BROADCASTS.com

I wanted to remind everyone about this show from last year because it\u2019s becoming increasingly relevant. We have this weird thing going on where everybody seems to be talking about physician incentives and payments and financial implications but so often disregards patient incentives and payments and financial implications.

Consider that we\u2019re at a place in the time-space continuum where it is inarguable that financial toxicity has become clinical toxicity. Patients are increasingly in huge numbers abandoning care, splitting pills, doing all kinds of things to save money that are clinically toxic. And these are patients with \u201cgood insurance\u201d that we are talking about here.

So, here\u2019s a role play: Provider organization is actually paying doctors for outcomes. In wanders a patient with a huge deductible. Doc says, \u201cWow, Patient \u2026 so important that you take your insulin or med as directed or get a follow-up on that scary colonoscopy finding.\u201d Patient says, \u201cSorry, Doc. Can\u2019t afford it.\u201d And the doc gets dinged because the patient outcomes are avoidably poor.

That\u2019s what this show with Dr. Mark Fendrick digs into: aligning patient incentives (aka benefit designs etc) with value-based payments on the provider side. And with that, here\u2019s your encore:

And here I thought I knew a lot about value-based care. In this healthcare podcast, I am speaking with Mark Fendrick, MD, who is the director over at the University of Michigan Center for Value-Based Insurance Design. This conversation is for those of you who already know pretty much about value-based care concepts. If you do not, I\u2019d go back and listen to, say, Encore! EP206, with Ashok Subramanian, before this one. \xa0

Dr. Fendrick talks in this healthcare podcast about what it takes for value-based care to happen in the real world. No kidding, it\u2019s about making sure that reimbursement is aligned with good things (no great surprise there).

But two light bulb moments I had in this conversation with Dr. Fendrick:

1. At the beginning of the year, how many doctors and nurses, inspired to do the right thing, have told their patients with diabetes, say, to go get an eye exam to check for diabetic retinopathy? No one would disagree that this is definitely a good idea. Diabetic retinopathy causes blindness. But here\u2019s the reality of that conversation. Doc says, \u201cGo get an eye exam.\u201d And patient says, \u201cI can\u2019t. My deductible is huge, and I can\u2019t afford it.\u201d So, the patient doesn\u2019t get the follow-up care and winds up in the hospital or blind. And the doctor gets dinged on his or her quality scores. Suboptimal outcomes all around, I\u2019d say. This also happens on the pharmacy side of the equation, but I think a lot of us are a little bit more familiar with that scenario\u2014like type 1 diabetics who can\u2019t afford to pick up their insulin because of a Medicare Part D or commercial deductible that they haven\u2019t met yet. I just never really connected the dots back to the provider getting black marks because their patient has a benefit design that\u2019s not aligned with the quality measures.
2. In a majority of benefit designs, consumer price sharing is based not on the value of the service but on how expensive the service just happens to be. Wow! So, we\u2019re trying to get our plan members to be consumers and use the power of their wallets to make good healthcare choices. And what we\u2019re really doing is driving them toward cheap things or no care and discouraging them from indulging\u2014and I say that sarcastically\u2014in expensive things. But the expensive things might be the high-value care, and the relatively cheap things might be crap that\u2019s fully unnecessary or harmful and, over a whole population, adds up to a lot of zeros.

Healthcare is not like a consumer market where the expensive things are usually a better version of the cheap things. For all you economists out there, you don\u2019t want the demand curve to be elastic when what\u2019s cheap and what\u2019s expensive has no correlation to quality or necessity. Nobody should be super flabbergasted when a $35 cure-all supplement peddled on YouTube makes some random influencer a millionaire. That\u2019s how supply and demand works.

Much to ponder in this episode.

A. Mark Fendrick, MD, is a professor of internal medicine in the School of Medicine and a professor of health management and policy in the School of Public Health at the University of Michigan. Dr. Fendrick received a bachelor\u2019s degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School. He completed his residency in internal medicine at the University of Pennsylvania, where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program.

Dr. Fendrick conceptualized and coined the term Value-Based Insurance Design (V-BID) and currently directs the V-BID Center at the University of Michigan (vbidcenter.org), the leading advocate for development, implementation, and evaluation of innovative health benefit plans. His research focuses on how clinician payment and consumer engagement initiatives impact access to care, quality of care, and healthcare costs. Dr. Fendrick has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design. His perspective and understanding of clinical and economic issues have fostered collaborations with numerous government agencies, health plans, professional societies, and healthcare companies. \xa0

Dr. Fendrick is an elected member of the National Academy of Medicine (formerly IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the US Senate Committee on Health, Education, Labor and Pensions; the US House of Representatives Ways and Means Subcommittee on Health; and the US Senate Committee on Armed Services Subcommittee on Personnel.

05:00 Is back surgery high-value care?
05:51 If care is patient to patient, how is high-value care decided upon?
06:40 \u201cFlintstones delivery: We have to move from the sledgehammer to the scalpel.\u201d
11:14 \u201cAlmost all of the services that we recommend to reduce cost sharing \u2026 do not save money.\u201d
12:30 \u201cI didn\u2019t go to medical school to learn how to save people money.\u201d
17:03 \u201cWhen a patient and their clinician agree \u2026 the patient should be able to get that [service] easily, and the clinician should be paid generously.\u201d
18:01 \u201cWhen patients and providers are aligned, they do much better.\u201d
19:59 What services are deemed high value, and what services should be pre-deductible?
21:50 \u201cAre primary care visits high value? \u2026 The answer is, it depends.\u201d
25:55 What are V-BID\u2019s core pillars to address value-based care?
28:04 How does Dr. Fendrick\u2019s method of value-based care and reimbursement actually enable better consumerism?
29:51 What do providers think about changing reimbursement on low-value and high-value care?
30:58 \u201cWe have incentives that are run amok.\u201d
32:12 EP176 with Dr. Robert Pearl.
32:49 \u201cIt\u2019s all about incentives.\u201d
33:43 \u201cYou do have the funding; you just have to have the courage.\u201d

Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

If care is patient to patient, how is high-value care decided upon? Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\u201cFlintstones delivery: We have to move from the sledgehammer to the scalpel.\u201d Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\u201cAlmost all of the services that we recommend to reduce cost sharing \u2026 do not save money.\u201d Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\u201cI didn\u2019t go to medical school to learn how to save people money.\u201d Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\u201cWhen patients and providers are aligned, they do much better.\u201d Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\u201cAre primary care visits high value? \u2026 The answer is, it depends.\u201d Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\u201cWe have incentives that are run amok.\u201d Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\u201cYou do have the funding; you just have to have the courage.\u201d Mark Fendrick, MD, of @UM_VBID discusses #valuebasedcare on our #healthcarepodcast. #healthcare #podcast #vbc #digitalhealth

\xa0

Recent past interviews:

Click a guest\u2019s name for their latest RHV episode!

Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O\u2019Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble

\xa0