Gregg Masters 00:09
So Fred and here we are, we’re kind of looking back a little bit at 2021. And looking forward to 2022, at a very unique period of time, and it probably safe to say that there’s been no greater influence on the healthcare sector writ large, from financing to delivery to regulatory, whatever, than the pandemic. So let me ask you, what has been the impact on on the healthcare ecosystem of this pandemic? And and how would you illustrate that significance reading the tea leaves, so to speak, maybe by by sector,
Fred Goldstein 00:51
yeah, that you’re dead on target. Essentially, when you think about it, the pandemic created a hit hit the ecosystem all over the place. So one thing that people forget is that huge government funds came in to cover a lot of stuff, funds to hospitals, funds for testing funds for all kinds of services that essentially took those costs off of what would have been the normal payment system, like the health plans, etc. And, and allow it hospitals and others to make up for the supposed issues they face, one treating patients with COVID, and to losing the ability to treat others and losing that influx of patients. What’s been interesting, and this is anecdotal, of course, is I’ve heard a couple of health systems that have honestly said, thanks to the influx of money from the federal government, we had a fantastic year last year and made a lot of money. And and interesting, a few of them have used that money for perhaps some other things. But it’s, it’s clear that you’ve had that impact from a financial perspective, you’ve then had the impact of just how hard this hit the delivery system. And by that I mean, the individuals that are taking care of these patients who are essentially pretty burnout now. And so the question is going to become over a longer period of time, do we see individuals stepping out of careers in the healthcare sector, we’re hearing about some of that from individuals in nursing and areas like that, although at the same time, we are hearing applications maybe up for certain specialties and medical school thing like that. So you’ve had you have that piece going on. And then you have this ongoing treatment issue and population health management issue, which we really haven’t done a great job at, you know, the recent announcement that you brought up before, we discussed this from the CDC talking about the new five day issue of having somebody, isolate if they’ve been or quarantine if they’ve been vaccinated, and asymptomatic, but testing positive. Obviously, that message, if you leave a few words out sounds like everybody can do a five day thing. So we have the swirling issues, on a very large scale basis, that ultimately are coming down to impact how well we deliver care or move forward. We’ve certainly seen where healthcare doesn’t work, the pandemic has exposed that pretty strongly. And now the question is, do we go forward with anything that’s different? Are there are there models we’re going to put in place that are going to one change the payment models, and to change how we ultimately deliver care to individuals, whether in new settings, or new technologies?
Gregg Masters 03:36
Here we have I mean, if you were to look at it this way, from a macro perspective, the primary constituents in the healthcare ecosystem are providers, then payers, then there’s some hybrid models, whether they’re integrated delivery systems, or as you’ve often noted, payviders. And somewhere in that spectrum are the advanced practice models from ACOs, the bundled payments to rolling out the direct contracting program, you know, on and on. So, and honestly, most of the progress that I’ve read about is primarily in the government market because of federal policy changes, but how would How would you drop down and maybe characterize the impact of the pandemic on in providers, payers, hybrids and some of these innovation models?
Fred Goldstein 04:27
Yeah, so the the more advanced innovation models in particular, those that maybe were accepting capitation obviously did not have this impact of suddenly their fee for service business dried up. Clearly, larger health care systems saw that whether that’s enough of an impetus for them to then move to these newer advanced payment models is still debatable. I’ve heard from some that it’s not quite enough. I’ve seen some surveys that say that. But at the end of the day, I think those that did some of these advanced payment models or alternatives were probably in better shape than those in a fee-for-service system. Clearly, there’s an a push now to at least continue to try to move that way. You know, obviously Medicare is looking at various new new ways to do it and tightening up various programs that they do. I think, you know, Medicare is an interesting space, there’s just, there’s been a plethora of companies coming into that space. And they, they many of them go public. And the question then becomes, are they actually able to better manage the care and there’s some questions as to whether or not it’s a coding issue that’s allowing for the increased reimbursement, or if they’re actually able to then leverage what they call their population health management programs to do a better job. The payers are interesting situation, because a lot of the costs for COVID were covered by the government. And some of their questions are going to be when does that fall in our lap? And we suddenly have to start paying for some of this like, like testing and things like that, as well as other other treatments and things. And then the then the question further becomes from a health plan perspective, and we’ve talked about this at some of the conferences I’ve been at is, the issue of long COVID, if it’s really very large, is that something that then gets could potentially be in a separate program or, or co-funded, similar to something like an ESRD program or something like that, where the government picks it up, because right now, it’s a big unknown. And while many of the payers have said, we don’t see major impacts in our rates, I’ve talked to some brokers who are saying they’re seeing double digit increases in premiums for their clients.
Gregg Masters 06:42
So in one respect, because of the massive federal infusion of funding into the provider space, primarily just to give them a bridge to stay alive to stay afloat. Yet, in some respects, it’s kind of a bridge to say, Hey, this is the transformation we’ve been talking about for decades. Maybe it’s really here now, because after all these integrated delivery systems that are assuming capitation, and our own all inclusive population based payments, they did much better, under at least the trauma of the still unraveling pandemic than their fee for service counterparts. Are there lessons being learned there? And why isn’t this the golden age for population health management?
Fred Goldstein 07:25
That’s great question. It’s still a lip service deal because the payment models are behind what should be implemented. So if it’s a fee for service model, which is a big chunk of it now everybody’s still asking for another CPT code, give me a CPT code to arrange housing, give me a CPT code for food services, give me a CPT code for telehealth and and while we keep adding those that just keeps it safe for everybody to not have to move. And the reason I think this is so important makes a lot of sense is if you move to a capitated model, and you’re a let’s say you’re a healthcare system, and you’re managing this population in your community that comes to your system. And you suddenly want to offer housing, if you’re capitated you make the best decision for that patient, based on whatever service it is not on whether or not you have a code for it. So you could say, well, I’m going to run them through a food pharmacy, and that’s going to save me over here. And that’s why I’m going to do it instead of I need to add more reimbursement so I can do more stuff. And we’re still stuck in that mindset.
Gregg Masters 08:32
And I keep coming back to what is the opportunity with the pandemic and some of these little niche sort of plays, whether it be virtual care, telehealth telemedicine, you know, are these likely to sort of retain the newfound gains? I mean, heck, joked on Twitter, a day or so ago that, you know, COVID did more for the telehealth telemedicine industry than 20 years of advocacy by the American Telemedicine Association. So, so the question is, are these sustainable durable gains? Or will they simply be seen as a bridge, a temporary bridge to get legacy healthcare through this pandemic?
Fred Goldstein 09:17
Well, we saw the huge spike obviously in telehealth it was enormous. And then it came back to Earth. And now it’s higher than it was prior to the pandemic, but nowhere near what it was before. And the issue becomes, again, everybody looks at telehealth, give me a CPT code. It’s an add on to my service. I shouldn’t say everybody because I’m hearing some innovative groups talk about it differently, where you completely restructure the practice and telehealth becomes a component of it, whether it’s your front door, or it’s a major piece of your service. But in order to do that, remember hospitals have had difficulty moving to many of these models because it will reduce their inpatient load. They’ve already built the facilities. Well, primary care has the same issue. If you could do 50 or 60% of primary care via telehealth, and you still own a building, with five offices, a bunch of staff, a parking lot, all of that, you still have to support that overhead. And so there needs to be some way to begin to transition that. And we haven’t gotten there yet. I think, you know, telehealth clearly was the golden child of of one of the new technologies,
Gregg Masters 10:27
it but these guys, I always saw the limited upside there, that they’re sort of centralized models that they’re not nested in in health or sponsored by a health system per se, where there’s sort of the back end, you know, and the front-facing thing is really the health system, or the health plan, or the local whatever in the region. I was thought they wouldn’t scale because they they weren’t nested in the fabric of health care delivery, per se, is that changed at all?
Fred Goldstein 10:55
No, I think you’ve got these competing models. One of them is we’re going to put the telehealth system into our practice, you know, and our clinicians, whether they’re 100%, telehealth or not, are the ones doing the work. I know University of Mississippi Medical Center, one of the National Centers of Excellence for telehealth from HHS, one or two, you know, has their own physicians, obviously, they cover the state and across multiple specialties are doing all kinds of different stuff. And then you have these that are independence that you bolt on to your healthcare system, or your or your payer system that essentially take the calls in and and have physicians around the country doing that. So it’d be interesting to see how those two models go. As you pointed out,
Gregg Masters 11:37
you were mentioning before we went on air that apparently at least one or several of these valuations from the stock market point of view have been radically hit.
Fred Goldstein 11:46
In particular, I had seen Amwell right after they went public, they essentially there was some rumor that they were being acquired, or maybe it was an Optum, or something I don’t even remember, and they shut up. And now they are really down considerably from their open, and everything. So it’ll be interesting to see where those go. I know, there have been some writings on TelaDoc, as well, whether they may be the one to just, you know, really be the the strong player in the space. But only only times gonna tell I think there’s there’s still this question of how do we successfully integrate this stuff to actually show results and reduce some costs. And at the end of the day, it’s it always seems to be the Double AIM. We’re working on improving health of populations, where we’re looking at, you know, the other one I’ve been, we’re not focusing on costs, you know, we’re just not, it just seems like they go up, and then they go up some more.
Gregg Masters 12:40
So I don’t claim a deep insights here, per se. But I’m wondering if there’s any merit to this idea that there’s a future for these telehealth companies in the Intel Inside model, where really the brand, the forward facing product is the local health system or the health plan, as I mentioned. So you think there’s any upside there?
Fred Goldstein 13:02
Yeah, potentially, I think a number of providers go that way. I don’t know. You know, who some of the hospitals that I know of use as their telehealth system, but they’re running it there, the doctors staffing it. Same with Mississippi, I don’t know what they’re riding on in terms of the platform, but they are doing it. And obviously, I think from a patient perspective, it’s always nice to sort of know your provider. And I guess you can get that through these outside ones. But if you’re a patient with some serious illnesses, and you know, being managed beyond perhaps primary care, and even primary care, you talk about the types of patients that initially walk in to a primary care practice. As somebody once said, Boy, it could be one to 10,000 things, you know, you really have to know your stuff and be good at it. And I think, you know, most doctors really work hard at that. So maybe there’s less of a difference between it. But I know, if I were needing some specialty care, I’d want to know that it was one of the specialists at one of these centers.
Gregg Masters 14:00
And that always depends on whether there’s continuity of care from the primary care providers point of view and whether he or she works with a network of preferred specialists that have had some kind of cohesive referral arrangements over the years.
Fred Goldstein 14:14
And of course, whether or not your insurance actually covers that specialist.
Gregg Masters 14:19
Can this be and will it be the golden age for population health beyond the rhetorical kind of sound bites?
Fred Goldstein 14:24
I think we’re making some progress. I really do. I think there are some things and some innovation going on, that is going to going to showcase some better health improvements and cost improvements from some players. I think a number of others are still early in this and trying to build a population health program is not easy. And I think what happens is, perhaps a lot of groups go at this and say we’re gonna pull together telehealth and we’re gonna do this new cool stuff and that cool stuff. At the end of the day success in almost everything is based on first setting a firm foundation of basic blocking and tackling. And that basic blocking and tackling is, you know that one to one interaction with the patient. Are you did you stratify them correctly? Are you providing basic services? And are you relating with them so that they can then make the changes that you’re trying to get done? And just saying, I’m going to pop a telehealth system, and I’m going to take this new app, and we’re going to go manage people with diabetes. Sometimes it’s a step beyond the first step of just building something that basically works.
Gregg Masters 15:37
Okay, one last question, I’m going to ask you about what you’re most excited about in terms of looking forward into 2022? Perhaps what lessons may we may have learned in the last two years that we can kind of pull forward into what’s on the come, if you will. So other than the golden age of population health is this? Will this will we witness the ascendance of the importance of public health? Will that continue? And will there be adequate infrastructure investment to make the public health world is similarly or with parity, if you will, of the acute health care system career path?
Fred Goldstein 16:23
Well, I’m going to become the questioner. And I’m going to turn that question around to the expert in public health. It’s on this show, give me your answer to that one. Gregg, you’ve been you’ve been that for 30 plus years public health expertise.
Gregg Masters 16:40
You know, I would watch what, thanks to Michael Lewis’s book and the based upon what charity Dean was doing the former health officer in Santa with Santa Clara County, if I’m not mistaken, she formed a company with the help of Venrock. And Bob Koecher, at all, called the public health company, and they’re kind of the, I guess they’re out there on the front end may be like, back in the day, well, like today who’s top of mind in Medicare Advantage space, who’s top of mind in the ACO world, you know, people are names will come up to you. You don’t hear much about that from a public health perspective. But clearly the government is putting investment in upgrading public health, but you know, there’s a long way to go. I mean, these are underfunded, public health departments, there’s no standard footprint, necessarily, it’s delegated from state to county, to county to wherever and I mean, it’s just a hodgepodge thing, I don’t have any confidence that there’s going to be coherent leadership to really steward that along the, the path, but I think more people are talking about it.
Fred Goldstein 17:51
yeah, and, and I would just add to that, this whole issue of the questioning of whether you call it the questioning of authority, the questioning of the science, the questioning of whatever that has permeated and really exposed itself during the COVID pandemic, I think that loud voice will negatively impact the potential funding for public health. It will be viewed as instead of as something that is really important for society. And, and and helps us move forward as something that is looked at like a government mandate type approach. And that’s, that’s my fear, clearly public health is deserving of, and as a country, we should be funding this thing up. We’ve shown the weaknesses of it glaringly in this pandemic, but also, because of some, by default, the public health groups themselves, messaging, or what appeared to be changes of position, when in reality, we knew more today than we knew yesterday. It’s why things change. And I think some of the messaging was probably too strong as if this is works all the time, or is 100% or 95%. Effective. And it’s incredible, too. We believe this is good, but there’s probably going to be something next may have been better, although nobody likes uncertainty.
Gregg Masters 19:31
Yeah, the thing that causes me the most grief is what’s the public health business model? Yeah, so I often joked with our friend and colleague, David Nash, that how will we know when we get there and there being population health and I always joked, I said, Well, when schools of medicine and schools of public health merge into colleges of population health, you know, then that’s probably a pretty good It indicated that we’ve made the trend that transition, but I’m not holding my breath on that. And I’ll just add one thing. I’ve said, why not have dual reporting between health system CEOs and your your local health officer, I mean, you know, have at least a dotted line relationship. So, you know, they have complex CEOs of health systems have tough jobs, a lot of constituencies, highly complex enterprises to manage. Who wants a dotted line reporting relationship to some county or government goon? You know, I mean, no, thanks. But these are kind of weird thoughts. All right, Fred, let’s pivot. Let’s talk about 2022. I mean, if you did a word cloud of, quote, innovation in healthcare, you get blockchain AI, you know, consumer-directed health, what’s exciting you as the where you think we might see some real innovation,
Fred Goldstein 20:54
the thing that excites me the most right now, is just the unbelievable final recognition of the impact of the health disparities. And, and this whole health equity issue, I think the burners been turned up high enough, that maybe it’s gonna create some boiling water. And we’re gonna actually, instead of paying lip service to these things, address it. Obviously, we just did the show with Dr. Joseph Webb, you know, and he talked about some of the innovative things, they’re doing at their hospital. And that’s, that excites me, you know, from Medicaid work, etc, I just think there’s golden opportunities to fix these systems, improve people’s health. And it’s going to require us honestly looking at what’s causing what are the fundamental causes of these disparities, and addressing those, and some of those can’t be addressed by the healthcare system, but they have funds for them probably need to come out of the healthcare system, because ultimately, they’ll impact the cost on the healthcare side. So, you know, the health care system shouldn’t be directing where to put parks and sidewalks and things like that. But perhaps, by having some role in funding that they can see some benefit in a alternate payment model, coming back to them through savings in health care.
Gregg Masters 22:20
Yeah, the question is, who’s going to lead and for those not familiar with Dr. Joseph Webb, he’s the CEO of Nashville General Hospital, who that is the academic, the primary academic medical center for the historic Meharry Medical College. So yeah, he had some interesting insights. And they’re based, obviously, Nashville. And Nashville is quite a for-profit, proprietary Health System culture. So it’s interesting to hear what he’s done there.
Fred Goldstein 22:46
But you know, at some point, we’re ultimately going to get to this n of one that we know exactly what this person needs to improve their health. And some of that advancement may come through AI, and become an ultimate sort of segmentation or assessment tool. But once again, you got to do the basic stuff first. And if these individuals, for example, so let’s say you can take AI, and you can suddenly better segment your population in rural Mississippi, do you have anything to impact that? Do you have connections there? Do they have Wi-Fi, all of those questions that we’ve discussed on and on over the years with the show, and that’s the basic blocking and tackling that I think we need to make sure we put in place first.
Gregg Masters 23:27
And again, really the context for all this is in the face of a 9.7% increase in spending in 2022 to $4.1 trillion. So on this population health side of things, Fred, it seems like every health plan, health system these days has a vice president, for population health management, what would you say to someone newly placed in that role or perhaps reassessing their strategy? What would you say is the top my Top of Mind considerations they ought to be thinking about?
Fred Goldstein 24:06
Yeah, I think if you’re if you’re, if you’re out there looking at this thing, what do I do? Where do I start? The easiest way to do this? And And first, let me start with something that Esther Dyson said to us years ago, and that, you know, don’t do pilots, pilots are like crack, you know, go ahead and do something that, you know, you can scale that if it works, you can scale it up because oftentimes you set up a pilot, and then you try to make it big and it doesn’t work. And so I would look at that. And I also say start simply. And this is just from experience, when I built the model to do disease management programs that we did with a community-based model and staff and the IT system, etc. We started with one disease state, but once the model was right, we could plug in any disease we wanted. And so if you build it that way, and just say, Wow, I started with diabetes, and here’s what we got going. And now I’m going to transfer that to asthma and bring in the clinical expertise to manage that in a similar way. And obviously, you’ll have some variation, because some conditions are much more severe, occur more quickly, and things like that you may need to staff differently or assess differently. But if you have a basic model on how you’re going to interact with your patients, with your providers, with the payer, potentially, and build that, then you can say, Okay, now let’s ramp it out.
Gregg Masters 25:32
And what would be a typical front-end investment of time to maybe gather these facts before coming up with essentially a preliminary game plan?
Fred Goldstein 25:43
Wow, that’s a great question. And I guess a lot of that would depend on who’s doing it, you know, how much knowledge do they have in the first place? Because it’s, it really is a team. It’s a broad group, if you’re looking at population health, from the clinical people, to the behavior, folks, to the technology folks, the analytics, folks, and you need to really bring that all together to solve that problem. It’s not just a one-person build this sucker. You know, it takes it takes a pretty substantial group.
Gregg Masters 26:13
And I assume there’s a role for brokers, consultants and benefits managers here in the narrative, what would that look like?
Fred Goldstein 26:20
Make sure if you’re offering something, it actually works?
Gregg Masters 26:23
Yeah, tell me more.
Fred Goldstein 26:24
And some brokers obviously, really good, just like anything else. And some have a you know, in there, there are a lot of services out there that claim to make a difference. But when you look behind the curtain, and you and I have both done stuff for the validation Institute, you know, when you look behind the curtain, the the outcomes may not be there, the measurements may be funny. But, but marketing is always good. And, and you’ve got to get beyond that. So I think brokers can play a huge role in this. Because if they then go to groups like the Validation Institute, or learn how to look at data, like they teach them to do it, then they can be better for their clients and choose or recommend services that actually make a difference.
Gregg Masters 27:07
Well, I think the key driver here is the payment model, and into an all inclusive capitation, or, you know, some kind of alternative payment model. I don’t see a whole lot of progress being made. And I’ve been at this since 1984. When we were sort of introducing IPA model HMOs into the into Southern California back then. I hear a lot of talk, I really want to see the promise of digital health, I really want to see the promise of virtual care. And as Doug Goldstein talked about the other day, real time care tech enabled but nested in some health plans, health systems and provider groups. I’m skeptical. I would love to see it. I just don’t see the I think the ultimate metric is does it deliver on the Triple Aim? And I see a lot of that in AD copying. But like you say, it’s really the the the Double Aim? Well, you know, but as far as the aggregate savings on a per capita basis, I just don’t see that happen. I don’t know. I hope to be wrong.
Fred Goldstein 28:08
I think I’m, I think I’m in the seat right next to you on this one, unfortunately, and, you know, great way to finish up and then look to 2022, whatever may show up in the future.
Gregg Masters 28:21
Well, I’ve had a lot of fun working with you on producing these broadcasts and co-hosting with you. And you know, I think we have an impressive track record some pretty top talent who have shared very candid views about what’s going on in their world and how they see it working better, but we’re part of the conversation, Fred.
Fred Goldstein 28:38
Absolutely. And looking forward to working with you some more next year and we’ll see some great folks that we bring in as guests again,
Gregg Masters 28:44
there you have it