Recently on Relentless Health Value, we’ve been tinkering around with a few recurring themes—recurring through lines—that are just true about American healthcare these days.
For a full transcript of this episode, click here.
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One of the things Matt McQuide and I talked about (EP468) from a few weeks ago that if a plan sponsor isn’t navigating or steering members, someone else is. Furthermore and wrapped up in all of this is the vital importance of trust and patients trusting who they are talking to.
The encore with Kenny Cole, MD, coming up is gonna hammer on this point even more than Matt McQuide did and Scott Conard, MD (EP462) did in those earlier episodes. If you want to steer or navigate a member, they need to have an existing, trusted relationship with somebody: a case manager, a primary care team, maybe even an on-site clinic.
You know, they all know Monica; and when she calls, they pick up the call because they already know her. And that is a huge part of the conversation today with Dr. Christine Hale when it comes to high-cost claimants, because it’s often not some random accident when a patient/member winds up in whatever care setting they find themselves—and that is especially true when that patient, again, is a high-cost claimant.
Let’s never forget that one person’s cost is someone else’s profit and high-cost claimants are not always but often exceptionally profitable. So, your members are getting steered, alright. And if it’s not you doing the steering, it’s someone else who has a huge financial incentive to figure out where that high-cost claimant is gonna wind up.
This is part of the story I discuss in great depth, by the way, next week with Eric Bricker, MD. So, as you listen to this show, keep who is steering my members/the patients in the back of your mind. Also, keep in mind the undeniable, almost-biblical-level commandment that comes up in almost every Relentless Health Value episode: the importance of not only having data, timely data, but also having the wherewithal to analyze it.
But what I also realized during this conversation is the absolute growing importance of recognizing a point that Dr. Scott Conard made in his show (EP462) about whole-person health and recognizing that we are all one whole person, not a bunch of little parts.
So, yeah, we really need to have pharmacy and medical claims data comingled altogether and at the member level. People in the know have been saying to get one dataset (not 2 or 12) for years, but at this point, given scientific advancements that are really expensive—such as cell and gene therapy and infusions that may or may not be billed under the medical benefit or the pharmacy benefit—not having one dataset to rule them all is going to have increasingly expensive consequences, which Dr. Christine Hale quantifies during the show that follows. So, I am not gonna get into it here.
One other recurring theme that comes up in the show today is the importance, the vital importance, as Steve Schutzer, MD, underscored about the Betsy Seals episode (EP463) recently, of keeping track of the value that is accruing to the patient or member, not forgetting the human being while we are looking at the spreadsheets.
Turns out in this high-cost claimant zone, you forget about the human being at your own financial peril while possibly also subjecting the member to potentially avoidable clinical suboptimal-ness or even harm at the same time. These are a few humans that, first of all, desperately need help; but also failing to align with their actual needs is going to wind up as a real-world fail.
Dr. Christine Hale says, quite crisply actually, that high-cost claimants don’t get cheaper a lot of times if our approach is mostly some kind of across the board trying to take things away from these high-cost claimants, is definitely one of those “sounds good on paper, doesn’t actually work out great” kinds of approaches.
Dr. Christine Hale, my guest today, is a pediatrician by training. She got an MBA because she wanted to work on changing the healthcare system and spent a bunch of years as a consultant and also working at primarily academic medical centers and children’s hospitals. Past eight years, she has worked for an employee benefits consultant.
And as I mentioned earlier, do tune in next week for the show with Dr. Eric Bricker, where we go hard on how provider organizations can very strategically and profitably take advantage of everything you learned on this show when plan sponsors and probably payers and definitely consultants are unaware or maybe getting paid to look the other way.
Not everything is gonna show up in a 5500 disclosure form, by the way. Don’t forget that, plan sponsors. But that is a conversation for another day.
Also mentioned in this episode are Lockton; Matt McQuide; Kenny Cole, MD; Scott Conard, MD; Eric Bricker, MD; Steve Schutzer, MD; Betsy Seals; Autumn Yongchu; Erik Davis; and Marty Makary, MD, MPH.
You can learn more by following Dr. Hale on LinkedIn.
Christine Hale, MD, MBA, joined Lockton as vice president in 2017 and was promoted to her current role of Senior Vice President, Chief Medical Officer, Clinical Consulting in 2023. She serves as the medical director and lead strategist for the clinical consulting team. Christine is known as an innovator, collaborator, and change agent; and she is particularly passionate about utilizing data and creative solutions to reduce waste and improve cost effectiveness in healthcare.
Upon completion of her MBA in 2005, she joined a major consultant agency, where she remained for over seven years. During this time, she worked with hospitals and health systems both across the country and internationally in a variety of functional areas, including strategy, operations, and organization. Christine was often sought out to facilitate in situations where building physician and administration alignment was key.
She joined Tenet Healthcare in 2013 as National Director Clinical Performance Excellence. In this role, Christine was responsible for advancing a number of high-stakes clinical performance improvement initiatives, including blood product utilization, sepsis identification and management, laboratory utilization, intensive care, palliative care, and cardiac quality. She also oversaw 15 clinical expert panels, which engaged across a spectrum of business issues relevant to their areas of clinical expertise.
05:22 What is a high-cost claimant, and how is the definition changing?
07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors.
10:19 What are plan sponsors getting wrong about this situation?
11:28 What do you need as an employer to understand your plan data fully?
13:41 EP462 with Scott Conard, MD.
17:35 What are plan sponsors currently doing that they should not being doing?
19:54 Why starting small is important.
23:02 EP468 with Matt McQuide.
25:37 What are the steps employers should take to improve their high-cost claimant spend?
31:02 EP371 with Erik Davis and Autumn Yongchu.
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Nikki King, James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467), Vivian Ho, Chris Crawford (EP465), Al Lewis, Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard
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