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In this healthcare podcast, I am talking with Dan Serrano; and we\u2019re talking about payer/provider collaboration\u2014blocking and tackling, I\u2019m gonna say\u2014from primarily a financial and revenue point of view. I\u2019d classify this as, say, a 201-level discussion (ie, not entry level, but it\u2019s also not super deep in the weeds). We mainly cover the ins and outs of why a provider organization should probably be looking to get paid to better take care of patients with chronic disease and drive better patient outcomes at lower downstream costs and, to some degree, also why payers should be helping provider organizations in their local communities to do so by providing some help and shelter on the journey from here to a capitated payment.

The focus today is really, I\u2019d have to say, on the messy middle, where a provider organization does not have capitated contracts nor access to any premium dollars, which, by all accounts, is the holy grail here. The premium is where it\u2019s at, and provider organizations might want to be aiming to get a piece of that action.

The why for this \u201cget the premium dollar\u201d prime directive is pretty self-evident when you look at the big bucks rolling around in the coffers of those who are collecting said premium dollars. So, this \u201cget the premium\u201d endgame is, for sure, a big piece of the why\u2014why, if I am a provider organization, I might want to take the time and energy and spend the money to embark on a path that might lead me to be able to get compensated for the stuff that patients really want and need to do better, which includes all of the things that I spoke about with Eric Gallagher in episode 405. Also, Vivek Garg, MD, MBA, in episode 407 and Amy Scanlan, MD, in episode 402.

Spoiler alert: It\u2019s not easy.

Now, I asked Dan Serrano, as aforementioned my guest today, to offer up his advice here in the context of CKD (chronic kidney disease) patients. Why did I ask Dan to use the CKD case study, as a touchstone? Well, first of all, talking about this topic in totally theoretical terms is not ideal. We need an actual example for a lot of this to kind of make sense, combined with the first step for most outcomes improvement programs, which is to study your data and pick a patient population to focus on where the data suggests that you can have a big impact. And speaking of impact, did you know that an underlying reason why heart failure patients get hospitalized and rehospitalized is because of underlying CKD? So, impact in the short term and longer term, which I\u2019ll get to in a sec.

Another reason is\u2014and I\u2019m quoting John Rodis, MD, MBA, here, who is the independent medical director of QC-Health\xae\u2014Dr. Rodis said the other day, \u201cI sure as heck hope I don\u2019t get CKD, because if I do, chances are I\u2019m not going to be diagnosed. And even if I am diagnosed, I won\u2019t be treated properly.\u201d

So, there\u2019s that. And I can see why he\u2019s saying that. Two out of five patients with ESRD (end-stage renal disease) don\u2019t even know they have kidney disease at all. And the number of patients with progressing CKD on any kind of evidence-based treatment plan is stunningly low.

But also, here\u2019s another reason I asked Dan Serrano to talk about CKD patient populations specifically as his example: I and Dr. Rodis and the team at QC-Health are not the only ones who have figured out that CKD patients are notoriously expensive and way underdiagnosed.

You know who else has figured this out? Payers. Also, private equity. In fact, I was in a meeting with a payer recently, and they stated they had to get CKD patients into point solutions.

This payer\u2014and I\u2019ve heard of others, too\u2014none of these entities are waiting around. And I guess, fair enough, if you look at some of the population health data, that I\u2019m sure these payers and others are looking at. But if you work for a payer and you\u2019re listening right now, what I would say, \u201cOkay, with the point solutions, one that you have carefully vetted, of course, because we have patients suffering right now and dollars being frittered away right now.\u201d But I also would submit that those point solutions will perform a whole lot better if we are all gunning for synergies.

PCPs (primary care physicians) and traditional FFS (fee-for-service) models in this country need your help. The payment models and admin burden are decimating. Payers certainly are a group with some culpability here. (Sorry to be saying the quiet part out loud.) Instead of forgoing them, please help PCPs. Am I saying be altruistic? Actually, no.

Listen to episode 409 with Larry Bauer or episode 391 with Scott Conard, MD, or an upcoming show with Jodilyn Owen and what you will hear is the amazing ability for clinicians rooted in the community to actually drive change in their local markets. In fact, I\u2019d hypothesize that these community-rooted organizations probably have a better track record for actually moving the needle on patient outcomes than any snazzy tech that I have seen, although I am sure that there are one or two very effective snazzy techs out there\u2014the exception proves the rule and all that.

Bottom line: As I do so often, I am advocating for payers and provider organizations within communities to collaborate, regardless of whether there\u2019s a third party also in the mix. I am reporting all of this in the spirit of being helpful but also with some degree of urgency for any care delivery organization because, I mean, really, forget about the holy grail of trying to capture a percentage of the premium if the money is already going elsewhere to too many point solutions who are already capturing a portion of the premium.

IRL, this is what\u2019s already going on out there.

But where there\u2019s a challenge, there is also opportunity. As I have said pretty repeatedly for the past four minutes, because the bar is so low and because CKD patient outcomes are bad news, in general, from a lot of angles, CKD is actually a great place for providers to work hard to improve care and quality.

From a financial standpoint, I think there\u2019s also a great business case for payers to help provider organizations do so. Doing better than the local standard of care is not hard, sadly. And what that means is that there\u2019s so much money that\u2019s possible to save due to the expense of this condition.

And if you\u2019re a payer, even a payer with a third-party CKD solution, if you can help local PCPs and others level up their care, then either you don\u2019t have to pay for the third-party point solution for patients who can be managed successfully locally and/or there\u2019s a more frictionless path for those patients to be identified and get into the point solutions that are available to them.

Let\u2019s all keep in mind that patients at rising risk are falling through a lot of cracks. You can have the best point solution in the world, but if patients aren\u2019t making it there, then, yeah, no outcomes will improve. No costs will be reduced.

Everything I just went through are also all of the reasons why we picked CKD as our focus for a national Groundswell Movement\u2122 that the benefit corp I am co-president of is kicking off to improve CKD patient outcomes. If you are also thinking about improving CKD patient outcomes, for sure, hit me up.

On to a few thank yous. Thank you so much to Carl Hansen, MD, a direct primary care physician, for a really generous tip in our tip jar. Also, thanks so much to Keith Passwater, who is CEO of Havarti Risk Services and Pasco Advisers, for a really nice donation to the cause over here. It was such an honor and a pleasure to moderate a panel at the Society of Actuaries\u2019 latest meeting at Keith\u2019s invitation also.

Additionally, may I extend thanks to Dffdgg, RKC2023, and Healthy economist for super nice iTunes reviews. The shout-outs are amazing, especially when public like this. Also much appreciated how you have shared Relentless Health Value with your colleagues.

Back on track, let\u2019s hear from Dan Serrano, who is a consultant with COPE Health Solutions, where he works to help clients figure out the best way to make investments that drive better outcomes in a more cost-efficient way.

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You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.

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Dan Serrano joined COPE Health Solutions in September 2022 as principal and senior vice president. He supports Analytics for Risk Contracting (ARC) finance build and cost models in terms of drive and delivery with Great Lakes Integrated Network (GLIN).

He is a seasoned healthcare/finance professional with 20+ years\u2019 experience and has held a number of roles across the industry and has primarily served as a senior finance leader with proven ability to drive strategy development and execution across multiple business lines for complex organizations in various stages of maturity.

Prior to COPE Health Solutions, Dan served as senior vice president of finance at CareAbout, a private equity\u2013backed start-up focused on driving performance for primary care physicians. He also was the vice president of value- and risk-based contracting at Mount Sinai Health System, where he worked to align contracting, operational performance, and network strategy for employed and voluntary physician groups. Prior to his role at Mount Sinai, Dan served as vice president of commercial products at Healthfirst, market chief financial officer at ChenMed, and Mid-Atlantic Region chief financial officer at Aetna, where he focused on driving strategic financial decisions by analyzing the value drivers for each of the stakeholders across the industry.

Dan holds a bachelor\u2019s degree in finance from the Peter J. Tobin College of Business at St. John\u2019s University.

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09:08 What is the importance of payer/provider partnerships in reducing costs with chronic condition care?

10:52 Josh Berlin, JD, of rule of three; look out for his episode in a few weeks.

11:19 What\u2019s the endgame here with this payer/provider collaboration?

11:43 What advice does Dan have for providers who want to do better by patients with chronic conditions?

15:11 Who\u2019s driving costs in the system?

15:50 Why is lowering the average cost of chronic condition care important?

17:03 Why is there a meaningful delta between well-controlled CKD patients and those who aren\u2019t well managed or identified?

21:57 What does a realistic time horizon look like for addressing chronic condition care?

22:38 Why is it important to start in a shared savings place?

25:25 William Shrank, MD, of Andreessen Horowitz; look out for his episode in the fall.

26:35 Financially, what is the goal and how are we achieving a sustainable goal?

29:06 What is the balance between progress and risk here?

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You can learn more at the COPE Health Solutions Web site or by emailing Dan at dserrano@copehealthsolutions.com.

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Dan Serrano of @COPEHS discusses #chronicconditions and #payer #provider #collaboration on our #healthcarepodcast. #healthcare #podcast

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Recent past interviews:

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

Larry Bauer, Dr Vivek Garg (Summer Shorts 3), Dr Scott Conard (Summer Shorts 2), Brennan Bilberry (Summer Shorts 1), Stacey Richter (INBW38), Scott Haas, Chris Deacon, Dr Vivek Garg, Lauren Vela, Dale Folwell (Encore! EP249)

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