Gregg Masters 00:05 And you’re listening to PopHealth Week on HealthcareNOW Radio. I’m Gregg Masters, Managing Director of Health Innovation Media and co founder and co host at PopHealth Week joined today by my partner and lead co host Fred Goldstein, President Accountable Health LLC, a Jacksonville, Florida based consulting firm. On today’s show, we are thrilled to re-engage with a colleague, who we met at the 19th Population Health Colloquium in Philadelphia, who is a published author, a definitive thought leader, patient advocate and former Chief Medical Officer at United Healthcare. Dr. Archelle Georgiou is the author of Health Care Choices Five Steps to Getting the Medical Care That You Want and Need. She’s a nationally recognized physician advocate and advisor earning her medical degree from the Johns Hopkins School of Medicine, and practicing and practiced internal medicine in Northern California. However, to have a broader impact on the healthcare system, she shifted her focus to the managed care industry. Between 1995 and 2007. She served as senior executive and Chief Medical Officer of United Healthcare where she dismantled many of the company’s legacy policies in order to minimize minimize the bureaucratic burdens imposed on patients and physicians. And we’ll hear more about that shortly. Since 2008. Archelle has served as a senior advisor for a diverse group of companies serving health needs in industries ranging from education to analytics and financial services to mining. She worked with former Speaker of the US House of Representatives, Newt Gingrich at his Center for Health Transformation, a nonpartisan Think Tank focused on advancing patient centric, sustainable health care policy. So Fred, with that truncated introduction over to you help us get to Norco.
Fred Goldstein 02:18 Thank you so much, Gregg, and welcome to PopHealth Week Archelle,
Archelle Georgiou 02:22 thank you so much.
Fred Goldstein 02:25 Yeah, it’s a pleasure to have you on it was great to talk to you a few weeks back at the colloquium. And glad we could get a little bit of time to to talk a little bit more and a little more in depth about some of the things you’re working on. So one of the areas we had discussed in advance was this, this idea that we’re seeing now in a number of major newspapers regarding some of the lawsuits going out against, in this case, United both for mental health, and for the proton beam therapies, where we’re seeing this sort of comeback of, of using utilization management and pre-authorization, and perhaps denying it and that was an area you really focused on early on are back at United days. So why were you looking at that then and looking to reduce it? And what do you think it’s coming back now?
Archelle Georgiou 03:09 Yeah, those stories are really disheartening, aren’t they? Well, let’s just start back and think about the definition of managed care this the three pillars of managed care, manage benefits, manage unit cost, and manage utilization. But when you manage utilization, you are really managing care, because you’re approving and denying services at an individual patient level. So in 2009, obviously, as a practicing physician, I really was distraught over the impact of utilization management on my relationship with my patients. And when I finally had the platform at United to address this, I worked with the leadership of our company who was a physician at the time, Dr. Bill McGuire, and we took a philosophical stand, that although utilization management was a key pillar to manage costs, that approach interfered with the integrity of the patient physician relationship, and we stopped it and we replaced it with a term that was brand new at the time called care coordination. And, and it was wildly successful at many levels. So but frankly, utilization management at United and and across the industry, has been returning since Bill McGuire left the company in 2006. Because really, it was a philosophical shift in 1999. It wasn’t it that really is what underlied that decision and at the highest level of United new leadership, there was a philosophical shift back to believing that that was the right way to be a steward of health care costs. And then if we do look across the entire healthcare industry, it is very clear to me as you know, as a Medical Director for many years that managing utilization through denials is harder than managing utilization through care coordination, which is really hard because it is so personal. So its health care costs are rising, employers are wanting trends to flatten out. And the going gets tough. The industry is going back to its comfort zone. And that’s UM and denial.
Fred Goldstein 05:19 So they have talked about, you said, this is great stuff, you said this fundamental shift to what you called care coordination. Could you discuss how that was perhaps different from utilization management, and pre authorization management?
Archelle Georgiou 05:33 Absolutely. So, as a health insurer, you have to be a steward of the medical dollar. And there’s two strategies that you can deploy. One is a supply side strategy, which you you limit supply, you do utilization management, you deny care. The other one is a demand side strategy, where you decrease the need for care. So as a 300,000 feet, those are, there’s a fork in the road there. And so it’s instead of focusing on the supply side of that strategy and denying care, we designed the first ever care coordination system that was, you know, a national system, where we proactively got in front of patients needs we, that’s when we deployed predictive modeling, which was a brand new innovative thought at that time. Now, it’s old news. We did readmission management programs to prevent readmissions, unheard of in 1999. So we created a whole system, a new system of care, that today sounds like same old, same old, but back, then it was very innovative to get in front of the need for demand so that we could manage health care costs and a more patient centric way.
Fred Goldstein 06:54 And, and now, obviously, United Optum has invested a lot of money over the years, bringing in a bunch of tech, they like they have all these systems, they claim they can do all kinds of wizardly things, to analyze the data and get some underlying knowledge out of that to be able to use to perhaps better take care of the patients. But given that, why is this is it really just a philosophical shift? That that they’re doing to, instead of using all that data to try and perhaps care coordinate people better?
Archelle Georgiou 07:28 Well, you know, I haven’t been at United for many years. So now I’m just speculating, and I want to be, you know, reputable, I think it’s a really great company. And they do great work, I will say that I maintain many relationships with individuals at the company, and at least at the Medical level, the, what I’m hearing is that it it really is a philosophical shift back the data internally, what’s been relayed to me is that utilization management does not show that it’s an effective tool, they approve most everything anyway. But it’s a comfortable tool to use. And it can be more easily measured, you know, when you have to report back to an employer, or whatever entity you’re accountable to, and you need to show the effectiveness of your work. It is really easy to count denials, and the economic value of a denial and show a return on investment to whatever fees they’re paying you for, for administering their services, it is really hard to demonstrate that avoidance of a service saved money. It’s hard to ever measure avoidance of the service. And so right, I remember being in that day and age, when our employer customers would ask us for the data and it was hard to deliver. It didn’t mean we weren’t effective, we just didn’t know how to manage it. So I, I suspect that all of those tensions, took them back into a zone where they felt that they needed to do that.
Fred Goldstein 09:01 Right. And let’s be honest, today, we do recognize we have this incredible issue with inappropriate utilization and over utilization of services in many cases. So there is a need to come up with some framework to use to try and drive that to a better situation.
Archelle Georgiou 09:18 Absolutely. And I didn’t mean to exclude that, except we can address all you know, all of the different angles of increased utilization in one answer, but you’re absolutely right. And there, there is excessive utilization across healthcare, and it is a big problem that we need to address. I just don’t know that the right way to address it is at the individual patient level when somebody is seeking care for somebody for a condition that they are suffering with at this moment.
Fred Goldstein 09:46 Right. And I would I would agree with you that you said earlier, you know you can do it through a UM type of pre-auth deal or you can say we’re going to coordinate these people and kind of drive it through them that side of the equation to do the right things and make it better. Much better than that walking in and saying, Oh, my service got denied. So really a fascinating area. And I hope, you know, hope at times people look at this they understand it’s it’s a complicated problem, but there are certainly good solutions to it, and ways to do it as well. How do you think those kinds of lessons learned might impact you know, the its current movement to ACOs and other value based care models, MA plans, as they seek to try to implement systems to better work with utilization and costs for their own members?
Archelle Georgiou 10:34 Well, I think that as we see the transition to ACOs, and and healthcare systems that are closer to the patient, the closer you are to the patients, the easier it is, to help coordinate their care and to have to really coordinate the services of an entire ecosystem, to have it be effective, you know, as an insurer, for where we sat, it was incredibly difficult to coordinate the services between, you know, home care and physical therapy and durable medical equipment, because we weren’t part of their system, we were, we were just the payer, and it was challenging. So what I look forward to seeing progress in is with, you know, with, with these entities that are so much closer to the patient, in the communities, with hands on care, with, with real relationships with the providers of care, that, you know, we can put everything we’ve learned from the past and deploy it so that that whole care coordination is easier, and and more effective.
Fred Goldstein 11:37 And for these ACOs, we’re seeing some of this move back, like we did back in the 90s. Everybody was moving to these risk based models. As we’ve talked a number of times in this show created a lot of problems, most of them didn’t work and ended up imploding. Is it different now, are there things that these providers have learned that will allow them to do this better as we move this risk to them?
Archelle Georgiou 12:00 Oh, my goodness, you bring that up from the 1990s. I mean, I lived in the day and age as in capitation, to individual providers. You know, I’m not, I don’t want to pick solely on united I was also with Cigna and, you know, watching individual physician practices be capitated for their panel of 100 or 200 patients, it just doesn’t, work risk is designed to be spread out over 1000s of people, not 100 or 200 patients. And as you just noted, it did not work. It imploded for some faster than others. So what we have learned is that it doesn’t work at the individual provider level. And I I hope that’s not happening anywhere out there. Certainly not it’s not common. What we haven’t learned is that taking risk, whatever kind of entity you are, requires a new culture, as well as infrastructure, analytics, and specifically good cost accounting systems. So when we see ACOs come together and form new organizations, and take risk, they need to be able to allocate those costs to all of the different areas that are incurring costs. And that takes good cost accounting, which is not in place in most hospital systems. So So while the good news is ACOs spread risk out over a larger population, how many of them really have the infrastructure to manage risk in a longer term sustainable way? And when we see the results from Medicare’s ACO, you know, programs? It’s I’m not impressed. I’m not impressed. Not the organizations aren’t doing a good job. I’m just not sure that that they’re already.
Fred Goldstein 13:46 And, you know, given that, how do you feel about and we’ve seen this pretty substantial growth in these globally capitated primary care doctors, we’ve had a number of them on the show as well. And they seem to be doing very well. Is it because they’ve put in that infrastructure because they’re closer to the patient? don’t have the high hospital costs associated with them? What do you think some of those reasons might be?
Archelle Georgiou 14:09 Well, I’m not as familiar as that. So with them, so I’m happy to hear that they are successful. But you know, the way that you structure the risk also has something to do with it as well. So if if the financial risk is limited to the services that they provide, in their, within the confines of their office that they have complete control over, I can certainly understand how that could be a successful model. But if the risk incurred is for services outside of the four walls of the provider’s office, so if you’re taking risk for that patient, hospital care and outpatient care, and other services that are outside of your small ecosystem, then that’s where I think the risk comes in. So if we’ve narrowed down the level of risk to their time and space, I think that that’s a model that might be sustainable.
Fred Goldstein 14:59 Got it. That makes sense. And in terms of where you think the future is going, we’re seeing a lot of health insurers suddenly become providers. I think United now the largest employer of doctors, Humana has got their Conviva network out there, Florida Blue set up, you know, become Guidewell. And they now separate the insurance arm and buying practices in ers. If you see that as a model that’s going forward, that’s going to get continued to grow. Is there is there some potential that they they just become providers themselves?
Archelle Georgiou 15:36 I do. I mean, we used to see distinct difference that, you know, we used to say payers and providers as if they were, they were completely different. Now. There’s not even a gray zone, they’re just one. So there are two dynamics in play here. One is that insurance companies for many years, and even more now are very concerned about being disintermediated, as employers started the trend of direct contracting, and now Medicare thinks it’s a good idea to so if there’s direct contracting, what is the role of the insurance company, and we’ve, you know, I had those conversations about disintermediation 10 years ago. So I think it’s, it’s just continuing to accelerate in terms of concerns. So if you’re concerned about being disintermediated, then become the provider, because you’re going to be able to provide value in that way. So that’s one dynamic. I think they’re pursuing it for that reason. But the other reason is that unit cost, by the way, not utilization is the key driver of medical cost trend. So if the insurer is the provider, they have more control over that unit costs, and more role, or where to steer care. And so I think that those two dynamics that are driving, that melding of payers becoming providers,
Fred Goldstein 17:01 So you so does that put them perhaps as they move into a larger role of providers to have a maybe perhaps an advantage over the healthcare systems that haven’t obviously, we talked about, been able to understand and manage risk?
Archelle Georgiou 17:18 Well, there, if they, if a health insurer is the provider, then they are in a uniquely strong position to manage risk. So it’s unit cost is the key driver, they manage the unit cost. And they’re the payer at the same time. If they have that lever, that’s going to give them the most the biggest opportunity to become most efficient, they have the best opportunity to grow from a
Fred Goldstein 17:44 right,
Archelle Georgiou 17:45 so they have the best opportunity to have the lowest premiums, and the company that has the lowest premiums gets the greatest growth.
Fred Goldstein 17:53 Yeah, that makes a lot of sense. And so I was thinking about, you know, if you had this, this payer, becoming a provider in a community, perhaps competing with a another free standing only provider who doesn’t have that expertise, obviously, that sounds like the payer, who discovered provider would have a fairly substantial advantage in that market.
Archelle Georgiou 18:13 Absolutely, because they can offer lower costs on the premium side, and on and on and on the unit of service line.
Fred Goldstein 18:24 Got it. That’s very, very interesting. On the other area, that seems to be getting a lot of attention. Now, as we move back to sort of national scale of things happening is Medicare for All. I don’t know how many of the folks running for president have announced that they’re in for Medicare for all, you discuss your thoughts on that, and what it might do to the health care companies and to the individual consumer.
Archelle Georgiou 18:48 Gosh, it it is a headline, right. And the devil is in the details. So there, there was recently a really excellent article written about all of the different models of national healthcare systems across the world. And so many of them look so very different. And so when we say that there’s Medicare for All as a policy stand, then you do need to ask the next question of what do you mean by that? Having said that, regardless of what the model is, if the country moves forward with that or not, I think that there’s one element that would have to be in place for it to work under any circumstances. And that is that our country has to be bold enough and brave enough to define a core set of basic benefits. By that I do not mean 10 essential benefit categories that include the totality of care that we saw with the with the ACA, I’m because we can’t afford that. It’s too big. It’s too broad and we need to come to terms with the fact that everyone can’t have everything. And I’m not talking about rationing care. But But the most essential benefits that all Americans deserve to have. So, until we are prepared as a country to make the difficult decision of what those core basic benefits are at the individual line item level, I don’t think that we can move forward in any design of a Medicare for All.
Fred Goldstein 20:32 And if people consider that, and obviously, it would be a lot of lobbying pressure from the various groups who might have been left out of those important essential benefits that somebody determines, as you said, it’s very broad right now. The current Medicare system includes a fairly substantial portion of individuals getting their care from private Medicare Advantage plans. Do people recognize that? Or do you think that that that would be in the model? Or are they talking about not using that kind of a system?
Archelle Georgiou 21:05 Well, my understanding as I’ve, I’m not an expert on all of the different policy stance, but the there are some proposals that suggest that Medicare for All, the current Medicare Advantage plans would get folded into the larger national plan. There are other policy proposals that would maintain Medicare Advantage and create a new system. For others that are not currently a part of it. There other policy proposals that would certainly decrease the age at which someone would be eligible for Medicare. So the the designs are all over the map. And that’s why I started with started out with a, you know, what do you mean by that? What do you mean by Medicare for all?
Fred Goldstein 21:48 Yeah, I think that’s so important that everybody’s using the same term to describe whatever could be fundamentally very different approaches to providing insurance for people. So let’s get to your book, Healthcare Choices, Five Steps to Getting the Care You Want and Need. Tell us, what made you first decide to write this?
Archelle Georgiou 22:10 Well, I’ve been in the market for 20 years, at in managed care, you know, I’ve been in the practicing position for five years. And through all of that, I really came to the conclusion that we are not going to truly have health reform, unless we start having empowering patients to have their own individual voice heard in their medical care decisions. And yes, there is a lot to fix about the health care system read and, and a lot of people are working on it and doing an amazing job. But where I saw a gap is that there aren’t that many people working on truly trying to help people be actively engaged in their care. We’re trying to create software, we’re trying to create technology. We talked a lot about patient centered care, you and I were at the same conference, where I was maybe one of two people. And I’m being generous here that talked about patients having a voice in their care. And so as a result, I decided that I needed to write a book, laying out for people, why they are the expert in their care, and how they can use that expertise appropriately in the medical care decision process.
Fred Goldstein 23:36 So your book has 30 stories, real life stories in it about people and their experience with health care, you’ve mentioned that people really are experts in in their care. But obviously we have these issues around health literacy in the country. And some people understand better and can advocate for themselves better. So is this the book is is a tool they can use that correct to to both help themselves understand better as well to interact better with the system.
Archelle Georgiou 24:05 That the book is written for the everyday healthcare consumer, I wrote it in really plain language. Thank you for reading it. And so it there, there are a lot of books out there talking about how important it is to advocate for yourself. What I think is unique about healthcare choices is that it’s not just a couple of stories and anecdotes about why you should it actually lays out a framework that you can apply to your care every single time you need care whether you sprained your ankle, or you need heart surgery. And so what I refer to it as is the CARES model, which stands for understand your Condition, know your Alternatives, Respect your preferences, Evaluate your options and Start taking action. And I lay out each of those steps that you can work through in five minutes for a quick simple decision, or it might take you a little bit longer for a more complex, life threatening decision. But of course, that’s worth it. And so that’s what I think is unique about it. It’s a tool. It’s a framework that people can use in any situation. And just like, you know, I have so many people saying to me, oh, yeah, if I really, really get sick, I’m gonna have to read that book. But we don’t learn to sing. When we’re at Carnegie Hall, right? We don’t learn to do their voice for the first time in public. Don’t, don’t learn to use your voice, when you have cancer, learn how to use it, when you have a sprain or a headache, or something simple or cold. And, and get proficient at learning to use your voice so that when you really need it, you know how to go there?
Fred Goldstein 25:41 Yeah, I think it’s a really great approach that just makes it and like you said, you can apply it to something very simple, or really complex. And these issues go on, you know, we’re all at some point can access the healthcare system. And there are reasons to notice stuff. Because things do happen. You know, and we talked about a case recently, with a friend of mine, who was getting a procedure and ended up having a nurse, you know, ask them, Hey, I see you’re allergic to this. And they said, What do you mean, I’m allergic to that? Well, it’s in your chart? Well, that can’t be my chart. And, and there was a mistake made with the wrong band. So So it’s important to be able to advocate for yourselves. And I think, you know, you give individuals the approach to start and ask those questions as well as to go further and, and begin to advocate and understand what’s really going on with themselves.
Archelle Georgiou 26:33 Yeah, you know, absolutely, I, this might be TMI, I have to tell you, but I have a, as you can imagine, my children grew up in a home where we always talked about advocating yourself and have an adult daughter, she was at, she was at a GYN and you know, on the table, and they were getting ready to insert an IUD and saw that it was the wrong brand, and spoke up and jumped right off that table. And I couldn’t have been prouder of her because someone else who didn’t grow up in that household, in our household would have just thought, well, they know best, they know what device is best, and it was wrong. And she would have never known because it was an implantable device. And that, you know, there would have been other complications from that. So we all no matter how expert no matter how good your doctor is, only you care most about your health. And so there’s there’s no harm in speaking up even if you’re wrong, asking the question, it only takes a few minutes and you could prevent, you know, a serious complication.
Fred Goldstein 27:38 Right. And I think you know, on the flip side of that you can get to this concept it is important to ask the questions and understand it, particularly as we see some things going on now with the measles outbreak etc. and vaccinations it’s important to understand that a lot of this stuff does work and there is a reason but know the facts and and understand how it impacts your situation. So I really appreciate the wrote this book. I think it’s just a great tool. And and then people really should read it because at some point everybody’s going to access the halth care system.
Archelle Georgiou 28:07 Well, thank you for referencing it. I really appreciate it.
Fred Goldstein 28:11 Oh, yeah, it’s my pleasure. As we as we’re heading out here, sort of toward the end. I want to thank you very much for joining us Archelle and hopefully we can get you back on there are so many areas we could discuss. I really appreciate your time.
Archelle Georgiou 28:25 I really appreciate you having me. Thank you.
Gregg Masters 28:28 And that will be today’s last word on PopHealth Week. I want to thank our guest Dr. Archelle Georgiou for her time insights and obvious passion today. Do check out her work on the web but www.Archellemd.com and be sure to follow her on Twitter at @ArchelleMD for Fred Goldstein. HealthcareNOW Radio and Dr. Archelle Georgiou, this is Gregg Masters saying bye now.