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Published: May 26, 2022, 11:30 a.m.

In INBW32, I talked about telehealth. In this episode, I\u2019m talking about collaboration between healthcare stakeholders or the lack thereof.

My grandfather suffered from heart failure. This was many years ago now. But when I say suffered, I mean it. As many of you know, when heart failure is uncontrolled, it is painful to go through or even watch a loved one go through.

There was that one time when I accompanied my grandfather (and my grandma was there, too) on a trip to the emergency room, you know, because he was drowning in his own lung fluid and could barely breathe. And when we arrived, they were going to wheel him into one of the exam rooms. But my grandmother put her foot down. She did not want to go into that one exam room because the TV was broken in there. Yes, the two of them had been in the ER so many times that they were familiar with the pros and cons of the various exam rooms.

The end of my grandfather\u2019s life was almost unbearable, and I can\u2019t even begin to estimate the hundreds of thousands of dollars racked up in ER visits and inpatient stays. He was in the ER once a month at a minimum, and he would come home disoriented and confused.

Now, as everybody listening to this show knows, this anecdote is also a data point that is, dare I say, all too common. But to that end, let me just talk about heart failure data for a second. Patients with heart failure generate a third of Medicare spending and 40% of Medicare fee-for-service deaths. They are also responsible for 55% of Medicare readmissions. You\u2019d think that if there were any chronic condition that we\u2019d be looking to improve outcomes on, it\u2019d be this one.

So, everybody\u2019s on it, right? Oh, wait \u2026 heart failure readmissions have actually gone up in recent years. \xa0

I just want to point out that in between ER visits and inpatient stays, my grandfather received effectively no education, no PCP or cardiology follow-ups, no community support. He did not get a case manager. He got no coaching.

He got 25 pages of tiny, printed instructions just before the door hit him in the butt on his way out to the parking lot. Obvious point here, but to do any of this in-between stuff would have required collaboration between the hospital and others. And it was conspicuous in its absence.

Look, this is sad and I\u2019m not telling the story because I think it\u2019s unique. If I asked who else has a story like this one where a family member or a loved one got lost in the gaps between their care, I am suspecting that everyone would raise their hands\u2014even those of you who have medical degrees. No matter how much any of us know or care or try to help, stories like my grandfather\u2019s are painfully and unequivocally common in this country today.

OK, so how to improve care, especially for chronic care patients. At its core, and I am not telling anyone listening something that you probably have not already thought about at great length, but there are two important contributors to patient outcomes. Not the only contributors for absolutely sure, but here are two important ones:

1. Nonfragmented patient journeys that adhere to evidence-based best-practice care. My grandfather and anyone with a chronic condition requires a patient journey that isn\u2019t a game of whack-a-mole. Carly Eckert, MD, says this so well in EP361.
2. Steering patients to the best care setting, which is required to get the highest-value best-practice care and also reduce financial toxicity. Short but important sidebar: We know that financial toxicity is clinical toxicity. There was just a study that came out that said in 2030, a leading cause of death will be noncompliance to treatment due to patients abandoning care because it costs too much.

Wayne Jenkins, MD, from Centivo (EP358) talks about other implications of financial toxicity for a half-hour. Also, there\u2019s another paper that, again, is just more on this point.

At this juncture, it is not arguable. Financial toxicity is clinical toxicity. So, we need to get patients, people, customers to the next place that is the highest value for them. Doing either or both of these things\u2014nonfragmenting the patient journey and making sure patients get to the next care setting\u2014it requires collaboration.

Let me quote Dr. Steve Klasko, who, until recently, was president and CEO over at Jefferson Health in Philly. He said\u2014and this is an adaptation of an old Steve Jobs mantra\u2014but Steve Klasko said that for hospitals, our old math was inpatient revenue, outpatient revenue, and in-person tuition and funding. The new math is going to be strategic partnerships around this healthcare at any address model.

Right? But good collaborations don\u2019t just improve patient outcomes. Here\u2019s another benefit: They also make happier clinicians or employees. If every outside interaction is a friction point, where employees, clinicians, doctors, nurses are rubbed raw because every interaction becomes a battle, if that\u2019s the ecosystem that any given party has created for themselves, patients aren\u2019t happy and clinicians aren\u2019t happy. And since everything in healthcare spirals around that one relationship, the one between the patient and their clinicians, this could not be more vital.

There\u2019s that famous Richard Branson quote, which I\u2019ll paraphrase: If you want to keep the customers happy, keep the employees happy. How anyone thinks that patients are going to get amazing care when those providing the care are miserable is just the very definition of magical thinking.

All right \u2026 so, let\u2019s get into the hard thing about hard things: why with the lack of collaboration across the industry there are a lot of excuses for why parties cannot collaborate. For example, interoperability, HIPAA, legal, cyber, bureaucracy \u2026 Also, people are busy, COVID response, being overworked and burned out is a big deal. And I\u2019m not saying that some of these are not valid, but the elephant in the room is this: In healthcare today, most (if not all) big organizations for sure and a lot of small ones have a business model that is built on revenue maximization.

Look, when I\u2019m referring to organizations as revenue maximizers, maybe I\u2019m not talking specifically about specific departments and people working hard in those departments within any given organization. Organizations are not one-celled organisms, after all. But what I am saying is that, as a whole, healthcare organizations\u2014the vast majority and certainly every so-called incumbent payer and health system\u2014when you factor in the actions of the CFO, the actions of the billing department, the group that sets premiums, the one that sets prices, the group that incentivizes brokers, the group that sells to employers, the group that lobbies politicians, the group that writes the contract terms \u2026 if you factor in the whole organization, what you get is an organization who acts to maximize outcomes\u2014financial outcomes, that is.

As per my normal MO, I\u2019m gonna say the quiet part out loud here. One big reason why parties do not collaborate is because they are thinking they are going to maximize their revenue by info blocking to prevent network leakage, or not sharing data with an employer because then the employer might steer the employee to an infusion center for their chemo, or drugs will get switched from the profitable one to the not profitable one.

I just saw another article the other day, entitled \u201cThe Many Barriers to Payer-Provider Alignment on Value-based Care.\u201d Two entities vital for a nonfragmented frictionless patient journey cannot figure out how to align incentives, share data, or even figure out what good looks like. Speaking industry-wide here, but if patient outcomes were the top of either the payer or the provider\u2019s organizational lists of priorities, I do not think that this would be the case decades later. Listen to the show with Kevin Schulman, MD (EP366); Scott Haas (EP365); or an upcoming one with Autumn Yongchu and Erik Davis coming out in a few weeks that just drives this point home. \xa0

So, can you do well by doing good? Yes, you can. I have a degree from a business school, after all; but there is a line that gets crossed when maximizing revenue harms patients. And I\u2019ll tell you how you can tell if you\u2019re over the line.

And again, I\u2019m talking organizations here who have power and control in their local markets. I would say that a lack of collaboration is a symptom. If we all agree that collaboration is essential and some organization is not doing it, maybe it is a sign. It is an actionable bit of information that I hope, if relevant, gets contemplated.

For example, back to my grandfather for a sec, it\u2019s pretty well known how to reduce heart failure revisits. There are more than a few care models that have definitely been shown to work.

Here is one of them, and this was talked about in Dr. William Bestermann\u2019s Substacks. There was a nurse in the Carolinas\u2014and I talked about this before\u2014but there was a nurse in the Carolinas who decreased heart failure readmissions markedly by simply calling up heart failure patients and making sure they were doing OK and that they understood how to take care of themselves. She was caring, and she had relationships with these patients. That\u2019s all she did. \xa0

So, hospital collaborates with a payer case manager or a CBO (community-based organization) or an MSO (management services organization), or maybe the hospital has pop health capabilities internally. I mean, we can manage to transplant important organs in this country, and most healthcare organizations cannot figure out how to work together well enough that a nurse calls up a bunch of patients? Is this some arcane or highly complex thing to do? No, it\u2019s not. But most are not doing anything even close to this because revenue maximization is the goal of one or more of the entities who would need to be a party to this, and everything else is just an excuse.

If anyone is thinking interoperability right now, I\u2019ve heard Don Lee say on The #HCBiz Show! often enough that there\u2019s lots of evidence at this point that interoperability has been solved from a technical standpoint. It\u2019s been solved for years. The problem is a business case problem. No one wants to be interoperable because \u2026 revenue maximization

All right \u2026 aspirationally here, despite all of this, great collaborations happen every single day\u2014collaborations that are bright spots and that definitely improve patient outcomes and reduce financial burdens short-term and long-term. Let me give you some examples: what 32BJ is doing in New York City (upcoming episode with Cora Opsahl talking about the cool things that they are doing with Mount Sinai); CINs (clinically integrated networks), like Lisa Trumble, who talks about SoNE HEALTH in EP349. \xa0

There are MSOs that work with ACOs (accountable care organizations) and others. Listen to Shawn Rhodes (EP354); also what Nicole Bradberry and Kelly Conroy are doing in Florida (EP324). \xa0

In an upcoming episode, Dave Chase from Health Rosetta: He\u2019s got one great story after another about how employers these days are teaming up with provider organizations, pharmacies, and their communities to put a serious dent in costs while raising patient outcomes and satisfaction.

Doug Hetherington\u2019s episode (EP367) talks about direct contracting with hospitals. Katy Talento (EP350) talks about this also. Steve Schutzer, MD, talks about collaborating with other local orthopedic surgeons to stand up a now nationally recognized center of excellence in Connecticut (EP294).

We also have some pharma companies who are developing some pretty great disease-centric resources for providers. Some pharma companies and some internal teams at those companies can actually be fair and good community players.

Mike Levitt and the work that he has done on the Accountable Care Learning Collaborative, which is headed up by Dr. Eric Weaver, who has been on the show (EP277); or I\u2019m sure after this show airs, I\u2019m gonna hear about more. Please send them my way. \xa0

Now, look \u2026 let\u2019s get real here. These collaborations may have been initiated with, let\u2019s just say, other beneficial side effects; but they all improve care and reduce costs.

If I were gonna list some common and appealing side effects that could motivate some prospective collaborators to come to the table, some of the usual suspects are proposing that the collaboration will, for example, improve HCAHPS scores, quality metrics, star ratings; improve predictable spend; reduce shock claims; avenge your common competitor and steal their market share; gang up against a payer or some consolidated health system; improve OR utilization; or improve efficiency in some way.

What I would say, though, is that if leveling up patient care happens and costs do not rise as a result, that\u2019s the shared priority I\u2019d focus on. If someone gets some beneficial side action, this is kind of the definition of doing well by doing good.

All right, so let\u2019s talk about the different kinds of collaboration just briefly. I\u2019m gonna say that there\u2019s three kinds of collaboration:

1. Collaboration along the patient journey by multiple parties who are all along the patient journey
2. Collaboration by parties who can help inform the patient journey, but they\u2019re not necessarily on the patient journey themselves
3. Collaboration by parties who can help navigate the patient journey

I am mentioning these three because there\u2019s often sort of this insinuation that collaborators should have equal stature in the care journey or have similar roles, that if you\u2019re not actually on the clinical journey, then you don\u2019t have any responsibility or accountability for the clinical journey and, therefore, are not a worthy collaborator. That is limiting if you are trying to figure out who you might be able to collaborate with to help you.

The patient journey is not like a movie showing all the minutes a patient spends in clinic, and then all the gaps in between visits are edited out. Care can be improved at the population level, at the community level. Care can be improved at the disease or the condition level when clinicians get needed insights or information or tools.

I mean, frankly, to my mind, it shouldn\u2019t be considered a plus when a pharma company or a payer actually does something in the service of improving patient outcomes. It should almost be a requirement that they do. I don\u2019t mean by delivering care in any way. And for the record, most prior auth programs are the opposite of collaborative.

Payers can collaborate by supplying data, as just one example. Heck, external collaborations are great, but we also could think about collaborating internally, like invite the CFO or maybe the gang rewarding brokers with sales competitions. I don\u2019t know. I\u2019d consider ethically dubious: Invite them to come to some meeting where oncology patients are choosing to die rather than bankrupt their families. Communication is the first step to collaboration, after all. That\u2019s a place to start.

Or life science types: They can supply knowledge and expertise about specific diseases or conditions with the purpose of improving patient outcomes. Informing the patient journey could be a collaboration with some of these amazing patient efficacy organizations or CBOs that are out in the community.

Now, I think one barrier to collaboration that we all need to get over is the whole, I call it, stakeholder prejudice thing. Here\u2019s what Colton Ortolf wrote on Twitter the other day. He tweeted, \u201cHospitals are the Lance Armstrong of healthcare. Pissed [off] at all the [crappy] things they do economically, but also grateful for all the lives they save.\u201d

If we\u2019re gonna eliminate everybody in healthcare who has revenue maximization as their organizational goal, as aforementioned, there is going to be basically no one left standing. As Ge Bai, PhD, CPA, said in EP356, there\u2019s no angels and no demons in healthcare. Everybody is both. \xa0

If we\u2019re talking about stakeholder prejudice, though, I would be remiss not to single out Pharma. When I mentioned them a sec ago, I bet some of your eyebrows went up. Here\u2019s my take on it. Consider Pharma\u2019s potential role in leveling up disease-/condition-specific outcomes. I mean, there are thousands, millions probably, of diseases and conditions and health problems out there that any given doctor or clinician has to be familiar with. Pharma has huge infrastructures and physicians and smart people who focused on, like, six of them. They know more about those six than anybody else.

We pay a ton also for their drugs. It\u2019s my view that people along the patient journey should ask for what they want and need relative to the expertise that Pharma possesses. It should be about helping those providing care on the patient journey to level up the standard of care. Frankly, I\u2019d expect collaboration from some of these entities. Ask for it on your own terms, and if all you get back is a sales pitch, you deserve better than that. Find somebody higher up on the food chain to talk to. And also, outcomes-based contracts \u2026 yeah, we need to figure out how to operationalize them so that really good drugs that actually produce outcomes like overall survival get paid for and those that do not do not.

Point of note must be said: Colluding and conflict of interest is not cost neutral. If someone is getting things bought for them and then thinking, falsely, that it does not impact prescribing, that is not collaboration. Any of these revenue-maximizing hookups are not included in my definition of collaboration.

So, in sum, ultimately, what we\u2019re talking about here is our legacy. As David Muhlestein, PhD, JD, talks about really well in EP364, we got to ask ourselves, What do we want to leave behind to our children and our grandchildren? Some of this is generational change, for sure. But seriously, talking about today, I mean, who wants to sign their family member up for what my grandfather went through? Right now, across the country, there are heart failure patients going through exactly what he did; and there are other patients with care journeys so dysfunctional that lives are shattered. \xa0

Chronic care patients, oncology patients \u2026 and this isn\u2019t going to change unless we contemplate, first of all, what we can do today\u2014right now. Even little things can matter a lot, but then also to really consider what we want healthcare to look like in 20 or 25 years and then start working back from that vision and collaborating today so that, slowly and surely, we reach a place with better care that is not financially toxic.

Check out the 8-Step Collaboration Roadmap for more resources to operationalize a collaboration.

For more information, go to aventriahealth.com. \xa0

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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03:07 How do we improve care, especially for chronic care patients?
03:18 What are two important contributors to patient outcomes?
03:40 EP361 with Carly Eckert, MD.
03:56 \u201cWe know that financial toxicity is clinical toxicity.\u201d
04:09 EP358 with Wayne Jenkins, MD.
06:05 Why can\u2019t parties across the healthcare industry seem to collaborate?
08:05 EP366 with Kevin Schulman, MD.
08:07 EP365 with Scott Haas.
08:10 Upcoming episode with Autumn Yongchu and Erik Davis.
08:34 \u201cI would say that a lack of collaboration is a symptom.\u201d
10:10 There\u2019s lots of evidence that interoperability has been solved. It\u2019s been solved for years.
10:37 Upcoming episode with Cora Opsahl.
10:46 EP349 with Lisa Trumble.
10:53 EP354 with Shawn Rhodes.
10:57 EP324 with Nicole Bradberry and Kelly Conroy.
11:04 Upcoming episode with Dave Chase.
11:19 EP367 with Doug Hetherington.
11:25 EP350 with Katy Talento.
11:28 EP294 with Steve Schutzer, MD.
11:50 EP277 with Eric Weaver, DHA, MHA.
13:00 What are the three kinds of collaboration in healthcare?
13:23 Do collaborators need to have equal status in a collaboration?
13:57 \u201cCare can be improved at the population level, at the community level \u2026 at the disease or the condition level.\u201d
15:10 How is stakeholder prejudice holding healthcare back?
15:42 EP356 with Ge Bai, PhD, CPA.
16:55 \u201cOutcomes-based contracts \u2026 we need to figure out how to operationalize them.\u201d
17:08 \u201cColluding and conflict of interest is not cost neutral.\u201d
17:30 EP364 with David Muhlestein, PhD, JD. \xa0

For more information, go to aventriahealth.com. \xa0

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Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

How do we improve care, especially for chronic care patients? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

What are two important contributors to patient outcomes? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

\u201cWe know that financial toxicity is clinical toxicity.\u201d Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

Why can\u2019t parties across the healthcare industry seem to collaborate? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

\u201cI would say that a lack of collaboration is a symptom.\u201d Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

There\u2019s lots of evidence that interoperability has been solved. It\u2019s been solved for years. Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

What are the three kinds of collaboration in healthcare? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

Do collaborators need to have equal status in a collaboration? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

\u201cCare can be improved at the population level, at the community level \u2026 at the disease or the condition level.\u201d Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

How is stakeholder prejudice holding healthcare back? Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

\u201cOutcomes-based contracts \u2026 we need to figure out how to operationalize them.\u201d Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

\u201cColluding and conflict of interest is not cost neutral.\u201d Stacey discusses #healthcarecollaboration on our #healthcarepodcast. #healthcare #podcast #healthcollab

Recent past interviews:

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

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, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms

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