joyner said, “We need to embrace telehealth, AI tools, and remote monitoring. If we haven’t embraced those tools, rapidly, we’re going to have that volume picked off by new entrants. Second, there are going to be new products that are neither PPOs nor HMOs, but that involve new plan designs that will allow us to embrace something in between PPO and HMO, where there’s both margin and value.” HI


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32