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Published: April 13, 2023, 10:30 a.m.

I hope you listened to episode 399, which was Part 1 of this two-part exploration of my manifesto, meaning my aims and my path or framework to achieve those aims. Regarding the first part of my manifesto, episode 399 from two weeks ago, here\u2019s the tl;dl (too long, didn\u2019t listen) version; but please go back and listen to that show (Part 1) because it\u2019s about you\u2014and it\u2019s a compliment and a thank you, and you deserve both.

Just to quickly recap, Part 1 of my manifesto is that I started this show because I want to, and wanted to, provide information to those in the healthcare industry trying to do the right thing by patients, to get you the insights that you might need to pull that off, to create a Coalition of the Willing, as I\u2019ve heard it called. When we get reviews like the one from Megan Aldridge, a self-proclaimed Relentless Health Value binge listener, I feel very gratified because it makes me feel like I\u2019m chipping away at this mission and in a non-boring way. Thank you, Megan.

Along these lines, there was also a recent review from Mallory Sonagere, who says she listens to learn new things and to be a little sharper at how she approaches her day job.

And just one more I\u2019ll mention: I loved the review from Mark Nixon calling Relentless Health Value the best healthcare podcast out there.

Every review like this I take as validation that maybe I can count some measure of success toward achieving the mission to empower others on their journeys to make it better for patients or to transform the healthcare industry.

But this whole endeavor to create a manifesto is also borne out of me struggling personally to figure out what \u201chaving personal integrity\u201d in this business actually means when it comes to deciding what to do and what not to do, when it comes to deciding who or what to try to help or support or who or what to step away from either passively or actively. I mean, how this podcast gets funded is my business partner and I pay for it with money from our consulting business and from some tech products that we have on offer. Who do we choose to take on as clients, and what are we willing to do for them or help them with? These are questions that literally keep me up at night.

And this is what this episode, Part 2, is all about. It\u2019s about my struggle and how I attempt to navigate my own path forward.

And holy shnikeys, it\u2019s tough to find a path, especially when you have the sort of perspective that I\u2019ve wound up with over these past however many years. It can feel like no matter what I do, there\u2019s negatives as it relates to the Quadruple Aim. You raise one of the quadrants, and something else for somebody else certainly has the potential to be negatively impacted.

We cannot forget here in the short term, but, for sure, often in the longer term as well, it\u2019s a zero-sum game. Every dollar someone takes in profit under the banner of improving health or even saving money is a dollar that someone else paid for. Is the amount of profit fair? Where\u2019d that money come from? Is there COI (conflict of interest), and if so, what\u2019s the impact? I think hard about things like this.

An inescapable fact is that there has been a financialization of the healthcare industry, and that includes everybody who also gets sucked into the healthcare industry whether they want to be or not (ie, patients/members and plan sponsors and, oftentimes, physicians and other clinicians, too).

But the financialization of healthcare means that most everybody at the healthcare industry party has a self-interest to either make money or save money. And sometimes the saving money means saving money for themselves, not necessarily anything that is ever gonna accrue to patients or members.

Now let\u2019s say I\u2019m trying to determine if I want to take on a new client or decide if I personally want to promote or do something or other. This self-interest that abounds all around matters here because it means it is often very tough to find some kind of \u201cpure\u201d initiative to hitch your wagon to.

The crushing reality that we all face is you gotta earn a living. The other reality is that often the person that benefits from the thing you want to do (ie, the patient) is not gonna pay for it. And frequently, physician organizations won\u2019t either. If everybody was lining up to pay to get something fixed, the problem would not be a problem, after all. But the only way your moral compass is the only moral compass in play is if you\u2019re doing whatever you\u2019re doing for free, really, or by yourself\u2014and thus you are not encumbered by anybody else or any self-interest beyond your own \u2026 and your own motives are the only motives that you can control. I hear all the time initiatives and coalitions and advocacy organizations and even research funded by grants \u2026 these things also get bashed as suspect because who\u2019d that money come from and whose \u201cside\u201d are the funders on.

Nikhil Krishnan wrote on LinkedIn the other day (and I\u2019m gonna do a little bit of editing, but yeah). He wrote:

\u201cPatients have low trust in healthcare because they think every stakeholder is incentivized not in their best interest. Many patients think the hospitals want to keep them sick, the [carriers and plan sponsors] don\u2019t want to pay their claims, the drug companies want to keep them on their meds, etc. And we can\u2019t pretend like that \u2026 isn\u2019t true.\u201d

Every party, every stakeholder has some measure of self-interest. They have to; otherwise, they\u2019d be out of business. It\u2019s all a matter of degrees. No big group, no entire category gets to stand on the high ground here when you think like a patient. There\u2019s great hospitals and great people who work at hospitals, and then there\u2019s people doing things that cause a strikingly large percentage of patients to fear going to the hospital for clinical and/or financial reasons. Pick any other stakeholder and I\u2019d tell you the same thing. Any other stakeholder. It\u2019s basically up to us as individuals to do the right thing. In every sector of the healthcare industry, there\u2019s good eggs and there\u2019s bad eggs and there\u2019s eggs in the middle just doing their day jobs as instructed. Personally, I want to be a good egg, and that\u2019s what my manifesto is all about.

Let me dig into this a bit further for just a sec and then I\u2019ll continue with my personal manifesto for how I find my own path of integrity through all of this confusion.

Here\u2019s another anecdote. Stuff like this I make myself crazy thinking about: I was listening to a podcast, and one of the guests said, \u201cI wanted to get my MPH [Master of Public Health] because I felt a personal calling to be altruistic.\u201d Then, 120 seconds later, he says something like, \u201cSo then, when it came time to pick my internship, I hunted around to find the one that paid the most money\u2014and that\u2019s how I wound up working for an HMO in the \u201990s.\u201d

Consider how that strikes you. How do you feel about that guy right now, who, by the way, has gone on to support some very interesting and probably impactful initiatives? There\u2019s this commonly used phrase, \u201cLet\u2019s do well by doing good.\u201d

So, back to that HMO intern. Let\u2019s just say we all agree that these HMOs were not unconflicted organizations. We all know they had a reputation for putting profits over members, and a reason they went out of business was because they denied care. They refused to pay claims for patients who had AIDS. And it turns out that the friends and families of people with AIDS are incredibly well organized and sued the crap out of the HMOs, which may have expedited their demise.

You know what the intern was doing at the HMO? He was helping them with data analytics, and his personal goal was to use that data to improve patient outcomes.

So, okay \u2026 here\u2019s the thought experiment: Do we want this HMO taking money that they\u2019re gonna take anyway and then not adding the value that they potentially could add with their data because they don\u2019t have any smart, dedicated, highly compensated interns working there to keep the ship pointed in a decent direction? I mean, I guess if I know I\u2019m gonna spend a dollar as a member of that plan, I\u2019d prefer to get as much as possible for my dollar that is already being spent. Maybe from that perspective, this guy is doing well by doing good. You see how this gets messy when you take a theoretical statement and then apply everyone\u2019s real-world prejudices and predilections to it.

Here\u2019s a last point to ponder, and this is another thought experiment \u2026 so, just heads up and then I\u2019ll get to the point here: Say you are asked to help with a program run by a Medicare Advantage (MA) plan to provide those in need of transportation a ride to their annual wellness exam. Do you help?

Those who listen to this show will fully understand there\u2019s a lot of self-interest involved in getting patients to the annual wellness exam because \u2026 risk adjustment. Also, star ratings. Listen to the show with Betsy Seals (EP375 and EP387) if you need the full story here. Short version is, MA plans can\u2019t upcode, either fairly or aggressively (if they are so inclined), if the patients don\u2019t show up for their annual physical. So, there\u2019s a lot of money for them at stake. But, then again, are physicals important for patients? Do they improve patient care and health? If we think yes, then again, is this doing well by doing good to help patients get to their appointments?

After literally years of asking myself questions like this\u2014and most of them were not thought experiments\u2014I came up with my manifesto. And there are three parts to it, and I will go through each of them. But here\u2019s my manifesto in full:

If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients.

Here\u2019s how I think about the first part of my manifesto: If the thing results in a net positive for patients, then I\u2019ll do it. And keep in mind, I could talk about this for seven hours; so everything I\u2019m saying is oversimplified to some degree and has as many nuances as there are stars in the sky.

So, to calculate the net-positive impact, I think through what good the thing could do and weigh that against the negatives. And there are always negatives because, most of the time, the work that I do anyway has to get paid for by somebody and that somebody has some self-interest. Self-interest means that they are attaining something that furthers their business goals.

Let me list two major upside/downside contemplations:

1. How much good does the thing actually do for patients? I think about this. What\u2019s the value here? Is it a little? Is it a lot? Will this thing be a distraction for clinicians, because time is often the most precious currency? If we\u2019re talking about some kind of navigation or utilization management, what\u2019s the reason someone wants to do this? Is the reason clinically and, for reals, evidence driven? Or are we predominantly doing this to enrich shareholders or save plan sponsors money in ways that are not a win-win for patients in the clinic right now trying to get cancer treatments for their kid? I try to think like a patient and be as impartial as possible.

2. Money. Where\u2019s the money for this thing coming from, and who wins in this particular initiative (ie, is it a win-win and patients win something worthwhile)? Now, the company doing the funding has got to win, too; otherwise, they wouldn\u2019t fund the thing. That\u2019s where it gets subjective, and, as aforementioned, do I care if the company in question wins if the patient wins, too? Or is this company so damn evil at its core that I am willing to sacrifice the opportunity to do a good thing for patients in order to not have anything to do with said possible funding entity. Or am I cutting off my nose to spite my face because this is a really important thing for patients and this particular company is the only one that\u2019s gonna fund it? Because tragedy of the commons or whatever else.

Again, this gets dicey really fast. Let me poorly paraphrase a little exchange I saw on LinkedIn the other day that had me completely preoccupied during my work-from-home midday walk around the block for at least three days. Somebody wrote (maybe that Master of Public Health intern), \u201cGiven how intractable it feels to me to try to reduce healthcare spend, I think I\u2019m going to try to help patients get more value out of the dollars that are currently being spent by them or on their behalf.\u201d

Do you think that\u2019s a worthy goal? Well, not everyone does. Somebody in T-minus 8 seconds responded, \u201cThat\u2019s a toxic way of thinking. Everyone who is not actively working to reduce healthcare spend by putting patients in cash-pay models is part of the problem.\u201d

This is a good segue into the second part of my manifesto.

The first part is: If the thing results in a net positive for patients, then I\u2019ll do it.

Here\u2019s the second part: The timeframe is short-term or medium-term. And here\u2019s what I mean by that. My main focus is helping patients right now. This is what this has to do with the aforementioned exchange on LinkedIn wherein someone was trying to figure out how to get more out of the dollars we\u2019re currently spending and someone else said that\u2019s toxic, because we should rip it all down and build a better model.

There\u2019s incremental change, and then there\u2019s disruptive change. These two things are not mutually exclusive. Apparently, Mr. This Is Toxic doesn\u2019t agree with me, but as I said in the last episode, there\u2019s that Buckminster Fuller quote: \u201cYou never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.\u201d And sure, I like to aspire to that as much as the next person. But does aspiring to a big hairy goal mean completely forgoing any incremental ways that patients can be helped immediately, like right now?

If you ask me\u2014and you\u2019re listening to this, so you de facto asked me\u2014incremental change will probably actually support and beget disruptive change. So, incremental versus disruption is not a battle royale. These things are not diametrically opposed. They\u2019re probably actually aligned. I could go on a tangent here to explain why, but I\u2019m not going to \u2026 except to say tipping points.

But forget about that for a sec. Here\u2019s the more basic question: If all parties are interested in transforming healthcare, legit, how does someone trying to do it incrementally, or improve value for patients right now, in any way negatively impact someone trying to be disruptive and/or trying to change financial models?

Keep all this in mind and now let me get back to my manifesto. I\u2019m worried about patients, and I\u2019m worried about them largely right now, short term to medium term. So, if I have the opportunity to help a patient\u2014and I think about my two grandmothers (God rest their souls) here, but both of them would have died in the healthcare system multiple times in avoidable ways had my family not been there advocating for them\u2014if I have the opportunity to help a patient, I will do so as long as I believe that the impact is a net positive in the shorter term.

Disruption is a longer-term operation. Some have said it\u2019s a generational change. When I see stuff like Toxicity Guy wrote on LinkedIn, I really try to understand what his point is, as I always try to understand what people\u2019s points are. Could he be arguing that no one should work to improve care right now or try to maximize what we get for the bucks that we\u2019ve already been shelling out? And, if so, for what reason \u2026 so that what happens? So that resentment about poor-quality care builds up to a boiling point such that everybody shuns the status quo and moves to a new care model and financial models faster? Is that the aim of Toxicity Guy? To force a let-them-eat-cake moment for the purposes of triggering a faster revolution? I\u2019ve probably thought about this guy\u2019s motives and his potential impact harder than he has. In my manifesto, in my worldview, I don\u2019t let grandmas suffer right now so that someone else has a better narrative, even if I am in full support of what that person is trying to do and the mission that they are on, which, by the way, is a longer-term one.

This gets me to the third part of my manifesto: The assumption is that transforming the healthcare industry will take a village and I am not alone.

When I state this outright, it\u2019s gonna seem self-evident; but sometimes it\u2019s hard to not push blame here like Toxicity Guy, so I say this sort of in his defense.

Here\u2019s the point of contemplation: There\u2019s maybe four big parts of the healthcare industry at a minimum. We have those trying to fix SDoH (social determinants [or drivers] of health). We have those trying to fix medical morbidity (ie, are patients on evidence-based pathways and taking meds appropriately, limiting polypharmacy side effects/cascades). Once a patient is in the healthcare system, what happens then? Then we have those working hard to improve behavioral/mental health. And lastly, everything going on with what I\u2019m gonna call FDoH (financial determinants of health)\u2014patients making decisions or having decisions made for them due to financial implications for them or for somebody else.

Lots of stuff rolls up under these categories, but even just listing out these four things, we got a hell of a lot of work to do to improve the lot of patients and taxpayers and make it easier to do business in this country.

I always try to keep in mind that it will take a village. Just because someone is working on getting patients housing or eating better does not imply that they don\u2019t care about employers struggling to curb claims billing waste, fraud, and abuse\u2014and vice versa. It\u2019s just not everybody can do everything. For me personally, I tend to focus my attention on helping as many patients as possible get on what would be for them the optimal treatment plan or best care pathway.

That does not mean I\u2019m anti-someone working on getting more competition in the payer space. Nor does it mean I\u2019m against trying to curb the price of overpriced (as per ICER [Institute for Clinical and Economic Review]) pharmaceutical products or legislate to rein in hospitals doing stuff that, in my book, they should not be doing. I am all for getting all of these things done. I just do not have the bandwidth or the depth of expertise to do everything myself. I would suspect that no one does.

As my grandma used to say (and anyone who attended a slumber party seance in eighth grade might know), many hands make light work. You get 15 girls each holding out but two fingers, and you can lift up your friend, no problem.

When I keep in mind that it takes a village, it helps me curtail the tendency to become paralyzed in my quest to help patients because I can see a potential problem it might create somewhere else in the industry or somewhere else down the line. I have to trust that one of my fellow villagers is holding down that end of the fort.

Here\u2019s a quote from J. Michael Connors, MD, that he wrote in his newsletter: \u201cWhen you point one finger, three are pointing back at you \u2026 It\u2019s like everything you learned in kindergarten seems to be so applicable to our approach to healthcare. Sadly, the game of finger pointing and pushing blame on others is killing real innovation in healthcare.\u201d

This is so real, which is why inherent in my manifesto here is my efforts to remember we are all on the same team (all the good eggs, anyway). That it takes a village, that there will be some things that some people are doing that I maybe don\u2019t fully agree with. There might be groups who don\u2019t accomplish much. There are certain people doing well (ie, doing self-interested things) but, at the same time, creating a better place for patients. As long as, in general, we are all following the same North Star, we\u2019ll achieve much more spending our time focused on our own missions and not worrying about what other people are doing. And when I say \u201cnot worrying about what other people are doing,\u201d I mean people in the \u201cgood egg\u201d village. I do not mean I intend to stop calling out conflicted and net-negative self-interested behavior, because this is what some people in the village should hopefully have their eyes on and get busy working against.

The village here, it\u2019s a Venn diagram. At the point where other people\u2019s circles intersect with my mission or what I think would be better for patients, these are the people I can work with and collaborate with. These are the people that I\u2019d take their business or I\u2019d try to help them if I can.

My manifesto is to determine when something is a positive for patients and then to find others who will win as a result of that thing happening. Then I can study why this is a win for those others, which is always going to be some self-interested why. And then I can think through what the negatives are if their self-interest comes to fruition. Is it still a net positive? If yes, proceed.

Look, this making it better for patients, this transforming healthcare, it is hard, dispiriting work. It\u2019s a long slog. I\u2019d like to suggest we encourage each other. Can we be the wind beneath each other\u2019s wings when we find a kindred spirit? Can we focus on the points of intersection and spend our energy deepening what\u2019s going on there?

So again, here\u2019s my manifesto: If the thing results in a net positive for patients, then I\u2019ll do it. The timeframe I\u2019m concerned about \u2026 short-term, medium-term. The assumption is that it will take a village to transform healthcare and I am not alone.

I feel kind of exhausted having finished that. But let me ask you this: What is your manifesto? If you have one or if you have thoughts on this, go to our Web site and click on the orange button to leave a voice message. My hope is to do an upcoming show sharing what you think.

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For more information, go to aventriahealth.com.

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Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry.

In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.

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03:16 \u201cIt\u2019s a zero-sum game.\u201d

03:26 Is the amount of profit fair?

03:37 What is an inescapable fact of the healthcare industry?

03:54 What does the financialization of healthcare mean?

04:19 Why does the self-interest in healthcare matter?

06:18 \u201cIt\u2019s basically up to us as individuals to do the right thing.\u201d

10:03 What is the first part of Stacey\u2019s manifesto?

10:18 How does Stacey calculate the net positive of an impact?

10:41 What are two major upsides/downsides that Stacey contemplates?

13:31 Why are incremental change and disruptive change not mutually exclusive?

17:40 \u201cI always try to keep in mind that it will take a village.\u201d

19:19 Why finger pointing is killing innovation in healthcare.

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For more information, go to aventriahealth.com.

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Our host, Stacey Richter, discusses our #healthcarepodcast and where she sees the path moving forward. #healthcare #podcast

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Recent past interviews:

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

Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355)

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